GENRES: Streptococcus and Enterococcus Grisel Rodriguez Cuns Streptococcus and E nterococcus genera are formed by spherical or ovoid

bacteria that grow in pairs or chains of varying length. Most are facultative anaerobes, obligate anaerobes species exist. They are Gram positive, non-spore forming, catalase negative, and are still complex and variable nutritional requirements. Streptococcal infectio n is one of the most frequent, with some of the most important paintings related to gender: acute tonsillitis, otitis media, sinusitis, pneumonia, meningitis, u rinary tract infection, abdominal or skin. The infections most frequently associ ated with the genus Enterococcus are endocarditis, urinary tract infections and colonization / superinfection of patients being treated with antibiotics, partic ularly cephalosporins. TAXONOMY There is no simple classification system to diff erentiate this heterogeneous group of microorganisms and the same is subject to constant revision. By contrast, the classification depends on a combination of f eatures, including a pattern of hemolysis in blood agar plates, antigenic compos ition, growth characteristics, biochemical reactions and more recently, genetic analysis. The hybridization of DNA technology has revolutionized the taxonomy, s howing that enterococci are so different from other streptococci, which constitu te a new genre. When streptococci are grown in blood agar, can be observed in ad dition to the gross morphology characteristic of each strain, the presence of a transparent halo around the colony where the red blood cells were completely lys ed. This pattern is designated Beta hemolysis rate and is of considerable import ance since the exhibits Streptococcus Streptococcus pyogenes and many other huma n pathogens. A second group of microorganisms, produces partial or hemolysis Alp ha hemolysis was observed as a greenish halo around the colony to belong to this group S. pneumoniae and other Streptococcus that inhabit the upper respiratory and gastrointestinal tract of man. Finally, the term Gamma hemolysis is used to designate those species that do not produce hemolysis, although the term non-hem olytic streptococcus is preferable. A more precise identification of beta-hemoly tic streptococci was created by Rebecca Lancefield. The classification into sero groups based on antigenic differences of cell wall carbohydrates. Group antigens are readily removable from the cell wall and identified by precipitation reacti ons using specific antisera. The streptococcal antigen without recognizable grou p are identified by phenotypic characteristics (fermentation reactions, enzyme p roduction) and DNA hybridization. It is now recognized about 30 species of Strep tococcus, being some of the most important species in human pathology: S. pyogen es (group A streptococcus), S. agalactiae (group B streptococcus) and S. pneumon iae (pneumococcus) . Streptococcus pyogenes Streptococcus pyogenes (Group A Stre ptococcus) is one of the most important bacteria in human pathology. This ubiqui tous organism is the most common bacterial cause of acute pharyngitis and also g ives rise to a variety of skin and systemic infections. It occupies a special pl ace in medical microbiology for causing two nonsuppurative sequelae, rheumatic f ever (RF) and acute diffuse glomerular nephritis postestreptocóccica (GNDA). MIC ROBIOLOGICAL CHARACTERISTICS group A Streptococcus (GAS) are presented as cells microscopically spherical or ovoid, 0.6-1.0 mm in diameter and are grouped in pa irs or chains of variable length in clinical samples, or when grown in liquid me dia enriched with serum or blood. They, like the rest of streptococci, Gram +, i mmobile, non-spore forming, catalase - and, optionally, anaerobes. SGA is demand ing from a nutritional standpoint, requiring complex media enriched with blood f or optimal development. When grown on solid media with blood is seen around the gray colonies 1-2 mm in diameter with a halo of hemolysis beta (there may be str ains that do not exhibit, but it is exceptional). They have identified a large n umber of structural components and extracellular products in SGA. Below are outl ined the most important. CELLULAR COMPONENTS a. The capsule is the uppermost lay er that surrounds the organism and is composed of hyaluronic acid, found in micr oorganisms only when studying disease in the host.€It is an accessory virulence factor hindering phagocytosis by polymorphonuclear leukocytes and macrophages of the host. b. The group-specific carbohydrate (carbohydrate C) consists of a dim er of rhamnose and Nacetilglucosamina. 1

