PATHOGENESIS

OF BACTERIAL INFECTION
Eka Jaiani

2024
 What is pathogenesis?
• Bacterial pathogenesis is the mechanism by
which bacteria cause infectious illness.
 Basic terms frequently used in describing
aspects of pathogenesis:

Adherence:
- The process by which bacteria stick to the surface of host cell.
Pathogenicity:
The ability of an infectious agent to cause disease.

Virulence:
The quantitative ability of an agent to cause disease.
Virulent agents cause disease when introduced into the
host in small numbers.
Virulence involves invasiveness and toxigenicity.
 Basic terms frequently used in describing
aspects of pathogenesis:
Carrier:
- A person or animal with asymptomatic infection that
can be transmitted to another susceptible person or
animal.
Toxigenicity:
The ability of a microorganism to produce a toxin that
contributes to the development of disease.
Invasion:
The process whereby bacteria, parasites, fungi and
viruses enter the host cells or tissues and spread
in the body.
 Basic terms frequently used in describing
aspects of pathogenesis:
 Pathogen:
› A microorganism capable of causing disease.
 Non-pathogen:
› A microorganism that does not cause disease. It may be part
of the normal flora.
 Opportunistic pathogen:
› An agent capable of causing disease only when the host´s
resistance is impaired (e.g. the patient is
immunocompromised).
› An agent capable of causing disease only when spread from
the site with normal bacterial microflora to the sterile tissue
or organ.
 Infection vs. Disease
 Infection is the multiplication of a pathogen in the host
 Disease results only if the invading pathogen alters the
normal functions of the body
 Etiology study of the cause of disease
 Transmission of Infection
• Contact
• Vehicle or vector
• Clinical manifestation often promote
transmission
• Asymptomatic infection
 Portals of Entry
 Sites through which pathogens enter the body
 Four major types
› Skin
› Mucous membranes
› Placenta
› Parenteral route
 Infectious dose
Vibrio cholerae - 106 cells Salmonella > 105 cells

Escherichia coli O157:H7

< 10 cells Bacillus anthracis – 104 spores
 Bacillus anthracis

Portal of Entry ID50

Skin 10–50 endospores

Inhalation 10,000–20,000 endospores

Ingestion 250,000–1,000,000
endospores
 Regulation of Bacterial Virulence
Factors
• Environmental signals:
temperature, pH, specific ions, nutrient factors and
etc.

Corynebacterium diptheriae toxin production– low iron

Vibrio cholerae toxin production - 30ºC, pH6.0, amino
acids
Listeria motility - 25ºC
 Pathogenesis
of bacterial infection
• Bacteria cause diseases by two major
mechanisms:
(1)Invasion and inflammation.
(2)(2) Toxin production.
• Characteristics of bacterial pathogens :
1) Transmissibility
2) Adherence
3) Invasion
4) Toxigenicity
5) Ability to evade the host’s immune system
Adherence, colonization, invasion, growth, disease
 Adherence factors
 Once bacteria enter the body of the host, they must
adhere to cells of a tissue surface. If they do not
adhere, they would be swept away by mucus and
other fluids from the tissue surface.

 Adherence (which is only one step in the infectious

process) is followed by development of microcolonies
and subsequent complex steps in the pathogenesis of
infection.
 Adherence factors
• The interactions between bacteria and tissue cell
surfaces in the adhesion process are complex.

• Several factors play important role:

– surface hydrophobicity and charge
– Capsule or slime layer
– binding molecules on bacteria and host cell receptor
interaction
– Pilli (e.g. E.coli)
– Fimbriae (e.g. Streptococcue pyogenes, Lipoteichoic
acid, F and M protein)
Adherence
Adherence
Adherence
 Penetration into the Host Cells and
Tissues
• Effector
molecules
– Salmonella
alters host
actin to enter
a host cell
• Use actin to
move from
one cell to
the next Pathogens may invade
– Listeria host intracellular or
extracellular environments.
 Toxins
 Toxins produced by bacteria are generally classified into
two groups:
› exotoxins
› endotoxins
 Some Definitions

• Toxin: Substance that contributes to

pathogenicity
• Toxigenicity: Ability to produce a toxin
• Toxemia: Presence of toxin in the host's blood
• Toxoid: Inactivated toxin used in a vaccine
• Antitoxin: Antibodies against a specific toxin
 Exotoxin

Source Gram +and Gram-

Relation to microbe By-products of growing cell
Chemistry Protein
Fever? No
Neutralized by antitoxin? Yes
LD50 Small

