Int J Biol Med Res.

2011; 2(4): 979- 981

Int J Biol Med Res
Volume 2, Issue 4, Oct 2011

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International Journal of Biological & Medical Research

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International Journal of BIOLOGICAL AND MEDICAL RESEARCH

Original Article

Moraxella catarrhalis - A Rediscovered Pathogen H. V. Prashanth a , R. M. Dominic Saldanha b*, Shalini Shenoy b
a Associate Professor, Department of Microbiology, Sri Siddhartha Medical College, Tumkur, karnataka. Associate Professor b, Professor b, Department of Microbiology, Kasturba Medical College, Mangalore, Karnataka.

ARTICLE INFO Keywords: Moraxella catarrhalis lower respiratory tract infection Beta Lactamase and Pneumonia

ABSTRACT

Aims: The purpose of our study was to evaluate the significance of Moraxella catarrhalis as a pathogen in causing lower respiratory tract infection. Methods: Patients suspected to be suffering from lower respiratory tract infection were considered Only sputum samples of high bacteriological quality were analysed. All specimens were cultured. Identification was done by standard microbiological methods. Certain criteria were considered for determining pathogenic significance of an Moraxella catarrhalis[6]. Results: A total of 2430 sputum samples were screened 1550 were further examined as they were of high bacteriological quality. Moraxella catarrhalis isolated were categarised as significant(71), probably significant(34), indeterminate and non significant(5). The pathogens associated with Moraxella catarrhalis were Streptococcus pneumoniae, Hemophilus influenza, Klebsiella spp. and Pseudomonas spp It was sensitive to Tetracycline(100%), Amoxyclav(100%) and pencillin(24%). Conclusion: M. catarrhalis has finally gained respect as a pathogen thanks to the many recent reports of its causal role in a variety of infections Our study shows that when microbiological and clinical criteria are met, Moraxella catarrhalis when isolated should be considered as a pathogen causing lower respiratory tract infections.
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1. Introduction Moraxella catarrhalis is a aerobic Gram negative diplococci [1]. For most of the past century, Moraxella catarrhalis was regarded as an upper respiratory tract commensal organism. However, since the late 1970s it has been clear that M. catarrhalis is an important and common human respiratory pathogen [2]. Many studies have revealed its involvement in respiratory (e.g., sinusitis, otitis media, bronchitis, and pneumonia) and ocular infections in children and in laryngitis, bronchitis, and pneumonia in adults [3,4]. Its capacity to produce beta lactamase, first noted in 1977, may cause penicillin resistance in mixed infection by protecting other pathogens usually susceptible to beta lactum antibiotics [2].
* Corresponding Author : Dr. R. M. Dominic Saldanha Associate Professor, Department of Microbiology, Kasturba Medical College, Mangalore, Karnataka, India-575 001. Email: drdoms@gmail.com
c

The emergence of M. catarrhalis as a pathogen in the last decade together with increasing prevalence of lactamase producing strains has renewed interest in this bacterial species [3]. The purpose of our study was to evaluate the significance of Moraxella catarrhalis as a pathogen in causing lower respiratory tract infection. 2. Materials and Methods Patients suspected to be suffering from lower respiratory tract infection were considered. Sputum samples were collected. Only sputum samples of high bacteriological quality were analysed (<10 epithelial cells, >25 polymorphonuclear leucocytes /low power field). All specimens were cultured on either 5% horse blood agar or chocolate agar. Identification was done by standard microbiological methods and antibiotic susceptibility testing was done by Kirby-Bauer disc diffusion technique [5]. The following criteria were considered for determining pathogenic significance of an isolate [6].

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H. V. Prashanth et.al / Int J Biol Med Res. 2011; 2(4): 979- 981 980

1. Clinical evidence of infection with Moraxella consistent with the disease spectrum associated with M catarrhalis (cough with sputum production, sinusitis ). 2. Moraxella catarrhalis as a predominant potential pathogen isolated from an appropriate and adequate specimen. 3. Clinical response on treatment with antibiotic to which isolate was susceptible. Taking the above mentioned criteria into consideration, the interpretation was as follows: Significant isolate: if criteria 1, 2 and 3 were present. Probably significant isolate: if criteria 1 and 2 were present and 3 could not be assessed. Indeterminate isolate: if only criterion 1 was present. Not significant: if none of the criteria were present. 3. Results A total of 2430 sputum samples were screened. Only 1550 were further examined as they were of high bacteriological quality. The specimens were subjected to culture and antibiotic sensitivity studies. Moraxella catarrhalis isolated were categarised as significant, probably significant, indeterminate and non significant. In 71 patients it was recovered as significant, 34 patients as probably significant, and in 5 patients isolates were not significant (Table 1). Table 1: Interpretation of isolates as per criteria 1, 2, and 3.
Organisms Total grown with M. Catarrhalis in culture. Number of Significant isolates. 41 Number of probable significant isolates. 16 Number of indeterminate isolates 0 Isolates not significant.

