Baedah Madjid

MEDICAL FACULTY
HASANUDDIN UNIVERSITY
2007
 Student must know how to explain about properties, virulance
factors, pathogenesis, clinical manifestation, laboratory
diagnosis, and treatment of the microbial agents of sepsis &
cardiovascular diseases

Student must know how to:

1. name the properties of the microbial agents of sepsis &
cardiovascular diseases
2. name the virulence factors and its effect on host
3. explain the pathogenesis of cardiovascular infection
4. name the clinical manifestation & microbial agents associated
with that illness,
5. explain the laboratory diagnosis of the cardiovascular diseases.
6. name the antibiotics to treat the infetion
 MICROBIAL AGENTS ACCOSIATED
WITH CARDIOVASCULAR DISEASES
COMMON ETHIOLOGUC % OF OTHER
AGENTS OF INFECTIVE CASES BLOCKS
ENDOCARDITIS
Viridans streptococci 30-40
Enterococci 5-18 Urogenital
Other streptococci 15-25
Staphylococcus aureus 15-40
Coagulase negtive stphylococci 4-30
Gram-negative bacilli 2-13
Fungi (e.g. Candida, Aspergillus) Respiratory
• Hemodynamic effects of cardiac abnormalities
create sites for bacterial attachment
• Transient bacteria with normal flora is the usual
organisms source
• Bacteria adhere to the damage surface, followed by
complement activation, inflammation, fibrin and
platelets deposition → further endothelial damage at
site
• Entrapment of organisms in the thrombotic of
platelets, fibrin, & inflammatory cells → mature
vegetation → protects organisms from host d.m.
• Vegetation → embolisms
 MICROBIAL AGENTS ACCOSIATED
WITH CARDIOVASCULAR DISEASES
COMMON ETIOLOGIC AGENTS IN
SUPPURATIVE THROMBOPHLEBITIS
SITES AGENTS
Superficial veins (eg. Staphylococcus aureus
Sapheneus, antecubital) Gram-negative aerobic bacteria
Pelvic veins, portal veins Bacteroides spp; microaerophylic or
anaerobic streptococci; Escherechia
coli; Β-hemolytic streptococci
(group A or B)
Intracranial venous Hemophilus influenzae;
sinuses (cavernous, Straptococcus pneumoniae;
sagital, lateral. Β-hemolytic streptococci group A;
Anaerobic or microaerophilic
streptococci, Staphyl. aureus
 MICROBIAL AGENTS ACCOSIATED
WITH CARDIOVASCULAR DISEASES
FREQUENCY OF DETECTION OF BLOOD STREAM
INVASION BY BACTERIA AND SOME FUNGI DURING
SIGNIFICANCE
SMALL (<10%) PROPORTION OF CASES
Shigella (except S. Campyl. jejuni Hemophilus , non-
flexneri) capsulated
Salm. enteritidis
Pasteurella
multocida
TO RARE TO JUSTIFY
Vibrio (intestinal inf Mycobacteriaum Clost. difficile
Coryn. diphtheriae Clostridium tetani Legionella

