The Story of Your Life

Normal Flora/ Bacterial

at oge es s / V
Virulence
u e ce
Pathogenesis
Factors

You are born

You become colonized with bacteria
You live
You die
The bacteria recycle you

Normal Flora
microorganisms found in particular sites in
normal, healthy individuals
they do not cause disease (usually)
1014 bacteria; most are anaerobes
certain yeasts may be part of normal flora; viruses
and parasites are always considered pathogens
constituents and numbers vary by body site, age,
when antibiotics are given, with disruption of
anatomic or physiologic function

Normal Flora
Resident / Commensal Flora: present invariably
in a particular site; generally benefit or
have neutral relationship with the host
Transient Flora: found briefly or intermittently
at a body site but generally eliminated
by competition from resident flora or by
hosts immune defenses
Carrier State: potential pathogen is found in
normal healthy host; may or may not
result in disease

Role of Normal Flora

A. Help to prevent infection with
amount of mucus you have depends
pathogenic organisms: the
on bacteria
occupation of binding sites
stimulate mucin secretion
secretion of noxious substances
especially if the substances can be harmful to another bacteria
B. Stimulation of immune system
we have immune diseases because current environments are too clean
C. Nutrient source for the host
help break down food, provide cofactors and vitamins that we don't make
D. Stimulation of epithelial turnover
ex) in bladder
- issues arise when turnover is too low

Normal Flora As Pathogens

A.

Opportunistic Infections:
immunocompromised state
broad spectrum antibiotics suppresses
antibacterial therapy -normal
bacteria in your body, will
cause high fungal infections
puncture
penetrating
trauma
wound that introduces outside bacteria inside

B.

Tissue Invasion:
eg. Streptococcus mutans and dental caries
- bacteria in your mouth produces parasitic agents

Normal Flora As Pathogens

C.

Bacterial Translocation (passage of bacteria

from the gastrointestinal tract, through the
epithelial mucosa and into the circulation):
i) Predisposing factors:
ischemia
i h i off g.i.
i circulation
i l ti
altered normal flora of g.i. tract
slowed intestinal transit
prematurity of neonate

Anatomic Location of Normal Flora

A.
Skin
104 - 105 organisms /cm2 of skin (higher in hair
follicles) highest in hair follicles because there is moisture, oil, nutrients
Distribution- greater numbers in moist areas
Type

- if there is an artery blockage in your GI tract, that section will die, then the
bacteria that was there will start coming through -> BAD!!
- taking antibiotics kill off the normal flora, will let through bugs that are more
dangerous
- slowed transit -> GI tract can't push things through, bacteria stays, grows and
goes after the GI lining, and Gram (-) bacteria may cause bacterial blood infections
- neonates don't have immune systems that can keep bacteria under control yet

Anatomic Location of Normal Flora

B. Oral cavity and upper respiratory tract
- streptococci, staphlococci are present if you have teeth
i) Oral Cavity in your mouth
- teeth are what keep Gram+ bacteria around
varies with age, teeth
eg. neonates - lactobacillus (vaginal delivery) or gram
negative bacilli (C
(C-section
section, bottle fed); children gram positive and anaerobic bacteria; elderly - gram
- acquire lactobacillus via natural birth, but not C section
negative bacilli - gram (-) grows quickly
- children: gram (+) shows up because you have teeth
- elderly: back to gram (-) because less teeth

ii) Upper Respiratory Tract

Nose - S. aureus and S. epidermidis in anterior nares
gram + in back of nose

- primarily Gram positive organisms

eg. S. epidermidis 85 - 100%
S. aureus 5 - 25%
Propionibacterium 45 - 100%
- elderly, yeast replace gram positives

drier than inside the body,

more harsh environments are
suitable for Gram (+)

skin dies out, less nutritious for bacteria, so

yeast takes over

Anatomic Location of Normal Flora

C.

