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Moraxella catarrhalis infection

Category: Illness or disabilities

Type

Involuntary

Introduction and description

Moraxella catarrhalis is a large, kidney-shaped, Gram-negative diplococcus.  [A diplococcus (plural diplococci) is a round bacterium (a coccus) that typically occurs in the form of two joined cells] .

M. catarrhalis was previously placed in a separate genus named Branhamella, as such you may find that the name Branhamella catarrhalis is used as well, especially in older papers.  It can be cultured on blood and chocolate agar plates after an aerobic incubation at 37 °C for 24 hours. Cultures revealed grey-white hemispheric colonies about 1 mm in diameter. 

They can cause infections of the respiratory system, middle ear, eye, central nervous system, and joints of humans.  Moraxella is named after Victor Morax, a Swiss ophthalmologist who first described this genus of bacteria. Catarrhalis is derived from catarrh, from the Greek meaning "to flow down" (cata- implies down; -rrh implies flow), describing the profuse discharge from eyes and nose typical of infection with this bacteria.

M. catarrhalis is now accepted as the third commonest pathogen of the respiratory tract after Streptococcus pneumoniae and Haemophilus influenza.   Incidence of M. catarrhalis infection is high in children and in the elderly.

Approximately 90% of strains are now β-lactamase positive.  The significance of this is that antibiotic resistance is achieved via the enzyme β-lactamase.  The bacteria has so far become resistant to the antibiotics penicillin, ampicillin, and amoxicillin.   Resistance to trimethoprim, trimethoprim-sulfamethoxazole (TMP-SMX), clindamycin, and tetracycline have also been reported.

Given that the first such strain was reported in 1976, this represents a dramatic increase in frequency over the last 20 years which has not been paralleled in any other species.  Indications are that it might lose susceptibility to fluoroquinolones, most second- and third-generation cephalosporins, erythromycin, and amoxicillin-clavulanate.

Symptoms

M. catarrhalis is an opportunistic pulmonary invader, and causes harm especially in patients who have compromised immune systems or any underlying chronic disease.  It is a significant cause of lower respiratory tract infections in adults, especially those with underlying chest disease.

Otitis media

Acute otitis media is diagnosed in patients with acute onset, presence of middle ear effusion, physical evidence of middle ear inflammation, and symptoms such as pain, irritability, or fever. Acute otitis media is usually a complication of eustachian tube dysfunction that occurs during a viral upper respiratory tract infection. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common organisms isolated from middle ear fluid. …. Antibiotics, decongestants, or nasal steroids do not hasten the clearance of middle ear fluid and are not recommended. PMID:  24134083

Sinusitis

M. catarrhalis is a significant cause of sinusitis in children, both acute sinusitis, and maxillary sinusitis.

Sinusitis is a complex involvement of the upper respiratory system by bacteria, viruses, fungi, or other allergens. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the dominant bacterial microorganisms involved in acute sinusitis, whereas in chronic sinusitis, Staphylococcus aureus and some anaerobic bacteria are the prevailing pathogens. Appropriate treatment requires sinusitis bacteriology assessment. PMID: 27282403

Bacteremia

M. catarrhalis is an important cause in bacteremia [the presence of bacteria in the blood].  M. catarrhalis infection can range in severity from a slight fever to lethal sepsis and an associated respiratory tract infection is usually also identified. Bacteremia infections caused by M. catarrhalis have a 21% mortality rate among patients.

The aim of this study was to compare the clinical characteristics of patients with bacteremia due to Moraxella catarrhalis against those with bacteremia due to Streptococcus pneumoniae and Haemophilus influenzae………………There were eight cases of M. catarrhalis, 110 cases of S. pneumoniae (105 patients) and 22 cases of H. influenzae. ….
 Univariate analysis revealed that underlying conditions, trans-nasal devices, lower body weight and low white blood cell count at the onset of illness were associated with the M. catarrhalis group compared to the S. pneumoniae group.
… the higher rates of the patients with underlying conditions and trans-nasal devices were associated with the M. catarrhalis group compared to the H. influenzae group.  PMID:  26861621

Meningitis

M. catarrhalis is an important cause in meningitis:

Moraxella catarrhalis has been reported with increasing frequency to be the aetiological agent of serious systemic infection in both children and adults. [A] case of neonatal meningitis due to this organism is described herein. The fatal outcome and causes of failure of response to antimicrobial therapy are also discussed.  PMID: 8893948

Asthma

Neonates with airways colonized by Haemophilus influenzae, Streptococcus pneumoniae or Moraxella catarrhalis can exhibit symptoms - a recurrent wheeze - which may resemble asthma early in life.