Bordetella pertussis Clost. botolinum

MICROBIAL AGENTS ACCOSIATED WITH
CARDIOVASCULAR DISEASES
FREQUENCY OF DETECTION OF BLOOD STREAM
INVASION BY BACTERIA AND SOME FUNGI DURING
SIGNIFICANCE
LARGE (90%) PROPORTION OF CASES
Hem. influenzae Strep. pneumoniae Samonella typhi
N. meningitidis Brucella spp Listeria
VARIABLE (10-90%) DEPENDING ON STAGE &
SEVERITY OF INFECTION
β-hem. streptococci Borellia Bacteroides
Strept. pneumoniae Acinetobacter Clostridium
Staph. aureus Shigella dysentriae Anaerobic coci
N. gonorrhoae Enterobacteriaceae Candida
Leptospira Pseudomonas Cryptococcus
neoformans
 MICROBIAL AGENTS ACCOSIATED
WITH CARDIOVASCULAR DISEASES
AGENTS ACCOSIATED WITH OTHER BLOCKS
MYOCARDITIS
Developed Viruses: Coxackie virus, Tropical infection
world echoviris, CMV, Epsein-
Barr virus, human herpes
virus-6, influenza virus
(A&B), adenovirus,
parvoviris, hepatitis B & C
viruses,.
Bacteria: C. diphtheriae, Tropical infection
any organisms associated
with infective edocarditis.
Parasite: trichinosis Tropical infection
Developing Viruses: poliovirus, mumps, Tropical infection
world rubella, arenaviruses,
dengue, rabies, chikungunya
Bacteria: Leptospira spp. Tropical infection
 MICROBIAL AGENTS ACCOSIATED
WITH PERICARDITIS
BACTERIA OTHER BACTERIA OTHER
BLOCKS BLOCKS
Strept. Pneumoniae Respiratory Rickettsia/ Coxella
Streptococcus spp burnetii
Staphyloc. aureus L. pneumophila Respiratory
N. meningitidis Respiratory Salmonella spp GEH
Haem. influenzae Camylobacter Tropical
infection
Enteric Gr-neg rods Urogenital Mycob. tuberculosa Respiratory
Mycob. chelonae Tropical
Mycob. avium complex infection
Brucella melitensis Respiratory Burrelia burdorferi
L. monocytogenes Respiratory M. pneumonia
Actinomyces spp Respiratory M . hominis Reproduction
Noc. asteroides Ureapl. urealyticum
 MICROBIAL AGENTS ACCOSIATED
WITH PERICARDITIS
VIRUS OTHER FUNGI OTHER
BLOCKS BLOCKS
Cytomegalovirus Reproduction Histoplasma capsulatum Respiratory
Herpes S Virus Reproduction Coccidiodes immitis Respiratory
Coxsackie A Virus Trop. med Crypt. neoformans Respiratory
Coxsackie B Virus Trop. med Blastmyc. dermatiditis Respiratory
Echovirus Trop. med Candida spp. Reproduct
Adenovirus Trop. med Aspergillus hominis Respiratory
Influenza Trop. med PARASITES
Mumps Trop. med Toxoplasma gondii Reproduct
Varicella-zoster Trop. med Entamoeba histolytica Trop. med
Epstein-Barr virus Reproduction Echinococcus Respiratory
granulosus
HIV Reproduction Shistosoma spp. Trop. med
A. Phylogenic classification
Family : Streptococcaceae,
Genera : Streptococcus.
Species : Strept. pyogenes,
Strept. agalactiae,
Strept. faecalis,
Strept. bovis
Strept. angionosus,
Strept. mitis,
Strept. pneumoniae.
B. Hemolytic pattern
1. -hemolytic streptococci
Streptococcus viridans groups
Strept. pneumoniae

2. β-hemolytic streptococci
Streptococcus pyogenes

3. -hemolytic streptococci
Non-pathogenic streptococci
C. Lancefield system
C substance Ag structure of cell wall,
A – H & K – U groups.
Pathogenic Strept : A-D & G groups.
D. Serotypes : cell wall proteins
M, R & T proteins.
80 tipe.
E. Casular polysaccharide
Str. pneumoniae : 83 serotypes
• Round or oval,
• form long chains.
• non-capsulated or
capsulated
(polysaccharide or
hyaluronic acid)
• Gram-positive
• ß-hemolysis
• facultative anaerob
some strict anaerobs
• microaerophilic,
• catalase-negative
• fastidious
A. M, F & G Proteins . E. Hemolysin
B. Hyaluronic capsule – Streptolysin-O
C. C Substance &
Cytoplasmic membrane – Streptolysin-S
antigen F. Spreading factors :
D. Exotoxin ▪ hyaluronidase,
▪ Erythrogenic toxin ▪ proteinase,
▪ Exotoxin A, connected ▪ streptokinase, &
with TSST-1 ▪ nuklease :
▪ Exotoxin B (cystein streptodornase (DNAse)
protease)
▪ Cardiohepatic toxin
A. Specimens:
Blood
Throath swabs.
Pus & secrets
Cerebro-spinal fluids
Other infections : urine, sputum, bile
Serum
B. Diagnose
1. Direct preparation: Gram staining.
2. Isolation
3. Antibiotic sensitivity testing
4. Serotyping
5. Lab. Diagnosis for rheumatic fever &
acute glumerulo-nephritis .
- High ASO & DNAse Ab titer .
- Strept. enzymes Abs ↑
- C3 ↓
Do susceptibility test:
If susceptible : penicillin + it’s derivates
• Erythromycin : the drug of choice in patient
who are allergic to penicillin or in case
resistance bacteria,
• Cephalosporin
Streptococcus viridans groups:
S. mutans, S. sanguis, S. salivarius, S. mutans,
S. mitis (mitior), S. anginosus (S. milleri,
S. intermedius, and S. constellatus)

Classified by fermentation patterns, cell wall

competition and production of dextrose or
levans (fructose 2-6 polymers) from sucrose.
- Frequently found in nasopharynx, mouth,
ginggival crevices, gastrointestinal tract.
- Occasionally on the skin
- Could invade blood stream after:
● chewing,
● dental manipulations,
● gastro-intestinal or genitourinary
instrumentation.
- Also may occur:
• cellulitis or wound infection,
• meningitis,
• sinusitis,
• biliary or intra abdominal infections,
• endocarditis
- S. anginosus: Brain or liver abscesses
- S. sanguis: single species cause subacute
bacterial endocarditis
A. Phylogenic
Family: Micrococcaceae.
Genera: Staphylococcus,
Micrococcus,
Stomacoccus, and
Planococcus
Species : Staph. aureus,
Staph. epidermidis,
Staph. saprophyticus
B. Practical classification
Genera Staphylococcus: > 30 species:
- Coagulase-positive staphylococci
Staph. aureus,
- Coagulase-negative staphylococci
Staph. epidermidis, Staph. saprophyticus,
- Other staphylococci: not in discussion

Staph. epidermidis: NF of skin, upper

respiratory tract, & GI tract.
Staph. aureus: 40-50 normal human.
• Clustered Gram-positive cocci
• Catalase positive
• Prefer aerobic condition but may behave as
facultative anaerobes
CHARACTERISTIC S. aureus S. epidermidis S. saprophyticus
Pigment Yellow to White White to pale
white gray

Hemolysis + ± -

Coagulase production Yes No No

Mannitol Yes No No
fermentation
Novobiocin sensitivity Sensitive Sensitive Resistance
PROPERTIES OF S. aureus

- Dry- and heat-resistent

- Resistance to 9 sodium chloride,
- Inhibited by hexachlorophene 3.
- penicillinase-positive
- Antibiotic resistance occur rapidly .
- NF of upper respiratory tract, skin &
mucous membrane
- Human pathogen
Specimens
Skin or mucous sawabs, pus, blood,
tracheal/bronchial washing, or
cerebrospinal fluids.

Diagnosis
● Direct-Gram preparation.
● Isolation
● Serology and sero-typing testing
● Antibiotic sensitivity test
1. Indication: antibacterial treatment is indicated both
for superficial and deep infection. But, deep infection
needs more intensive, prolonged chemotherapy.

2. Originally S. aureus susceptible , almost 100% now

resistance to penicillin.
a. Empirical therapy: a penicillinase-resistance
penicillin (methicillin, oxacillin, nafcicillin) or 1st
generation cephalosporin,
b. Vancomycin : the drug of choice for methicillin resistance
staphylococci,
c. Cepahlosporin, erythromycin, or clindamycin also can be
used.
- Very small bacteria,
- Microscopically : inclusion body
- Can grow only on tissue
- -lactam antibiotic : no use.
- Life cycle unique
Ordo : Chlamydiales,
Family : Chlamydiaceae,
Genera : Chlamydia,
Species : Chl. trachomatis,
Chl. psittaci,
Chl. pneumoniae,
Chl. pecurium.
Chl. trachomatis: Prototype
Characteristics C. trachomatis C. psittaci C. pneumoniae

Inclusion Oval, Variable, Oval, dense

morphology vacoular
dense
Elementary Round Round Pear-shape
body morph.
Folate Positive Positive Negative
biosynthesis
Glycogen in Positive Negative Negative
inclusions
No. of serovars 15 NA 1
a. Mild upper respiratory infection

b. Pneumonia in young adult

c. Coronary heart diseases

Reservoir
Chl. pneumoniae: strictly human pathogen,
No animal reservoir
Transmission: man to man contact
Insidence.
• US: 50% sero-positive
• Mostly sub-clinic
• Re-infection with other strain
• Epidemic easy happen in close related
community
– Tissue culture
– Antigen detection
• Elisa Test
• Direct fluorescence antibody
– DNA detection
– Serology: most sensitve
• Complement fixation test
• Elisa test
• Microimmunofluorescence test
Tetracyclines are the drug of choice
for Chlamydia pneumoniae infection.
We have discussed about:
■ the microbial agents associated with sepsis
and cardiovascular disorder.
■ the classification, properties, virulence
factors, clinical manifestation, laboratory
diagnose and infection treatment, of:
● Streptococci
● Staphylocuccus aureus
● Chlamydia pneumoniae
 FURTHER READING
• Brooks, GF., Butel, JS., Morse, SA. Jawetz, melnick, &
Adelberg’s Medical Microbiology. 23rd Edition,
International Edition, McGraw-Hill, Singapore, 2004.
• Cohen, J. et al. Infectious Diseases, 2nd Edition, Mosby,
Sydney, 2004.
• Joklik, WK., Willett, HP., Amos, DB., Wifert, CM. Zinsser
Microbiology, 20th edition, Appleton & Lange,
Connecticut1992.
• Mims, C., et al. Medical Microbiology, 3rd Edition, Mosby,
Sydney, 2004
• Ryan, KJ., Ray, CG. Sherris Medical Microbiology , an
Introduction to Infectious Diseases, McGraw-Hill,
Singapore, 2004.
• Virella G. Microbiology and Infectious Diseases, 3rd
Edition, Edited., Williams and Wilkins, Baltimore, 1997.