Actinomyces Systematics, laboratory diagnosis and clinical aspects © by author ESCMID Online Lecture Library Trefor Morris, UK Anaerobe Reference Unit, Cardiff UK Anaerobe Reference Unit • Serves the whole of the UK • One of a select few world-wide • Remit of the ARU includes: 1. Identification & susceptibility testing 2. C. difficile ribotyping and surveillance 3. Clinical & technical advice 4. Maintenance of a reference collection of clinical isolates© c.30,000by author 5. Training ESCMID6. R&D, product Online evaluations Lecture Library Actinomyces • Non-sporing gram positive bacilli • Facultative anaerobes • Metronidazole resistant • Not acid-fast • Fermentative • Catalase variable© by author • Indole negative ESCMID• ~40 species, Online ~20 affecting Lecture humans Library Levels of Bacterial Classification • Kingdom – All bacteria are in the Prokaryotes • Subkingdom – Bacteria, Archea • Phylum – e.g. Firmicutes, Actinobacteria • Class – e.g. ‘Clostridia’, ‘Actinobacteria’ • Order – e.g. Clostridiales, Actinomycetales • Family – e.g. Actinomycetacae • Genus – This is the level that most bacteriologists deal with • Species - © by author • Sub-species - ESCMID Online Lecture Library Classification of Actinomyces • Phylum = Actinobacteria • Class = Actinobacteria • Order = Actinomycetales • Family = Actinomycetaceae • Genus = Actinomyces © by author ESCMID Online Lecture Library 1990 2001 human and animal species • A. hyovaginalis • A. bowdenii • A. bovis • A. canis • A. israelii • A. catuli • A. meyeri • A. europaeus • A. naeslundii • A. funkei • A. odontolyticus • A. graevenitzii • A. viscosus • A. marimammalium • A. denticolens • A. neuii (2 subspecies) • A. georgiae • A. radicidentis • A. gerencseriae • A. radingae • A. hordeovulneris © by author• A. suimastitidis • A. howellii • A. turicensis • A. slackii • A. urogenitalis ESCMID Online Lecture Library Additional species recognised by 2007 From human sources Animal sources A. cardiffensis A. canis A. dentalis A. catuli A. funkei A. coleocanis A. hongkongensis A. marimammalium A. nasicola A. ruminicola A. oricola A. suimastitidis A. radicidentis A. vaccimaxillae A. urogenitalis © by author ESCMID 2012 - Actinomyces Online Lecturenaturae - environmentalLibrary Not to be confused with … • Aerobic 'Actinomycetes' – Nocardia – Streptomyces • Mycobacteria • Corynebacteria • Other facultative anaerobic NSGPB (Propionibacteria, Lactobacilli, Bifidobacteria, Gardnerella…) © by author ESCMID Online Lecture Library …but closely related to… • Arcanobacterium • Actinobaculum • Varibaculum • Mobiluncus © by author ESCMID Online Lecture Library Normal habitats (Man and mammals) • Oral cavity (tongue, plaque, periodontal) • Gastro-intestinal tract (small numbers) • Genito-urinary tract • ? Lipid rich areas© byof skin author ESCMID Online Lecture Library Actinomycosis - historical Actinomycosis in humans - Wolf & Israel, 1891 © by author ‘LumpyESCMID jaw’ in Onlinecattle - Bollinger Lecture / Harz Library 1879 Spectrum of Disease Classically: cervico-facial Less commonly: thoracic, abdominal, pelvic sites Rarely: CNS, long bones, joints Some very rare presentations: Paediatric osteomyelitis Robinson et al, 2005. Pediatr Infect Dis J. 24:365-9. Midfacial osteomyelitis in a chronic cocaine abuser Talbott et al, 2001. ©Ear byNose authorthroat J. 80:738- 43. Gastric actinomycosis after gastric bypass ESCMIDFernandez-Acenero Online et al, 2004. Lecture Obes Surg. Library 14:1012-5 . Actinomycosis of the head and neck Swelling Osteoradionecrosis Chronic submandibular (ORN) of jaw abscesses with draining sinus tracts Other© sites by include: author Permanent disfigurement Brain abscess May be fatal if not treated Canaliculitis ESCMID OnlineDental abscess Lecture Library Actinomycosis – other sites Thoracic – lung, pleura, chest wall, spine Abdominal – stomach, liver, appendix, gallbladder, abdo. wall Pelvic – tubo-ovarian, intra-uterine, bladder, colon, psoas Other – 'punch' actinomycosis (fist), skin, long bones © by author ESCMID Online Lecture Library Pelvic actinomyces / IUCDs • Association of actinomyces-like organisms (ALOs) in Cx smears of IUCD-users noticed by cytologists in 1970s • Association has been proven but ? colonisation • Significance re. pelvic disease is much debated • ? Removal of IUCD - infection risk must© be by balanced author against risks of unwanted pregnancy, other contraceptives, re- ESCMIDinsertion of IUCDOnline Lecture Library IUCDs • ~20% colonisation with Actinomyces • Usage = common, pelvic infection = rare • ? Significance of Actinomyces spp. • BUT ? best specimen short of surgery British Faculty of Family Planning and Reproductive Healthcare recommendations, Cayley et al (1998) • Actino + symptoms = ©remove by IUCD,author treat, review • Actino – symptoms = counsel re. risks / symptoms, follow-up, ? leaveESCMID / remove / replaceOnline IUCD Lecture Library Agents of actinomycosis Producing granules / filamentous microcolonies: A. israelii A. gerencseriae (A. israelii serotype II) A. graevenitzii Propionibacterium propionicum (formerly Arachnia propionica) Usually smooth colonies, diphtheroid cells: ©A. meyeriby author A. naeslundii / viscosus complex A. odontolyticus ESCMID Online? other Lecture species Library Actinomyces in other infections • Periodontal disease / dental A. naeslundii, A. odontolyticus, caries A. israelii, A. gerencseriae • Superficial soft tissue A. turicensis, A. radingae, abscesses A. europaeus, A. funkei, A. • perianum, axilla, breast neuii, • pilonidal sinus Varibaculum cambriense • balanitis A. naeslundii, A. odontolyticus, • Bacteraemia / endocarditis A. turicensis, A. funkei • Chronic / complicated UTI © by authorActinobaculum spp., A. neuii • 'sterile' pyuria Hall ESCMIDV (2008). Actinomyces – gatheringOnline evidence of Lecturehuman colonization and Library infection. Anaerobe 14:1-7. Non-classical Actinomyces species Actinomyces turicensis • ? Flora of genital and GI tracts, skin • Common in superficial soft tissue abscesses: pilonidal, perianal, axilla, penile etc. • Rare cause of endocarditis © by author ESCMID Online Lecture Library © by author ESCMIDA. naeslundii Online LectureA. odontolyticus Library A. funkei A. neuii subsp. neuii subsp. anitratus • Habitats, clinical sources • ? Flora of skin similar to A. turicensis • From breast abscess etc. © by author ESCMID Online Lecture Library A. graevenitzii A. cardiffensis • ? Oral flora • ? Habitat • ? Rare cause of actinomycosis, • Sources as 'classic' Actinos. intra-oral, thoracic • ? significance Red under UV light © by author ESCMID Online Lecture Library Actinomyces spp. initiate a 'foreign body' response from the immune system Dense filamentous microcolonies (eosinophilic) Surrounded by basophilic material (bacterial and host) Granulomas / cavitations / sinuses develop Bacteria protected from further host responses Protected from antimicrobial activity Similar to TB interaction© by author ESCMID Online Lecture Library Early actinomycosis • Boil-like appearance Usually after trauma e.g. dental surgery, fist-fight Intra-oral effects • Early colonisers of oral cavity • Adhere to teeth and bacteria – help form plaque • ?? Significant in© dental by authorcaries • Periodontal diseases •ESCMID Root canal infectionsOnline Lecture Library Actinomycosis – clinical summary • Advanced cases are rare in the UK • Chronic, progressing slowly, spreading across fascia, disfiguring • Difficult to diagnose – may be mistaken for malignancy or TB • Prolonged / radical therapy required • 60% cervico-facial, 20% thoracic, 20% abdominal / pelvic© by author • relapse / treatment failure = common • ESCMIDMay be eventually Online fatal Lecture if not treatedLibrary Patient management • Surgery if necessary: drainage of exudate / debridement / excision of infected tissue • Long-term high-dose penicillin But… Advanced disease may be difficult to treat Relapses may occur months / years later Vague symptoms,© slowby authorprogression • difficult to diagnose Mis-diagnosis as cancer or TB is common ESCMID• may result Online in unnecessary Lecture therapy Library / surgery Laboratory diagnosis • Appropriate specimen • Direct microscopy • Culture • Identification • Antimicrobial© by susceptibilities author ESCMID Online Lecture Library Problems with Specimens • If disease is not overt it may be difficult to get specimen (CT guided needle biopsy, FNA may help) • Diagnosis = Ca. Tissue in formalin = histology only • Pus drained, but only swab sent to lab. • Dry swab = worst case • Unsuitable: oral swab,© by sputum, author vaginal swab (normal flora) • LackESCMID of clinical Online info. = may Lecture not culture Library for Actinos Primary lab. problems • Only found if looked for! – May need prolonged incubation (5-10 days) – May only grow anaerobically – May not grow on selective (Neo) plates © by author • Need good clinical indications ESCMID Online Lecture Library Culture • Invariably mixed • Plate microscope • Need selective media or hand lens can help – Metronidazole/Nalidixic acid – ? Mz / mupiricin – NOT neomycin or gentamicin – can use discs • Other orgs. may be inhibitory • >10 days AnO2 incubation© by author • Unfamiliar with morphologyESCMID Online Lecture Library Good specimens - 1 Cerebral abscess pus Direct Gram's stain of crushed granules © by author CultureESCMID = No growth Online @ 10 days. Lecture Prior antibiotics, Library old specimen . Good specimens - 2 Aspirate - liver abscess Direct Gram's stains granule free pus © by author ESCMID Online Lecture Library Direct microscopy