MICROBIAL AGENTS

OF OB-GYN INFECTIONS

dr. Zulkaidah
Bagian Mikrobiologi
Fakultas Kedokteran Universitas Hasanuddin,
Makassar 2012

tes for taking specimen for vaginal discharge

VAGINITIS

CAUSES OF VAGINITIS IN ADULT

Common
Infection

Bacterial vaginosis
Vulvovaginal Candidiasis
Trichomonal vaginitis

Uncommon
Infection

Atropic vaginitis with secondary infection

Foreign body with secondary infection
Desquamative inflamatory vaginitis
Streptococcal vaginitis
Ulcerative vaginitis associated with Staph.
aureus & Toxic Shock Syndrome
Idiopathic volvovaginal ulceration
associated with HIV

Non-infectious vaginitis

BACTERIAL VAGINOSIS (BV)

Is a disorder of the vaginal ecosystem
characterized by a shif in the vaginal flora
from

the

normally

predominant

Lacto-

bacillus to one dominated by a mix flora

including

Gardnerella

Provotella,

Bacteroides,

species.

vaginalis
and

and

Mycoplasma

MICROBIAL AGENTS OF INFECTIOUS

VAGINITIS

VAGINITIS

AGENTS

Bacterial vaginosis Gardnerella vaginalis

Provotella spp.
Bacteroides spp.
Mycoplasma spp

Vulvovaginal
candidiasis
Trichomonal
vaginosis

Candida albicans
Candida tropicalis
Candida stellatoidea
Candida pseudotropicalis
Trichomonas vaginalis

INFECTION OF FEMALE PELVIS

MICROBES WILL BE DISCUSSED

FACULTATIVE ANAEROBES

Gardnerella vaginalis

Fungi

Candida albicans

PARASITE
Flagellate Trichomonas vaginalis
Sporozoan Toxoplasma gondii

GARDNERELLA VAGINALIS

Gardnerella vaginalis:

Found in the human urogenital tract

In BV large number Serves as one
indicator organism of the syndrome
In BV hydrogen peroxide producing
Lactobacillus increase of:
- G. vaginalis,
- anaerobic negative-gram bacilli
- Peptostreptococci (is a genus of
anaerobic,
gram +, non-spora
forming bacteria. )
- Mycoplasma

CLASSIFICATION-TAXONOMY

Taxonomy position of Gardnerella vaginalis

remained unsolved
On the basic of superficial growth
characteristic or morfology classified as
a member of genus:
- Haemophilus, or
- Corynebacterium
But by DNA-hybridization studies: new
genus Gardnerella

GENERAL CHARACTERISTICS

GARDNERELLA VAGINALIS GRAM STAIN

GARDNERELLA VAGINALIS

Penyebab terbanyak BV
Morfologi: Basil
Bakteri gram (- & +)
Motilitas (-)
Fakultatif anaerob

LABORATORY IDENTIFICATION

Specimens:
- Cervical, urethral & vaginal swabs
- Sign of sepsis : blood
Can be detected best by Gram stain
Culture not recommended result
not specific enough to predict
reliability the presence of the
syndrome.

PRESUMPTIVE DIAGNOSIS OF BV
Amsels criteria 3 of the following 4:
Homogenous vaginal discharge
Direct wet mount of vaginal discharge
shows clue cells
Characteristic fishy odor of material,
particularly after addition of 10% KOH
(potassium hydroxide)
pH >4.5

CLUE CELL
squamous epithelia
cells covered with
tiny bacilli,
especially around
the periphery,
giving the cell a
stippled
appearance.

DISCHARGE FEATURES OF INFECTIOUS VAGINOSIS

FIATURES CANDIDA
VAGINITIS

BACTERIAL
VAGINOSIS

TRICHOMONAS
VAGINITIS

Amount

Moderate

Profuse

White/gray
Homogenous,
uniformly coating
walls
Present
>4.7
Positive

Yellow
Homogenous

Clue cells,
coccobacillary
flora predominant, absent of
leukocytes
Clue cells, Gr-neg
coccobacil, no
PMN

PMNs +++, motile

trichomonands (8090%), no clue cell,
abnormal flora.