Preschool children (n = 42) with severe persistent wheeze but no symptoms of acute pulmonary infection were investigated by bronchoscopy and bronchoalveolar lavage (BAL). …... Of the 42 children with severe wheezing, 34 (81%) showed a neutrophilic inflammation and 20 (59%) of this subgroup had elevated bacterial counts (≥ 10⁴ colony forming units per milliliter) suggesting infection. Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis were the most frequently isolated species. PMID:  22140482

COPD

Moraxella catarrhalis is implicated in the pathogenesis of some COPD patients.

We sought to investigate whether the M. catarrhalis strain is variable between COPD subjects; that an exacerbation is associated with acquisition of a new strain and that certain strains are more commonly associated with exacerbations…………Sputum M. catarrhalis strains exhibit marked diversity within and between COPD subjects. Acquisition of a new strain is common between stable and exacerbation events such that no strain is specifically associated with an exacerbation.  PMID: 30510409

Laryngitis

Subglottic laryngitis (pseudocroup) is one of the acute children's diseases, directly caused by a violently growing oedema of the subglottic area.  The symptoms are: “dry barking cough, stridor, inspiratory dyspnoea with the participation of auxiliary respiratory muscles, agitation and change of colour of skin”.

Our research showed that out of 72 patients with subglottic laryngitis 56.95% had bacterial symptoms. ….. We observed that 50.51% of the patients suffering from subglottic laryngitis had an inflammation of upper airways (otitis media, rhinitis, pharyngitis) and 13.89% of lower respiratory tract (bronchitis, pneumonitis). PMID: 17877117

M. catarrhalis is also an important cause of acute laryngitis in adults.

Pharyngitis

Pharyngitis is inflammation of the pharynx, which is in the back of the throat. It is most often referred to simply as “sore throat.” Pharyngitis can also cause scratchiness in the throat and difficulty swallowing

Antibiotics are often inappropriately used for the treatment of pharyngitis, which can contribute to antimicrobial resistance, therefore non-antibiotic treatments which have broad antiseptic effects may be more appropriate. … Seven bacterial species are associated with pharyngitis, namely Streptococcus pyogenes, Fusobacterium necrophorum, Streptococcus dysgalactiae subspecies equisimilis, Moraxella catarrhalis, Haemophilus influenza, Arcanobacterium haemolyticum and Staphylococcus aureus. PMID: 30568479

Conjunctivitis

Most cases of conjunctivitis in adults are probably due to viral infection, but children are more likely to develop bacterial conjunctivitis than they are viral forms. The main bacterial pathogens are Haemophilus influenzae and Streptococcus pneumoniae in adults and children, and Moraxella catarrhalis in children. Contact lens wearers may be more likely to develop gram-negative infections. Bacterial keratitis occurs in up to 30 per 100,000 contact lens wearers.  PMID:  22348418

Bacterial croup

Bacterial croup may be divided into laryngeal diphtheria, bacterial tracheitis, laryngotracheobronchitis, and laryngotracheobronchopneumonitis. Laryngeal diphtheria is due to Corynebacterium diphtheriae while bacterial tracheitis, laryngotracheobronchitis, and laryngotracheobronchopneumonitis are usually due to a primary viral infection with secondary bacterial growth. The most common bacteria implicated are Staphylococcus aureus, Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis

Bacterial bronchitis

Protracted bacterial bronchitis is usually caused by Streptococcus pneumoniae.  The other bacteria implicated in causing bronchitis include:

  • Mycoplasma pneumoniae,
  • Chlamydophila pneumoniae,
  • Bordetella pertussis
  • Haemophilus influenzae
  • Moraxella catarrhalis and
  • Pseudomonas aeruginosa

M. catarrhalis is an important cause in acute purulent irritation of chronic bronchitis

Mastoiditis

Mastoiditis is an infection of mastoid process, the portion of the temporal bone of the skull that is behind the ear which contains open, air-containing spaces.  Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus, Haemophillus influenzae, and Moraxella catarrhalis are the most common organisms causing acute mastoiditis.

