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Klebsiella+proteus+uti Klebsiella+proteus+uti Presentation Transcript

  • KlebsiellaDr Kamran AfzalAsst Prof Microbiology
  • Enterobacteriaceae Gram-negative rods (2-5 by 0.5 microns) Most motile with peritrichous flagella  Shigella and Klebsiella are non-motile Oxidase negative Catalase positive Facultative anaerobes Reduce nitrates to nitrites Breakdown glucose and other CHO by fermentation with the production of either acid or acid with gas Growth can occur readily on NA, BA, MacConkey’s agar Do not form spores Grow readily at 35-37oC, except Yersinia (25o-30oC)
  • Microbiological Properties Many genera  Escherichia, Salmonella, Shigella, Klebsiella, Proteus, Enterobacter, Yersinia, etc Some strains opportunistic pathogens Some strains true pathogens  Salmonella, Shigella, Yersinia, some strains of E. coli
  • Classification of Enterobacteriaceae Enterobacteriaceae Lactose fermenters Non-lactose fermenter E. coli, Citrobacter, Salmonella, Shigella Klebsiella, Enterobacter Proteus, YersiniaThere are several selective and differential media used todistinguish between LF and NLF MacConkey agar Eosin Methylene Blue (EMB) agar Salmonella Shigella (SS) agar Triple Sugar Iron (TSI) agar
  • Classification of Klebsiella Enterobacteriaceae of clinical interest  Genus: Klebsiella  Species:  K. pneumoniae  ssp. pneumoniae  ssp. ozaenae  ssp. aerogenes  ssp. rhinoscleromatis  K. oxytoca
  • Description Straight Gram Negative Rods Pronounced capsule – Extremely mucoid colonies on media rich in CHO – Complex acid polysaccharides – Glucoronic acid and pyruvic acid – K antigen of E. coli resembles capsule of Klebsiella Non-motile, but most strains have fimbriae 370C (12-430C) Facultative anaerobes No hemolysis on sheep or horse blood agars
  • Antigenic structure 80 Capsular (K) antigens  Gram stain  Capsular ‘swelling’ reaction  CCIE  ELISA 5 Somatic (O) antigens
  • Virulence factors and Pathogenesis Capsule  Anti phagocytic  Prevents from complement mediated bacteriolysis LPS  Prevent from complement mediated bacteriolysis Adhesins (Fimbrial and non-fimbrial)  Type-I and Type-III  Adhesion to host tissues
  •  Toxins  Heat labile and heat stable toxins  Role not well defined Enzymes  β-lactamase and ESBL
  • Lab Diagnosis Specimens Culture  Highly mucoid colonies on NA, BA, MA and DCA  After 24/48 hrs incubation at 370C aerobically Gram stain  Gram-negative rods  Arranged in singles
  •  Colonial morphology  Low convex, grey, mucoid or smooth colonies on nutrient agar and blood agar  Non-hemolytic  Pink colonies on MacConkey agar and DCA indicate lactose fermentation
  •  Biochemical Reactions  Conventional sugar set – Lactose –sucrose – glucose – mannitol – maltose – citrate – VP –indole – urease – TSI  API / QTS Molecular Techniques
  • IMViC Reactions I M Vi CEscherichia coli + + – –Proteus vulgaris + + – –Klebsiella pneumoniae– – + +Klebsiella oxytoca + – + +Enterobacter spp. – – + +Serratia marcescens – – + +Citrobacter freundii – + – +Citrobacter koseri + + – +
  • Pathogenicity Community acquired infections  UTI  Bronchopneumonia  ‘Friedlander’s pneumonia’  Multiple abscess formation in lungs Hospital acquired infections  Surgical-site infections  UTI  Bronchopneumonia  Bacteremia – high mortality rate  Central nervous system (neonatal meningitis)  Bacterial peritonitis, abdominal abscess
  •  K. rhinoscleromatis  Rhinoscleroma – Ch. URT disease – granulomatous infiltrations of nasal submucosa K. ozaenae  Atrophy of nasal mucosa
  • Treatment Clinical isolates produce β-lactamase, ESBLs  Resistant to Ampicillin and Cephalosporins  Addition of anti – β-lactamase such as clavulanate Usually susceptible to  2nd, 3rd and 4th generation Cephalosporins  Fluoroquinolones  Aminoglycosides  Carbapenems
  • Proteus
  • Species of Proteus Proteus mirabilis Proteus vulgaris Proteus myxofaciens Proteus penneri
  • Proteus The genus is named after a Greek sea deity Proteus The god is flexible, versatile and adaptable and, like the flowers, assumes many different forms
  • Virulence Factors Urease activity Protease Fimbriae Motility test Haemolysins Motility Swarming
  • Pathogenicity P. mirabilis -70-90 % UTI – Commonest site  Young / elderly patients  High concentration of Urea in urine Superficial septic lesions Meningitis Osteomyelitis Septicemia Otitis media
  • Lab Isolation and Identification Morphology GNR, 1 – 3 um Motile-peritrichate flagella Cultural Characteristics Grow well on ordinary media Swarming  Continuous  Discontinuous Faint ammonia / fishy odor
  • Biochemical reactions
  • Swarming Characteristic but not unique  Serratia marcescens  Vibrio parahaemolyticus  Pseudomonads  Bacillus Continuous swarming Discontinuous swarming Ascending infection
  • Anti-swarming Agents Increasing Agar concentration 3-4 % Incorporation into media of a polyvalent-H anti-sera Incorporating growth inhibitors  Sulphonamides Neomycin  Chloral Hydrate Barbiturates  p-Nitrophenyl Glycerol Incorporation of  Detergents  Bile Salts-MacConkey Agar Electrolyte Deficiency- CLED