Color
Consistency

Scant to
moderate
White
Clumped but
variable

Bubbles
pH
Amine test
10% KOH
Saline
microscopy

Absent
<4.5
Negative

Gram

Blastospore
Pseudohyphe
Gr+ Rods

Normal flora,
Blastospore, 4045% pseu
dohype

Present
5.0 6.0
Occasionally present

PMNs +++,
Trichomonad, no clue
cell

CANDIDA

VULVOVAGINAL CANDIDIASIS
Superficial Candidiasis:
The most common candidiasis skin &
mucosa
By NF of skin & mucosa colonization
Predispose factors :
- Impaired cellular immunity or
neutropenia
- Prolonged antibiotic therapy
- Invasive procedure

CLASSIFICATION
.

Order: Cryptococcales
Genera: Candida
Species:

C. albicans : paling patogen.

C. tropicalis,
C. parapsilosis,
C. guilliemondi,
C. kefyr,
C. krusei,
C. lusitaniae,
C. glabrata

MORPHOLOGY
C. albicans : dimorphic fungi

budding yeast cells, reproduce by budding or fission

pesudohyphae,
true hyphae = mycelium
chlamydospores : big and round (Chlamydospore is
the thick-walled big resting spore of several kinds of
fungi. It is the life-stage which survives in
unfavourable conditions, such as dry or hot
seasons.)
Blastospores (an asexual fungal spore produced by
budding )

SPORE FORMATION

Segmentation of hyphae = ARTHROSPORE

Thick-walled spore = CHLAMYDOSPORE

Spore formed in a sac (sporangium) at the

tips of hyphae = SPORANGIOSPORE

Spore formed at the tips or sides of hyphae

=
CONIDIOSPORE
(Macroconidia
&
microconidia)

Spore formed by budding from a mother cell

= BLASTOSPORE

A. BLASTOSPORES & PSEUDOHYPHAE

B. CLAMYDOSPORES, PSEUDOHYPHA & BLASTOSPORA
C. YEAST CELLS FORM GERM TUBES

COLONIES

On agar Sabouraud (24 hr at 37ooC):

soft, cream-colored
yeasty odor
pesudohyphae grow below the agar surface

Only C. albicans produce pseudohyphae

In serum for 90 at 37ooC:
germtubes & true hyphae

On corn-meal agar :

- blastospores,
- pseudohyphae
- chlamydospores

Identification confirmation:

Sugar fermentation & assimilation tests

PATHOGENESIS

Superficial Candidiasis
(mucocutaneus): increased local census of

candida damage the skin or epithelium

permit local invasion of the yeast &
pseudohyphae imflamatory reaction:
pyogenic abscesses to chronic granulomas.

Systemic Candidiasis
candida enter the blood stream &
phagocytic host defences are inadequate to
contain the growth and dissemination of the
yeasts.

CLINICAL FINDING

Cutaneus and Mucosal Candidiasis

- Vulvovaginitis
- Oral trush
- Cutaneus Candidiasis
- Oncomycosis

Systemic Candidiacis: everywhere, eg:

- arthritis
- meningitis
- endphthalmitis

Chronic Mucocutaneus Candidiasis:

onset in early childhood, associated with cellular

immunodeficiency & endocrinopathies chronic
superficial disfiguring infections of skin or
mucous.