Figure 15.4a
 Exotoxins & Lysogenic Conversion

Exotoxin Lysogeny
Corynebacterium A-B toxin
+
diphtheriae
Streptococcus Membrane-disrupting
+
pyogenes erythrogenic toxin
Clostridium botulinum A-B toxin; neurotoxin +

C. tetani A-B toxin; neurotoxin

Vibrio cholerae A-B toxin; enterotoxin +

 Endotoxins

Source Gram
Relation to Microbe Outer membrane
Chemistry Lipid A
Fever? Yes
Neutralized by Antitoxin? No
LD50 Relatively large
Endotoxins and the Pyrogenic
Response
 Pathophysiological effects of endotoxins are
similar regardless of their bacterial origin:
› fever
› leukopenia
› hypotension
› impaired organ perfusion and acidosis
› activation of C3 and complement cascade
› disseminated intravascular coagulation (DIC)
The Action of an A-B Exotoxin

Figure 15.5
 Action of Tetanus Neurotoxin

– Tetanus causes irreversible muscle paralysis (‘spastic paralysis’ or ‘lockjaw’)

 Action of Botulinum Neurotoxin

• Botulinum toxin, the most poisonous substance known, causes

‘flaccid paralysis.
 Toxins of Clostridium perfringens
 Spores of Clostridium perfringens are introduced into
the wounds by contamination with soil or feces.
 Many of these are necrotizing and hemolytic and favour
the spread of gangrene:
› alpha toxin is a lecithinase that damages cell
membranes
› theta toxin also has a necrotizing affect
 Exotoxins associated with
diarrheal diseases
• Vibrio cholerae toxin
• Staphylococcus aureus enterotoxin
• Other enterotoxins - enterotoxins are also
produced by some strains of:
– Yersinia enterocolitica
– Vibrio parahaemolyticus
– Aeromonas species
 Enzymes
 Many species of bacteria produce enzymes that are not
intrinsically toxic but play important role in the infectious
process.
 Collagenase:
› degrades collagen, the major protein of fibrous connective
tissue, and promotes spread of infection in tissue.
 Coagulase:
› Staphylococccus aureus produce coagulase, which works in
conjuction with serum factors to coagulate plasma. Coagulase
contributes to the formation of fibrin walls around
staphylococcal lesions, which helps them persist in tissues.
 Enzymes
 Hyaluronidases:
› enzymes that hydrolyze hyaluronic acid, a constituent of the
ground substance of connective tissue. They are produced by
many bacteria (e.g. staphylococci, streptococci and anaerobes)
and aid in their spread through tissues.

 Streptokinase:
› many hemolytic streptococci produce streptokinase
(fibrinolysin), substance that activates a proteolytic enzyme of
plasma. This enzyme, also called fibrinolysin, is then able to
dissolve coagulated plasma and probably aids in the spread of
streptococci through tissues. Streptokinase is used in treatment
of acute myocardial infarction to dissolve fibrin clots.
Enzymes
 Enzymes
 Hemolysins and leukocidins:
› Many bacteria produce substances that are cytolysins - they
dissolve red blood cells (hemolysins) or kill tissue cells or
leukocytes (leukocidins).
– Streptolysin O, for example, is produced by group A
streptococci and is letal for mice and hemolytic for red blood
cells from many animals.
– The cytotoxin leukocidin, produced by the periodontopathogen
Aggregatibacter actinomycetemcomitans, can destroy
neutrophils and macrophages.
Antiphagocytic factors
 Intracellular pathogenicity
• Some bacteria (M. tuberculosis, Brucella,
Legionella) invade macrophages
Three ways:
• Avoid entry into phagolysosome
• Prevent phagosome-lysosome fusion
• May be resistant to lysosomal enzymes
 Antigenic Heterogenity
• Serological classification
• Based on O (lipopolisaccharide chain) H
(flagellar) antigens
• Many bacteria have ability to make frequent
antigenic shifts (N. gonorrhoeae)
 The requirement for Iron
• Host’s iron is not accessable for bacteria
(Host’s iron binding transport proteins: Transferrin,
Lactoferrin, Hemoglobin and etc.)
Bacteria have methods to obtain iron – high affinity
systems, siderophores.
 Biofilms

Biofilms are a complex structured community of microbial cells attached

strongly to a surface and enclosed in a matrix primarily made of
polysaccharides produced by the cells.
Portals of exit
Summary
Antimicrobial Chemotherapy
 The pre-antimicrobial era
• Black death ( Plague) in 14th and 15th centuries
– European population halved
• Puerperal (streptococcal) sepsis
– Accounted for 70% of deaths in birthing mothers
• Typhus
– Napolean Bonaparte’s army reduced from 665,000 to
93,000. Returners infected and killed 2,000,000
• Influenza
– 1918 – 19 pandemic
killed 30,000,000
in Europe, Asia,
Australia and the
Americas
Milestones in antimicrobial
chemotherapy
Origins of Antibiotic
Drugs

