CHAPTER Normal Flora 0 Concept of Normal Flora Normal Flora of the Genitourinary Tract Normal Flora of the Skin Pearls Normal Flora of the Respiratory Tract Self-Assessment Questions Normal Flora of the Intestinal Tract Practice Questions: USMLE & Course Examinations CONCEPT OF NORMAL FLORA are usually not considered members of the normal flora, Normal lor isthe term used to describe the various bac yhw@h hey can et Re ere teria and fungi that are permanent residents of certain mensals. Commensals are organisms that derive benefit body sites, especially the skin, oropharynx, colon, and from another host but do not damage that host. vagina (Tables 6-1 and 6-2). The viruses and parasites, The members of the normal flora vary in both number which are the two other major groups of microorganisms, and kind from one site to another. Although the normal flora extensively populates many areas of the body, the internal organs usually are sterile. Areas such as the central nervous system, blood, lower bronchi and alveoli, liver, spleen, kidneys, and bladder are free of all but the occa [Anatomic Location sional transient organism, There is a distinction between the presence of these TABLE 6-1 Summary of the Members of Normal Flora and Their Anatomic Locations ‘Members of the Normal Fora Bacteroides species Colon throat, vagina RITE Ta organisms and the cartier state. In a sense, we al are carri- rs of microorganisms, but that isnot the normal use of the od a term in the medical context. The term carrier implies that Conmebacterum species (diphtheroids) Nasopharyn. skin vagina__an individual harbors a potential pathogen and therefore Enterococcus sca Colon can bea source of infection of others. It is most frequently Cates Caeser used in reference to a person with an asymptomatic infec- uretiva tion or to someone who has recovered from a disease but eas — contin cry the ogi nd may shed for long scepter Nasophanmc conti, FT also a distinction tobe made between members were Mouth, colon, vagina of the normal flora, which are the permanent residents, and Netsera species Mouth, nasopharynx the colonization of the individual with a new organism. In cqree skin a sense, we are all colonized by the normal flora organisms, eC Ee but the term colonization typically refers to the acquisition of a new organism. After the new organism colonizes (i.e SRL SEEGE ease) attaches and grows, usually on @ mucosal membrane), it Staphylococcus epidermidis Skin,pose, mouth, vagina, may cause an infectious disease or it may be eliminated by ete) our host defenses. Furthermore, the person colonized by a Veldans steptococel Mouth, nasopharynx ‘new organism can transmit that organism to others (ie. act Imalphabetcal order, as a reservoir of infection for others). 26TABLE 6-2 CHAPTER 6 Normal Flora 27 Location ‘Less Important Organisms? ‘skin Staphylococcus epidermidis Staphylococcus aureus, Cormebacterium (diphtheroids), various streptococcl, ‘Pseudomonas aeruginosa, anaerobes (e.,Fropionibacterium), yeasts (¢., Candida albicans) Nose Staphylococcus aureus ‘epidermidis, Cormnebacterum (diphtherolds), various steptococel Mouth Viridans steptococe! Various streptococl Eitenela contdens Dental plaque Streptococcus mutans ‘Prevotlla Intermedia, Porphyromonas gingivalis Gingival crevices Various anaerobes (e.g, Bacteroides, Fusobacterum, sreptococc, Actinomyces) Various streptococl (including Streptococcus pyogenes and Streptococcus ‘pneumoniae Nessena species, Haemophilus influenzae S.epidermids ‘ifdobacterum, Eubacterium, Fusobacterium, Lactobacillus, varous aerobic ‘gram-negative rods, Enterococcus faecalis and other ste-ptococe, Closdum Various streptococl varlous gram-negative ros 8. fragilis Corynebacterlum (diphtheroids),c ebicans ‘Throat Virdans teptococe! Colon Bacteroides fags Escherichia coll Vagina Lectobacilus, cl group 8 streptococe!? Urethra ‘. epidermidis, Corynebacterum (diphtheroi), various streptococevarlous ‘fam-negative rade (29, Ec" “organisms that ae less medial signiantor presetin smaller numbers mete organs are not ptf the normal fora nthilcaton but are Important colonizers. ‘The members of the normal flora playa role both in the maintenance of health and in the causation of disease in three significant ways: (1) They can cause disease, especially in immunocom: promised and debilitated individuals. Although these organisms are nonpathogens in their usual anatomic loca- tion, they can be pathogens in other parts of the body. (2) They constitute a protective host defense mecha- nism. The nonpathogenic resident bacteria occupy attach- ment sites on the skin and mucosa that can interfere with colonization by pathogenic bacteria. The ability of mem- bets ofthe normal flora to limit the growth of pathogens is called colonization resistance. If the normal flora is sup- pressed, pathogens may grow and cause disease. For example, antibiotics can reduce the normal colonic flora that allows Clostridium difficile, which is resistant to the antibiotics, to overgrow and cause pseudomembranous (3) They may serve a nutritional function. The intestinal bacteria produce several B vitamins and vitamin K. Poorly nourished people who are treated with oral antibiotics can have vitamin deficiencies as a result ofthe reduction in the normal flora. However, since germ-free animals are well nourished, the normal flora is not essential for proper nutrition NORMAL FLORA OF THE SKIN The predominant organism is Staphylococcus epidermidis, which is a nonpathogen on the skin but can cause disease ‘when it reaches certain sites, such as artificial heart valves and prosthetic joints It is found on the skin much more frequently than its pathogenic relative Staphylococcus aureus (Table 6-2). There are about 10°-10" organismsfem’ of skin Most of them are located superficially in the stratum cor- rneum, but some are found in the hair follicles and act as @ reservoir to replenish the superficial flora after hand wash- ing, Anaerobic organisms, such as Propionibacterium and Peptococeus, are situated in the deeper follicles in the der- ‘mis, where oxygen tension is low. Propionibacterium acnesis common skin anaerobe that is implicated in the pathogen- esis of acne. ‘The yeast Candida albicans is also a member of the nor: mal flora of the skin. It can enter a persons bloodstream ‘when needles pierce the skin (eg, in patients with intrave- nous catheters or in those who use intravenous drugs). It is an important cause of systemic infections in patients with reduced cell-mediated immunity NORMAL FLORA OF THE RESPIRATORY TRACT ‘A wide spectrum of organisms colonize the nose, throat, and mouth, but the lower bronchi and alveoli typically con- tain few, ifany, organisms. The nose is colonized by a vari ety of streptococcal and staphylococcal species, the most significant of which is the pathogen S. aureus. Occasional outbreaks of disease due to this organism, particularly in the newborn nursery, can be traced to nasal, skin, or peria- nal carriage by health care personnel