  • Antimicrobial Susceptibility P. mirabilis resistant to Polymyxin B and Colistin P. mirabilis sensitive to  Nalidixic Acid and other Quinolones  Semi synthetic Penicillins – Mezlocillin, Azlocillin, Piperacillin, Carbenicillin and Ticarcillin  Most Aminoglycosides  Carbapenems
  • Antimicrobial Susceptibility P. vulgaris resistant to  Penicillin, Ampicillin and many Cephalosporins like Cefazolin and Cefamandole  Inducible β-Lactamase (Cefuroximase) – Cefuroxime, Cefotaxime P. vulgaris sensitive to  Ceforoxime, Cefotaxime and Cefoxitin  Quinolones  Most Aminoglycosides  Carbapenems
  • Urinary Tract Infection
  • Epidemiology One of the commonest infections Factors influencing prevalence/incidence – Age and sex – Diseases of urinary system – Obstruction in urinary tract – Instrumentation – Predisposing diseases (DM, neuropathies, pregnancy)
  • Urinary Tract Infection Lower tract infection – Cystitis – Urethritis  Urethritis in men  Urethritis in women – Prostatitis and epididymitis Upper tract infections – Acute pyelonephritis – Chronic pyelonephritis
  • Urinary Tract Infection In adult women  Specific In adult male – Tuberculosis – Fungal In the elderly – Chlamydial In children – Mycoplasmal Transplant recipients – Parasitic Catheter associated
  • Pathophysiology Ascending infection – Colonize vaginal introitus, urethra, bladder – Prostate - Recurrent UTI Haematogenous infection (less common) – Acute pyelonephritis may be due to bacteremia – Renal abscess due to bacteremia and endocarditis
  • Pathogenesis (Bacterial factors) Inoculum size Virulence of the organism Bacterial attachment Antigenicity Toxin production Other factors (urease production)
  • Pathogenesis (Host factors) Factors which facilitate ascent of infecting agent – Patients with indwelling catheters – Urethral, prostate or bladder surgery – Sexual intercourse – Vaginal prolapse and length of urethra – Poor personal hygiene Factors which cause stagnation of urine – Inadequate fluid intake/urinary output – Inadequate bladder emptying Humoral or cellular factors – Ig A and IgE – Phagocytic activity of uroepithelium
  • Pathogenesis (Host factors) Vesico-ureteric reflux Impairment of neurogenic control of bladder Obstruction in urinary tract – Urethral stricture – Stone in the urinary tract – Prostatic hypertrophy – Pregnancy – Growth in the urinary tract – Bladder diverticula Miscellaneous − Contraceptive diaphragm − Spermicide
  • Clinical Manifestations Lower tract infections – Acute cystitis – Urethritis  In women  In men – Prostatitis Upper tract infections – Pyelonephritis – Renal abscess
  • Microbiology Bacteria – Enterobacteriaceae – Pseudomonads – Enterococci – Staphylococci Fungi – Candida albicans and other candida spp. – Torulopsis glabrata Viruses – Varicella-zoster virus (Haemorrhagic cystitis) – Adenovirus type 8 (Haemorrhagic cystitis in children) – Measles, mumps, CMV
  • Microbiology Special – Chlamydia trachmomatis – Mycoplasma hominis – Neisseria gonorrhoeae – Trichomonas vaginalis – Mycobacteria Diagnostic value – Typhoid salmonellae – Leptospira – Schistosoma
  • Laboratory Diagnosis Microscopic Examination of Urine – Pyuria  10 WBCs per HPF (centrifuged urine)  Sterile pyuria (acute urethritis, renal tuberculosis, foreign bodies, tumour of urinary tract, non-bacterial infections) – Bacteriuria  >105 CFU/ml – Stain (Gram, ZN and other)  1 bacterium per oil immersion= 105 CFU/ml – Microscopic exam of spun urine  Pus cells/WBCs  20 bacteria per oil immersion= 105 CFU/ml
  • Laboratory Diagnosis Urine Culture – Clean-catch urine specimen  Women (washing perineal area from front to back)  Men  Midstream collection  Other collections (suprapubic, from catheter) – Urine culture interpretation  Clean-catch urine  Straight catheter and suprapubic aspiration  Indwelling catheter  Limitations of urine culture – Transport time
  • Laboratory Diagnosis Routine culture – Estimation of bacterial count  Calibrated wire loop  Measured filter paper strips  Automated equipment – Culture media  CLED Agar  MacCONKEY Agar Special culture – Blood agar anaerobically with 5-10% CO2 (Mycoplasma) – Selenite F or TT broth – LJ Medium or Bactec B12 medium – Sabouraud agar
  • Laboratory Diagnosis Rapid diagnosis tests – Leukocytes esterase dipstick test (Pyuria) – Nephlometry – Bioluminescence – Colorimetric filtration system Blood culture Patients – Fever – History of rigors – Hospitalized
  • General Management Principles Nonspecific treatment – Hydration General principles of antimicrobial therapy – Choice of antimicrobial agent  Resistance to common antimicrobials  Dose modification in renal functional impairment and end stage renal disease  Oral and parenteral therapies – Duration of therapy
  • General Management Principles Determinants of antimicrobial therapy – Age and sex – Asymptomatic versus symptomatic bacteriuria – Localization of the site of infection  Invasive techniques  The noninvasive technique – Recurrent UTI  Reinfection  Relapse