The document discusses the normal microbial flora that inhabit healthy humans. It describes how the skin, mouth, intestines and other areas each have distinct resident and transient bacterial populations that protect against pathogens. The resident flora establishes itself and repopulates if disturbed, while the transient flora does not permanently colonize. These normal flora provide colonization resistance against infection and have important nutritional and protective functions. Figures show bacterial numbers by body site and mechanisms of pathogen competition.
Cholera is a serious bacterial disease that usually
causes severe diarrhea and dehydration. The disease is typically spread through contaminated water.
Modern sewage and water treatment have effectively eliminated cholera in most countries. It’s still a problem in countries like Asia, America and Africa. Mostly in India.
Countries affected by war, poverty, and natural disasters have the greatest risk for a cholera outbreak.
Taxonomy:
class : Gamma Proteobacteria
Order: Vibrionales
Family: Vibrionaceae
Genus: Vibrio
Species: v.cholerae, v.parahaemolyticus,
v. vulnificus, v. alginolyticus
MORPHOLOGY:
Gram negative, actively motile, short, rigid curved bacilli
Resembling letter “V”
about 34 genus
most common in water
1.5µ X 0.2 -0.4 µ in size
polar flagellum , strongly aerobic
Smear – fish in stream appearance
PATHOGENESIS:
Source: Ingestion of contaminated water, food,
fruits and vegetables etc.,
Incubation periods: 1-5 days
Symptoms: Watery diarrhoea, vomiting, thirst, dehydration, muscle cramps
Complications: muscular pain, renal failure, pulmonary edema, cardiac arrhythrnias
DIAGNOSIS:
Specimen: stool sample, water sample(envt)
Microscopy: a) Hanging drop : +ve
b) Gram stain :-ve
Culture: Mac conkey Agar :colourless to light pink
TCBS : yellow colonies
Serology: serological tests are no diagnostic value
TREATMENT:
Adequate replacement of fluids and electrolytes.
Oral tetracycline reduces the period of vibrio excreation.
PREVENTION:
Drink and use bottled water
Frequent washing
Sanitary environment
Defecate in water
Cook food thoroughly
Cholera is a serious bacterial disease that usually
causes severe diarrhea and dehydration. The disease is typically spread through contaminated water.
Modern sewage and water treatment have effectively eliminated cholera in most countries. It’s still a problem in countries like Asia, America and Africa. Mostly in India.
Countries affected by war, poverty, and natural disasters have the greatest risk for a cholera outbreak.
Taxonomy:
class : Gamma Proteobacteria
Order: Vibrionales
Family: Vibrionaceae
Genus: Vibrio
Species: v.cholerae, v.parahaemolyticus,
v. vulnificus, v. alginolyticus
MORPHOLOGY:
Gram negative, actively motile, short, rigid curved bacilli
Resembling letter “V”
about 34 genus
most common in water
1.5µ X 0.2 -0.4 µ in size
polar flagellum , strongly aerobic
Smear – fish in stream appearance
PATHOGENESIS:
Source: Ingestion of contaminated water, food,
fruits and vegetables etc.,
Incubation periods: 1-5 days
Symptoms: Watery diarrhoea, vomiting, thirst, dehydration, muscle cramps
Complications: muscular pain, renal failure, pulmonary edema, cardiac arrhythrnias
DIAGNOSIS:
Specimen: stool sample, water sample(envt)
Microscopy: a) Hanging drop : +ve
b) Gram stain :-ve
Culture: Mac conkey Agar :colourless to light pink
TCBS : yellow colonies
Serology: serological tests are no diagnostic value
TREATMENT:
Adequate replacement of fluids and electrolytes.
Oral tetracycline reduces the period of vibrio excreation.
PREVENTION:
Drink and use bottled water
Frequent washing
Sanitary environment
Defecate in water
Cook food thoroughly
Poxviruses are brick or oval-shaped viruses with large double-stranded DNA genomes. Poxviruses exist throughout the world and cause disease in humans and many other types of animals. Poxvirus infections typically result in the formation of lesions, skin nodules, or disseminated rash.
The human microbiome is the aggregate of all microbiota that reside on or within human tissues and biofluids along with the corresponding anatomical sites in which they reside, including the skin, mammary glands, placenta, seminal fluid, uterus, ovarian follicles, lung, saliva, oral mucosa, conjunctiva, biliary tract, etc
Poxviruses are brick or oval-shaped viruses with large double-stranded DNA genomes. Poxviruses exist throughout the world and cause disease in humans and many other types of animals. Poxvirus infections typically result in the formation of lesions, skin nodules, or disseminated rash.
