Aim- To study the pattern of oral microflora in HIV Infected Individuals and compare it with normal individuals.

Material & Methods- It was a one year prospective study conducted at a tertiary care centre. The study group consisted of seventy subjects divided into normal control & HIV infected individuals. HIV Patients were selected not on anti-retroviral therapy and not having any active oral lesions. Routine examination and CD4 blood count was performed. Oral saline gargles were used to obtain the flora. Culture of organisms was performed as per standard protocol.

Results- The mean age of control group were 35.7 years and HIV group was 33.7 years. The mean CD4 count of control group was > 500 and of HIV were 208. Organism isolated in control group were Streptococcus viridians (51%), Acinetobacter (22.8%) whereas in HIV group Streptococcus viridians was 42.8%, Micrococcus spp. (28.5%) and Acinetobacter (14.3%).

Conclusion- There was increased colonization of Micrococcus spp. in oral cavity of HIV infected individuals which is usually a normal commensal of skin.

 
Keywords: Oral Microflora; HIV;AIDS; Micrococcus  

Acquired Immune Deficiency Syndrome (AIDS) as being one of the devastating disease has killed more than 25 million people worldwide since 1981 [1].India being a country having population about 1.25 billion and almost half the population is sexually active. National AIDS Control Organization (NACO) estimates 8,10,399 people living with Human Immune Deficiency Virus (HIV) in India till September 2014[2]. Immunosuppression in HIV infected patients is due to depletion of cell mediated immunity response. The CD4 count is inversely proportional to morbidity and mortality. HIV infected individuals are predisposed to streptococcus pneuominae and non typhi salmonella [3]. Other studies have found an increased incidence of infection with Haemophilus influenza and Pneumococci which are capsulated organisms [4]. Schmidt et al. [5] in his study found that 5.0% of the HIV infected patients had colonization with different species of Enterobacteriaceae. As described by various studies that injudicious use of antibiotics leads to change in oral flora [6,7]. Such changes are documented in leukemia [8], but there lacks documentation in HIV infected patients. The idea of present study is to identify a significant shift in oral microflora of HIV infected patients.

Present study was conducted over a period of one year in a tertiary care center, UPRIMS &R, Saifai, Etawah, Uttar Pradesh, India. HIV infected patients were sent randomly to ENT OPD for examination from Anti-Retroviral Therapy (ART) center of the institute. Control patients were selected randomly from ENT OPD. The subjects were included with no evidence of upper respiratory tract infection, local lesions in oral cavity like ulcers, hairy leukoplakia, erythroplakia and tumor etc. AIDS patients were not on antiretroviral therapy and were not receiving any antibiotics or regularly using mouthwash. Controls were excluded who were immunosuppressed like suffering from chronic liver disease, uncontrolled diabetes mellitus, transplant recipient, cancer patient on treatment.

HIV infection was diagnosed by HIV Enzyme Linked Immunosorbent Assay (ELISA) and confirmation was done by western blot method. All subjects in study were asked a detailed clinical history, followed by a detailed clinical examination. Routine investigations like complete blood count, Cluster of Differentiation (CD4) count and urine routine were performed.

We used 0.85 to 0.9% normal saline mouth gargles or oral washings for collecting specimens. Subjects were asked to gargle for 1 min and then the contents are collected in a sterile container. Early morning samples were collected and samples were transported to the lab within 30 min.

Once in the laboratory, the washings were inoculated in 5% sheep blood agar for aerobic culture using standard calibrated loop with an internal diameter of 4 mm. The inoculated plates were incubated for 24–48 hours at 37 ̊C. The bacteria were identified by colony morphology, gram staining, test for motility, catalase test, oxidase test and other biochemical tests. The data was statically analyzed by SPSS 14.0 software.

