MIDTERM TOPICS

MICRO-PARA

Controlling Microbial Growth in Vitro Using Antimicrobial Agents to Control Microbial Growth Microbial Ecology Epidemiology and Public Health Health Care Epidemiology: Nosocomial Infections and Infection Control Diagnosing Infectious Disease Pathogenesis of Infectious Diseases

Controlling Microbial Growth in Vitro

Some places encourage the growth of microorganisms.

Some places necessitates inhibition of the growth of microorganisms.

Factors that Affect Microbial Growth

Nutrients

various chemical compounds to sustain life For energy sources Sources of C-H-O-N-S + Phosphorus and other elements

Na+, K+,Cl-,Mg++, Ca++ Trace elements Fe, I, Zn

Moisture

Cells consist of 70 95% water, most will die in environments with too little water. Other microbial stages (endospores and protozoan cysts) can survive desiccation in their dormancy or resting states

Temperature

Thermophiles Mesophiles Psychrophiles

Psychroduric organisms prefer warmer temp, but can tolerate very cold temperature (eg. Psychroduric E. coli from fecal material left by early Arctic explorers)

pH

Most microorganisms prefer a neutral or slightly alkaline growth medium (7.0 7.4) Acidophiles survive acid stomach (2.0-5.0) Alkalophiles found in the intestines (9.0)
V. cholerae only human pathogen that grows well above pH 8.0

Osmotic pressure and salinity

Pressure exerted on a cell membrane by solution both inside and outside the cell.

Types of solutions:

Isotonic equal concentration of solutes outside and inside the cell Hypertonic - concentration of solutes outside the cell is greater than inside the cell Hypotonic - concentration of solutes outside the cell is lesser than inside the cell

WHATS THE WORD?

Osmosis movement of a solvent from lower concentration of solute to a higher concentration of solute

Isotonic solution
- Balance solution - No movement of water

Hypotonic solution
If sufficient water enters the cell, it will swell, then eventually lyse or burst. Hemolysis bursting of red blood cells. Plasmoptysis cell rupture of bacterial cell.

Hypertonic solution
If sufficient water leaves the cell, it will shrink. Crenation shrinkage of red blood cell due to loss of water. Plasmolysis shrinking away of bacterial cell membrane and cytoplasm from the cell wall. (Application :Use of salt and sugar in food preservation)

WHATS THE WORD?

Haloduric organisms do not prefer to live in salty environments but are capable of surviving there (such as Staphylococcus aureus)

Dead Sea Salt Beds, Israel The Dead Sea, between Jordan and Israel, has grown smaller over the last 10,000 years due to evaporation, which removes water faster than precipitation can replenish it. The resulting salt deposits form an enormous salt reserve.

Barometric Pressure

Barophiles thrive deep in the ocean where the atmospheric pressure is very high

Gaseous Atmosphere

Aerobes Anaerobes Capnophiles

JUST ASKING. . .

WHY IS THE GROWTH OF MICROORGANISMS ENCOURAGED IN MICROBIOLOGY LABORATORIES?

Identification of pathogens Learn more about them Harvest antibiotics and other microbial products Produce vaccines Used in industries

CULTURING BACTERIA IN THE LABORATORY

Culture medium

possess nutritional and other environmental requirements for bacterial growth

Culture

growth of microorganisms obtained from culture medium

Culture Types

Pure only one specie is present (important for the isolation of pathogenic organism) Mixed different species Stock pure culture of microorganisms used as a source of supply for industry, research and students use

Classification of Culture Media

According to consistency (physical state)

Liquid- no agar, hardening or solidifying agent

TSB, thioglycollate broth, tetrathionate broth

Semi- solid- 0.5 1.0 % agar

SIM

Solid- 2- 3% agar
BAP, Citrate, EMB, MacConkey

According to Composition

Synthetic (Artificial) - exact composition is known

(Any commercially prepared medium)

Non-synthetic- exact composition is not known (Meat extract broth)

Tissue Culture- from living cells- for culture of viruses and rickettsia (WI 38 from normal human skin)
( Hela cells from human cervical cancer cells)

How the Medium is dispensed

Tubed

Plated- sterile Petri dishes

According to Use

Simple- with nutrients to support growth allows most non-fastidious organisms to grow at their natural rate used for routine culture Nutrient Agar

Enriched- with nutritive supplements needed for bacterial growth Blood Agar Plate (+ 5% sheep red blood cells) Chocolate Agar Plate N. gonorrheae

Differential - organisms growing together with differences in their cultural characteristics EMB and Mac Conkey lactose fermenters (red) non-lactose fermenters(colorless)

Blood Agar Plate alpha (partial/incomplete hemolysis) beta (complete hemolysis/ clear) gamma (no hemolysis)

Selective- with one or more agents inhibitory to all organisms EXCEPT organisms being sought
SSA - BSA (S. typhi) PEA Gram (+) cocci CNA Columbia Colistin Nalidixic Acid Gram (+) streptococci Mannitol Salt Agar for Salt tolerant bacteria

THIO - Thioglycollate broth

Primary isolation medium that supports the growth of obligate aerobes to obligate anaerobes

WHATS THE WORD?

INOCULATION
Adding a portion of the specimen to the medium

WHATS THE WORD?

STERILE TECHNIQUE
Techniques used in an attempt to create an environment that is sterile (devoid of microorganisms)

WHATS THE WORD?