The human microbiome is the aggregate of all microbiota that reside on or within human tissues and biofluids along with the corresponding anatomical sites in which they reside, including the skin, mammary glands, placenta, seminal fluid, uterus, ovarian follicles, lung, saliva, oral mucosa, conjunctiva, biliary tract, etc
Normal flora is the term used to describe the various bacteria and fungi that are permanent residents of certain
body sites, especially the skin, oropharynx, colon, and
vagina (Tables 6–1 and 6–2). Viruses and parasites (protozoa
and helminths), which are the other major groups of
microorganisms, are usually not considered members of
the normal flora, although they can be present in asymptomatic individuals. The normal flora organisms are often
referred to as commensals. Commensals are organisms
that derive benefit from another host but do not damage
that host. The term human microbiome is often used to
describe the normal flora.
The members of the normal flora play a role both in the
maintenance of health and in the causation of disease in
three significant ways:
(1) They can cause disease, especially in immunocompromised and debilitated individuals. Although these
organisms are nonpathogens in their usual anatomic location, they can be pathogens in other parts of the body.
(2) They constitute a protective host defense mechanism.
The nonpathogenic resident bacteria occupy attachment
sites on the skin and mucosa that can interfere with colonization by pathogenic bacteria. The ability of members of the
normal flora to limit the growth of pathogens is called colonization resistance. If the normal flora is suppressed, pathogens may grow and cause disease. For example, antibiotics
can reduce the normal colonic flora that allows Clostridium
difficile, which is resistant to the antibiotics, to overgrow and
cause pseudomembranous colitis.
(3) They may serve a nutritional function. The intestinal bacteria produce several B vitamins and vitamin K.
Poorly nourished people who are treated with oral antibiotics can have vitamin deficiencies as a result of the reduction in the normal flora. However, since germ-free animals
are well-nourished, the normal flora is not essential for
proper nutrition.
THE HUMAN MICROBIOME
The human microbiome is the term used to describe the
thousands of microbes (“microbiota”) located on the skin,
on mucosal surfaces, and within the lumen of the
TABLE 6–2 Medically Important Members of the Normal Flora
Location Important Organisms1 Less Important Organisms2
Skin Staphylococcus epidermidis Staphylococcus aureus, Corynebacterium (diphtheroids), various streptococci,
Pseudomonas aeruginosa, anaerobes (e.g., Propionibacterium), yeasts (e.g.,
Candida albicans)
Nose S. aureus3 S. epidermidis, Corynebacterium (diphtheroids), various streptococci
Mouth Viridans streptococci Various streptococci, Eikenella corrodens
Dental plaque Streptococcus mutans Prevotella intermedia, Porphyromonas gingivalis
Gingival crevices Various anaerobes (e.g.,
Bacteroides, Fusobacterium,
streptococci, Actinomyces)
Throat Viridans streptococci Various streptococci (including Streptococcus pyogenes and Streptococcus
pneumoniae), Neisseria species, Haemophilus influenzae, S. epidermidis
Colon Bacteroides fragilis, Escherichia
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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2. The term "normal microbial flora" denotes the population
of microorganisms that inhabit the skin and mucous
membranes of healthy normal persons
3. The skin and mucous membranes always harbor a
variety of microorganisms that can be arranged into two
groups:
(1) The resident flora consists of relatively fixed types of
microorganisms regularly found in a given area at a
given age; if disturbed, it promptly reestablishes itself.
(2) The transient flora consists of nonpathogenic or
potentially pathogenic microorganisms that inhabit the
skin or mucous membranes for hours, days, or weeks; it
is derived from the environment, does not produce
disease, and does not establish itself permanently on
the surface.
4. Members of the transient flora are generally of little
significance so long as the normal resident flora
remains intact. However, if the resident flora is
disturbed, transient microorganisms may colonize,
proliferate, and produce disease.
5. FIGURE: Numbers of bacteria that colonize different parts of the body. Numbers
represent the number of organisms per gram of homogenized tissue or fluid or per
square centimeter of skin surface.
6. Significance of the Normal Flora
Can cause infection
- misplaced, e.g., fecal flora to urinary tract or abdominal
cavity, or skin flora to catheter
- or, if person becomes compromised, normal flora may
overgrow (oral thrush) .
Contributes to health
- protective host defense by maintaining conditions such as
pH so other organisms may not grow
- Produce antimicrobial substances against pathogens
- Compete for attachment and nutrient with pathogenic bacteria
- serve nutritional function by synthesizing: vitamin K and B
vitamins
8. FIGURE (A) : Scanning
electron micrograph of a cross-
section of rat colonic mucosa.
