INFEKSI SALURAN

PERNAFASAN BAWAH
(LOWER RESPIRATORY
TRACT INFECTION)

Dian Widiyanti, SSi., MSi., Ph.D

Bagian Mikrobiologi

Fakultas Kedokteran Univ. YARSI

RESPIRATORY TRACT INFECTION

Sumber : http://www.atsu.edu/faculty/chamberlain/Website/lectures/lecture/introurt.htm

Bordetella

Morphology and other characteristic

Rod/cocobasil,

Gram negative
Obligate aerob, non motil
Growth temperature 35-37o C
Not fermenting carbohydrate
Oxidize amino acid
Generally positive catalase (B. pertussis variatif)
Example spesies of Bordetella :
1.
2.
3.

4.

B. pertussis pertussis (whooping cough) in human

B. parapertussis mild whooping cough
B. bronchiseptica opportunistic of respiratory tract and wound
infection in human, also infection in animal(kennel cough in dog)
B. avium turkey coryza

Bordetella pertussis
Aerobe, cocobasil Gram negative
Specific to human
Cause whooping cough (pertussis)

Severe

or uncontrollable coughing which can lead to

vomiting and aspiration

Colonizing respiratory tract pertussis (whooping

cough)
Transmision highly contagious, via respiratory
droplet or respiratory secretion. Most infectious
catarrhal stages and the first 2 weeks after onset
Pertussis cases 20-50 million / year

VIRULENCE FACTOR
No

Virulence factor

Function/Effect

Filamentous haemagglutinin
(FHA)

Adherence to ciliated respiratory

epithelial cells

Fimbriae

Facilitate binding capabilities

Pertactin

Bacterial adherence

Pertussis toxin

Lymphocytosis

Adenylate cyclase
toxin/haemolysin

Catalyzing production of cAMP

inhibit phagocytic and NK cell
activity

Dermonecrotic toxin

Inflammation and local necrosis

Tracheal cytotoxin

Ability to damage ciliated respiratory

epithelial cells

Lipooligosaccharide

Endotoxin, aid colonization

PATHOGENESIS

Sumber :http://www.my-pharm.ac.jp/~yishibas/research/Pertussis1.jpg

CLINICAL MANIFESTATION

Incubation period 7-10 hari

Consist of 3 stages:
1.
Catarrhal (1-2 minggu)
2.
Paroxysmal (1-6 minggu)
3.
Convalescent

Sumber : http://www.cdc.gov/pertussis/images/Pertussis-timeline-lg.jpg

COMPLICATIONS

Complication in children
1.
2.
3.
4.

Pneumonia
Complication neurologis (kejang & encelopati)
Apnea
Death

Complication in adult
1.
2.
3.
4.

Pneumonia
Weight loss
Loss of bladder control
Rib fracture

LABORATORY DIAGNOSIS

Isolation and culture

Nasopharing

posterior sample Dacron or calcium

alginate swab
Termasuk fastidious microorganism membutuhkan
medium khusus untuk pertumbuhan dan transport
charcoal agar, Bordet-Gengou agar, Regan-Lowe agar

Polymerase chain reaction (PCR)

Optimum

Direct fluorescent antibody

For

sensitivity sampling during the first 3 weeks

screening

Serologi
No

standardization
Positive if IgA is detected against whole cell of B. pertussis

Sample collection :
A. Nasopharyngeal swab
B. Nasopharyngeal aspirate

Sumber :
http://www.cdc.gov/pertussis/clinical/diagnostictesting/specimen-collection.html

Pertumbuhan koloni B. pertussis pada agar

Bordet-Gengou
Sumber : Committee on Infectious Diseases et al.
Red Book Online 553-566

PREVENTION

Vaccination
Whole

cell pertussis vaccine

Contain of suspension of formalin-inactivated B. pertussis

cells.
Known as DTwP
Efficacy 70-90%, protection reduce 5-10 yr after last booster
Local reaction redness, swelling, pain at injection site, fever.

Acellular

pertussis vaccine

Contain purified, inactivated component of B. pertussis (i.e

FHA, PT, pertactin, fimbriae)
Known as DTaP (for children 6 wk- 6yr) or Tdap (for
adolescence 10-64 yr)
Efficacy 80-85%
Local adverse reaction less frequently than DTwP

TREATMENT

Antibiotic

Macrolide

erithromycin, azithromycin, clarithromycin

Tetracycline doxycycline
Fluoroquinolone antibiotic levofloxacin, moxifloxacin

ATYPICAL PNEUMONIA
Pneumonia where the symptoms differ from those
pneumonia caused by common bacteria.
Causative agent :

Mycoplasma

pneumoniae
Legionella pneumophilla
Chlamydia pneumoniae

Mycoplasma

Morphology and other characteristic

Belong

to Mycoplasmataceae family
Smallest free-living organisms (diameter 0,3 m)
Slowly grow, facultative anaerobe, fastidious
Membrane contain cholesterol
No cell wall pleomorphic, stain poorly with Gram
stain and resistant to cell-wall active antibiotics (i.e.
penicillin, cephalosphorin)

Mycoplasma pneumoniae (electron

micrograph)