INCUBATION
Holding a culture at a particular temperature for a certain length of time

TYPES OF INCUBATOR USED IN A CLINICAL MICROBIOLOGY LABORATORY

Carbon dioxide incubator

With 15 20 % Oxygen With 5 10% Carbon dioxide

Non - Carbon dioxide incubator

With 20 21 % Oxygen

Anaerobic incubator
With atmosphere devoid of oxygen

BACTERIAL POPULATION COUNTS

VIABLE PLATE COUNT

Used to determine the number of viable bacteria in a liquid sample, such as milk, water, ground food diluted in water, or a broth culture. It is also an important part of urine culture as an indicator of Urinary Tract Infection

DEVELOPMENTAL MILESTONES IN INFANCY

Human growth refers to increase in size;going from a tiny baby to a large adult.

BACTERIAL GROWTH

Increase in the number of organisms rather than an increase in size.

Generation Time/ Doubling Time time for an organism to double its number by binary fission.

Examples:
E. coli, Staphylococcus, Streptococcus, V. cholerae 20 - 30 minutes Pseudomonas and Clostridium 10 minutes M. tuberculosae 18 24 hours

Bacterial Growth Curve

when bacteria are grown in suitable media and samples taken at intervals, plotting of results will yield a characteristic growth curve.
It tends to increase cell mass and number in an exponential

Bacterial Growth:
The bacterial growth curve:

Lag phase Exponential phase

Stationary phase
Death phase

A. Lag Phase (Phase of Physiologic Youth or Rejuvinescence)

period of adjustment necessary for replenishment of cells maximum cell synthesis

little or no multiplication occurs

B. Exponential/Logarithmic

maximum rates of cell division and increase in cell mass most metabolically active

C. Stationary /Equilibrium/ Plateau

occurs as essential nutrition in medium begins to disappear

balance between cell growth , cell division and cell death number of organisms alive = number of organisms dying

occurs : a. exhaustion of nutrients b. accumulation of metabolic products c. changes in pH

D. Death/ Decline Phase

bacterial lysis and cell destruction

complete cessation of multiplication increase death rate in medium

CULTURING OBLIGATE INTRACELLULAR PATHOGENS IN THE LABORATORY

OBLIGATE INTRACELLULAR PATHOGENS

Only survive and multiply within living host cell Examples: Viruses, Rickettsias and Chlamydias Must be inoculated into embryonated chicken eggs, laboratory animals or cell cultures

FUNGI
Brain-Heart Infusion Agar Brain-Heart Infusion Agar + Blood Sabouraud Dextrose Agar

PROTOZOA
Not usually done Example of protozoa that can be cultured in vitro are Amebae

CLOSURE / CARRY-OVER ACTIVITY

Unlock the following terms:

Sterilization Disinfection Disinfectants Antiseptics Sanitazation Germicidal agents Bactericidal agents

Microbistatic agent Bacteriostatic agents Lyophilization Sepsis Asepsis Antisepsic technique Thermal Death Point Thermal Death Time

MAKE A SUMMARY OF THE PHYSICAL METHODS TO INHIBIT MICROBIAL GROWTH

Method
HEAT Dry Heat Moist Heat Autoclave COLD DESSICATION RADIATION ULTRASONIC WAVES

Mechanism of Action

Comment

Preferred Use

FILTRATION
GASEOUS ATMOSPHERE

Sterilization

Complete destruction of all microorganisms, (includes cells, spores and viruses)

Disinfection

Destruction /removal of pathogens from nonliving objects by physical or chemical means.

Disinfectants

Chemicals used to disinfect inanimate objects (bedside equipments and operating rooms

Antiseptics
Solutions used to disinfect skin and other living tissues

Sanitization
Reduction of microbial populations to levels considered safe by public standards.

Germicidal agents General term referring to disinfectants that kill microbes

Bactericidal Sporicidal Fungicidal Algicidal Viricidal Pseudomonicidal Tuberculocidal

Microbistatic agent Drug/chemical that inhibit the growth of microorganisms Bacteriostatic agents One that specifically inhibits the metabolism and reproduction of bacteria Lyophilization Process that combines dehydration (drying) and freezing

Sepsis Refers to the presence of pathogens in blood or tissues

Asepsis Absence of pathogens in blood Antisepsic technique The use of antiseptic

Thermal Death Point

Lowest temperature that will kill all types of microorganisms in a standardized pure culture within a specified period

Thermal Death Time

Length of time necessary to sterilize a pure culture at a specified tempertature

Using physical methods to Inhibit Microbial Growth

HEAT
DRY HEAT
160 165 C for 2 hours 170 180 C for 1 hour Use of Oven Incineration Flaming Using electric heating devices

MOIST HEAT
Heat applied in the presence of moisture (boiling/steaming) Autoclave
like a metal pressure cooker that uses steam under pressure to completely destroy all microbial life. 121.5 C, 15 psi, 20 minutes Kills veratative microorganisms, bacterial endospores, viruses

COLD
Inhibits bacterial growth Refrigeration (slow freezing) Liquid Nitrogen (rapid freezing) * Refreezing of thawed food is an unsafe practice.

DESICCATION
Process of being thoroughly dried

Microorganisms grow rapidly in moist, warm nutrient environment.