Table 2: Presentation of patients with M. cararrhalis isolates interpreted as significant and probably significant.
Diagnosis Pneumonia Bronchitis Bronchiectasis Sinusitis Total Significant 43 13 9 6 71 Probably Significant 19 8 5 2 34

4. Discussion In the past, M. catarrhalis was considered a nonpathogenic member of the resident flora of the nasopharynx. The clinical interest in M. catarrhalis is only relatively recent, and many laboratories did not report M. catarrhalis as a pathogen, especially when a well-recognized pathogen (e.g., S. pneumoniae or H. influenzae) was present as well[3]. Colonies of M. catarrhalis resemble commensal Neisseria that are present in the normal human upper airway flora. The difficulty in distinguishing colonies of M. catarrhalis from those of Neisseria explains, in part, why M. catarrhalis has been overlooked as a respiratory tract pathogen [2]. It has been suggested that there is a possible underestimation of isolation rates for M. catarrhalis, since the bacterium stops growing in environments with reduced oxygen concentrations, a condition frequently present during sinusitis and otitis media. This would indicate an even greater role for M. catarrhalis in the etiology of these infectious diseases. Over the last 20 to 30 years, the bacterium has emerged as a genuine pathogen and is now considered an important cause of upper respiratory tract infections in otherwise healthy children and elderly people. Moreover, M. catarrhalis is an important cause of lower respiratory tract infections, particularly in adults with chronic obstructive pulmonary disease (COPD)[3]. In immunocompromized hosts, the bacterium can cause a variety of severe infections including pneumonia, endocarditis, septicemia, and meningitis [3]. The M. catarrhalis carriage rate in children is high (up to 75%). In contrast, the carriage rate of M. catarrhalis in healthy adults is very low (about 1 to 3%). This inverse relationship between age and colonization has been known since 1907 and is still present today. At present, there is no good explanation for the difference in rates of colonization between children and adults; one explanation may be the age-dependent development of secretory immunoglobulin A (IgA). In Children, nasopharyngeal colonization often precedes the development of M. Catarrhalis mediated disease [7]. Studies have shown that organisms from the nasopharynx can spread easily to the middle ear and lungs [8]. Investigators using an in vitro oropharyngeal cell assay have shown that adherence of M.catarrhalis to epithelial cells is increased in the winter and in the elderly, especially those with underlying disease It is likely that colonization and adherence precede and facilitate infection in the upper and lower respiratory tract [6].

Streptococcus pneumoniae H. influenzae Klebsiella spp Pseudomonas spp None.

60

26 6 5

17 3 3

7 3 2

2 -

13

Of the 110 patients whose isolates were significant or probably significant, pneumonia was the commonest presentation in 62(56.36%), followed by bronchitis 21(19.09%) bronchiectasis 14(12.73%), and sinusitis in 8(7.27%) (Table 2). The pathogens associated with Moraxella catarrhalis were Streptococcus pneumoniae, Hemophilus influenza, Klebsiella spp. and Pseudomonas spp. (Table 1). In 36 cases, M catarrhalis was associated with both Streptococcus pneumoniae and H. influenzae. Thirteen cases revealed Moraxella catarrhalis alone as the single significant pathogen. It was sensitive to Tetracycline(100%), Amoxyclav(100%), Co-trimoxazole(82%), ceftriaxone(60%) and pencillin(24%).

H. V. Prashanth et.al / Int J Biol Med Res. 2011; 2(4): 979- 981 981

The isolates were sensitive to penicillin in only 24% of cases. However they were sensitive to amoxycillin-clavunilic acid combination in 100% of cases. This shows that majority of isolates (>70%) were beta lactamase producers as was seen in several studies [9,10]. In M. catarrhalis two types of -lactamases can be found that are phenotypically identical: the BRO-1 and BRO-2 types. Both are membrane associated, and they differ by only a single amino acid. The enzymes are encoded by chromosomal genes, and these genes can be relatively easily transferred from cell to cell by conjugation). Fortunately, both enzymes are readily inactivated by -lactamase inhibitors, and all isolates are still susceptible to amoxicillin in combination with clavulanic acid [3]. The production of Beta -lactamase M. catarrhalis, was first reported in 1977. Today, more than 90% of the strains isolated worldwide produce beta-lactamase. Beta-Lactamase from M. catarrhalis not only protects the bacteria producing the enzyme but also is thought to inactivate penicillin therapy of concomitant infections by serious airway pathogens such as S. pneumoniae and/or nontypeable H. influenzae. This phenomenon is referred to as the indirect pathogenicity of M. catarrhalis. Indeed, in such circumstances, treatment failures have been reported [3,11]. In our study, M. catarrhalis was associated with both Streptococcus pneumoniae and H. influenzae in 36 cases. Therefore, taking into consideration that M. catarrhalis has evolved to become a betalactamase producer, specific antibiotic therapy should be instituted in mixed infections for the adequate management of patients [12]. 5. Conclusion M. catarrhalis has finally gained respect as a pathogen thanks to the many recent reports of its causal role in a variety of infections [13]. It has become an important human pathogen that causes otitis media, sinusitis, conjunctivitis, acute exacerbation of chronic bronchitis, pneumonia, endocarditis, septicaemia and meningitis. Indeed, beta lactamase producing isolates of M. catarrhalis appear to be wide spread, and this may play an important role in the therapy of infections, particularly in the treatment of mixed infections [3].Our study shows that when microbiological and clinical criteria are met, Moraxella catarrhalis when isolated should be considered as a pathogen causing lower respiratory tract infections. 6. References
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