Alexander Fleming 1928: discovery of

Penicillin
 Nobel Prize for development of
Penicillin

Howard Walter Florey Ernst Boris Chain

 ANTIMICROBIAL CHEMOTHERAPY
CHEMOTHERAPEUTIC AGENTS
•Compounds used in treatment of diseases

ANTIMICROBIAL AGENTS
•Compounds used in treatment of microbial diseases

Categories of antimicrobial agents

•Antibiotics : biologically produced by microbes
•Synthetic
•Semi-synthetic : other chemical groups are added to
a nucleus of antibiotic
 Antimicrobial Chemotherapy Principles / Definitions

Origins of Antibiotic Drugs

• Antibiotics are common metabolic products of aerobic spore-
forming bacteria and fungi.
– bacteria in genera Streptomyces and Bacillus
– molds in genera Penicillium and Cephalosporium

• By inhibiting the other microbes in the same habitat, antibiotic

producers have less competition for nutrients and space.

Streptomyces
 Antimicrobial Chemotherapy
Principles / Definitions

• Differential toxicity: based on the concept that the drug is

more toxic to the infecting organism than to the host

• Spectrum of Activity:
- Narrow spectrum - drug is effective against a limited number of
species
- Broad spectrum - drug is effective against a wide variety of species
Gram negative agent
Gram positive agent
 Characteristics of Antibacterial Agents
Cidal vs Static

Bactericidal
Agents that kill bacteria
•Are useful in life-threatening infections
•Also useful in patients with low WBC count

Bacteristatic
Agents that inhibit but do not kill bacteria
•Bacteria may grow again when drug is withdrawn
•Host defences are needed to kill bacteria
•In large doses may become bactericidal
 Antimicrobial Chemotherapy
Principles / Definitions

• Minimum Inhibitory Concentration (MIC)

- minimum concentration of antibiotic required to inhibit the
growth of the test organism.
• Minimum Bactericidal Concentration (MBC)
- minimum concentration of antibiotic required to kill the test
organism.
 Interactions between Drug and Microbe
Mechanisms of Drug Action
 Antibiotic Classes
-LACTAMS

Penicillins Cephalosporins

Carbapenems Monobactams
 Antibiotic Classes
-LACTAMS
•The first, most diverse and most commonly used class of
antibiotics.

Thiazolidine ring
•They work by inhibiting the
enzymes responsible for the
final step in the synthesis of
the peptydoglycan layer of
the cell wall.

•They are bactericidal. Dihydrothiazine

ring
Mechanisms of Drug Action – Cell Wall Synthesis

Healthy cell

Drug affected cell

 Antibiotic Classes
-LACTAMS
Mechanism of action

•Inhibition of TRANSPEPTIDASE.
--The last step of peptidoglycan synthesis
• Alteration of bacterial morphology.
--Inhibition of SEPTUM formation (Penicillin Binding Protein
mechanism)
• Inhibition of availability of Autolysin Inhibitor.
--Stimulation of bacterial cell lysis (PBP mechanism)
Mechanisms of Drug Action – Cell Wall Synthesis
 BETA LACTAMS
Cephalosporins
• History
– Discovered in sewage in Sardinia in the mid 1940s.
– Cephalosporium sp was recovered and proved a source
of cephalosporin.
– Subsequently, five generations of cephalosporins have
emerged.
Advantage over Penicillins
• Broad range of activity
• Less susceptibility to β-lactamases
• Fewer hypersensitivity reactions
 Cephalosporins
• 1st generation- Cefazolin (Kefzol) and cephalexin (Keflex)
Mainly Gram +, some Gram - , some anaerobes
No penetration of CNS
• 2nd generation- Cefuroxime,Cefoxitin/cefotetan
weaker Gram +, better Gram - , mixed anaerobic infections (
including B. fragilis)
• 3rd generation – Cefotaxime, ceftriaxone & Ceftazidime (IV)
Excellent Gram – (including P. aeruginosa), some Gram +( Staph)
Enhanced activity against Enterobacteriaceae and streptococci,
including PcR S. pneumoniae
Penetration of CNS
• 4th generation – Cefepime
excellent Gram – ( Enterobacter, Citrobacter), good Gram+
• 5th generation - Ceftaroline, MRSA
NO Enterococci coverage
Hypertsensitivity reactions, thrombophlebitis after IV use
 BETA LACTAMS
Monobactam
• Aztreonam
Effective against G (-), not G (+)
IV only
Tolerated by penicillin allergic patients
No major toxicity reported
 Beta Lactams
Carbapenems (Imipenem, Meropenem,Ertapenem,
Doripenem)
• Very broad spectrum but not covering: MRSA,
Vancomycin resistant enterococci, acinetobacter,
stenotrophomonas and atypicals.
• Imipenem, Meropenem, Doripenem are active
against Pseudomonas.
• Imipenem is inactivated by human dehydropeptidase
I is administered together with cilastatin.
• All are administered IV.
Glycopeptides (Vancomycin): Mechanism of Action