RADIATION
Suns rays include infrared (heat) rays and ultraviolet (UV) rays Penetrate cells and damage DNA UV lamps are used as germicidal lamps:
Nurseries Operating rooms Elevators Entryways

Caution: when working with UV lamps avoid exposure or eyes or skin to the rays (can cause serious burns and cellular damage)
Skin cancer can be caused by excessive exposure to UV

X-rays, gamma rays, beta rays may be lethal or cause mutations to microorganisms
Damage DNA and proteins within the cell

ULTRASONIC WAVES
Used in cleaning and sterilizing equipment delicate equipments in hospitals, medical clinics and dental clinics. Sound waves mechanically dislodge organic debris on instruments and glass wares.

FILTRATION
Micropore filters are used in the laboratories to filter bacteria and viruses out of liquids Variety of filters include plastic films, unglazed porcelein, asbestos, diatomaceous earth, and cellulose membrane filters. Biologic Safety cabinets contain High-Efficiency Particulate Air (HEPA) filters.

GASEOUS ATMOSPHERE
Aerobes and microphiles are killed by placing them in atmosphere devoid of oxygen. Obligate anaerobes are killed by placing them into an atmosphere containing oxygen

Using chemical agents to Inhibit Microbial Growth

Factors affecting the efficiency and effectiveness of disinfectants:

Prior cleaning of the object or surface to be disinfected The organic load present in the material to be treated (feces, blood, vomitus, pus) Bioburden (type and level of microbial contamination

Concentration of disinfectant
Contact time (amount of time disinfectant must remain in contact with the organism in order to kill them Physical nature of the object being disinfected(smooth,rough,crevices,hinges) Temperature and pH

Characteristics of an Ideal Chemical Antimicrobial Agent

Wide antimicrobial spectrum

Fast acting

Not affected by the presence of organic matter

Non-toxic to human tissues, noncorrosive, nondestructive Should leave a residual antimicrobial film on the treated surface

Soluble in water and easy to apply

Inexpensive and easy to prepare Stable both as a concentrate and as a working solution Odorless

USING ANTIMICROBIAL AGENTS TO CONTROL MICROBIAL GROWTH IN VIVO

WHATS THE WORD?

CHEMOTHERAPY
Use of drug to treat any disease or condition These drugs are called CHEMOTHERAPUETIC AGENT

ANTIMICROBIAL AGENT
A drug used to treat an infectious disease, either by inhibiting or killing pathogens in vivo.
Antibacterial Antifungal Antiprotozoal Antiviral

ANTIBIOTICS
Antimicrobial substance produced by a microorganism that is effective in killing or inhibiting the growth of other microorganisms. Semisynthetic antibiotics chemically modified to kill a wider variety of pathogens or reduce side effects

Ideal Qualities of an Antimicrobial Agent

Kill or inhibit the growth of pathogens

Cause no damage to the host Cause no allergic reaction in the host

Stable when stored in solid or liquid form

Remain in specific tissues in the body long enough to be effective

Kill the pathogens before they mutate and become resistant to it.

Unfortunately

Most antimicrobials have:

Some side effects Produce allergic reaction Permit development of mutant strains

Most Common mechanisms of Action of Antimicrobial Agents

Inhibition of cell wall synthesis

Damage to cell membranes

Inhibition of nucleic acid synthesis (DNA or RNA)

Inhibition of protein synthesis Inhibition of enzyme activity

Antibacterial Agents (Table 9-1)

Inhibition of cell wall synthesis

Penicillin interferes with the synthesis and cross-linking of peptidoglycan in Gram (+) like Staphylococcus and Streptococcus

JUST ASKING. . .

WHY DOESNT PENICILLIN ALSO DESTROY HUMAN CELLS?

COMPETITIVE INHIBITION
Sulfonamide molecule is similar in shape to PABA (para-amino benzaldehyde) PABA is converted to folic acid which is essential in the synthesis of some bacterial proteins If there is no conversion of PABA to folic acid to essential proteins, the bacterial cell will eventually die Sulfa drugs are BACTERIOSTATIC AGENTS

JUST ASKING. . .

WILL HUMAN CELLS BE AFFECTED BY SULFA DRUGS?

WHATS THE WORD?

NARROW - SPECTRUM ANTIBIOTICS

Destroys only Gram (+) bacteria

Vancomycin

Destroys only Gram (-) bacteria

Colistin and Nalidixic acid

BROAD - SPECTRUM ANTIBIOTICS

Destructive to both Gram (+) and Gram (-) bacteria
Ampicillin Chloramphenicol Tetracycline

SOMETHING TO REMEMBER

Antimicrobial agents work well against bacterial pathogens because the bacteria (being procaryotic) have different cellular structures and metabolic pathways that can be disrupted or destroyed by drugs that do not damage the eucaryotic hosts cell.

MULTIDRUG THERAPY

Two or ore drugs are used simultaneously to kill all the pathogens and to prevent resistant mutant strains from emerging.
Four drugs used in M. tuberculosae infection

Isoniazid Rifampin Pyrazinamide Ethambutol or Streptomycin

Synergism VS Antagonism
SYNERGISM
Two antimicrobial agents are used to treat an infectious disease a greater degree (effect) than that achieved by either drug alone.

Trimethoprim + Sulfamethoxazole =
Co-trimoxazole (Bactrim and Septra)

ANTAGONISM
Two drugs working against each other The extent of pathogen killing is less than that achieved by either drug alone.