The bar indicates the thick layer
of bacteria between the
mucosal surface and the lumen
(L)
9. FIGURE: (B) Higher magnification of the
area indicated by the arrow in Fig. A,
showing a mass of bacteria (B)
immediately adjacent to colonized
intestinal tissue (T), (X2,624.)
10. Normal Flora of the Skin
Because of its constant exposure to and contact with the
environment, the skin is particularly apt to contain
transient microorganisms. Nevertheless, there is a
constant and well-defined resident flora, modified in
different anatomic areas by secretions, habitual wearing
of clothing, or proximity to mucous membranes (mouth,
nose, and perineal areas).
11. The predominant resident microorganisms of the skin
are:
- aerobic and anaerobic diphtheroid bacilli (eg,
corynebacterium,propionibacterium);
- Nonhemolytic aerobic and anaerobic staphylococci
(Staphylococcus epidermidis and other coagulase-
negative staphylococci, occasionally S aureus, and
Peptostreptococcus species);
12. - gram-positive, aerobic, spore-forming bacilli that are
ubiquitous in air, water, and soil; alpha-hemolytic
streptococci (viridans streptococci) and enterococci
(Enterococcus species); and gram-negative coliform
bacilli and acinetobacter.
- Fungi and yeasts are often present in skin folds; acid-
fast, nonpathogenic mycobacteria occur in areas rich in
sebaceous secretions (genitalia, external ear).
13. Among the factors that may be important in eliminating
nonresident microorganisms from the skin are the low
pH, the fatty acids in sebaceous secretions, and the
presence of lysozyme.
Neither profuse sweating nor washing and bathing can
eliminate or significantly modify the normal resident flora.
Placement of an occlusive dressing on skin tends to
result in a large increase in the total microbial population
and may also produce qualitative alterations in the flora.
14. Anaerobes and aerobic bacteria often join to form
synergistic infections (gangrene, necrotizing fasciitis,
cellulitis) of skin and soft tissues. The bacteria are
frequently part of the normal microbial flora. It is usually
difficult to pinpoint one specific organism as being
responsible for the progressive lesion, since mixtures of
organisms are usually involved.
15. Normal Flora of the Mouth & Upper
Respiratory Tract
The flora of the nose consists of prominent
corynebacteria, staphylococci (S epidermidis, S aureus),
and streptococci.
The mucous membranes of the mouth and pharynx are
often sterile at birth but may be contaminated by
passage through the birth canal. Within 4–12 hours after
birth, viridans streptococci become established as the
most prominent members of the resident flora and
remain so for life. They probably originate in the
respiratory tracts of the mother and attendants.
16. Early in life, aerobic and anaerobic staphylococci, gram-
negative diplococci (neisseriae, Moraxella catarrhalis),
diphtheroids, and occasional lactobacilli are added.
When teeth begin to erupt, the anaerobic spirochetes,
Prevotella species (especially P melaninogenica),
Fusobacterium species, Rothia species, and
Capnocytophaga species establish themselves, along
with some anaerobic vibrios and lactobacilli.
Actinomyces species are normally present in tonsillar
tissue and on the gingivae in adults, and various
protozoa may also be present. Yeasts (Candida species)
occur in the mouth.
17. In the pharynx and trachea, a similar flora establishes
itself, whereas few bacteria are found in normal bronchi.
Small bronchi and alveoli are normally sterile. The
predominant organisms in the upper respiratory tract,
particularly the pharynx, are nonhemolytic and alpha-
hemolytic streptococci and neisseriae. Staphylococci,
diphtheroids, haemophili, pneumococci, mycoplasmas,
and prevotellae are also encountered.
18. Infections of the mouth and respiratory tract are usually
caused by mixed oronasal flora, including anaerobes.
Periodontal infections, perioral abscesses, sinusitis, and
mastoiditis may involve predominantly Prevotella
melaninogenica, fusobacteria, and peptostreptococci.
Aspiration of saliva (containing up to 102
of these
organisms and aerobes) may result in necrotizing
pneumonia, lung abscess, and empyema.
19. Normal Flora of the Intestinal Tract
At birth the intestine is sterile, but organisms are soon
introduced with food.
In breast-fed children, the intestine contains large
numbers of lactic acid streptococci and lactobacilli.
These aerobic and anaerobic, gram-positive, nonmotile
organisms (eg, Bifidobacterium species) produce acid
from carbohydrates and tolerate pH 5.0.
