Anaerobic Infections

Definition

An anaerobic infection is an infection caused by bacteria (called anaerobes) which cannot grow in the presence of oxygen. Anaerobic bacteria can infect deep wounds, deep tissues, and internal organs where there is little oxygen. These infections are characterized by abscess formation, foul-smelling pus, and tissue destruction.

Description

Anaerobic means "life without air." Anaerobic bacteria grow in places which completely, or almost completely, lack oxygen. They are normally found in the mouth, gastrointestinal tract, and vagina, and on the skin. Commonly known diseases caused by anaerobic bacteria include gas gangrene, tetanus, and botulism. Nearly all dental infections are caused by anaerobic bacteria.

Anaerobic bacteria can cause an infection when a normal barrier (such as skin, gums, or intestinal wall) is damaged due to surgery, injury, or disease. Usually, the immune system kills any invading bacteria, but sometimes the bacteria are able to grow and cause an infection. Body sites that have tissue destruction (necrosis) or a poor blood supply are low in oxygen and favor the growth of anaerobic bacteria. The low oxygen condition can result from blood vessel disease, shock, injury, and surgery.

Anaerobic bacteria can cause infection practically anywhere in the body. For example:

• Mouth, head, and neck. Infections can occur in the root canals, gums (gingivitis), jaw, tonsils, throat, sinuses, and ears.
• Lung. Anaerobic bacteria can cause pneumonia, lung abscesses, infecton of the lining of the lung (empyema ), and dilated lung bronchi (bronchiectasis ).
• Intraabdominal. Anaerobic infections within the abdomen include abscess formation, peritonitis, and appendicitis.
• Female genital tract. Anaerobic bacteria can cause pelvic abscesses, pelvic inflammatory disease, inflammation of the uterine lining (endometritis), and pelvic infections following abortion, childbirth, and surgery.
• Skin and soft tissue. Anaerobic bacteria are common causes of diabetic skin ulcers, gangrene, destructive infection of the deep skin and tissues (necrotizing fascitis), and bite wound infections.
• Central nervous system. Anaerobic bacteria can cause brain and spinal cord abscesses.
• Bloodstream. Anaerobic bacteria can be found in the bloodstream of ill patients (a condition called bacteremia).

KEY TERMS

Abscess— A lump filled with pus resulting from an infection.

Anaerobic— Living and growing in the absence of oxygen.

Necrosis— Tissue death and destruction resulting from infection or disease.

Causes and symptoms

People who have experienced shock, injury, or surgery, and those with blood vessel disease or tumors are at an increased risk for infection by anaerobic bacteria. There are many different kinds of anaerobic bacteria which can cause an infection. Indeed, most anaerobic infections are "mixed infections" which means that there is a mixture of different bacteria growing. The anaerobic bacteria that most frequently cause infections are Bacteroides fragilis, Peptostreptococcus, and Clostridium species.

The signs and symptoms of anaerobic infection can vary depending on the location of the infection. In general, anaerobic infections result in tissue destruction, an abscess which drains foul-smelling pus, and possibly fever. Symptoms for specific infections are as follows:

• Tooth and gum infections. Swollen, tender bleeding gums, bad breath, and pain. Severe infections may produce oozing sores.
• Throat infection. An extremely sore throat, bad breath, a bad taste in the mouth, fever, and a sense of choking.
• Lung infection. Chest pain, coughing, difficulty breathing, fever, foul-smelling sputum, and weight loss.
• Intraabdominal infection. Pain, fever, and possibly, if following surgery, foul-smelling drainage from the wound.
• Pelvic infection. Foul-smelling pus or blood draining from the uterus, general or localized pelvic pain, fever, and chills.
• Skin and soft tissue infection. Infected wounds are red, painful, swollen, and may drain a foul-smelling pus. Skin infection causes localized swelling, pain, redness, and possibly a painful, open sore (ulcer) which drains foul-smelling pus. Severe skin infections may cause extensive tissue destruction (necrosis).
• Bloodstream. Bloodstream invasion causes high fever (up to 105°F [40.6°C]), chills, a general ill feeling, and is potentially fatal.

Diagnosis

The diagnosis of anaerobic infection is based primarily on symptoms, the patient's medical history, and location of the infection. A foul-smelling infection or drainage from an abscess is diagnostic of anaerobic infection. This foul smell is produced by anaerobic bacteria and occurs in one third to one half of patients late in the infection. Other clues to anaerobic infection include tissue necrosis and gas production at the infection site. A sample from the infected site may be obtained, using a swab or a needle and syringe, to determine which bacteria is (are) causing the infection. Because these bacteria can be easily killed by oxygen, they rarely grow in the laboratory cultures of tissue or pus samples.

The recent medical history of the patient is helpful in diagnosing anaerobic infection. A patient who has or recently had surgery, dental work, tumors, blood vessel disease, or injury are susceptible to this infection. The failure to improve following treatment with antibiotics that aren't able to kill anaerobes is another clue that the infection is caused by anaerobes. The location and type of infection also help in the diagnosis.

Diagnostic tests may include blood tests to see if bacteria are in the bloodstream and x rays to look at internal infections.