ANTIFUNGAL AGENTS
How do they work ?

Binding with cell membrane sterols

(nystatin, amphotericin B)

Interfere with sterol synthesis

(clotrimazole and miconazole)

Blocks mitosis or nucleic acid synthesis

(griseofulvin and 5-flucytosine)

ANTIPROTOZOAL AGENTS
How do they work ?

Interfere with DNA and RNA synthesis

(chloroquine, pentamidine,quinacrine)

Interfere with protozoal metabolism

(metronidazole Flagyl)

ANTIVIRAL AGENTS

ZIDOVUDINE (AZT)
First antiviral drug effective against HIV (1987) Coctails (1990s) a combination of antiviral drugs

SUPERBUGS

Microorganisms that have become resistant to one or more antimicrobial agents.

MRSA (Methicillin-resistant S. aureus) MRSE (Methicillin-resistant S. epidermidis) VISA (Vancomycin-Intermediate S. aureus) VRSA (Vancomycin-Resistant S. aureus)-very common in nosocomial infection VRE (Vancomycin Resistant Enterococcus spp.) MRTB (Multidrug-Resistant M. tuberculosis)

How can Bacteria Become Resistant to Drugs

INTRINSIC RESISTANCE
Lack specific target site for the drug (Mycoplama cellwalless) Drug cannot cross the bacterial cell wall or cell membrane

ACQUIRED RESISTANCE
Alteration of drug- binding sites due to chromosomal mutation Alteration of the structure of the cell mebrane

 Ability of organism to produce enzymes that destroys the drug (R-factor is passed on to other bacteria via conjugation)
Ability to develop Multidrug- Resistance pumps (MDR transporters)-pumps drug out of the cell before it causes damage

BETA-LACTAMASES

B-lactam ring the heart of Penicillin and Cephalosporin structures

If B-lactam is destroyed, the antibiotic no longer works

Two types of B-lactamases:

Penicillinases destroys the B- lactam rings of Penicillins Cephalosporinases destroys the Blactam ring of Cephalosporins

Combination of Drugs to Combat the Effect of B-lactamases:

Clavulinic acid + Amoxicillin = Augmentin Clavulinic acid + Tiracarcillin = Timentin Sulbactam + Ampicillin = Unasyn Tazobactam + Piperacillin = Zosyn

EMPIRIC THERAPY

Clinicians initiate therapy before laboratory results are available.

Based on an educated guess based on prior knowledge/ experiences with the particular type of infectious disease the patient has.

Factors to consider. . .

Laboratory result of pathogens identity refer to pocket chart. Is patient allergic to any antimicrobials? Age of the patient? Is patient pregnant? In-patient or out-patient?

Availability of the drug What is the site of infection? Medications received by the patient. Other medical problems? Is patient immunocompromised? Cost of the drug?

Side Effects. . .

Allergies Toxicity (Chloramphenicol aplastic anemia) Superinfection (opportunists and secondary invaders overgrowth)
Antibiotic Associated Diarrhea (AAD) and Pseudomembranous Colotis (PMC) caused by C. difficile Candida albicans infection

Closure / Carry Over Activity

What Can Clinicians, Paramedical Professionals and Patients Do To Help in the War Against Drug Resistance? (pp154-155)
Editorial Cartoon Poster Slogan Jingle Radio Advertisement Poem

MICROBIAL ECOLOGY

Study of the numerous interrelationships between microorganisms and the world around them. Microbes interact with. . .
other microbes _ organisms other than microbes non-living world around them

Symbiotic relationships involving microorganisms

Symbiosis
Living together or close association of two dissimilar organisms (symbionts)

Neutralism
A symbiotic relationship in which neither symbiont is affected by the relationship Different microorganisms occupy the same etiologic niche, but have absolutely no effect on each other.

Commensalism
Beneficial to one symbiont and neither beneficial nor harmful to the other. Many organisms in the indigenous flora are considered commensals.

Mutualism
Beneficial to both symbionts E. coli obtains nutrients from food materials ingested by the host and produces vitamin K which is a blood clotting factor

Parasitism
Beneficial to one symbiont and detrimental to the other organism

SYNERGISTIC RELATIONSHIP
Microorganisms may team up to produce a disease that neither could cause by itself Synergistic Infection

Example: Oral bacteria can cause

ANUG Acute Necrotizing Ulcerative Gingivitis

INDIGENOUS MICROFLORA

MICROFLORA OF THE SKIN

Consists of 30 different types of bacteria and fungi Most common species - S. epidermidis

FACTORS AFFECTING THE NUMBER AND VARIETY OF ORGANISMS IN THE SKIN

Amount of moisture present

pH Temperature Salinity

Presence of chemical waste such as urea and fatty acids

Presence of other microbes which maybe producing toxic substances

TABLE 10 - 1
Anatomic Locations of Bacteria and Yeasts Found As Indigenous Microflora of Humans

MICROFLORA OF THE EARS AND EYES

Middle ear and inner ear are usually sterile Outer ear and auditory canal contain same types of organisms as on the skin

Coughing, sneezing, blowing of nose can carry these microbes along the eustacian tube to the middle ear
External surface of the eye is lubricated, cleansed and protected by tears, and the presence of enzyme lysozyme and other substances