20. In bottle-fed children, a more mixed flora exists in the
bowel, and lactobacilli are less prominent. As food habits
develop toward the adult pattern, the bowel flora
changes.
Diet has a marked influence on the relative composition
of the intestinal and fecal flora. Bowels of newborns in
intensive care nurseries tend to be colonized by
Enterobacteriaceae, eg, klebsiella, citrobacter, and
enterobacter.
21. In the normal adult, the esophagus contains
microorganisms arriving with saliva and food.
The stomach's acidity keeps the number of
microorganisms at a minimum (103
–105
/g of contents)
unless obstruction at the pylorus favors the proliferation
of gram-positive cocci and bacilli.
The normal acid pH of the stomach markedly protects
against infection with some enteric pathogens, eg,
cholera.
As the pH of intestinal contents becomes alkaline, the
resident flora gradually increases.
22. In the adult duodenum, there are 103
–106
bacteria per
gram of contents;
In the jejunum and ileum, 105
–108
bacteria per gram;
In the cecum and transverse colon, 108
–1010
bacteria per
gram.
In the upper intestine, lactobacilli and enterococci
predominate, but in the lower ileum and cecum, the flora
is fecal.
23. In the sigmoid colon and rectum, there are about 1011
bacteria per gram of contents, constituting 10–30% of
the fecal mass.
Anaerobes outnumber facultative organisms by 1000-
fold.
In diarrhea, the bacterial content may diminish greatly,
whereas in intestinal stasis the count rises.
24. In the normal adult colon, 96–99% of the resident
bacterial flora consists of anaerobes: Bacteroides
species, especially B fragilis; Fusobacterium species;
anaerobic lactobacilli, eg, bifidobacteria; clostridia (C
perfringens, 103
–105
/g); and anaerobic gram-positive
cocci (Peptostreptococcus species).
Only 1–4% are facultative aerobes (gram-negative
coliform bacteria, enterococci, and small numbers of
protei, pseudomonads, lactobacilli, candidae, and other
organisms).
25. Intestinal bacteria are important in synthesis of vitamin
K, conversion of bile pigments and bile acids, absorption
of nutrients and breakdown products, and antagonism to
microbial pathogens.
The intestinal flora produces ammonia and other
breakdown products that are absorbed and can
contribute to hepatic coma.
Among aerobic coliform bacteria, only a few serotypes
persist in the colon for prolonged periods, and most
serotypes of Escherichia coli are present only over a
period of a few days.
26. Antimicrobial drugs taken orally can, in humans,
temporarily suppress the drug-susceptible components
of the fecal flora. This is commonly done by the
preoperative oral administration of insoluble drugs.
- For example, neomycin plus erythromycin can in 1–2
days suppress part of the bowel flora, especially
aerobes. Metronidazole accomplishes that for
anaerobes.
27. The feeding of large quantities of Lactobacillus
acidophilus may result in the temporary establishment of
this organism in the gut and the concomitant partial
suppression of other gut microflora.
The anaerobic flora of the colon, including B fragilis,
clostridia, and peptostreptococci, plays a main role in
abscess formation originating in perforation of the bowel.
Prevotella bivia and P disiens are important in
abscesses of the pelvis originating in the female genital
organs.
28. Normal Flora of the Urethra
The anterior urethra of both sexes contains small
numbers of the same types of organisms found on the
skin and perineum. These organisms regularly appear in
normal voided urine in numbers of 102
–104
/mL.
29. Normal Flora of the Vagina
Soon after birth, aerobic lactobacilli appear in the vagina and
persist as long as the pH remains acid (several weeks).
When the pH becomes neutral (remaining so until puberty), a
mixed flora of cocci and bacilli is present.
At puberty, aerobic and anaerobic lactobacilli reappear in large
numbers and contribute to the maintenance of acid pH through
the production of acid from carbohydrates, particularly
glycogen.
This appears to be an important mechanism in preventing the
establishment of other, possibly harmful microorganisms in the vagina.
30. - If lactobacilli are suppressed by the administration of
antimicrobial drugs, yeasts or various bacteria increase
in numbers and cause irritation and inflammation.
31. After menopause, lactobacilli again diminish in number
and a mixed flora returns.
The normal vaginal flora includes group B streptococci in
as many as 25% of women of childbearing age.
During the birth process, a baby can acquire group B
streptococci, which subsequently may cause neonatal
sepsis and meningitis.