HIV infected patients are more vulnerable to invasive bacterial infections than immunocompetent persons. Numerous immunologic system deficits are responsible for the increased vulnerability to various infections. These include defect in the cell mediated and the humoral arms of the immune system; phagocytic abnormalities including decrease in neutrophil number, multiple defects in neutrophil function and impairment in macrophage and monocyte function [9]. These defects become more severe as the HIV disease progresses. Other factors that increase susceptibility to infection in the HIV infected include frequent use of broad-spectrum antibiotics, frequent hospitalizations, use of indwelling intravascular catheters that disrupt the integrity of skin, malnutrition, micronutrient deficiencies, and lack of adequate medical care.

Sarkar K et al. [10] found that female sex workers had HIV infection much higher (12.5%) in younger sex workers with age 20 years compared with older age groups (5.4%). In our series the age range was 19–55 years with a mean age of 33.7 years. Men were three times more commonly affected than women. The most common age group affected was 21–30 years; this is consistent with the findings of Leynaert et al. [11] and Kumar [12] et al. who observed the highest incidence of HIV in the late twenties and thirties.

In our study the mean CD4 T cell count in the HIV group was 208 cells/ mm3. Rogers MC et al. [13] found the median CD4 count was 97 cells/ mm3 amongst concordant men and 222 cells/ mm3 amongst discordant men.

Schmidt-Westhausen et al. [5] found that 5% of the HIV infected patients and 4.8% of the controls had different species of Enterobacteriaceae in the oral cavity. Yeasts were always associated with Enterobacteriaceae in the HIV infected patients. In our series the most common microorganism isolated in the control group was the Streptococcus viridans (51%); this was followed by the Acinetobacter in 22.8% cases. In the HIV group, we found a shift in oral microflora with a reduction in the isolation of Streptococcus viridans (42.8%) and Acinetobacter (14.3%). We found an increase in the incidence of colonization with Micrococcus spp. (28.5%). Micrococcus species are usually considered normal inhabitants of the skin [14]. Micrococcus species has been reported to cause localized cutaneous infections like folliculitis [14] and keratitis [15] in HIV infected patients. Gray et al. [4] stated that the HIV infected individuals are predisposed to infection with bacteria like S. pneumoniae, non-typhi Salmonella, S. aureus, Enterobacteraciae, Rhodococcus spp, Nocardia spp. Mascellino et al. [16] found high incidence of nosocomial bacterial infections in patients with AIDS and it was associated with high fatality rates. The most common micro-organisms isolated were gram-negative bacteria like E. coli, Proteus, Enterobacter, Serratia, and Klebsiella. The organisms that were isolated in our series were Streptococcus viridans, Micrococcus spp., Acinetobacter, Klebsiella spp, Pneumococcus, Bacillus, and Moraxella catarrhalis. All these organisms are potentially pathogenic organisms especially so in a patient with HIV. Streptococcus viridans have been reported to cause various infections in HIV patients. Corti et al. [14] evaluated 61 episodes of infective endocarditis in intravenous drug abusers and human immunodeficiency type-1 virus infection. He isolated S. aureus in 73.1%, S. viridans in 19.5%, S. epidermidis in 2.4%, S. hominis in 2.4% and S. pneumonia 2.4%. Milgrim et al. [15] studied sinusitis in human immunodeficiency virus infection and the most common organisms isolated were S. pneumoniae (19%), S. viridians (19%), and Pseudomonas aeruginosa (17%). It is important to recognize that infection due to atypical organisms must be considered if an HIV infected patient with sinusitis does not respond to initial antibiotic therapy [16].

Acinetobacter has been reported to cause sepsis, urinary, respiratory tract diseases and bacteremic pneumonia [17,18] in HIV infected patients. As opportunist pathogens with predominant nosocomial origin Acinetobacter spp. Organisms may be responsible for an appreciable morbidity in patients with HIV disease, especially when additional risk factors like immunodeficiency, underlying diseases, and hospitalization are present [17].

Opportunistic infections are the most common cause of death in patients with HIV and many of these are caused by commensal bacteria which are otherwise indolent in normal individual. We found an increased colonization of the oral cavity by Micrococcus spp. which is a normal commensal of the skin. Although the exact significance of this phenomenon is not established, further research is required to ascertain its potential significance.

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