c. The mucopeptide (peptidoglican) which gives rigidity to the wall, which bind proteins, carbohydrates and lipids. Antigenic components in nature and may contr ibute to pathogenicity. d. The M protein is a major virulence factors of SGA. It is located in fibrillar structures conferring upon her rich strains, resistance to phagocytosis by polymorphonuclear leukocytes. Strains that do not express ar e avirulent. EMS can be divided into serotypes based on antigenic differences of the protein molecule M. About 80 serotypes are currently recognized. Acquired i mmunity against streptococcal infection is based on the development of opsonizin g antibodies directed against the portion of the antiphagocytic M protein molecu le Such immunity is type-specific and remains for several years, perhaps indefin itely. It has been shown in some cases cross-protection by antibodies against on e serotype of a serotype heterologous organisms. M protein is a filamentous macr omolecule that is found as a stable dimer with an alpha helical structure. Is an chored to the cell membrane and traverses the cell wall. The proximal portion of the molecule contains epitopes conserved in all USG, while the distal portion c ontains type-specific epitopes. This configuration locates the sector-specific r ate at the tip of the fibrils, protruding on the cell surface (Fig. 1). In the n onimmune host, M protein exerts its antiphagocytic effect by inhibiting the acti vation of the alternative pathway of complement on the cell surface. This effect is mediated in part by the ability of M protein to precipitate fibrinogen direc tly on the bacterial surface. The antiphagocytic effect is nullified in the pres ence of adequate concentrations of type-specific antibodies. e. The serum opacit y factor (OF) is another antigen closely associated with the M protein molecule This factor alpha is a proteinase that is detected by its property of opacify ho rse serum. Not all strains of SGA for the M protein typable have this factor. Th e FO's and type-specific antigen, ie their ability to opacify serum antibodies c an be inhibited by homologous and heterologous M protein This substance is impor tant mainly for two reasons - is a useful epidemiological marker to aid in the c lassification of streptococci when it is not detectable by the type of M protein - Type-specific response and not type-specific M protein is generally weaker af ter a pharyngeal infection with serotypes FO FO positive with negative. f. T and R proteins are another antigenic complex are not involved in the pathog enicity of the organism, but are useful to complete the characterization of Stre ptococcus, especially in strains not identifiable by the M protein g. The F prot ein, no fibrillar, plays a critical role in the first step of colonization, whic h is the GHS adhesion molecule fibronectin, glycoprotein located on the surface of human epithelial cells. Lipoteichoic acid formed by polyglycerol phosphate un its attached to lipid could also play a role in adhesion, in association with su rface proteins. h. Recently it has been reported linked to the cell peptidase th at cleaves the C5 component of complement and inhibits neutrophil chemotaxis in vitro and in vivo. Extracellular products during development in vivo and in vitr o, GHS produces numerous extracellular products, but only a limited number of th em have been well characterized. Some have antigenic character, and determinatio n of antibodies against them is used for diagnosis of recent streptococcal infec tion. a. Hemolysins, there are two types of hemolysins produced by EMS are calle d O and S. Streptolysin O derives its name from its oxygen lability. It is rever sibly inhibited by oxygen and irreversibly by cholesterol. In addition to its ly tic effect on erythrocytes, is toxic for a variety of cells and cell fractions i ncluding polymorphonuclear leukocytes, platelets and lysosomes. Streptolysin O i s produced by almost all strains of SGA (as well as by some agencies and groups C and G) and is antigenic.€Titration of antistreptolysin 0 antibodies (AELO) in human serum has proven to be a useful test as an indicator of recent streptococc al infection. Streptolysin S is a hemolysin produced by streptococci in the pres ence of serum (hence the "S") or in the presence of a variety of other substance s such as albumin, alpha-lipoprotein, RNA. Streptolysin S is not antigenic. Has the ability to damage the membrane of leukocytes, platelets, and subcellular org anelles. It is inactivated by oxygen, but it is labile. Given the characteristic s of both hemolysins hemolysis is observed that on the surface of agar plates is

due primarily to streptolysin S, while haemolysin O exhibits its effect on the depth of the agar beneath the bacterial growth. b. The streptococcal pyrogenic e xotoxin (SPE), formerly known as erythrogenic toxin is responsible for the rash of scarlet fever. Experimentally, this substance exhibits a variety of other tox ic properties, including pyrogenicity, cytotoxicity, and 2 increased susceptibility to the lethal effects of endotoxin. Toxin production is induced by the presence of a temperate phage lysogenic phase. There are three k nown toxins serologically different (AC), whose effects can be neutralized by an tibodies. Exotocinas It is acting as superantigens, ie, products that stimulate so intense and unspecific immune system. c. Many extracellular products, can in theory promote the liquefaction of pus and dissemination of S.pyogenes through d ifferent tissue planes. These include: 1. four antigenically distinct enzymes in volved in degradation of DNA (DNase A, B, C and D), 2. hyaluronidase enzyme that degrades hyaluronic acid connective tissue, 3. streptokinase, which promotes th e dissolution of clots by catalyzing the conversion of plasminogen to plasmin. d . Other extracellular products are: Nadas, proteinase, amylase and esterase. Mos t recently listed substances are antigenic and antibodies to five of these produ cts have been used for serodiagnosis of infection by SGA. They are: anti-DNase A ELO, antihialuronidasa, anti-Noughts and antiestreptoquinasa. CLINICAL MANIFESTA TIONS two clinical manifestations of infections with EMS are pharyngitis and pyo derma. Streptococcal Pharyngitis: acute Pharyngeal infection is one of the most frequent reasons for consultation in clinical practice. The same can be viral or bacterial infection. Among the latter SGA is responsible for most of these infections can cause it but other serogroups (groups C and G). It is a self-limi ted disease, although it should always be performed antimicrobial treatment to p revent complications, which most commonly affects children aged between 5 and 15 years, but all ages are susceptible. It is spread from person to person by aero solized droplets of secretions. The number of microorganisms and their virulence are decreasing since the acute phase to convalescence, marking a different degr ee of infectivity. The clinical picture is not specific to streptococcal etiolog y. Scarlet fever is caused by streptococcal infection with a strain that produce s pyrogenic exotoxin. This disease is generally associated with pharyngitis, but may follow streptococcal infections such as wounds. Complications - Complicatio ns of pharyngitis caused by the EMS can be divided into: suppurative and nonsupp urative. