Taxonomy, morphology and culture
Corynebacteria are gram-positive, non-motile rods bacteria. The following types of C. diphtheriae biotype gravis which, mitis, Belfanti and intermedius. The microscopic slide can occasionally observe a characteristic V-shaped storage.
Corynebacteria are found worldwide, in Europe, there were outbreaks in the early 90s in Russia and other countries of the former Soviet Union, is currently in Europe Lithuania affected; 1 outside Europe accumulations especially in India beobachtet.2 In Germany, two cases were in 2007 reported no case was registered in 2008. Only reservoir for pathogens is the man. The most common is the airborne transmission of pathogens (droplet infection) in the skin diphtheria, the smear is relevant. Vaccinated persons can transfer the germs without getting sick yourself! The duration of infectivity is dependent on the presence of the pathogens and without antibiotic therapy is about two to four weeks, with therapy two to four days. In more recent times, C. ulcerans strains in patients detected with diphtheria, which indicate the diphtheria toxin A closely related toxin produzieren.3 Epidemiological studies suggest that it might be in these infections is a zoonosis.
Pathogenesis, clinical picture
The transfer of the gene for the formation of diphtheria toxin carried by bacteriophage (phage tox +), therefore exist C. diphtheriae and C. ulcerans strains with and without toxin formation. Under the action of diphtheria toxin reduction of nerve conduction is observed (polyneuritis) occur on soft palate paralysis, paralysis of the swallowing muscles as well as a accomodation. The ECG changes within the meaning of ST depression, T wave inversion-undAV- or left bundle branch block. The pathology of pharyngeal diphtheria (incubation time 2-5 days) is characterized by an adherent pseudomembrane that exceeds the tonsils; spread to the palate and uvula to the larynx is possible. Upon removal, the membranes can cause bleeding. Patients suffer from sore throat, difficulty swallowing and belonging neck lymph nodes are swollen ("Caesars-neck"). Particularly characteristic a clearly perceptible sweet smell is described. Other possible clinical manifestations are diphtheria eyes, nose diphtheria (with bloody mucous discharge) as well as skin and wound diphtheria. The last form can sometimes tropical travelers (backpackers) werden.4 introduced prognostic importance is the development of myocarditis. The death of the patient is carried out by a sudden obstruction of the airways or heart failure. The mortality rate is usually between 5 and 10%, up to 25%, however, is possible. Other important but rare manifestations of infections caused by C. diphtheriae (mostly non-toxic strains) are: endocarditis, sepsis 5, arthritis, osteomyelitis and brain abscesses.
Corynebacterium Diphtheriae therapy, prevention, reporting obligation
The therapy has been around for disease suspicion in the administration of diphtheria antitoxin by horse (with respect to international pharmacy) and the administration of penicillin G (PENICILLIN-GRUNENTHAL etc.) or erythromycin (ERYCINUM etc.) in patients with penicillin allergy for ten days. In endocarditis, valve replacement is necessary. Prevention is done by immunization with toxoid vaccine, according to the STIKO with booster doses at intervals of ten years. Even when recovering from diphtheria active immunization is required! The sick are to be isolated for 10 to 14 days; the insulation can be waived if three-time negative bacteriological examinations at intervals of two days. In close contacts chemoprophylaxis (penicillin G or erythromycin) is recommended regardless of vaccination status. Reporting requirement according to P6 IfSG (suspected disease and death), Section 7 (laboratory) and Section 34 (communal).
|Erythromycin||250 - 500 mgs||4 times a day at least 2 hours before a meal|
|Lincomycin||500 mgs (max - 1,5-2 gramm a day)||3 times a day for at least 10 days|
|Tryiodinerezorcine||Apply a thin layer to affected skin||1-3 times a day for 1-4 weeks|
|Josamycin||1 g||once or twice a day between a meal|
|Benzylpenicillin||8-12 million IU / day in 4-6 injections||from 7-10 days to 2 months or more|
|Benzathine benzylpenicillin||300000-600000 IU||once per week|
|Vancomycin||500 mgs - 1 g||500 mgs every 6 hours, 1g every 12 hours|
|Pefloxacin||400 mgs|| twice a day for 7 - 14 days|
|Nitroxoline||100 mgs (max daily dose - 800 mgs)||4 times a day during a meal for 2-3 weeks.|
|Cefalexin||250 - 500 mgs||2-4 times a day before a meal for 7 - 14 days|
|Oleandomycin||250 - 500 mgs (2 g - Max in a day)||4-6 times a day following a meal for 5 - 7 days|
|Cefazolin||Intramuscular, intravenous. 1-4 g / day (max - 6 gramm a day)||2-3 times a day for 7-10 days|
|Cefotaxime||1 - 2 g||every 8 - 12 hours|
|Neomycin||Topically||Apply to affected skin 1-3 times a day.|
|Sulfathiazole||3 - 6 g a day (max dose - 7 g a day)||course dose of 20-30 g|
|Sulfanilamide||Topically (5–10–15 g)||bandage once a 1-2 days|
|Sulfadimidine||1 g 4–6 times a day (max 7 g a day)||dysentery prescribed under the scheme: 1 cycle of treatment - 25-30 g, 2 cycle - 18-21 g|
|Sulfacetamide||Parenterally slowly (for at least 5 minutes) at 3-5 ml of 30% solution||2 times a day with an interval of 12 hours|
|Ceftizoxime||Intramuscular, intravenous. 1-2 g||every 8 - 12 hours|
|Benzyldimethyl-myristoilamine-propylammonium chloride monohydrate||Topically. 1-5 ml 2-3 times a day||7-14 days|
|Midecamycin||400 mgs||3 times a day before a meal for 14 days|
|Roxithromycin||300 mgs||once or twice a day|
|Spiramycin||2 - 3 million IU||2 - 3 times a day (increased to 15 million units/day, given in divided doses for severe infections)|
|Flucloxacillin||250 - 500 mgs||4 times a day for 7 – 10 days|
|Ampicillin + Oxacillin||0,5 - 1 g (max - 2 -4 gramm a day)||5-7 days to 2 weeks|
|Brilliant green||Externally applied to the affected area, covering the surrounding healthy tissue|
Corynebacterium Diphtheriae diagnostics
If there is clinical suspicion of diphtheria microbiological laboratory must be informed immediately in order to use in the cultural approach appropriate media. Suitable for investigation throat swabs with removal under the false membranes, and nose or wound swabs, tissue if necessary. Repeated detection of corynebacteria in blood cultures should not be dismissed as contamination! The toxin detection (ELEC-test, PCR) is currently available only in a few laboratories.