DIAGNOSTIC LABORATORY TESTS

Specimen
scraping
scraping from
from superficial
superficial lesion,
lesion, exudates,
exudates, blood,
blood, spinal
spinal fluid,
fluid, tissue
tissue
biopsies,
biopsies, urine,
urine, material
material from
from removal
removal intravenous
intravenous catheter
catheter

Microscopic examination
- Gram
Gram stain
stain of
of tissue,
tissue, centrifuged
centrifuged spinal
spinal fluid,
fluid, &
& other:
other:

pseudohyphae
pseudohyphae &
& budding
budding cells
cells (strongly
(strongly Gram-positive)
Gram-positive)
-- Skin
Skin &
& nail
nail scraping
scraping
10%
10% KOH
KOH

Culture
- Yeast
Yeast colonies:
colonies: wet
wet mount
mount or
or Gram:
Gram: pseudohyphae,
pseudohyphae,
-

chlamydospore,
chlamydospore, germ
germ tubes
tubes
Biochemical
Biochemical reaction
reaction

Serology (limited used: sensitivity & specificity )

Ab titers & cell mediated immunity

Candidiasis
Candida albicans (85%)
C. stellatoidea, C. tropicalis,
C. krusei, Torulopsis
glabrata
Sexually-associated
disease
Itchy / thick curdy discharge
Vaginal soreness, vulvar
burning, dyspareunia, dysuria

MICROSCOPIC FIGURE CANDIDA ALBICANS

IN LACTOPHENOL COTTON BLUE

YEAST (DIRECT SMEAR)

YEAST (GRAM)

CANDIDA ALBICANS PADA SEKRET VAGINA

CANDIDA ALBICANS

PERTUMBUHAN CANDIDA ALBICANS

MEDIUM PERTUMBUHAN JAMUR

SDA (Saboroud Dextrose Agar)

Patato Dextrose Agar
Corn Meal Agar

TREATMENT

Mucocutaneus candidiasis
- nystatin, ketokonazole, or fluconazole
(topical)
- eliminating contributing factors

Systemic candidiasis:
- systemic amphotericin, sometimes +
- flucytonsine, fluconazole, or caspofungin orally

Chronic mucocutaneus candidiasis

- ketoconazole or other azones
- lifelong treatment

TRICHOMONAS VAGINALIS

CLASSIFICATION
Kingdom: Protozoa
Phylum: Sarcomastigophora

Subphylum: Mastigophora (flagellate)

1. Intestinal & Genitourinary flagellates
Giardia, Trichomonas, Dientamoeba,
Chilomastrix
2. Blood & Tissue flagellates
trypanosoma, Leismania

Species:
1. Trichomonas tenax
2.
2. Trichomonas hominis
3.
3. Trichomonas vaginalis

MORFOLOGY

Pear shape
Axostyle (is a sheet of microtubules
found in certain microbial
eukaryotes. It arises from the bases
of the flagella, sometimes
projecting beyond the end of the
cell, and is often flexible or
contractile, and so may be involved
in movement and provides support
for the cell
Short undulating membrane lined
with a flagellum
4 anterior flagella

Chromatin basal
body
Chromatin granules
Nucleolus
Para basal fiber
Posterior flagellum
Move with wobbling
& rotating motion

LIFE CYCLE

PATHOGENESIS

Normal habitats: human vagina & prostate

gland
T. hominis & T. tenax: harmless commensals
T. vaginalis: low-grade inflammation
In : infection normally limited to vulva,
vagina and cervix
In : Prostate, seminal vesicles, and urethra
may be infected.

Factors affecting pathogenicity:

Intensity of infection

pH & physiological status of the vagina and

other genitourinary tract surfaces
The organism do not survive at normal
vaginal acidity of pH 3.8-4.4

Accompanying bacterial flora

LABORATORY DIAGNOSIS

Specimen:
Vaginal or urethral discharge
Microscopic examination:
Wet preparation in a drop physiological
saline motile trichomonas
Dried smears can be stain with
hematoxylin, Gram or Giemsa
Culture if microscopic negative
- Vaginal or urethral discharge,
- Prostatic secret
- Semen specimen

Trichomoniasis
Protozoan : Trichomonas vaginalis
Profuse, offensive,
greenish-yellow,
frothy vaginal
discharge
Vulvar irritation
Some normal /
minimal
symptoms
Strawberry cervix