Sumber :
http://bioweb.uwlax.edu/bio203/s2007/wojtowic
_trav/Structure.htm

FRIED EGG COLONY IN SOLID

MEDIA

Sumber :
http://intranet.tdmu.edu.te.ua/data/cd/
disk2/ch037.htm

Sumber :
http://pathmicro.med.sc.edu/mayer/m
%20hominis.jpg

Exc. : M. pneumoniae show granular appearance

Mycoplasma species important for

human
Organism

Disease

Mycoplasma pneumoniae

Upper respiratory tract,

tracheobronchitis, atypical pneumoniae

Mycoplasma hominis

Pyelonephritis, pelvic inflammatory

disease, postpartum fever

Mycoplasma genitalium

Non-gonococcal urethritis

Ureaplasma urealyticum

Non-gonococcal urethritis

Mycoplasma pneumoniae
Also known as Pleuropneumoniae-like organism
(PPLO)
Caused atypical pneumoniae or walking pneumoniae
Predominant in children, young adult and confined
population or close contact group
Transmission via respiratory droplets

PATHOGENESIS

Adherence
P1

adhesin (168 kD) bind to

sialic acid on host epithelial
cell
Colonization of respiratory
tract cessation of ciliary
movement
Clearance mechanism stop
contamination dry cough

PATHOGENESIS

Toxic metabolic
product
H2O2

Superoxide

Immunopathogenesis
superantigen
Activate

macrophage
Stimulate cytokine
production
Stimulate lymphocyte
activation

CLINICAL MANIFESTATION

Tracheobronchitis
70-80

% infection

Pneumoniae
Primary

atypical
pneumoniae, mild but
long duration
Incubation 2 3 weeks
fever, headache,
malaise
Persistent productive
cough
Radiological sign
precede symptoms
Slow resolution, rarely
fatal

COMPLICATIONS

Pulmonary
ARDS

Bronchiolitis

obliterans
Respiratory failure

Extrapulmonary (< 10%)

Myocarditis
Pericarditis

Encephalitis

Guillain-Barre
Erythema
Steven

Syndrome

Johnson Syndrome

LABORATORY DIAGNOSIS

Microscopy

Difficult to be stained

Culture

Sputum (usually scant) or throat washing take times 2-3 weeks

Molecular diagnosis PCR

Serology

Complement Fixation test

Take 4-6 weeks

Positive if there is fourfold rise of antibody titer

Cold agglutinin

34-68% patients develop cold agglutinin

Antibody (anti I antigen) which agglutinate human erythrocyte at 4 o C but
not 37o C
Non specific, presumptive diagnosis

ELISA

Detect IgM

TREATMENT

Antibiotic

Macrolide

erithromycin, azithromycin,
clarithromycin

Legionella

History
In

1976, American Legion Convention in

Philadelphia, Pennsylvania
184 Legionnaires developed pneumonia
29 Legionnaires and 5 other in same hotel died

Legionella pneumophila

Morphology and other characteristic

Belong

to Legionellaceae family
Rod, Gram negative (weakly stained)
0,3 0,9 m (width) x 1,5 m (length)
Motile by polar flagella
Obligate aerobe
Facultative intracellular
Nutritionally fastidious

L-cysteine and iron are required

Medium Buffered charcoal yeast extract (BCYE)

Sumber : http://wiki.ggc.edu/wiki/File:Sy.jpg

Risk Factor :
Smoking,

alcohol
Increased age
Underlying disease

Lymphoma, leukimia, pulmonary disease, emphysema

Immuno-compromised

status

AIDS, T cell dysfunction

PATHOGENESIS
Dual host protozoa &
human alveolar macrophages
Intracellular pathogen
invade & replicate within
phagosome
Two phase growth

Replicative

phase non or
low toxicity, no flagel
Infectious phase toxic, has
flagel

Virulence factor :
Type

IV pili adherence
LPS endotoxin

Sumber : http://wiki.ggc.edu/wiki/File:Legionella-life-cycle.png

CLINICAL MANIFESTATION
Incubation period : 2 10 days
Clinical syndrome : pneumonia
Local symptoms : high fever, headache, cough,
chest pain, nausea, dyspnea, haemoptysis
Systemic symptoms : disorientation, vomiting,
confusion, nausea, diarrhea, renal insufficiency
PONTIAC FEVER :

Milder

infection of Legionella bacteria which lasted 2

5 days after infection. The symptom is different
because the patient dont have pneumonia. Selflimiting.

COMPLICATIONS
Lung failure
Death (5-30%)

LABORATORY DIAGNOSIS

Culture

Samples

sputum, lung biopsy specimen, pleural fluid,

bronchial washing, blood, environment
Inoculate on BCYE agar, which contain L-cysteine, iron,
polymixin B, anisomycin and vancomycin
Legionella stain poorly with Gram stain, but positive with
silver strain

Colony of Legionella on
BCYE agar

Enzyme Linked Immunosorbent Assay (ELISA)

Sample

paired sera (acute and convalescent stage)

Four-fold increase of antibody titer from paired sera
positive result

Urinary antigen detection

Principle

sandwich ELISA immunochromatography

TREATMENT