MICROFLORA OF THE RESPIRATORY TRACT

Nasal passages and throat have an abundant and varied population of microorganisms Healthy carriers harbor virulent pathogens in their nasal passages or throats

MICROFLORA OF THE ORAL CAVITY (MOUTH) Shelter for numerous anaerobic and aerobic bacteria
Thrive well in particles of food and in the debris of dead epithelial cells around the teeth

 Poor dental hygiene results in the development of dental caries, gingivitis and other periodontal diseases
Species include: Actinomyces, Bacteroides, Lactobacillus, Streptococcus, Neisseria and Veillonella

MICROFLORA OF THE GASTROINTESTINAL TRACT Gastric enzymes and extremely acidic pH of the stomach usually prevent growth of indigenous microflora and most transient microbes
Helicobacter pylori lives in some people s stomachs and is a common cause of ulcer

 Many of the microflora of the colon are opportunists like E. coli E. coli is the most common cause of UTIs (Urinary Tract Infection)

MICROFLORA OF THE GENITOURINARY TRACT

Healthy kidneys, ureters and urinary bladder are sterile External opening of the urethra harbor many microbes, including bacteria, yeasts and viruses

 Frequent urination prevents UTI Most common cause of urethritis: Chlamydia trachomatis, Neisseria gonorrheae and Mycoplasmas through sexual intercourse Vaginal secretions are acidic, encouraging the growth of lactobacilli that produces lactic acid (inhibit growth of bacteria associated with bacterial vaginosis)

BENEFICIAL ROLE OF INDIGENOUS MICROFLORA

Aids in the synthesis of vitamins K and B12, pantothenic acid, pyridoxine and biotin
Source of irritants and antigens to stimulate the immune system

MICROBIAL ANTAGONISM
microbes against microbes

Microflora competes for space and nutrients against newcomers Effects of antibiotics produced by some organisms against other microorganisms Some produce protein bacteriocins which kill other bacteria

WHATS THE WORD?

BIOTHERAPEUTIC AGENTS (PROBIOTICS)

Bacteria and yeasts that are used to reestablish and stabilize microbial balance Example: Use of Lactobacillus in yogurt or in medications

MICROBIAL COMMUNITIES

BIOFILMS
Complex communities of assorted organisms Examples: dental plaque, slippery coating on rocks, slime that acculmilates

Medical Significance:
Form on urinary catherter, implants Implicated in endocarditis, middle ear infection, kidney stones, etc. Examples: C. albicans, S. aureus, Enterococcus spp,Klebsiella and Pseudomonas

WHATS THE WORD?

BIOTECHNOLOGY
industrial use of microbes in the production of certain foods and beverages, food additives, chemicals, amino acids, enzymes, etc. as well as refining of ores to obtain copper, uranium and gold

WHATS THE WORD?

BIOREMEDIATION
Use of microbes to dispose of industrial and toxic wastes and other environmental pollutants pesticides, herbicides, oil spills

EPIDEMIOLOGY AND PUBLIC HEALTH

1976

Legionnaires Disease
severe form of pneumonia, characterized by headache, chest pain, lung congestion, and high fever. The name is derived from an outbreak at an American Legion convention in a Philadelphia hotel in July 1976.

1992 - 1993

Escherichia coli O157

A food-borne disease caused by a particular variant of the common intestinal bacterium E. coli . Although E. coli is normally present in the human intestines, the variant E. coli O157:H7 produces toxins that cause bloody diarrhea and, in some cases, far more severe problems, including kidney failure and death. A person can become infected by eating contaminated meat. Thorough cooking kills the bacteria.

1993

Hantaviruses are carried by specific rodent hosts and are transmitted directly from host to host by virus-laden saliva, urine, and feces. Humans are infected through exposure to the dried excretions from infected rodents. Hantaviruses cause two different human diseases: hemorrhagic fever with renal syndrome, in which damage to the kidneys is common, and acute respiratory distress syndrome, in which damage to the lungs is common.

1993

Cryptosporidiosis
A diarrheal disease which resulted from drinking water that was contaminated with Cryptospridium parvum

2002

West Nile Virus

infectious organism that can cause fatal neurological disease in birds, horses, and humans. The virus is transmitted by the bite of an infected mosquito. West Nile virus is named for a district in Uganda where the virus was first identified in humans in 1937. As the virus spread, U.S. public health officials worked with local communities to track the spread of the virus and to control mosquito populations to prevent virus transmission.

WHATS THE WORD?

EPIDEMIOLOGY
The study of disease, basically the factors that determine the following:
Frequency Distribution Determinants in human population

These FACTORS are included if it is an infectious diseases:

Characteristics of various pathogens Susceptibility of the population resulting from overcrowding Lack of immunization Nutritional status Inadequate situation Location (reservoir) Various ways it is transmitted

Questions asked by EPIDEMIOLOGISTS:

What pathogens are causing the infection? Where do the pathogens come from? When do certain diseases occur Why do some diseases occur in some places but not in others How are pathogens transmitted? Do some diseases occur only at certain time of the year? If so, why?