• Inhibition of early stages of peptidoglycan synthesis in bacterial cell

wall
- Binds to the terminal D-alanyl-D-alanyl portion of the cell wall
precursor and prevents cross-linking of these peptide to form mature
peptidoglycan
 Vancomycin
• Produced by Streptomyces orientalis.
• Bactericidal for staphylococci, some
clostridia, soma bacilli
• Given intravenously in systemic infections
(staphylococcal and enterococcal
endocardatis).
• Emergence of resistant enterococci and
staphylococci is of worldwide concern.
 Other Antibacterial drugs acting on
cell wall – non β-lactam antibiotics
• Bacitracin – narrow-spectrum produced by a strain of Bacillus
subtilis, active against G+ bacteria
- used topically in ointment
• Isoniazid – works by interfering with mycolic acid synthesis;
- used to treat infections with Mycobacterium tuberculosis;
- in combination with other antimicrobials such as rifampin,
ethambutol
 Interactions between Drug and Microbe

Mechanisms of Drug Action – Disruption of Membrane Function

Polymyxins interact with

phospholipids and cause
leakage, particularly in
Gram-negative bacteria
(Pseudomonas, Serratia,
mostly topically).
Polymixin E (colistin) used
parenterally against
Acinetobacter,
Pseudomonas and
Klebsiella.
Ionophores – permit rapid
diffusion of specific cations
- e.g. potassium
( Valinomycin) - not
selective for bacteria
Daptomycin – skin and soft
tissue infections caused by
gram-positive cocci
 Inhibitors of Nucleic acid synthesis

A. Inhibitors of mRNA synthesis

• Rifampin
• Inhibits mRNA synthesis by affecting DNA-dependent
polymerase of bacterial cell without affecting human
cells
• First-line anti-TB drug.
 Inhibitors of Nucleic acid synthesis
• B. Inhibitors of DNA synthesis
• 1. Quinolones (Nalidixic acid)
• Bind to 2 essential enzymes required for DNA replication:
DNA gyrase and topoisomerase IV
•Are broad spectrum bactericidal agents
2.Fluroquinolones
• Ciprofloxacin,Ofloxacin, Sparfloxacin
• Are broader spectrum than quinolones
 Inhibitors of Nucleic acid synthesis
B. Inhibitors of DNA synthesis (anti-metabolites)

Block folic acid synthesis at two different

points Para-aminobenzoic
acid (PABA)
3.Sulfonamides and Sulfamethaxazole
trimethoprim
Compete with PABA to Dihydrofolic acid
stop synthesis of folic
acid which is needed for Trimethoprim
purine synthesis. These
are used in combination Tetrahydrofolic acid

Purines and other

DNA
precursors
 Inhibition of Protein Synthesis
• Ribosomes are the site of protein synthesis
• Many classes of antibiotics inhibit protein synthesis by
binding to the ribosome
• Binding may be reversible or irreversible

• Ribosomes of eukaryotes differ in size and structure from

prokaryotes;
• Selective toxicity is due to differences in ribosomes
• In human cells 80S = 60S & 40 S subunits
• Bacterial cells 70S = 50S & 30S subunits

• Antimicrobics usually have a selective action against

prokaryotes; can also damage the eukaryotic mitochondria
 Inhibitors of protein synthesis : sites of actio