Gastrointestinal tract
- everytime you swallow, bacteria goes down into
stomach
i)
Esophagus - transient mouth flora
- killing bacteria is good because
ii) Stomach - 103 bacteria; >99% there is less competition for the
nutrients you eat
killed by acid
- neutralized, start to break up
iii) Small intestine - scant bacteria food, provide nutrients for bacteria
to eat
iv) Colon - 1011 organisms / gram
of feces, more than any
other site - >90%
are
- here there is digested food, so huge number
of bacteria
anaerobes - most are anaerobes, not much oxygen in the
colon, and what little is there is used by
bacteria for the digestion process

Anatomic Location of Normal Flora

D. Urogenital Tract
bacteria may enter the first
1 cm
i) Urethra
- sterile after lst cm distally
- mostly gram-positive
- due to Gram+
bacteria ((103 - 104) contamination from
skin
ii) Vagina
- Lactobacilli (premenopausal) - maintains
acid environment (pH 4 to 5)
- Gram-negative bacilli
(post-menopausal)
- at puberty, female bodies start producing estrogen
- estrogen causes the epithelial cells of the vaginal to secrete glycogen
- glycogen can be used by lots of bacteria, but lactobacilli use it best
- will produce acids, lowering environmental pH to 4 or 5,
and other bacteria can't survive in this environment
- female body therefore encourages the growth of lactobacilli to keep other
bacteria out -> gate keeping method
- post menopause = no more estrogen, lactobacilli goes away and Gram- shows up

Host Defenses Against Infection

and Disease
- if immune system is functional, it should be able to keep most pathogens
away

2 mechanisms of protection:
Non-specific (innate) defenses ex) fever, tears
Acquired Specific defenses
- Antibody mediated or Cell mediated
1) making antibodies
2) immune cells hunt down infections

- skin: barrier, defense keeping things out

- phagocytes: eating bad cells
- natural killer cells: excrete things to kill pathogens
- fever: bacteria cells operate at lower range, so fevers kill infection
- interferons: cells excrete these warning signals regarding virus
- complement: proteins self assemble
Fever:
- best indication of infections
- fever of unknown origins: probably has a infection, can't figure out what's happened
- immune system controls your body temperature carefully via cytokines (signals between body cells)
- increased temperature: your cells are at slight disadvantage, but bacteria are at even
more of a disadvantage

Non-Specific Host Defense Mechanisms

Local

Systemic

Physical integrity of skin / mucosae

Lysozyme (tears, saliva, sweat, others)
Low pH (stomach, vagina)
Mucus secretions (Resp. tract, Intestine)
Intestinal motility
Flushing effect (tears, urine, etc.)
Competition by normal flora
Ciliated epithelium

Fever
Interferon
production
Phagocytosis
Natural killer cells

Local
- skin: intact skin keeps bacteria away
- lysozymes: dissolves bacteria
- low pH: ex) stomach
- mucus secretions: mucus produced as sheet and is moved along
- intestinal motility: by the time bacteria overgrows, mostly it's been moved out
- flushing: urinary tract always at risk of being infected but you remove it by peeing
- competition:
- ciliated epithelium: grows with mucus secretions, epithelium pushes the mucus along

Non-Specific Systemic Mechanisms of

Defense
iii)

Phagocytosis - 2 major cell types:

polymorphonuclear
leukocytes (neutrophil, pus
cells)) and macrophages
cells

- macrophages come from monocytes, goes around engulfing things

- neutrophils

iv)

Natural killer cells - eliminate cells

infected by viruses or
intracellular bacteria
natural killer cells go around and touch cells to check surface and
find out whether or not it's been infected and put on signaling molecules
- if there are a lot of these signals, the NK cell will kill that cell

- antibodies will bind directly to the pathogen

- if there are lots of antibodies bound, the immune system will react
- this attracts cytotoxic T cells that gobble things up
- antibodies stuck to surface blocks adhesion of pathogens and viruses to cells that they may
normally infect
- exotoxins tend to be proteins, so antibodies can neutralize these

Antibody-Mediated (Humoral) Immunity

Specific antibodies protect host by several
mechanisms:
elimination of infecting organism - direct
damage to organism cell wall, promote
phagocytosis, recruit cytoxic T cells
inhibition of attachement to mucosal cells (IgA)
toxin neutralization
- cells from anemnestic response will wake up upond second
encounter, and will remember how to make antibodies

Primary response (takes approximately 1 week) vs

anemnestic response (immediate 20 to immunologic
memory)
1st response: first see it, produce antibodies
- takes a couple days to make the antibodies to neutralize it at first
- then produce subset of cells that remember how to make these antibodies
but go to sleep
2nd response: these cells wake up, produce antibodies
- 2nd response usually less serious
- you may keep getting bacterial infections because if there's a sugar capsule
on the bacteria, you can't make antibodies against it
- everytime you come across it is like the first time