Pneumonia

Gram-negative bacteria cause pneumonia less frequently than gram-positive bacteria. Some of the gram-negative bacteria that cause pneumonia include Haemophilus influenzae, Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa and Moraxella catarrhalis. These bacteria often live in the stomach or intestines and may enter the lungs if vomit is inhaled.

Elderly patients and long-term heavy smokers with chronic obstructive pulmonary disease should be aware that M. catarrhalis is associated with bronchopneumonia, as well as exacerbations of existing chronic obstructive pulmonary disease.

The peak rate of colonisation by M. catarrhalis appears to occur around 2 years of age, with a striking difference in colonization rates between children and adults (very high to very low).

Septic arthritis

M. catarrhalis has been linked with septic arthritis in conjunction with bacteremia. Although cases of bacteremia caused by M. catarrhalis have been reported before, this was the first instance in which bacteremia caused by M. catarrhalis was also associated with septic arthritis.

Moraxella catarrhalis was isolated from blood from a 41-year-old man who had a 24-hour history of increasing pain in and swelling of the left knee. No history of trauma, arthropathy, fever, chills, cough, or chest pain was noted. What is believed to be the first case of bacteremia caused by M. catarrhalis that was associated with septic arthritis is described in this report. [Reviews of Infectious Diseases, Volume 13, Issue 3, 1 May 1991, Pages 428–429, https://doi.org/10.1093/clinids/13.3.428

Urethritis

Urine samples from men attending sexually transmitted disease clinics have identified a whole host of bacteria associated with urethritis-  Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis, Ureaplasma urealyticum, U. parvum, adenovirus, herpes simplex virus, Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae.  In general the number of lifetime sexual partners is negatively associated with bacterial load and the use of anal sex or other sexually abnormal approaches.[PMID: 26658669]

M. catarrhalis however, is an important but frequently overlooked cause of urethritis.

A case of heterosexual transmission of Moraxella catarrhalis by fellatio, which resulted in acute purulent urethritis mimicking gonorrhoea in the male partner, is described. In male patients with urethritis due to M. catarrhalis, orogenital contact with a sexual partner carrying the organism in his/her oropharynx is the probable route of transmission.  PMID:  17686227

Cause

Moraxella catarrhalis is a fastidious, nonmotile, Gram-negative, aerobic, oxidase-positive diplococcus.  It causes the infection of the host cell by sticking to the host cell using trimeric autotransporter adhesins.  Current research priorities involve determining factors involved with virulence.  According to medical literature this bacteria shows “complement resistance”.  The complement system is part of the immune system.  But does it?

Suppressed immune system - If one looks at the papers on this bacteria, one finds some common factors amongst those who appear to be suffering most from the disease:

  • In babies, they are often already sickly with a low body weight, and their immune system is not functioning correctly
  • In others, there is a Low white blood cell count - in other words their immune system is not functioning correctly

M. catarrhalis bacteremia - There are other changes that are significant. M. catarrhalis is now being found all over the body.  Many chronic diseases in patients with M. catarrhalis bacteremia can be linked to those patients with immune defects or respiratory debility.

Infection of high-grade bacteremia has been linked with the development of endocarditis – heart disease and as we have seen above it is associated with meningitis and arthritis. 

Over the last decade, an increase in invasive infections due to Moraxella catarrhalis has been reported. We have analysed 58 cases of bacteraemia due to M. catarrhalis …... Patients with bacteraemia could be divided into 3 groups ….. They were either immunocompromised, had underlying respiratory disorders or were normal hosts. The clinical manifestation of M. catarrhalis bacteraemic infection ranged from a mild febrile illness to a fatal disease. PMID:  9730292

So we have two main causes for the increased disease incidences of this bacteria:

  •  A suppressed immune system
  • Entry of the bacteria into the blood, as opposed to its normal confinement in the gastrointestinal tract

Stress and Pharmaceuticals – the role of immunosuppressants

The suppression of the immune system can be caused by stress and indeed one cannot find a more stressful or terrifying, noisy, hostile or unhelpful place for a baby, child or an adult to be than a hospital or that oxymoron of the hospital system the Intensive Care Unit.