TERMINOLOGIES

COMMUNICABLE DISEASE
Transmission : person to person

CONTAGIOUS
Communicable disease that is easily transmitted from one person to another

ZOONOTIC DISEASES
Infectious diseases that human acquire from animal sources

INCIDENCE
Number of new cases of that disease in a defined population during a specific time period

PANDEMIC DISEASES
A disease occurring worldwide
HIV / AIDS (pp.179 180) Tuberculosis (p. 180) Malaria (p. 180)

BE READY TO UNLOCK MORE TERMINOLOGIES

Interactions Among Pathogens, Hosts and the Environment

FACTORS AFFECTING THE OCCURRENCE OF INFECTIOUS DISEASES

Pertaining to the Pathogen

Virulence Portal of Entry Number of organisms

Pertaining to the Host

Health status Nutritional status Socioeconomic, hygiene, travel,immune status, substance abuse

Pertaining to the Environment

Physical factors
Location, climate, heat, cold, humidity, season of the year

Availability of appropriate reservoir

Sanitary and housing conditions, adequate waste disposals

Availability of potable water

SIX COMPONENTS IN THE INFECTIOUS DISEASE PROCESS (CHAIN OF INFECTION)

Presence of a pathogen Source of the pathogen (reservoir) Portal of exit Mode of transmission Portal of entry Susceptible host

A Case of an Infamous Carrier

Typhoid Mary (p.183)

FIVE PRINCIPAL MODES OF TRANSMISSION

Contact (direct or indirect) Airborne Droplet Vehicular Vectors

Communicable diseases are transmitted from person to person in the following ways:

Direct Skin-to-Skin Contact

Handshake

Direct Mucous membrane Mucous membrane Contact

Kissing Sexual intercourse

Indirectly by airborne droplets

Sneezing Coughing

Indirectly by contamination of food and water by fecal material

Indirectly by arthropod vectors

Mosquitoes Flies Fleas

Indirectly by Fomites
Stethoscope Gloves

Indirectly by transfusion of blood or blood products

Syringes Needles

UNLOCK THE FOLLOWING TERMINOLOGIES

MORBIDITY RATE MORTALITY RATE PREVALENCE SPORADIC DISEASE ENDEMIC DISEASE EPIDEMIC DISEASE RESERVOIR OF INFECTION

PASSIVE CARRIERS INCUBATORY CARRIERS CONVALESCENT CARRIERS ACTIVE CARRIERS FOMITES PARENTERAL INJECTION BIOLOGICAL WARFARE BIOTERRORISM AGENTS

CARRY-OVER ACTIVITY
TRACE THE CHAIN OF INFECTION IN A FORM OF A DIAGRAM

HEALTHCARE EPIDEMIOLOGY: NOSOCOMIAL INFECTIONS AND INFECTION CONTROL

HEALTHCARE EPIDEMIOLOGY
-

Any activity designed to study and / or improve patient care outcomes in any type of healthcare institution or setting.
Includes a variety of disciplines and activities directed at enhancing the quality of healthcare and preventing and controlling adverse outcomes. (SHEA)

What is the importance of MICROBIOLOGY to the healthcare professionals?

Whether they are working in a hospital, nursing home, medical or dental clinic, or caring for a sick person they MUST follow standardized procedures to prevent the spread of communicable diseases.

TWO TYPES OF INFECTIOUS DISEASES (INFECTIONS)

Hospital acquired (Nosocomial)

Includes those that erupt within 14 days of hospital discharged

Acquired outside the healthcare facilities (Community-acquired)

Iatrogenic Infections
physician induced
Result of medical or surgical treatment (surgeons, physicians,healthcare personnel) Examples: post - surgical wound infections and urinary tract infections (catheterization)

PATHOGENS MOST OFTEN INVOLVED NOSOCOMIAL INFECTIONS

Gram (+) cocci

Staphylococcus aureus Coagulase (-) Staphylococcus Enterococcus spp.

Gram (-) bacilli

Escherichia coli Pseudomonas aeroginosa Enterobacter spp. Klebsiells spp.

Urinary catheters provide a superhighway for indigenous normal flora to access the urinary bladder
70% of nosocomial infections involved drug resistant bacteria

HARD TO TREAT NOSOCOMIAL AGENTS

Pseudomaonas infections MRTB VRE MRSA MRSE Others (developed drug-resistant)

HIV Candida spp. Malarial parasites

MOST COMMON TYPES OF NOSOCOMIAL INFECTIONS

1.
2. 3. 4.

Urinary Tract Infections Surgical Wound Infections Lower Respiratory Tract Infections Bloodstream Infections

Nosocomial Infection of the GIT is commonly caused by Clostridium difficile

Produces enterotoxin and cytotoxin AAD (Antibiotic- Associated Diarrhea)enterotoxin PMC (Pseudomembranous Colitis) - cytotoxin

MOST VULNERABLE PATIENTS IN HOSPITAL SETTINGS

Elderly patients Women in labor and delivery Premature infants and newborns Surgical and burn patients Diabetic and cancer patients Patients receiving treatment with steroids, anticancer drugs, anti-lymphocyte serum and radiation Immunosuppressed patients Patients who are paralyzed and undergoing renal dialysis or catheterization

MAJOR FACTORS CONTRIBUTING TO NOSOCOMIAL INFECTIONS

Increasing number of drug resistant pathogens Failure of personnel to follow infection control guidelines Increased number of immunocompromised patients

OTHER FACTORS

Indiscriminate use of antimicrobial agents

False sense of security about antimicrobial agents Lengthy, more complicated type of surgery Overcrowding of hospitals, shortages of staff

Increase use of less-highly trained healthcare workers Increase use of antiimflammatory and immunosuppressed agents Overuse and improper use of indwelling medical devices

TABLE 12 1 (p.201)

TWELVE STEPS TO PREVENT ANTIMICROBIAL RESISTANCE AMONG HOSPITALIZED ADULTS

WHAT CAN BE DONE TO REDUCE THE NUMBER OF NOSOCOMIAL INFECTIONS?

