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Papel dos Anaeróbios nas
Infecções Supurativas
Carlos M. Luna MD
Profesor de Medicina, Hospital de Clinicas,
Universidad de Buenos Aires, Argentina
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Most common Etiology of CAP
Streptococcus pneumoniae
Haemophilus influenzae
Influenza A and B, adenovirus
parainfluenza 1,2 y 3
Aerobic gram-negative bacilli
Pseudomonas aeruginosa
Staphylococcus aureus
Mycoplasma pneumoniae
Chlamydia pneumoniae
Chlamydia psitacci
Coxiella burnetti
Legionella species
Mycobacterium tuberculosis
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Pathogenic fungi
Pneumocystis carinii
Aspirative
Postobstructive
Unknown
Pneumonia
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Absceded
Pneumonia
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Role of Anaerobes in Lung Infections
Peptostreptococcus
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Bacteroides
Fusobacterium
Role of Anaerobes in Lung Infections
1: Obligate aerobic; 2: Obligate anaerobic (avoid oxygen); 3: Facultative bacteria (mostly at the
top, but can be found all along the test tube), 4: Microaerophiles (upper part of the test tube but
not at the top); 5: Aerotolerant bacteria (not affected by oxygen, and they are evenly spread)
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Role of Anaerobes in Lung Infections
Anaerobes are the predominant constituents of the
normal flora that inhabits the mucosal surfaces of the
gingival crevice.
The crevicular fluid flora normally is
predominantly gram-positive and the
predominant anaerobic is Actinomyces.
If periodontitis is present, the flora
becomes predominantly gram-negative
(Porphyromonas, Prevotella, Bacteroides,
and Fusobacterium).
Over 200 microbial species are found in
the crevicular fluid in numbers of 1012
CFU/g.
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Levison ME. Curr Opin Infect Dis. 2001; 14:187.
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Anaerobic Bacteria
Anaerobic bacteria are the most overlooked bacterial
pathogens of the lower respiratory tract.
They are often infrequently recovered from this site
because of improper specimen collection and lack of
appropriate anaerobic identification techniques.
Isolation of anaerobics in two studies was around 65%
of cases of empyema .
However, in various other studies, incidence of
anaerobes in empyema is as high as 76-100 %to as low
as 31-39%.
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When to think in Anaerobes?
Alcoholism: S. pneumoniae, oral anaerobes, K.
pneumoniae, Acinetobacter sp, M. tuberculosis.
Aspiration pneumonia: Gram – negative enteric bacilli,
oral anaerobes.
Lung abscess: CA – MRSA, oral anaerobes, endemic
fungal pneumonia, M. tuberculosis, atypical mycobacteia
Injection drug use: S. aureus, anaerobes, M.
tuberculosis, S. Pneumoniae.
Mandell L, et al. IDSA/ATS CAP guidelines. CID 2007;44:S27
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Role of Anaerobes in Lung Infections
Anaerobic bacteria are the causative agent of aspiration
pneumonia, lung abscess and empyema.
These agents are especially abundant in the upper and
lower respiratory tracts.
Anaerobic agents should be taken into account also in
alcoholic patients, in those presenting non-resolving
pneumonia, in pulmonary infections in lung cancer
patients.
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Risk Factors for Specific Pathogens in CAP
(n:346)
Condition
Associated Pathogens
Respiratory
Diabetes
Alcohol abuse
Hepatic
Neurological
Age  65
Age < 65
Current smoker
P. aeruginosa, EGNB, M. catarrhalis
M. tuberculosis
M. tuberculosis
S. pneumoniae
Aspiration Pneumonia
Aspiration Pneumonia
M. pneumoniae, H. influenzae, C. pneumoniae
M. tuberculosis
Luna CM, et al. Chest 2000;118: 1434
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Role of Anaerobes in Lung Infections
Anaerobes are the causative bugs of various infectious
diseases. The need of special techniques and equipment
for culture hampers the detection from clinical specimens.
Finegold SM. 1989; Anaerobic infections in humans.
Hill RT, et al. J Gen Microbiol 1989; 135:3271.
Holland JW, et al. J Clin Microbiol 1979; 10:121.
Transtracheal and percutaneous lung aspiration and
protected brush are used to obtain specimens for culture
to avoid oropharyngeal contamination. Culture is difficult,
biochemical tests or gas-liquid chromatography used for
identification are troublesome and time-consuming.
Bartlett JG, et al. Chest 1987;91:901.
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Anaerobes in Pleuropulmonary
Infections
76 anaerobes and 122 aerobes were isolated in 100
patients with pleuropulmonary infections: empyema (64),
pleural effusion (19) and lung abscess (17).
In 14% only anaerobes and in 58% mixed, aerobes +
anaerobes were encountered.
Amongst anaerobes gram-negative bacilli included
Prevotella melaninogenicus, Fusbocterium spp and
Bacteroides spp predominate. Amongst the gram-positive
Peptostreptococcus spp. Coliform bacteria and
Pseudomonas aeruginosa were the predominant aerobes.
De A, et al. Indian J Med Microbiol 2002: 20: 150
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Necrotizing Pneumonia and Pulmonary
Gangrene
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Necrotizing Pneumonia and Pulmonary
Gangrene
Necrotizing pneumonia and pulmonary gangrene are
complications of severe CAP and represent distinct
entities along the spectrum of pulmonary infections.
Early recognition and treatment of these complications
are critical because patients often require intensive care
unit monitoring, mechanical ventilation, aggressive
drainage of infected fluid, and possible surgical
intervention.