Non-Specific Systemic Mechanisms of Defense

i) Fever

induced by cytokines (interleukin-1,

tumor necrosis factor; others)
d body temperature inhibits
replication
ii)) Interferons pproduced byy manyy human cell
Interferons:
types, usually in response to viral
- immune system sends out
infections
signals to each other
Type I block synthesis of viral
proteins don't allow unlimited protein
synthesis because virus is around
Type II activate macrophages
and natural killer cells
- wakes immune system up
- 2 problems with immune system
- immune system doesn't wake up
- immune system all wakes up and goes crazy

Antibody-Mediated (Humoral) Immunity

3 main antibodies produced in infection:
IgM
earliest antibody produced
formed about a week after infection
persists for 4-6 wks (up to months)
IgG
gG
persists
pe
s sts for
o months
o t s oor yea
yearss
responsible for immunity
predominant antibody in circulation
IgA
predominates on mucosal surfaces
main antibody responsible for
immunity after enteric infection

Mediated
by
B
lymphocytes
IgM: first antibody you see in an infection
- big, lots of binding sites, but they don't bind vary well so make up for that with high quantity
- shows up after a week of infection
- lasts 6 weeks because trying out different combinations of binding sites -> converts to IgG
IgG: circulates and lasts for long time -> very tight fit for antigen
- IgM turn into IgG -> these IgG's can show you what you're immune to
IgA: GI tract, mouth, lungs, on mucosal surfaces
- this is best way to study blood and see what you're immune to, but don't know how to measure these
levels

Cell-Mediated Immunity (CMI)

essential for elimination of intracellular
pathogens viruses, parasites and some bacterias
mediated via T lymphocytes T because from thymus
Cytotoxic T lymphocytes - eliminate virus
infected cells - detect virus-infected cells and destroy them
Macrophages - stimulated to kill
intracellular bacteria by interferon released
by T helper cells

-usually just circulates -> if you give it certain signals which come from
T helper cells, macrophages will inactivate
- in HIV, the immune system cells are still present but you no longer
have control over them

Mechanisms Used To Evade The Immune

System
i)
ii)
iii)
iv)
v)
vi)
vii)

Virulence factor

Antiphagocytic capsules - protect from

phagocytosis and/or enzymes
Anticomplementary activity
A id
Avoidance
off intracellular
i t
ll l ingestion
i
ti
Direct cell-to-cell propagation
Antigenic variation
Interfere with immune response
(cytokines, blocking factors)
Interfere with expression of cell surface markers

- characteristic that enables

bacteria to cause disease
- may be common to all bacteria,
or a specific genus, species or
maybe common to all bacteria
pathogenic strain ex) all Gram- have LPS layer
maybe unique to a specific type
ex) cholera toxin

-can be either species specific or

strain specific

Mechanisms:
1) capsules - sugar signals prevent recognition
2) anticomplementary - prevent proteins from activating other proteins
3) ingestion - instead of being eaten and dissolved, they escape back out
4) propagation: go from cell to cell, never in serum so immune system doesn't detect
5) variation: change surface proteins, by the time you make antibodies they've already changed
6) immune response: ex) hepatitis, produces fake factors to throw off your immune system
7) surface markers: some bugs can prevent infected cells from display infection signals

Definitions
Pathogen:
Pathogenesis:
Infection:
Disease:
may be infecting you, but
Opportunist:
need special conditions to cause disease

Incubation:

Routes of Transmission

any microorganism capable of

causing disease
mechanism or route by which a
microbe causes disease
persistence on or within another
organism is present -> may not be
living organism causing a disease
end product (damage) resulting from an
if you have a bug but you're not
infectious process suffering any symptoms, then no disease
an organism that does not normally cause a disease
but can become pathogenic under certain circumstances
time from infection to onset of symptoms / disease
time between acquiring the organism and the time
you can tell it's there

Horizontal transmission: - ex) blood transfusions

Direct contact (secretions, blood, etc.)
Respiratory (aerosol) every time someone coughs / sneezes
Contaminated inanimate objects (foamites)
Insect vector - mosquito, tick, louse

Vertical transmission:
mother to fetus passing pathogen across placenta

Dose of Microorganisms Required To

Produce Disease

Colonization

Microbe

Resident Flora
Asymptomatic carriage

Di
Disease

Host Response

- most of the time, when they set up shop and colonize on you, they don't cause disease
- they switch over and cause disease only when host response is different
- ex) if we became immunocompromised, the organisms take over