32. The normal vaginal flora often includes also alpha
hemolytic streptococci, anaerobic streptococci
(peptostreptococci), Prevotella species, clostridia,
Gardnerella vaginalis, Ureaplasma urealyticum, and
sometimes listeria or Mobiluncus species.
The cervical mucus has antibacterial activity and
contains lysozyme.
33. Normal Flora of the Conjunctiva
The predominant organisms of the conjunctiva are
diphtheroids, S epidermidis, and nonhemolytic
streptococci.
Neisseriae and gram-negative bacilli resembling
haemophili (Moraxella species) are also frequently
present.
The conjunctival flora is normally held in check by the
flow of tears, which contain antibacterial lysozyme.
Editor's Notes
A diverse microbial flora is associated with the skin and mucous membranes of every
human being from shortly after birth until death. The human body, which contains about
1013 cells, routinely harbors about 1014 bacteria (Fig.). This bacterial population
constitutes the normal microbial flora. The normal microbial flora is relatively stable,
with specific genera populating various body regions during particular periods in an
individual's life. Microorganisms of the normal flora may aid the host (by competing for
microenvironments more effectively than such pathogens as Salmonella spp or by
producing nutrients the host can use), may harm the host (by causing dental caries,
abscesses, or other infectious diseases), or may exist as commensals (inhabiting the host
for long periods without causing detectable harm or benefit). Even though most elements
of the normal microbial flora inhabiting the human skin, nails, eyes, oropharynx,
genitalia, and gastrointestinal tract are harmless in healthy individuals, these organisms
frequently cause disease in compromised hosts. Viruses and parasites are not considered
members of the normal microbial flora by most investigators because they are not
commensals and do not aid the host.
Significance of the Normal Flora
The fact that the normal flora substantially influences the well-being of the host was not
well understood until germ-free animals became available. Germ-free animals were
obtained by cesarean section and maintained in special isolators; this allowed the
investigator to raise them in an environment free from detectable viruses, bacteria, and
other organisms. Two interesting observations were made about animals raised under
germ-free conditions. First, the germ-free animals lived almost twice as long as their
conventionally maintained counterparts, and second, the major causes of death were
different in the two groups. Infection often caused death in conventional animals, but
intestinal atonia frequently killed germ-free animals. Other investigations showed that
germ-free animals have anatomic, physiologic, and immunologic features not shared with
conventional animals. For example, in germ-free animals, the alimentary lamina propria
is underdeveloped, little or no immunoglobulin is present in sera or secretions, intestinal
motility is reduced, and the intestinal epithelial cell renewal rate is approximately onehalf
that of normal animals (4 rather than 2 days).
The microorganisms that are constantly present on body surfaces are commensals. Their flourishing in a given area depends upon physiologic factors of temperature, moisture, and the presence of certain nutrients and inhibitory substances. Their presence is not essential to life, because "germ-free" animals can be reared in the complete absence of a normal microbial flora. Yet the resident flora of certain areas plays a definite role in maintaining health and normal function. Members of the resident flora in the intestinal tract synthesize vitamin K and aid in the absorption of nutrients. On mucous membranes and skin, the resident flora may prevent colonization by pathogens and possible disease through "bacterial interference." The mechanism of bacterial interference may involve competition for receptors or binding sites on host cells, competition for nutrients, mutual inhibition by metabolic or toxic products, mutual inhibition by antibiotic materials or bacteriocins, or other mechanisms. Suppression of the normal flora clearly creates a partial local void that tends to be filled by organisms from the environment or from other parts of the body. Such organisms behave as opportunists and may become pathogens.
On the other hand, members of the normal flora may themselves produce disease under certain circumstances. These organisms are adapted to the noninvasive mode of life defined by the limitations of the environment. If forcefully removed from the restrictions of that environment and introduced into the bloodstream or tissues, these organisms may become pathogenic. For example, streptococci of the viridans group are the most common resident organisms of the upper respiratory tract. If large numbers of them are introduced into the bloodstream (eg, following tooth extraction or tonsillectomy), they may settle on deformed or prosthetic heart valves and produce infective endocarditis. Small numbers occur transiently in the bloodstream with minor trauma (eg, dental scaling or vigorous brushing). Bacteroides species are the most common resident bacteria of the large intestine and are quite harmless in that location. If introduced into the free peritoneal cavity or into pelvic tissues along with other bacteria as a result of trauma, they cause suppuration and bacteremia. There are many other examples, but the important point is that microbes of the normal resident flora are harmless and may be beneficial in their normal location in the host and in the absence of coincident abnormalities. They may produce disease if introduced into foreign locations in large numbers and if predisposing factors are present.