Delay in treatment may result in overwhelming sepsis,
multiorgan system failure, and even death.
Tzeng DZ, et al. Clin Pulm Med 2007; 14: 166
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Necrotizing Pneumonia and Pulmonary
Gangrene
Bacteroides fragilis, and other gram-negative anaerobes
are known to have procoagulant activity.
Aerobics causing necrotizing pneumonia include K.
pneumoniae, P. aeruginosa, other gram-negatives, S.
aureus, and S. pneumoniae.
S. aureus and some gram-negatives produce enzymes
that digest tissue; S. pneumoniae and most gram-negative
aerobes have procoagulant properties like anaerobics.
As anaerobes are difficult to culture, it is reasonable to
treat, even if cultures are negative, in severely ill patients.
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Karmy-Jones R, et al. Clin Pulm Med 2003; 10: 17
Anaerobic Necrotizing Lung Infection
The necrotizing infection is referred to as a lung abscess
if each cavity is 2 cm or more in diameter.
If there are multiple, small cavities, each less than 2 cm
in diameter, the process is usually referred to as
necrotizing pneumonia.
Both lung abscess and necrotizing pneumonia are
thought to be different manifestations of the same
pathogenetic processes.
Extension of the anaerobic pulmonary infection to the
pleural space may result in anaerobic empyema.
Levison ME. Curr Opin Infect Dis. 2001; 14:187.
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Etiology of Microorganisms in Acute
Lung Abscess.
In a third-world setting, acute community-acquired lung
abscess is associated with dental caries, poorly controlled
epilepsy, previously damaged lungs, and alcohol abuse.
In more developed populations, however, this disease is
now uncommon except in patients immunocompromised
by drugs or disease or as a postobstructive complication.
Pohlson EC, et al. Am J Surg 1985; 150:97
Pena Grinan N, et al. Chest 1990; 97:69
Anaerobic organisms have been identified as the most
common pathogens in studies in which percutaneous lung
or transtracheal aspiration techniques have been used.
Bartlett JG, et al. Am J Med 1974; 56:202
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Lung Abscess, Analysis of 66 cases.
Sixty six patients treated between 1979 and 1991 in the
Juntendo University Hospital, Tokyo.
The most commonest anaerobes were Bacteroides spp,
Peptostreptococcus, Fusobacterium spp., micro-aerophilic
Streptococcus and Veillonella.
The mortality was higher in P. aeruginosa, Klebsiella
spp. and Candida spp. cases.
The prognosis of lung abscess patients depend on the
presence of underlying diseases and on superinfection
with aerobes.
Mori T, et al. Intern Med 1993;32:278
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Aspiration Pneumonia and Dysphagia in
the Elderly
CAP is a major cause of death in nursing homes.
Oropharyngeal aspiration is an important etiologic factor
leading to pneumonia in the elderly.
The incidence of neurologic diseases increase with
aging and are associated with dysphagia, impaired cough
reflex and increased risk of oropharyngeal aspiration.
Elderly with clinical signs of dysphagia or with CAP
should perform swallow evaluation. A multidisciplinary
approach to swallowing management include diet, oral
care, and consideration for using ACE inhibitor.
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Marik PE, et al. Chest 2003; 124: 801.
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Diagnosis and Therapy of Anaerobe’s
Pleuropulmonary Infections
Because of the difficulties the recovery of obligate
anaerobes from clinical specimens and their in-vitro
antimicrobial susceptibility testing, the microbial diagnosis
frequently remains based on the clinical presentation,
especially predisposition to aspiration or the putrid odor of
the breath or infected material (sputum or pleural fluid).
Antimicrobial therapy consequently often remains
empirical and based on published studies of in-vitro
activity against the presumed anaerobic pathogens.
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Karmy-Jones R, et al. Clin Pulm Med 2003; 10: 17
Role of Anaerobes in Lung Infections
Amoxicillin/clavulanic, metronidazole, chloramphenicol,
piperacillin/tazobactam and meropenem remain very
useful antimicrobials for treating anaerobic infections.
Cefoxitin, cefotetan and clindamycin were less active. In
particular, only 62%, 52% and 48% of B. fragilis group
strains were susceptible, respectively
Anti-anaerobic activity of the new antibiotics is
interesting, with MIC50 and MIC90 of 1 and >32 mg/L for
moxifloxacin, 2 and 4 mg/L for linezolid and 0.5 and 8
mg/L for tigecycline.
Wybo I, et al. J Antimicrob Chemother. 2007;59:132.
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Treatment of Anaerobic Infections
Since anaerobic infections are generally polymicrobial,
(anaerobes mixed with aerobic organisms), therapy should
provide coverage of both types of pathogens.
Antimicrobials is to limit the local and systemic spread of
infection. Surgical drainage, debriding and increasing
tissue oxygenation is essential.
The most effective antimicrobials are metronidazole,
carbapenems, chloramphenicol, combinations of β-lactam
+ a β-lactamase inhibitor, tigecycline and clindamycin.
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Brook I. Expert Rev Anti Infect Ther 2007;5:991. 25
Summary
Anaerobic bacteria are the most overlooked bacterial
pathogens of the lower respiratory tract.
They are infrequently recovered because of improper
specimen collection and lack of appropriate techniques.
Anaerobic bacteria are the causative agent of aspiration
pneumonia, lung abscess and empyema.
Therapy includes antimicrobial coverage for aerobes
and anaerobes to limit the local and systemic spread and
surgical drainage and debriding.
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Thanks for your atention!!
Iguazú Falls, Brazil and Argentina
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