MICROBIAL DISEASES and EPIDEMIOLOGY = Transmission Based Discussion

1. - Opportunistic Infections = (OIs) are infections that occur more often or are more severe in people with weakened
immune systems than in people with healthy immune systems.
Certain opportunistic infections are signs that your HIV has become AIDS:
• Candidiasis or thrush, a fungal infection in the mouth, throat, or vagina

• Cryptococcus neoformans (crypto), a fungus that can lead to meningitis, a serious inflammation of the membranes that
surround the brain and spinal cord

• Cryptosporidiosis and microsporidiosis, infections of microscopic animals called protozoa that mess up the gut
• Cytomegalovirus (CMV), a virus that causes eye disease (CMV Retinitis) and can lead to blindness. It can also cause severe
diarrhea and ulcers.

• Herpes simplex, a group of viruses that cause sores around the mouth (cold sores) and on the genitals.

• Mycobacterium avium complex (MAC), bacteria that cause fevers, problems with digestion, and serious weight loss.

• Pneumocystis pneumonia (PCP), a fungus that causes a deadly lung infection.

• Toxoplasmosis, a disease caused by a parasite that can lead to encephalitis, which is an inflammation of the brain, as well as
blurry vision and eye damage

• Tuberculosis (TB), a bacterial infection that attacks your lungs. It can also invade other organs and lead to meningitis.

• Men are three times more likely than women to develop a cancer called Kaposi's sarcoma.
• Women have a greater chance of getting certain infections like HPV that can lead to cancers of the reproductive system
such as cervical cancer.

Prevention
 The most important way to prevent opportunistic infections is to take the HIV medicines and keep the CD4 count from
becoming low. If starting with a low CD4 count (less than 200 cells per microliter of blood), one should take steps to lower
the chances of getting these infections.
 Wash and cook all of the food well. Avoid raw or undercooked meats and eggs, and unpasteurized dairy. Thoroughly clean
and disinfect the hands, knives, cutting boards, and counters where one makes food.
 Have someone else handle cat litter or pick up dog waste, or use gloves. Keep cats indoors so they don't bring in parasite
that could harm.
 Use a towel on shared gym equipment and a different towel to dry self.
 Try not to swallow water in pools, lakes, or streams.
 Take HIV medicines and see the doctor regularly to make sure that they are working and that the immune system remains
strong. Take other medicines and get vaccinated as recommended by the doctor.
 For a woman, get regular pelvic exams and Pap tests to spot infections, pre-cancers, and cancers.

2. - Community Acquired (Respiratory) = Community-acquired pneumonia (CAP) is one of the most common infectious
diseases and is an important cause of mortality and morbidity worldwide. Typical bacterial pathogens that cause CAP include
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis

3. - Hospital Acquired (Respiratory)= Hospital-acquired pneumonia or nosocomial pneumonia refers to any pneumonia
contracted by a patient in a hospital at least 48–72 hours after being admitted.

Types:
= Bacterial pneumonia: The majority of cases related to various rod shaped gram-negative organisms (52%) and Staphylococcus
aureus (19%), usually of the MRSA type. Others are Haemophilus spp. (5%). ICU results were S. aureus (17.4%),
Pseudomonas aeruginosa (17.4%), Klebsiella pneumoniae and Enterobacter spp. (18.1%), and Haemophilus influenzae
(4.9%).
= Viral pneumonia: influenza and respiratory syncytial virus (RSV) and, in the immunocompromised host, cytomegalovirus – cause
10–20% of infections.
= Ventilator-associated pneumonia (VAP) is a sub-type of hospital-acquired pneumonia (HAP) which occurs in people who are
receiving mechanical ventilation. VAP is restricted to patients undergoing mechanical ventilation while in a hospital
= Healthcare-associated pneumonia (HCAP) = HCAP is a condition in patients who can come from the community, but have frequent
contact with the healthcare environment

Benzylpenicillin may be used alone when Streptococcus pneumoniae is the suspected pathogen.
Chloramphenicol should only be used when no alternatives are available, as it may cause the grey baby syndrome.
= Legionellosis = Legionellosis, caused by Legionella pneumophila, is a waterborne infection spread by aerosolization. It mainly
occurs in elderly persons with chronic obstructive airway disease. It usually presents as severe pneumonia, often associated with
nonpulmonary symptoms such as mental confusion, diarrhoea and renal failure. The diagnosis may be suggested by the presence of
purulent sputum without pathogens visible on Gram-staining, and/or failure to respond to treatment with β-lactam antimicrobials.