Growing polypeptide
Chloramphenicol
50S
Tetracycline
tRNA
Erythromycin
Transcription
DNA mRNA
Direction of
30S
ribosome travel
Streptomycin
70S prokaryotic
ribosome
Antibacterial drugs acting on Protein Synthesis
Aminoglycosides
• Products of various species of soil
actinomycetes in genera Streptomyces and
Micromonospora
• Broad-spectrum, inhibit protein synthesis,
especially useful against aerobic Gram-
negative rods and certain gram-positive
bacteria
– Streptomycin – bubonic plague,
tularemia, TB
– Gentamicin – less toxic, used against
Gram-negative rods
– Tobramycin and amikacin Gram-
negative bacteria
Streptomycin
Antibacterial drugs acting on Protein Synthesis
Tetracyclines
• Broad-spectrum ( G+ and G-)bacteriostatic agents;
concentrated by susceptible bacteria
• Block protein synthesis by inhibition the binding of aminoacyl-
tRNA to 30S unit of ribosomes
• Tetracycline, aureomycin, terramycin,, doxycycline and
minocycline – low cost oral drugs; side effects are a concern
• Treatment for typhus and cholera, Rocky Mountain spotted
fever, Lyme disease, acne and protozoa; chalmydial genital
infections
 Antibacterial drugs acting on Protein Synthesis –
Chloramphenicol
• Isolated from Streptomyces venezuelae; no longer
derived from natural source
• Potent broad-spectrum drug with unique nitrobenzene
structure
• Blocks peptide bond formation
• Very toxic, restricted uses, can cause irreversible
damage to bone marrow
• Typhoid fever, brain abscesses, rickettsial and chlamydial
infections
Antibacterial drugs acting on Protein Synthesis
Macrolides
• Erythromycin –large lactone ring with
sugars; attaches to ribosomal 50s
subunit
• Broad-spectrum, fairly low toxicity
• Taken orally for Mycoplasma
pneumonia, legionellosis, Chlamydia,
pertussis, diphtheria and as a
prophylactic prior to intestinal surgery
• For penicillin-resistant – gonococci,
syphilis, acne
• Newer semi-synthetic macrolides –
clarithomycin, azithromycin
 Antimicrobial resistance

• Resistance: the inability to kill or inhibit the

organism with clinically achievable drug
concentrations

• Resistance may be innate (naturally resistant)

• Resistance may be acquired via

- mutation
- acquisition of foreign DNA
 The Acquisition of Drug Resistance
Natural Selection and Drug Resistance

• Large populations of microbes likely to include drug resistant cells due

to prior mutations or transfer of plasmids – no growth advantage until
exposed to drug
• If exposed, sensitive cells are inhibited or destroyed while resistance
cells will survive and proliferate.
• Eventually population will be resistant – selective pressure - natural
selection.
• Worldwide indiscriminate use of antimicrobials has led to explosion of
drug resistant microorganisms.
 Antimicrobial resistance
Factors which may accelerate the development of resistance

- Inadequate levels of antibiotics at the site of infection

- Duration of treatment too short
- Overwhelming numbers of organisms
- Overuse / misuse of antibiotics

- Subinhibitory concentrations of disinfectants, which might occur

during poor disinfection and cleaning procedures, can lead to selection
of strains with reduced susceptibility, or even resistance to antibiotics
Antimicrobial resistance mechanisms
• Common cause of beta-lactam resistance is production of a
beta-lactamase
• β-Lactamase- inhibitors – Clavulanic acid, Sulbactam,
Tazobactam
• Irreversibly bind to some β-Lactamases, not hydrolyzed by
them
• Protect simultaneously present hydrolyzable penicillins
- Sulbactam ( with ampicillin)
- Clavulanate (with amoxicillin or ticarcillin)
- Tazobactam (with piperacillin)
Considerations in Selecting an Antimicrobial Drug

• Identify the microorganism causing the infection.

- test as soon as possible
- sample taken before antimicrobials are initiated

• Test the microorganism’s susceptibility (sensitivity) to various drugs

in vitro when indicated
 Estimation of susceptibility to various drugs in vitro
• Kirby-Bauer disk diffusion test
- filter paper disks containing a measured quantity of a drug
- methods of Clinical and laboratory Standards Institute (CLSI)
• Dilution tests
- graded amounts of antimicrobial substances incorporated
- Minimum inhibitory concentration (MIC) - smallest concentration of drug
that visibly inhibits growth
 Antimicrobial Chemotherapy in vivo
Drug-pathogen relationship
• Environment
• State of metabolic activity
• Concentration and Distribution of drug
• Location of microbes
• Interfering substances

Host – drug

Host pathogen

Drug- pathogen
Interaction between Drug and Host– adverse
effects
• Estimate that 5% of all persons
taking antimicrobials will
experience a serious adverse
reaction to the drug – side effects

• Major side effects:

– direct damage to tissue due to
toxicity of drug
– allergic reactions
– disruption in the balance of
normal flora- superinfections
possible

Superinfections
Problem of antibiotic resistance
• Chapters 7, 10, 11
Levinson
• Chapters 9, 28
Jawetz, Melnick