Diagnostic guidelines
Trichomoniasis Presumptive Definitive diagnosis
diagnosis
Purulent, frothy Ovoid protozoan Culture for
malodorous
with jerky motility trichomonads
using
vaginal discharge (sensitivity:60-70%) FeinbergWhittington
dysuria, vaginal
or Trichosel broth
itch
media (Baltimore
Biological Lab)
(Most sensitive)

Saline wet mount

Flagellated
trichomonad
Giemsa stain

TRICHOMONAS VAGINALIS

TREATMENT

Successful treatment destruction of the

trichomonands
Best: topical and systemic metronidazole
(flagyl)
Tinidazole (Fasigyn) and ornidazole
(tiberal) equally effective with fewer side
effects.
Patient sex-partner examined & treated
simultaneously.
Postmenopausal: may be need estrogen

TOXOPLASMA GONDII

MORFOLOGY

Tropozoite:

Boat shape
Thin wall : 4-7 x 2-4m
within tissue cells larger
outside them
Stain lightly with Giemsa

MORFOLOGY
Oocyst

Within oocyst 2
sporocysts form
4 sporozoites in each
sporocyst

LIFE CYCLE

Coccidian protozoan world wide

Infect wide range animals and birds not cause
disease
Normal final host: cats in which oocystsproducing sexual stage of toxoplasma can develop.
Organisms (sporozoites from oocyts or bradyzoites
from tissue cysts) invade mucosal cells of cats
intestine form schizonts or gametocytes.
After sexual fusion of the gametes, oocysts
develop, exit from the host cell into the gut lumen
of the cat and pass out via the feces.

Human infection may acquired in several ways:

Ingestion of undercooked infected meat containing
Toxoplasma cysts
Ingestion of oocysts from fecally contaminated
hands or food
Organ transplantation or blood transfusion
Transplacental transmission
Accidental inoculation of tachyzoites

LABORATORY DIAGNOSTIS

Specimens:
Blood, sputum, bone marrow, cerebrospinal fluid, &
exudates.
Lymph node, tonsillar, striated muscle biopsy.

Microscopic examinations
Smears & sections stained with Giemsas, or other special
stain such as periodic acid-Schiff technique densely
packed cysts.

Animal inoculation
Commonly used for definitive diagnosis.

Serology
IFA and ELISA tests

TOXOPLASMA GONDII
A. TACHYZOITES: STAINED WITH GIEMSA
B. CYSTS IN BRAIN TISSUE

TOXOPLASMA GONDII

TREATMENT

Combination:
pyrimethmine & sulfadiazine/trisulfapyrimidines
Alternative drugs:
spiramycin, clindamycin, trimethoprimsulfamethoxazole
For use in pregnancy:
spiramycin (Rovamycin) until delivery.

FURTHER READING

Baron, JD; Peterson, LR; Finegold, SM: Bailey & Scotts

Diagnostic Microbioloy, 9th edition, Mosby, Sydney, 1994.
Brooks, GF; Butel, JS; Morse, SA: Jawezt, Melnick, &
Adelbergs Medical Microbiology, 23rd Edition,
International Edition, McGraw-Hill, Kuala Lumpur, 2004.
Cohen, J., et all: Infectious Diseases, Volume 1, 2nd Edition,
Mosby, Sydney, 2004.
Ryan, KJ; Ray CG: Sherris Medical Microbiology, an
Introduction to Infectious Diseases, 4th Edition, McGrawHill, Singapore, 2004.
Joklik, WK; Willett, HP; Amos, DB; Wilfret, CM: Zinsser
Microbiology, 20th Edition, Appleton & Lange,
Connecticut, 1992.
Virella, G.: Microbiology and Infectious Diseases, 3rd
Edition, Wlliams & Wilkins, Tokyo, 1997.

TERIMA KASIH