= Erythromycin or ciprofloxacin

= Pneumonia associated with HIV infection = Pneumocystis carinii is the most frequent pathogen, although in some areas,
tuberculosis is more common. Other potential pathogens include Candida albicans, Aspergillus fumigatus and cytomegalovirus.
= Sulfamethoxazole + trimethoprim = Alternative regimen - Clindamycin ; primaquine

= Aspiration pneumonia and lung abscesses = Aspiration pneumonia and lung abscesses are most frequently caused by penicillin-
sensitive anaerobic bacteria such as Peptostreptococcus spp., as well as aerobic bacteria such as Streptococcus pyogenes and
viridans streptococci. Sometimes penicillin-resistant pathogens such as Bacteroides fragilis, Escherichia coli and Klebsiella
pneumoniae may be involved. Predisposing factors include impaired consciousness, bronchial obstruction, alcohol dependence,
cerebrovascular accidents and intestinal obstruction.
= Benzylpenicillin ; metronidazole Alternative regimen. Amoxicillin 500mg + clavulanic acid
clindamycin

= Pneumonia due to Staphylococcus aureus = following recent influenza infection.

= Cloxacillin; cefazolin ; clindamycin ; vancomycin ; gentamicin
= Vancomycin should only be used if the pathogen is proven to be methicillin-resistant Staphylococcus aureus (MRSA).

Nosocomial pneumonia

Nosocomial pneumonia is pneumonia that is acquired in hospital 48 hours or more after admission. Multiresistant bacteria such as
staphylococci, enterococci, enterobacteria, Pseudomonas aeruginosa and other aerobic bacteria may be responsible for such
infections. Hospital-acquired legionellosis has also been described. Common sources of nosocomial infections include:

• Infected intravenous devices: Gram-positive bacteria, especially staphylococci.

• Indwelling urinary catheters: Gram-negative bacteria.
• Tracheostomy and ventilators: mixed bacterial flora.
• Post-surgical wound infections: variable - depends on the operation site.
= cloxacillin ; gentamicin Alternative regimens. Ceftazidime ; gentamicin ; ciprofloxacin

In hospitals with a high prevalence of meticillin-resistant Staphylococcus aureus (MRSA), vancomycin should be added to
the above regimens. ; Imipenem
 4. - Sexually Transmitted Infections
> Sexually transmitted infections (STIs), also referred to as sexually transmitted diseases (STDs), are infections that are
commonly spread by sexual activity, especially vaginal intercourse, anal sex and oral sex.
> Many times STIs initially do not cause symptoms. This results in a greater risk of passing the disease on to others.
> Symptoms and signs of disease may include vaginal discharge, penile discharge, ulcers on or around the genitals, and pelvic pain.
> STIs can be transmitted to an infant before or during childbirth and may result in poor outcomes for the baby.
> Some STIs may cause problems with the ability to get pregnant.
> STIs include chlamydia, gonorrhea, and syphilis.
> Viral STIs include genital herpes, HIV/AIDS, and genital warts. - Herpes simplex, HIV , Human papilloma virus
> Parasitic STIs include trichomoniasis. Ex. Trichomonas vaginalis
> While usually spread by sex, some STIs can be spread by non-sexual contact with donor tissue, blood, breastfeeding, or during
childbirth.

 The most effective way of preventing STIs is by not having sex.

 Some vaccinations may also decrease the risk of certain infections including hepatitis B and some types of HPV.
 Safer sex practices such as use of condoms, having a smaller number of sexual partners, and being in a relationship where
each person only has sex with the other also decreases the risk.
 Circumcision in adult males may be effective to prevent some infections.
 During school, comprehensive sex education may also be useful.
 Most STIs are treatable or curable.
 Of the most common infections, syphilis, gonorrhea, chlamydia, and trichomoniasis are curable, while herpes, hepatitis B,
HIV/AIDS, and HPV are treatable but not curable.
 Resistance to certain antibiotics is developing among some organisms such as gonorrhea.

a.) Gonorrhoea
= Gonorrhoea results from infection with the Gram-negative coccus Neisseria gonorrhoeae. Gonococcal and chlamydial
infections often coexist. In women, gonorrhoea causes cervicitis. In men, gonorrhoea is confirmed by demonstrating Gram-negative
intracellular diplococci in urethral smears. Ideally, blood samples should be taken for serological tests to exclude concurrent
infection with syphilis.

