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. B. pertussis pertussis (whooping cough) in human
2. B. parapertussis mild whooping cough
3. B. bronchiseptica opportunistic of respiratory tract and wound
infection in human, also infection in animal(kennel cough in dog)
4. 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
1 Filamentous haemagglutinin
(FHA)
2 Fimbriae
3 Pertactin
4 Pertussis toxin
5 Adenylate cyclase
toxin/haemolysin
6 Dermonecrotic toxin
7 Tracheal cytotoxin
8 Lipooligosaccharide
9 Tracheal colonization factor
Function/Effect
Adherence to ciliated respiratory
epithelial cells
Facilitate binding capabilities
Bacterial adherence
Lymphocytosis
Catalyzing production of cAMP
inhibit phagocytic and NK cell activity
Inflammation and local necrosis
Ability to damage ciliated respiratory
epithelial cells
Endotoxin, aid colonization
Bacterial 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. Pneumonia
2. Complication neurologis (kejang & encelopati)
3. Apnea
4. Death
Complication in adult
1. Pneumonia
2. Weight loss
3. Loss of bladder control
4. 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 sensitivity sampling during the first 3 weeks
Direct fluorescent antibody
For screening
Serologi
No standardization
Positive if IgA is detected against whole cell of B. pertussis
 B
A

Sample collection :
A. Nasopharyngeal swab
B. Nasopharyngeal aspirate
Sumber :
http://www.cdc.gov/pertussis/clinical/diagnostic-
testing/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 : Sumber :
http://intranet.tdmu.edu.te.ua/data/cd/ http://pathmicro.med.sc.edu/mayer/m%20h
disk2/ch037.htm ominis.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 Syndrome
Erythema
Steven 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 4o 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. Self-
limiting.
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