Normal Flora of Skin
Skin provides good examples of various microenvironments. Skin regions have been
compared to geographic regions of Earth: the desert of the forearm, the cool woods of the
scalp, and the tropical forest of the armpit. The composition of the dermal microflora
varies from site to site according to the character of the microenvironment. A different
bacterial flora characterizes each of three regions of skin: (1) axilla, perineum, and toe
webs; (2) hand, face and trunk; and (3) upper arms and legs. Skin sites with partial
occlusion (axilla, perineum, and toe webs) harbor more microorganisms than do less
occluded areas (legs, arms, and trunk). These quantitative differences may relate to
increased amount of moisture, higher body temperature, and greater concentrations of
skin surface lipids. The axilla, perineum, and toe webs are more frequently colonized by
Gram-negative bacilli than are drier areas of the skin.
The number of bacteria on an individual's skin remains relatively constant; bacterial
survival and the extent of colonization probably depend partly on the exposure of skin to
a particular environment and partly on the innate and species-specific bactericidal activity
in skin. Also, a high degree of specificity is involved in the adherence of bacteria to
epithelial surfaces. Not all bacteria attach to skin; staphylococci, which are the major
element of the nasal flora, possess a distinct advantage over viridans streptococci in
colonizing the nasal mucosa. Conversely, viridans streptococci are not seen in large
numbers on the skin or in the nose but dominate the oral flora.
The microbiology literature is inconsistent about the density of bacteria on the skin; one
reason for this is the variety of methods used to collect skin bacteria. The scrub method
yields the highest and most accurate counts for a given skin area. Most microorganisms
live in the superficial layers of the stratum corneum and in the upper parts of the hair
follicles. Some bacteria, however, reside in the deeper areas of the hair follicles and are
beyond the reach of ordinary disinfection procedures. These bacteria are a reservoir for
recolonization after the surface bacteria are removed.
Staphylococcus epidermidis
S epidermidis is a major inhabitant of the skin, and in some areas it makes up more than
90 percent of the resident aerobic flora.
Staphylococcus aureus
The nose and perineum are the most common sites for S aureus colonization, which is
present in 10 percent to more than 40 percent of normal adults. S aureus is prevalent (67
percent) on vulvar skin. Its occurrence in the nasal passages varies with age, being greater
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in the newborn, less in adults. S aureus is extremely common (80 to 100 percent) on the
skin of patients with certain dermatologic diseases such as atopic dermatitis, but the
reason for this finding is unclear.
Micrococci
Micrococci are not as common as staphylococci and diphtheroids; however, they are
frequently present on normal skin. Micrococcus luteus, the predominant species, usually
accounts for 20 to 80 percent of the micrococci isolated from the skin.
Diphtheroids (Coryneforms)
The term diphtheroid denotes a wide range of bacteria belonging to the genus
Corynebacterium. Classification of diphtheroids remains unsatisfactory; for convenience,
cutaneous diphtheroids have been categorized into the following four groups: lipophilic
or nonlipophilic diphtheroids; anaerobic diphtheroids; diphtheroids producing porphyrins
(coral red fluorescence when viewed under ultraviolet light); and those that possess some
keratinolytic enzymes and are associated with trichomycosis axillaris (infection of
axillary hair). Lipophilic diphtheroids are extremely common in the axilla, whereas
nonlipophilic strains are found more commonly on glabrous skin.
Anaerobic diphtheroids are most common in areas rich in sebaceous glands. Although the
name Corynebacterium acnes was originally used to describe skin anaerobic
diphtheroids, these are now classified as Propionibacterium acnes and as P granulosum. P
acnes is seen eight times more frequently than P granulosum in acne lesions and is
probably involved in acne pathogenesis. Children younger than 10 years are rarely
colonized with P acnes. The appearance of this organism on the skin is probably related
to the onset of secretion of sebum (a semi-fluid substance composed of fatty acids and
epithelial debris secreted from sebaceous glands) at puberty. P avidum, the third species
of cutaneous anaerobic diphtheroids, is rare in acne lesions and is more often isolated
from the axilla.
Streptococci
Streptococci, especially ß-hemolytic streptococci, are rarely seen on normal skin. The
paucity of ß-hemolytic streptococci on the skin is attributed at least in part to the presence
of lipids on the skin, as these lipids are lethal to streptococci. Other groups of
streptococci, such as a-hemolytic streptococci, exist primarily in the mouth, from where
they may, in rare instances, spread to the skin.