= Sexual partners should be treated simultaneously.

= Gonococcal conjunctivitis threatens sight and progresses rapidly. Since it is highly contagious, every effort should be made
to prevent transmission of infection. Antimicrobial therapy should be started immediately and the eyes should be irrigated
frequently with saline solution.
= Ceftriaxone ; spectinomycin ; ciprofloxacin 500 mg orally in a single dose (contraindicated during pregnancy).
= If systemic treatment is not available and infection is con- firmed, tetracycline, 1% ointment, should be instilled
into each
eye every hour, pending referral of the infant for parenteral therapy.
= All infants should receive topical antigonococcal therapy immediately after birth. Tetracycline, 1% ointment, should be
applied after gently cleansing the eyelids. Erythromycin, 1% ointment, is as effective, but more expensive. Some authorities
recommend that therapy should continue for 7 days.
= Neonates who fail to respond to treatment should be treated for chlamydial ophthalmia
b.) Lymphogranuloma venereum
Lymphogranuloma venereum is caused by Chlamydia trachomatis serotypes L1, L2 and L3. The primary genital lesion, which
is rarely demonstrable in women, usually occurs in men as a purulent ulcer on the penis that heals within a few days. After a latent
period of days or months, an acute fluctuant inguinal lymphadenopathy develops. In the late stages of the disease, chronic lymphatic
obstruction may result in lymphoedema (elephantiasis) of the external genitalia.
= Doxycycline ; erythromycin

c.) Other chlamydial infections

Chlamydia trachomatis (serotypes D - K) causes non-gonococcal urethritis in men. It may also cause epididymitis and
chronic prostatitis. In women, infection is associated with cervicitis, salpingitis and endometritis. Infants born to mothers with
cervical infection may develop purulent conjunctivitis (chlamydial ophthalmia) or pneumonia.
All patients with chlamydial infections should be treated concurrently for gonorrhoea, unless microbiological facilities exist
to exclude the latter diagnosis. In every instance, sexual partners should be treated simultaneously
= Doxycycline ; erythromycin = Infants with chlamydial ophthalmia should be treated with erythromycin syrup
d.) Vaginitis
=Vaginal discharge may be caused by candidiasis (due to Candida albicans), trichomoniasis (due to Trichomonas vaginalis)
or bacterial vaginosis (due to Gardnerella vaginalis and vaginal anaerobes).
=Treatment
d.1. Candidiasis = Nystatin pessaries = Administration should be continued for 48 hours after clinical cure.
Higher doses and a longer period of treatment may be required in
immunocompromised patients.
d.2. Trichomoniasis= Metronidazole
d.3. Bacterial vaginosis = Metronidazole

e.) Pelvic inflammatory disease

= Acute pelvic inflammatory disease is often a consequence of sexually transmitted disease. The pathogens most
commonly involved are Neisseria gonorrhoeae and Chlamydia trachomatis. However, bacteria present in the normal vaginal flora,
including streptococci, Escherichia coli, Haemophilus influenzae and anaerobes such as Bacteroides, Peptostreptococcus and
Peptococcus spp. also often contribute. Trauma to the endocervical canal from an intrauterine device (IUD) may facilitate the ascent
of these organisms into the endometrial cavity.
= Ceftriaxone ; doxycycline ; metronidazole
= Hospitalized patients with very severe disease= Gentamicin ; clindamycin ; doxycycline
= Hospitalized patients with moderate or severe disease = Ceftriaxone ; doxycycline
= Alternative regimen. Ciprofloxacin ; metronidazole ; doxycycline
f.) Syphilis
= Syphilis is caused by the spirochaete Treponema pallidum. Transmission results almost exclusively from sexual contact
with infected persons, but infection can also be transmitted from mother to fetus during pregnancy and through blood transfusion.
= Where facilities and resources are available, all patients and their contacts should be concurrently tested and treated, as
appropriate, for chlamydial infection, gonorrhoea and HIV infection according to national policy. Patients with a history of primary or
secondary syphilis should be tested for the presence of specific antitreponemal antibodies, which indicate latent syphilis.
= Benzathine benzylpenicillin ; procaine benzylpenicillin
= Late syphilis (other than neurosyphilis) = Benzathine benzylpenicillin ; procaine benzylpenicillin
g.) Chancroid
= Chancroid, which results from infection with Haemophilus ducreyi, is the most common cause of genital ulceration in
developing countries and its incidence has been rising with increasing rates of HIV infection. Clinically, the disease is readily confused
with syphilis. When facilities for dark-field microscopy and serological diagnosis of syphilis are not available, benzathine
benzylpenicillin should always be administered at the same time.
= Erythromycin ; ciprofloxacin ; ceftriaxone ; spectinomycin