WASH HANDS BEFORE YOU . . . WASH HANDS AFTER YOU. . .

WASH HANDS IN THE FOLLOWING MANNER. . .

Roughly 1/3 of adults seem to have forgotten one of the most basic lessons their mothers taught them: wash your hands properly. Although 95% of people say that they scrub after using public toilets, researchers from the American Society of Microbiology found that only 67 % actually do.

PROPER HANDWASHING-It is better to be safe, than to be sorry.

WHATS THE WORD?

INFECTION CONTROL
Numerous measures that are taken to prevent infections from occurring in healthcare settings

TWO TYPES OF ASEPSIS

MEDICAL ASEPSIS
clean technique involves procedures and practices that reduce the number and transmission of pathogens
Hand washing Personal grooming Proper cleaning of supplies and equipments Disinfection

SURGICAL ASEPSIS
sterile technique practices use to keep objects and areas sterile
Scrubbing hands and fingernails Sterile gloves , masks, gowns, shoe cover Using sterile solutions and dressing

STANDARD PRECAUTIONS (CDC)

designed to reduce the risk of transmission of blood borne and other pathogens in hospitals contains guidelines for:
Hand washing Wearing of gloves, masks, eye protection Cleaning of patient care equipment Others

FIGURE 12-6 (P.207)

STANDARD PRECAUTIONS FOR INFECTION CONTROL

FIGURE 12-9 (P.210)

AIRBORNE PRECAUTIONS FIGURE 12-9 (P.211) DROPLET PRECAUTIONS FIGURE 12-12 (P.212)

CONTACT PRECAUTIONS

WORD TO PONDER. . .
All healthcare workers MUST fully comprehend the problem of nosocomial infections, MUST be completely knowledgeable about infection control practices, and MUST personally do everything in their power to prevent nosocomial infections from occurring.

CARRY OVER - ACTIVITY

(1/2 CW)
Interview doctors and paramedical practitioners of the effective ways employed in the hospital to reduce nosocomial infections.

DIAGNOSING INFECTIOUS DISEASES

The proper diagnosis of an infectious disease requires the following:

Taking a complete patient history Conducting a thorough physical examination of the patient Carefully evaluating the patients signs and symptoms, and

Implementing the proper selection, collection, transport and processing of appropriate clinical specimens

Various clinical specimens used to diagnose or follow up infectious diseases

Blood Urine Feces Cerebrospinal fluid Others

It is extremely important that these specimens are of the highest possible quality and that they are collected in a manner that does not jeopardize either the patient or the person collecting the specimen.

When an attending physician suspects that a patient has a particular infectious disease, appropriate clinical specimens must be obtained and certain diagnostic tests may be requested.
The doctor or any qualified healthcare professional must select the appropriate specimen, collect it properly, and then properly transport it to the laboratory where it is processed.

All specimens should be collected or transferred into a leakproof primary container with a secure closure. Care should be taken by the person collecting the specimen not to contaminate the outside of the primary container within the institution , the primary container should be placed into a second container, which will contain the specimen if the primary container breaks or leaks in transit to the laboratory.

Clinical and Laboratory Standards Institute (CLSI)

THREE COMPONENTS OF SPECIMEN QUALITY

Proper selection of the specimen (i.e., to determine the proper specimen)

Proper collection of the specimen Proper transport of the specimen to the laboratory

WHEN CLINICAL SPECIMENS ARE IMPROPERLY COLLECTED AND HANDLED:

The etiologic agent may not be found or maybe destroyed

Overgrowth by indigenous microflora may mask the pathogen Contaminants may interfere with the identification of pathogens and the diagnosis of the infectious disease

PROPER SELECTION, COLLECTION AND TRANSPORT OF CLINICAL SPECIMENS

Specimen must be properly selected

Specimen must be properly and carefully collected

Specimen should be collected at the right site, where the least contamination is likely to occur
Specimen should be taken before antimicrobial therapy has begun

The acute stage of the disease is the most appropriate time to collect most specimens
Exercise care and tact, avoid harming patient or causing discomfort or undue embarrassment to the patient Collect sufficient quantity of the specimen

Collect specimen in sterile container

Protect specimen from heat and cold and prompt delivery to the lab is a must Hazardous specimens must be handled with even greater care to avoid contamination of the courier, patients and healthcare professionals

Use sterile, disposable specimen containers Properly label specimen container, submit with appropriate request slip
Specimen should be delivered to the lab ASAP.

DATA INCLUDED IN THE REQUEST SLIP

Patients name, age, sex Hospital identification number Name of the requesting physician Info about the type of specimen Site from where it is collected Date and time of collection Initials of the person who colleted the specimen Information about any antimicrobial agents taken by the patient

The proper specimen to diagnose UTI is a clean-catch, mid-stream urine (CCMS). It must be refrigerated until it can be transported to the laboratory
Cerebrospinal specimen should be submitted to the laboratory and processed immediately

Routine throat swabs are collected to determine whether a patient has strep throat.