Gram-Negative Bacilli
Gram-negative bacteria make up a small proportion of the skin flora. In view of their
extraordinary numbers in the gut and in the natural environment, their scarcity on skin is
striking. They are seen in moist intertriginous areas, such as the toe webs and axilla, and
not on dry skin. Desiccation is the major factor preventing the multiplication of Gram131
negative bacteria on intact skin. Enterobacter, Klebsiella, Escherichia coli, and Proteus
spp are the predominant Gram-negative organisms found on the skin. Acinetobacter spp
also occurs on the skin of normal individuals and, like other Gram-negative bacteria, is
more common in the moist intertriginous areas.
Nail Flora
The microbiology of a normal nail is generally similar to that of the skin. Dust particles
and other extraneous materials may get trapped under the nail, depending on what the
nail contacts. In addition to resident skin flora, these dust particles may carry fungi and
bacilli. Aspergillus, Penicillium, Cladosporium, and Mucor are the major types of fungi
found under the nails.
The number of superficial microorganisms may be diminished by vigorous daily scrubbing with soap containing hexachlorophene or other disinfectants, but the flora is rapidly replenished from sebaceous and sweat glands even when contact with other skin areas or with the environment is completely excluded.
The Role of the Normal Mouth Flora in Dental Caries
Caries is a disintegration of the teeth beginning at the surface and progressing inward. First the surface enamel, which is entirely noncellular, is demineralized. This has been attributed to the effect of acid products of bacterial fermentation. Subsequent decomposition of the dentin and cement involves bacterial digestion of the protein matrix.
An essential first step in caries production appears to be the formation of plaque on the hard, smooth enamel surface. The plaque consists mainly of gelatinous deposits of high-molecular-weight glucans in which acid-producing bacteria adhere to the enamel. The carbohydrate polymers (glucans) are produced mainly by streptococci (Streptococcus mutans, peptostreptococci), perhaps in association with actinomycetes. There appears to be a strong correlation between the presence of S mutans and caries on specific enamel areas. The essential second step in caries production appears to be the formation of large amounts of acid (pH < 5.0) from carbohydrates by streptococci and lactobacilli in the plaque. High concentrations of acid demineralize the adjoining enamel and initiate caries.
In experimental "germ-free" animals, cariogenic streptococci can induce the formation of plaque and caries. Adherence to smooth surfaces requires both the synthesis of water-insoluble glucan polymers by glucosyltransferases and the participation of binding sites on the surface of microbial cells. (Perhaps carbohydrate polymers also aid the attachment of some streptococci to endocardial surfaces.) Other members of the oral microflora, eg, veillonellae, may complex with glucosyltransferase of Streptococcus salivarius in saliva and then synthesize water-insoluble carbohydrate polymers to adhere to tooth surfaces. Adherence may be initiated by salivary IgA antibody to S mutans. Certain diphtheroids and streptococci that produce levans can induce specific soft tissue damage and bone resorption typical of periodontal disease. Proteolytic organisms, including actinomycetes and bacilli, play a role in the microbial action on dentin that follows damage to the enamel. The development of caries also depends on genetic, hormonal, nutritional, and many other factors. Control of caries involves physical removal of plaque, limitation of sucrose intake, good nutrition with adequate protein intake, and reduction of acid production in the mouth by limitation of available carbohydrates and frequent cleansing. The application of fluoride to teeth or its ingestion in water results in enhancement of acid resistance of the enamel. Control of periodontal disease requires removal of calculus (calcified deposit) and good mouth hygiene.
Periodontal pockets in the gingiva are particularly rich sources of organisms, including anaerobes, that are rarely encountered elsewhere. While they may participate in periodontal disease and tissue destruction, attention is drawn to them when they are implanted elsewhere, eg, producing infective endocarditis or bacteremia in a granulopenic host. Examples are Capnocytophaga species and Rothia dentocariosa. Capnocytophaga species are fusiform, gram-negative, gliding anaerobes; Rothia species are pleomorphic, aerobic, gram-positive rods. Both probably participate in the complex microbial flora of periodontal disease with prominent bone destruction. In granulopenic immunodeficient patients, they can lead to serious opportunistic lesions in other organs.
Gastrointestinal Tract Flora
The stomach is a relatively hostile environment for bacteria. It contains bacteria
swallowed with the food and those dislodged from the mouth. Acidity lowers the
bacterial count, which is highest (approximately 103 to 106 organisms/g of contents) after
meals and lowest (frequently undetectable) after digestion. Some Helicobacter species
can colonize the stomach and are associated with type B gastritis and peptic ulcer disease.