h.) Granuloma inguinale

= Granuloma inguinale (donovanosis) is a chronic granulomatous infection caused by the Gram-negative encapsulated
bacterium Calymmatobacterium granulomatis.
= Sulfamethoxazole + trimethoprim ; chloramphenicol
 5. – Enteric
A) Acute enteric infections
1. Typhoid and paratyphoid fever are caused, respectively, by the pathogens Salmonella typhi and S. paratyphi, which are specific
to humans. Transmission occurs via contaminated water and/or food. Following treatment with antimicrobials, about 10% of
patients relapse and 1 - 3% become chronic carriers of infection.
= A. Acute carrier = Chloramphenicol ; ciprofloxacin ; sulfamethoxazole + trimethoprim
= B. Chronic carriers = Ciprofloxacin

B. Infectious enteritis due to Salmonella spp. other than S. typhi

= In infectious enteritis due to Salmonella enteritidis, treatment is the same as that recommended for typhoid fever (see above).
However, chronic bacteraemia, metastatic infections or enterocolitis in patients with sickle-cell disease, HIV infection or other
predisposing conditions must be treated.

C. Enteritis due to enterotoxigenic Escherichia coli

= Chemoprophylaxis against so-called "traveller’s diarrhoea" is not indicated. Mild cases require no treatment. However,
antimicrobial therapy should be considered if diarrhoea persists or is severe (e.g. more than five bowel movements per day, bloody
diarrhoea and/or fever).
= Sulfamethoxazole + trimethoprim ; ciprofloxacin

D. Intestinal protozoal infections

1. Amoebiasis = Amoebiasis is an uncommon form of bloody diarrhoea due to the protozoan Entamoeba histolytica. The diagnosis
should be considered if a patient has persistent bloody diarrhoea (dysentery) despite therapy for shigellosis. Only certain strains of
E. histolytica are pathogenic and asymptomatic carriers are common in endemic areas. Clearance of cysts in the feces should be
mainly considered in patients living in non-endemic areas.
= Metronidazole ; diloxanide furoate

2. Giardiasis = Giardia lamblia is a flagellated protozoan which is transmitted from person to person mainly via faecal contamination
of food or hands. It occurs worldwide, particularly where sanitation is poor, and is a common cause of both acute and persistent
diarrhoea among children in developing countries.
= Metronidazole ; tinidazole

E. Necrotizing enterocolitis due to Clostridium difficile

= This is a form of pseudomembranous enterocolitis caused by toxigenic Clostridium difficile, following alteration of the
intestinal microflora.
= Metronidazole = Patients who fail to respond to treatment with metronidazole should receive vancomycin

F. Non-diarrhoeal gastrointestinal infections

1.) Acute gastritis and peptic ulcer disease = are commonly associated with infection of the mucosa of the upper gastrointestinal
tract with Helicobacter pylori. If possible, presence of the organism should be confirmed by biopsy (for bacterial culture) or by a
positive breath test (for ketones).

Treatment
= Bismuth salicylate 107.7 mg (1 tablet) orally every 6 hours for 2 weeks plus
= metronidazole 200 mg orally every 8 hours and 400 mg orally at night for 2 weeks (contraindicated during pregnancy)
plus either
= tetracycline 500mg orally every 6 hours for 2 weeks (contraindicated during pregnancy) or
= amoxicillin 500 mg orally every 6 hours for 2 weeks.
Alternative regimen. Omeprazole 40mg orally every 24 hours for 2 week plus
= metronidazole 400 mg orally every 8 hours for 2 weeks (contraindicated during pregnancy) plus
= amoxicillin 500 mg orally every 8 hours for 2 weeks.

2.) Acute cholecystitis = is often associated with obstruction by calculi. The infecting organisms are predominantly ascending bowel
flora, especially Escherichia coli and Klebsiella spp. Sudden onset of pyrexia, often with rigors, and pain and tenderness in the right
upper quadrant are characteristic. Jaundice is often an accompanying sign. Immediate surgery is required for gangrenous
cholecystitis, associated perforation and abscess formation.