Normal Flora

Ali M Somily MD,FRCP,D(ABMM),FCCM Assist Professor & Consultant microbiologist

A)What is Normal Flora ?

These are mixture of microorganisms

regularly found at any anatomical site

on /within the body of a healthy person. Some of these microorganisms are found in association with humans / animals only. Others are found in the environment as well.

Normal flora
Resident vs. Transient
Resident populations (normal flora, microbiota, indigenous microbial population, microflora, microbial flora) Vast majority of normal flora are bacteria.

Internal tissues normally sterile

Symbionts
Symbiosis: living together of two dissimilar organisms Optional or obligatory Temporary or permanent Entosymbiosis Ectosymbiosisides Symbiotic relationships Commensalism Mutualism Parasitism Amensalism Synnecrosis

B.
1.

What are The Roles Of Normal Flora:

May be source of opportunistic infections e.g. In-patients with impaired defense Mechanisms. Immunostimulation a) They produce antibodies which may contribute to host defenses. b) Some of these antibodies may cross react with normal tissue components.

2.

3)

Protection from External Invaders Because of the normal flora occupy bodys epithelial surfaces, they are able to prevent other bacteria from establishing themselves by blocking receptors (attachment), competing for essential nutrients or producing antibacteria substances e.g. Fatty acids, peroxides , Bacteriocins. 4) Nutrition Some of the normal intestinal flora e.g. E. coli & Bacteroids produce Vitamin K in the gut which is available for use by host.

5)

Production of Carcinogens

Some normal flora may modify, through their enzymes, some chemicals in our diets into carcinogens e.g. Artificial sweeteners may be enzymatically modified into bladder carcinogens. Predominant and important flora of various body sites in normal health.
6) Stimulate development of certain tissues: Caecum and lymphatic tissues (Peyers patches) in GI tract and influence immunology of gut-associated lymphatics

Normal flora
Human body
1013 cells 1014 bacteria

Normal flora
Some bacteria occupy more than one niche Some bacteria occupy only one niche: tissue tropism Tropism determined by bacterial ligand-host receptor interactions

Variation in microflora at one site Combinations of microflora at same site

Normal flora - Skin

Human adult has 2 square meters of skin Overall, a hostile environment toward bacteria Periodic drying Eccrine (simple sweat) glands Apocrine glands: sweat and nutrients Sebaceous glands: associated with hair follicles Transient microbes: in contact with environment Resident microbes

Normal flora - Skin

Skin: 3 main microenvironments Axilla, perineum, toe webs Hands, face and trunk Upper arms and legs S. epidermidis Major inhabitant making up more than 90% of the flora S. aureus Nose, perineum, vulvar skin Occurrence in nasal passages varies with age being greatest in newborns, less in adults Micrococci, Diphtheroids, Propionibacterium Eg. P. acnes = children younger than 10 years are rarely colonized with it

Normal flora - Skin

Neither profuse sweating nor washing significantly modifies normal skin flora Soap or disinfectant (hexachlorophene) diminish microbial population But normal flora rapidly replenished from sebaceous and sweat glands Pathogenic organisms eliminated

Normal flora - Conjunctiva

Variety of bacteria: low numbers present High moisture Blinking mechanically removes bacteria Lachrymal secretions include lysozyme

Normal flora - Respiratory tract

Nostrils:
Staph spp ,coryne

Nasopharynx :
and Strep Neisseria spp., Haemophilus influenzae

Oropharynx:
Staph spp,coryne Strep, Neisseria spp

Normal flora - Respiratory tract

Lower respiratory tract (trachea, bronchi, pulmonary tissues) Usually sterile Ciliated epithelium Mucus blanket: entrapment Alveolar macrophages If breached: opportunistic infections

Normal flora - Oral cavity

Ecology and developmental stages Birth: sterile mouth within 4-12 hours
(lactobacilli,

streptococci)

Neonate (Streptococcus salivarius, staphylococci,

Neisseriae, Moraxella catarrhalis

Teeth appear (Streptococcus mutans,

Streptococcus parasanguis)

Gingival crevice area (Anaerobic species, yeasts) Puberty (Bacteroides, spirochetes) 108 bacteria/mL of saliva; potentially >700 species

Normal flora Gastrointestinal tract

Ecology Birth: sterile Breast-fed Bifidobacteria species Switch to cows milk Enteric,
bacteroides, enterococci, lactobacilli and clostridia

Switch to solid food Microflora similar to parents

Normal flora - Gastrointestinal tract

GI ecology varies Esophagus saliva ,food Stomach harsh 10 Small intestine (103 -108) Proximal small intestine (duodenum and jejunum) Distal small intestine (ileum)
Large intestine 109-1011/ml >350 species E. coli = 0.1% of total population Primarily anaerobic Facultative aerobes deplete oxygen Adult excretes 3x1013 bacteria/day 25%-35% of fecal mass = bacteria

Normal flora - Gastrointestinal tract

Location (adult) Bacteria/gram contents duodenum jejunum and ileum 103-106 105-108 108-1010 1011

cecum and transverse colon

sigmoid colon and rectum

Normal flora - Urogenital tract

Upper urinary tract (kidneys, ureters, bladder) usually sterile Male anterior urethra Same as skin +enteric+enterococcus Vagina: complex microbiota At birth Same as mother (PH 5) Neonate Same as skin+enteric+ strept (PH 7) At puberty Lactobacillus+same as skin+anaerobes+strep (PH 5) At menopause: return to prepuberty flora

Sputum Sample

Vaginal Flora

Urethritis

Bacterial-human relationships
Normal flora Opportunistic infections Pathogenic infections

Normal flora - Risks

Dental plaque Dental caries: destruction of enamel, dentin or cementum of teeth Periodontal disease Inflammatory bowel disease Obesity

Opportunistic flora
Some normal flora become opportunistic pathogens (Staphylococcus aureus, Streptococcus mutans, Enterococcus faecalis, Streptococcus pneumoniae, Pseudomonas aeruginosa, etc.) Breach of skin/mucosal barrier: trauma, surgery, burns Bacterium at one site may be commensal, but might be pathogenic at another site

Mouth flora

Opportunistic flora
Growth of commensals may put patient at risk Broad-spectrum antibiotic therapy decreases total number of bacterial in gut During repopulation, faster-growing aerobic Enterobacteriaceae over slower-replicating anaerobes increases probability of gram-negative bacteremia Cross-reactive responses to host tissue: Superantigen Chronic, low-grade inflammation Perturbation of cytokine network

Gastrointestinal flora
Antibiotics overuse Antibiotic associated diarrhae C. dfficile -associated diarrhea (CDAD) Pseudomembranous colitis toxic megacolon

Normal flora - Risks and Opportunistic

Clinical conditions that may be caused by members of the normal flora

Probiotics/Prebiotics
Probiotic Oral administration of living organisms to promote health Mechanism speculative: competition with other bacteria; stimulation of nonspecific immunity Species specific: adherence and growth (tropism) Prebiotic Non-digestible food that stimulates growth or activity of GI microbiota, especially bifidobacteria and lactobacillus bacteria (both of which are noninflammatory) Typically a carbohydrate: soluble fiber

Gnotobiology
Gnotobiotic animals: germfree (axenic) Fetus is sterile Cesarean sections to obtain fetus Fetus growing in sterile isolator Not anatomically or physiologically normal Poorly developed lymphoid system, thin intestinal wall, enlarged cecum, low antibody titers Die of intestinal atonia ( motility problem) Require vitamin K and B complexes No dental caries or plaque More susceptible to pathogens