But we also have the one pharmaceutical given to patients without thought or understanding of the effects – the immunosuppressant – given to suppress symptoms but which as a consequence suppresses the one system the body has to fight disease -  the immune system

The aim of this study was to observe efficacy of the treatment of the subglottic laryngitis with glucocorticoids, especially budesonide in nebulization. PMID:  16273861

Glucocorticoids are immunosuppressants.  Those receiving treatment for leukemia have acquired the infection

In two young children with leukaemia, a girl and a boy aged 5 and 4 years, respectively, an invasive infection due to Moraxella catarrhalis was diagnosed …. The first child developed pneumonia and recovered, the other developed severe septic shock and died. Immunocompromised patients … have an increased risk of severe infections.  PMID:  12822523

So we can say that the main cause of the increase in severity, frequency and incidence of infection with this bacteria are the medical profession. As Wikipedia say “Nosocomial [originating in a hospital] spread of infection, especially within respiratory wards, has been reported”.

Hospital equipment

How does the bacteria get into the blood?  It appears that the principle mechanism is hospital equipment.  Haemodialysis equipment for example:

A 43-year-old male with chronic kidney disease on maintenance hemodialysis presented with breathlessness, cough and right-sided abdominal pain. Examination revealed a large right-sided pleural effusion ….sputum culture produced Moraxella catarrhalis.  PMID:  23393539

And trans nasal devices. 

Nasal administration is a route of administration in which drugs are insufflated through the nose. It can be a form of either topical administration or systemic administration.  “The nasal cavity is covered by a thin mucosa which is well vascularised. Therefore, a drug molecule can be transferred quickly across the single epithelial cell layer directly to the systemic blood circulation without first-pass hepatic and intestinal metabolism.”

Treatment

Treatment should always be of the cause and not the symptom, as such given the cause is the combination of the bacteria and the medical profession and its procedures and equipment one might be wise to address the latter.

References and further reading

  • Bacteremia and Septic Arthritis Caused by Moraxella catarrhalis  - Philipp R. Melendez Royce H. Johnson Reviews of Infectious Diseases, Volume 13, Issue 3, 1 May 1991, Pages 428–429, https://doi.org/10.1093/clinids/13.3.428  Published:  01 May 1991
  • Otolaryngol Head Neck Surg. 2018 Nov 27:194599818815109. doi: 10.1177/0194599818815109. [Epub ahead of print]  The Microbiology of Complicated Acute Sinusitis among Pediatric Patients: A Case Series. Mulvey CL1, Kiell EP2, Rizzi MD3, Buzi A3.
  • J Chin Med Assoc. 2016 Aug;79(8):440-4. doi: 10.1016/j.jcma.2016.03.002. Epub 2016 Jun 6.  Detection of Streptococcus pneumoniae and Moraxella catarrhalis in patients with paranasal chronic sinusitis by polymerase chain reaction method.  Farajzadeh Sheikh A1, Ahmadi K2, Nikakhlagh S3.
  • Ann Trop Paediatr. 1996 Sep;16(3):199-201.  Neonatal meningitis due to Moraxella catarrhalis and review of the literature.   Daoud A1, Abuekteish F, Masaadeh H. 1  Department of Paediatrics, Jordan University of Science and Technology, Irbid, Jordan
  • Int J STD AIDS. 2007 Aug;18(8):579-80.  Moraxella catarrhalis associated with acute urethritis imitating gonorrhoea acquired by oral-genital contact.  Abdolrasouli A1, Amin A, Baharsefat M, Roushan A, Hemmati Y.  Microbiology Department, Pathology Centre, Hammersmith Hospital NHS Trust, Du Cane Road, London, UK. AAbdolrasouli@hhnt.nhs.uk DOI: 10.1258/095646207781439775
  • PLoS One. 2011;6(11):e27913. doi: 10.1371/journal.pone.0027913. Epub 2011 Nov 29.  Wheeze in preschool age is associated with pulmonary bacterial infection and resolves after antibiotic therapy.  Schwerk N1, Brinkmann F, Soudah B, Kabesch M, Hansen G. PMCID: PMC3226624
  • Int J Chron Obstruct Pulmon Dis. 2018 Nov 8;13:3663-3667. doi: 10.2147/COPD.S180961. eCollection 2018.  Sputum Moraxella catarrhalis strains exhibit diversity within and between COPD subjects.  George LM1, Haigh RD1, Mistry V1, Haldar K1, Barer MR1, Oggioni MR2, Brightling CE1.

 

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