N. gonorrheae is a fastidious pathogen that

is both microaerophilic and capnophilic. Therefore it should be inoculated immediately into a highly enriched and highly selective medium

PATHOGEN ESIS OF INFECTIOUS DISEASES

Clinicians and people in the paramedical field like nurses are aware that something is wrong with a patient when they see some changes in the person - like his skin color
(eg. yellowish discoloration in jaundice, paleness in anemia or bluish black discoloration in the case of hematoma)

SIGN OR SYMPTOM?

Symptom of the disease

experienced or perceived by the patient (subjective)

Sign of the disease

objective evidence of the disease (palpation of lumps, enlarged liver or spleen, abnormal heart or breath sound, pulse rate, heart rate, lab results, ultrasound, CT scan, etc)

Do all sick people manifest signs and symptoms of the disease?

Symptomatic patient experiencing symptom

Asymptomatic patient is unaware, not experiencing any symptoms

When we study the structural and functional manifestations of disease we are interested in PATHOLOGY.

Prefix Path disease

+ logist person (WHO) + gen causative agent (WHAT) + genecity ability to cause (WHY) + genesis steps in the development (HOW)

Infection versus Infectious diseases

Infection = pathogen ---landed and enters the persons body but may or may not cause the disease Infectious disease = pathogen landed and enters the persons body and cause the disease

Why an infection does not always occur?

Microbes land in anatomic sites where it is unable to multiply .(eg. H. influeanzae on skin) Microbes land on sites with no receptors Antibacterial factors like lysozymes in tears, saliva, perspiration Indigenous microflora (microbial antgonism)

Indigenous microflora produce antibacterial factors like bacteriocin Individuals health status Immunity to particular pathogen (vaccination) Presence of phagocytic wbc

Note : When all the mechanical barriers and cellular protection fail to do their job we get sick of infectious diseases

Four periods/phases in the course of infectious disease

The incubation Period - time between

the arrival of pathogen and the onset of symptoms.

Prodromal Period feeling of coming

down with something but are not yet sure what is it.

The period of illness time when patient

experiences the typical symptoms : sore throat, headache, sinus congestion (Communicable dses are most easily transmitted during the third period)

The convalescent period recovery

period (but for certain infectious diseases permanent damage may be caused by destruction of tissues. Eg. Deafness my follow ear infection)

Terminologies:

Localized infections disease localized in

one site or it my spread eg. Pimples, boils, abscess

Systemic infections (generalized)

infection spread throughout the body
eg. TB = miliary TB (spread in many internal organs)

Acute diseases rapid onset followed by

rapid recovery eg. Measles, mumps

Chronic slow onset and lasts a long time

eg. TB

Subacute more suddenly than chronic,

less suddenly than acute eg. Bacterial endocarditis

which go symptomatic to asymptomatic, and then go back to being symptomatic eg. Shingles

Latent infection infectious disease

Primary infection refers to the first

infection eg. Common cold

Secondary infection - second disease eg.

Secondary bacterial infection like pneumonia

Virulent strains microbes capable

of causing disease eg. encapsulated S. pneumoniae

Avirulent strains not capable of

causing disease eg. Nonencapsulted S. pneumoniae

Steps in the pathogenesis of infectious disease

Entry skin (bite of an arthropod), inhalation, ingestion, introduction thru the GUT, introduction directly into the blood)
Attachment to some tissues in the body Multiplication result in local infection (abscess) to systemic (throughout the body)

Invasion or spread of the pathogen

Evasion of host defenses Damage to host tissues- extensive damage = cause of patients death

Virulence factors
(attributes that enable pathogens to attach, escape destruction and cause disease)

Attachment
Receptors ( molecules in host cell that a pathogen recognize and attach to) and adhesions (molecules in the pathogen that is able to recognize and bind to a particular receptor) Fimbriae (pili) enable bacteria to attach to surfaces, hair-like

Flagella motility to avoid phagocytosis

Exoenzymes or toxins they produce (evade host defense mechanism)

Necrotizing enzymes destroys tissues (eg. C. perfringens gas gangrene)
Coagulase form sticky coat of fibrin around themselves (eg. S. aureus) Kinases fibrinolysin ( dissolution of clots) Hyaluronidase spreading factor destroys hyaluronic acid which cements the tissues together

 Collagenases-destroys collagen in tissues thus enables pathogens to invade tissues (C. perfringens)
Hemolysins cause damage to hosts rbc (hemolysis) Lecithinase destruction of muscle tissues (C. perfringens)

Toxins
Endotoxin released by Gram (-) organisms cauring fevers, chills and eventully shock (low bp and inadequate blood supply to brain and kidneys)

Exotoxins secreted by organisms

Neurotoxins target CNS (C. tetani) Enterotoxins affect GIT (B. cereus) Exfolitive toxin affects layers of the skin (S. aureus scalded skin syndrome) Leukocidins destroy wbc (Stph, Strep, Clostridia)

How can Pathogens escape Immune Response?

Antigenic variation pathogens able to change their surface antigens - host cell cannot recognize (eg, influenza virus)

Camouflage and Molecular mimicry some coat themselves with host protein so as not to be recognized as foreign (eg. N. gonorrheae)
Destruction of Antibodies produce enzymes that destroy IgA antibodies (H. influenza)