Treatment

Serious infections may require hospitalization for treatment. Immediate antibiotic treatment of anaerobic infections is necessary. Laboratory testing may identify the bacteria causing the infection and also which antibiotic will work best. Every antibiotic does not work against all anaerobic bacteria but nearly all anaerobes are killed by chloramphenicol (Chloromycetin), metronidazole (Flagyl or Protostat), and imipenem (Primaxin). Other antibiotics which may be used are clindamycin (Cleocin) or cefoxitin (Mefoxin).

Surgical removal or drainage of the abscess is almost always required. This may involve drainage by needle and syringe to remove the pus from a skin abscess (called "aspiration"). The area would be numbed prior to the aspiration procedure. Also, some internal abscesses can be drained using this procedure with the help of ultrasound (a device which uses sound waves to visualize internal organs). This type of abscess drainage may be performed in the doctor's office.

Prognosis

Complete recovery should be achieved with the appropriate surgery and antibiotic treatment. Untreated or uncontrolled infections can cause severe tissue and bone destruction, which would require plastic surgery to repair. Serious infections can be life threatening.

Prevention

Although anaerobic infections can occur in anyone, good hygiene and general health may help to prevent infections.

Resources

BOOKS

Fauci, Anthony S., et al., editors. Harrison's Principles of Internal Medicine. New York: McGraw-Hill, 1997.

Anaerobes and anaerobic infections

Anaerobes are bacteria that are either capable of growing in the absence of oxygen (referred to as facultative anaerobes) or that absolutely require the absence of oxygen (these are also called obligate anaerobes). Among the oxygen-free environments in which such bacteria can grow are deep wounds and tissues in the body. Growth in these niches can produce infections.

Examples of infections are gas gangrene (which is caused by Streptococcus pyogenes ) and botulism (which is caused by Clostridium botulinum ). Other anaerobic bacteria that are frequently the cause of clinical infections are members of the genus Peptostreptococcus and Bacteroides fragilis.

There are a number of different types of anaerobic bacteria. Two fundamental means of differentiation of these types is by their reaction to the Gram stain and by their shape. The genus Clostridium consists of Gram-positive rod-shaped bacteria that form spores. Gram-positive rods that do not form spores include the genera Actinomyces, Bifidobacterium, Eubacterium, Propionibacterium, and Lactobacillus. Gram-positive bacteria that are spherical in shape includes the genera Peptostreptococcus, Streptococcus, and Staphylococcus. Rod-shaped bacteria that stain Gram-negative include Bacteroides, Campylobacter, and Fusobacterium. Finally, Gram-negative spherical bacteria are represented by the genus Veillonella.

The word anaerobic means "life without air." In the human body, regions that can be devoid of oxygen include the interior of dental plaque that grows on the surface of teeth and gums, the gastrointestinal tract, and even on the surface of the skin. Normally the anaerobic bacteria growing in these environments are benign and can even contribute to the body's operation. Most of the bacteria in the body are anaerobes. However, if access to underlying tissues is provided due to injury or surgery, the bacteria can invade the new territory and establish an infection. Such bacteria are described as being opportunistic pathogens. That is, given the opportunity and the appropriate conditions, they are capable of causing an infection. Typically, anaerobic bacteria cause from five to ten per cent of all clinical infections.

Anaerobic infections tend to have several features in common. The infection is usually accompanied by a foul-smelling gas or pus. The infections tend to be located close to membranes, particularly mucosal membranes, as the infection typically begins by the invasion of a region that is bounded by a membrane. Anaerobic infections tend to involve the destruction of tissue, either because of bacterial digestion or because of destructive enzymes that are elaborated by the bacteria. This type of tissue damage is known as tissue necrosis. The tissue damage also frequently includes the production of gas or a fluid.

There are several sites in the body that are prone to infection by anaerobic bacteria. Infections in the abdomen can produce the inflammation of the appendix that is known as appendicitis. Lung infections can result in pneumonia , infection of the lining of the lung (empyema) or constriction of the small air tubes known as bronchi (bronchiectasis). In females, pelvic infections can inflame the lining of the uterus (endometritis). Mouth infections can involve the root canals or gums (gingivitis). Infections of the central nervous system can lead to brain and spinal cord infections. Infection of the skin, via bites and other routes of entry, causes open sores on the skin and tissue destruction. An example is that massive and potentially lethal tissue degradation, which is known as necrotizing fascitis, and which is caused by group A b-hemolytic Streptococcus. Finally, infection of the bloodstream (bacteremia) can prelude the infection of the heart (endocarditis).

The diagnosis of anaerobic infections is usually based on the symptoms, site of the infection and, if the infection is visible, on both the appearance and smell of the infected area. Most of the bacteria responsible for infection are susceptible to one or more antibiotics . Treatment can be prolonged, however, since the bacteria are often growing slowly and since antibiotics rely on bacterial growth to exert their lethal effect. In the case of infections that create tissue destruction, the removal of the affected tissue is an option to prevent the spread of the infection. Amputation of limbs is a frequent means of dealing with necrotizing fascitis, an infection that is inside of tissue (and so protected from antibiotics and the host's immune response) and is exceptional in that it can swiftly spread.

See also Bacteria and bacterial infections