Pseudomonas & Other Non-fermenters

1. Pseudomonas & Other Non-fermenters Professor Sudheer Kher

2. Pseudomonas aeruginosa Pigments Pyocyanin Fluorescein Toxin A Opportunistic Infections Greenish Pus Non-fermenter Oxidase positive Motile Hospital infection Antibiotic resistance KEY WORDS

3. Pseudomonas • Obligate Aerobe, mostly saprophytic • Gram-negative non-sporing rods • Motile • Majority of human infections • P. aeruginosa

4. Medically important species of Pseudomonas Pigment production Greenish yellow pigment No pigment Pseudomonas aeruginosa Burkholderiamallei Burkholderia pseudomallei

5. Common in the environment • water • air • soil

6. P. aeruginosa and compromised host • Burns and wounds • destruction of blood vessels • phagocyte access limited • Cancer • cytotoxic drugs • destroy the immune system • Cystic fibrosis • altered respiratory epithelium • pneumonia • . Cystic fibrosis (CF) is a hereditary disease that affects mainly the lungs and digestive system, causing progressive disability, and, for some, early death. Formerly known as cystic fibrosis of the pancreas, this entity has increasingly been labeled simply cystic fibrosis.[1] Average life expectancy is around 37 years, although improvements in treatments mean a baby born today could expect to live longer.[2]

7. Identification • Pigments • Pyocyanin (blue-green) • Fluorescein (green-yellow, fluorescent) • Best produced in King’s A & B Media • Biochemical reactions – Non fermenter • Oxidase positive • Cultures have fruity smell (Grape like)

13. Pathogenesis • Toxin A - ADP ribosylates EF2 • functions as NADase • similar to diphtheria toxin • Slime layer is anti-phagocytic

14. Virulence factors of P. aeruginosa • Lipopolysaccharide: endotoxin, pyrogen • Capsule: anti-phagocytosis, inhibits complement fnc. • Proteases: damage host proteins such as complement and IgA • Hemolysins • Exotoxin A: a diptheria-like toxin - toxic for macrophages • Pyocyanin: impairs ciliary activity • Fimbriae: adherence factor • Other non-pilus adhesins • Others like elastases………..

15. Pathogenesis Source Endogenous (skin of axilla, perineum or GIT) Exogenous Respirators, bed pans, lotions, ointments, eye drops, stock of distilled water, disinfectants (QAC) Transmission Endogenous infection Contact spread Virulence Toxin and Extracellular products Protease , Pyocyanin, Cytotoxin (leukocidin) Endotoxin, Haemolysin, Exotoxin A & Exotoxin S Mucoid strains in Cystic fibrosis due to alginate

16. Diseases (Pathogenicity) Community Suppurative Otitis Nosocomial infection Hospital Eye Keratitis and Endophthalmitis Ear Otitis externa and Otitis media Skin Burns infection, wound sepsis Ecthyma gangrenosum UTI Cystitis (catheterized) Pneumonia (ventilation / tracheostomy) RTI GIT Infantile diarrhea CNS Meningitis brain abscess (iatrogenic)

17. LabDiagnosis Specimens Wound discharge, sputum, urine, blood Microscopy Gram negative bacilli MAC NLF, blue green with distinct feathered edges NA Green diffusible pigment Selective media Cetrimide agar Oxidase + TSI: K- / K- (non fermenter) Identificationtests Ceftazidime, ticarcillin, piperacillin, ciprofloxacin, amikacin, gentamicin, Polymyxin B AST Hospital outbreak investigation Bacteriophagetyping 11 Indicator strains Aeroginocine (Pyocine) typing

18. Phage Typing

19. Treatment & Control Antipseudomonad beta lactam Aminoglycosides Fluoroquinolones Combination therapy in impaired defense mechanism Strict attention to asepsis Treatment of underlying disease (correction of granulocytopenia)

20. 8:10 PM Atul: are you there  • me: Hi  • Atul: hi • 8:11 PM me: That day I came on line in d evening but by that time u were off!  How's life?  • Atul: did i tell you about isolation of burkholderia pseudomallei at dharwad me: Saw my mail? • 8:12 PM Atul: yha me: No. Just now I am preparing my power point on that very topic. May be I can use ur story to make lecture interesting! • 8:13 PM Atul: please send me as many full text articles you can on this topic.\  sure  i will send you the case report. when do you want it • 8:14 PM me: Certainly. Can u send me a brief summary. May be tomorrow a real brief one.. but incl all essentials.  • Atul: sending it now • 8:15 PM me: Wonderful. The students will like it and I will mention the co-incidence that my friend was talking of exactly the same organism!!  Telepathy?

21. Burkholderia pseudomalai septicaemia – a case report • A 35 old male working as daily labourer presented to the Medicine OPD on 19th September 2007 at 1 pm with complaint of fever for 8 days and reduced urine output for about one month. He was known diabetic and was on regular insulin therapy of which precise duration could not be known. He belonged to the costal town Karwar of Karnataka, India. • On examination the patient was emaciated and dehydrated. His blood pressure was 70 mm / 50 mm of Hg and pulse rate was 120 per minute. CVS examination revealed S1 S2. On auscultation he showed bilateral basal crepitations. There was a vertical scar on the abdomen and the patient gave history of splenectomy 10 years ago of which reason was not identified. Liver was palpable one finger below costal margin and he had mild ascitis. Samples were sent for investigation including blood culture and he was put on Metrogyl (Dose) and Monocef 1 gm i/v.

22. Burkholderia pseudo mallei Burkholderia mallei Whitmore’s bacillus No pigment, motile Cause Melioidosis (glanders like disease) Acute septicemia (typhoid like disease) Multiple abscess formation Transmitted via rats either by rat fleas or food contaminated with excreta No pigment, non motile Cause Glanders in horses, donkeys and mules Rarely cause human disease (suppurative lesions)

23. Stenotrophomonas maltophilia (cont.) REVIEW

24. Acinetobacter baumanii (calcoaceticus) REVIEW

25. Moraxella catarrhalis REVIEW

26. Pseudomonas aeruginosa Pigments Pyocyanin Fluorescein Toxin A Opportunistic Infections Greenish Pus Non-fermenter Oxidase positive Motile Hospital infection Antibiotic resistance KEY WORDS