Salmonella typhi:
Salmonella spp.
Shigella spp.
Vibrio cholerae
M. tuberculosis

Route

Disease-Producing
Dose

Incubation

Oral
Oral
Oral
Oral
Inhalation

105
106
10 - 103
108
1 - 10

14 days
7 - 24 hours
1 - 2 days
1 - 3 days
Variable

- need a LOT of cholera to become infected, need very few tuberculosis

to be infected

Virulence Factors
Capsules
Adhesins
Invasiveness
Exoenzymes
Toxins

- outer sugar coating that keeps things away from outer bacterial membrane
- difficult for immune system to detect / identify
- immune system is good at making antibodies against proteins, not polysaccharides
- hard to make memory cells

Capsules

located external to the cell wall

enable bacterium to avoid or survive
phagocytosis
mechanism not completely understood

one of the most common virulence factors

most often composed of polysaccharides
production is genetically determined,
therefore varies between strains
capsules are different depending on strain, so even if you have immune response
one, it doesn't help against others

- bacteria can infect you because it grabs onto your own cells and pull itself in,
otherwise mucus would wash it away

Adhesins
allow bacteria to stick to mucosal cells
(first step in causing disease)
eg. pharyngeal, intestinal and urinary tract
different bugs target different sites

Types:
i)
ii)
iii)

adhesion factors are surface structures

filaments since outer membrane
Pili (fimbriae) protein
doesn't have much proteins
Lipopolysacchcride (LPS) side chains your cells have
LPS receptor sites
M protein (Streptococcus pyogenes)

Invasiveness
ability of bacterium to invade the host cell
tends to be multifactorial, complex process
may include adhesion and enzyme factors

interact with different cells / tissues depending on the

expression of cell surface receptors
various adhesins allow bacteria to infect particular cells, and they're able to
choose the environment they want to be in

Exoenzymes

Toxins

Enzymes produced and secreted by bacteria

Many different types:

i)

ii)

iii)

Enzymes that break down collagen and

fibrin (eg. collagenases, hyaluronidases,
- breaks down glue between cells
fibrinolysins)
Enzymes that break down cellualar material
(eg. proteases, lecithinases)
break down the cells themselves
- lecithinases dissolve the membrane

Enzymes that modify and inactivate

antibiotics (eg. -lactamases)

Classified into 2 broad categories:

p
and released
i)) Exotoxins - pproteins produced
outside
from the bacteria
inside

ii) Endotoxins - part of the bacteria itself, they

are a signal to the hosts immune system of the
presence of a pathogen
Gram (-) have LPS
Gram (+) have peptidoglycan
these are the triggers that cause our immune systems to react

Characteristics of Toxins
Characteristic

Endotoxin

Exotoxin

Source

Gram-negative
bacteria LPS

Gram-positive and
Gram-negative bacteria

Chemical composition

Lipopolysaccharide

Protein various enzymatic

Toxic moiety

Lipid A

Active domain

Weakly

Yes

activities

Antigenic

hard to make antibodies

Heat sensitivity

Stable

Labile

doesn't denature in heat

Species - specificity
Cellular release

No

Yes

Bacterial lysis

Active

treating Gram (-) may

release endotoxins

Exotoxins
Functional classification:
i) Enterotoxins - affect the gastrointestinal
alter the way your GI tract works
tract (cholera,
(cholera shiga toxin)
ii) Neurotoxins - affect the nervous system
(tetanus, botulism, ergot)
iii) Cytotoxins - affect cells in a variety of
tissues (scalded skin syndrome,
Scarlet Fever, flesh eating disease)
affect particular cells
- lots of exotoxins are A+B, where A subunit helps get the toxin into the cell, while
subunit B is what does the bad stuff
- cholera causes all the salt water in your body to be excreted -> must put in saline line
to save the person

Endotoxins
All gram negative bacteria have endotoxin in outer
membrane - different bacteria, different potency very inflammatory
Released as bacteria are lysed
Responsible for development of sepsis and septic
shock - hypotension, fever, leukopenia, severe
diarrhea can be very overwhelming very quickly
highly fatal
effect is mediated by release of a variety of host
cytokines (eg. tumor necrosis factor, interleukins,
etc.)