Aspirates of duodenal or jejunal fluid contain approximately 103 organisms/ml in most
individuals. Most of the bacteria cultured (streptococci, lactobacilli, Bacteroides) are
thought to be transients. Levels of 105 to about 107 bacteria/ml in such aspirates usually
indicate an abnormality in the digestive system (for example, achlorhydria or
malabsorption syndrome). Rapid peristalsis and the presence of bile may explain in part
the paucity of organisms in the upper gastrointestinal tract. Further along the jejunum and
into the ileum, bacterial populations begin to increase, and at the ileocecal junction they
reach levels of 106 to 108 organisms/ml, with streptococci, lactobacilli, Bacteroides, and
bifidobacteria predominating.
Concentrations of 109 to 1011 bacteria/g of contents are frequently found in human colon
and feces. This flora includes a bewildering array of bacteria (more than 400 species have
been identified); nonetheless, 95 to 99 percent belong to anaerobic genera such as
Bacteroides, Bifidobacterium, Eubacterium, Peptostreptococcus, and Clostridium. In this
highly anaerobic region of the intestine, these genera proliferate, occupy most available
niches, and produce metabolic waste products such as acetic, butyric, and lactic acids.
The strict anaerobic conditions, physical exclusion (as is shown in many animal studies),
and bacterial waste products are factors that inhibit the growth of other bacteria in the
large bowel.
Although the normal flora can inhibit pathogens, many of its members can produce
disease in humans. Anaerobes in the intestinal tract are the primary agents of intraabdominal
abscesses and peritonitis. Bowel perforations produced by appendicitis,
cancer, infarction, surgery, or gunshot wounds almost always seed the peritoneal cavity
and adjacent organs with the normal flora. Anaerobes can also cause problems within the
gastrointestinal lumen. Treatment with antibiotics may allow certain anaerobic species to
become predominant and cause disease. For example, Clostridium difficile, which can
remain viable in a patient undergoing antimicrobial therapy, may produce
pseudomembranous colitis. Other intestinal pathologic conditions or surgery can cause
bacterial overgrowth in the upper small intestine. Anaerobic bacteria can then
deconjugate bile acids in this region and bind available vitamin B12 so that the vitamin
and fats are malabsorbed. In these situations, the patient usually has been compromised in
some way; therefore, the infection caused by the normal intestinal flora is secondary to
another problem.
More information is available on the animal than the human microflora. Research on
animals has revealed that unusual filamentous microorganisms attach to ileal epithelial
cells and modify host membranes with few or no harmful effects. Microorganisms have
been observed in thick layers on gastrointestinal surfaces (Fig. 6-3) and in the crypts of
Lieberkuhn. Other studies indicate that the immune response can be modulated by the
intestinal flora. Studies of the role of the intestinal flora in biosynthesis of vitamin K and
other host-utilizable products, conversion of bile acids (perhaps to cocarcinogens), and
ammonia production (which can play a role in hepatic coma) show the dual role of the
microbial flora in influencing the health of the host. More basic studies of the human
bowel flora are necessary to define their effect on humans.
Administration of cimetidine for peptic ulcer leads to a great increase in microbial flora of the stomach, including many organisms usually prevalent in feces.
More than 100 distinct types of organisms, which can be cultured routinely in the laboratory, occur regularly in normal fecal flora. There probably are more than 500 species of bacteria in the colon including many that are likely unidentified. Minor trauma (eg, sigmoidoscopy, barium enema) may induce transient bacteremia in about 10% of procedures.
If lower bowel surgery is performed when the counts are at their lowest, some protection against infection by accidental spill can be achieved. However, soon thereafter the counts of fecal flora rise again to normal or higher than normal levels, principally of organisms selected out because of relative resistance to the drugs employed. The drug-susceptible microorganisms are replaced by drug-resistant ones, particularly staphylococci, enterobacters, enterococci, protei, pseudomonads, Clostridium difficile, and yeasts.
In some women, the vaginal introitus contains a heavy flora resembling that of the perineum and perianal area. This may be a predisposing factor in recurrent urinary tract infections. Vaginal organisms present at time of delivery may infect the newborn (eg, group B streptococci).
Conjunctival Flora
The conjunctival flora is sparse. Approximately 17 to 49 percent of culture samples are
negative. Lysozyme, secreted in tears, may play a role in controlling the bacteria by
interfering with their cell wall formation. When positive samples show bacteria,
corynebacteria, neisseriae, and moraxellae are cultured. Staphylococci and streptococci
are also present, and recent reports indicate that Haemophilus parainfluenzae is present in
25 percent of conjunctival samples.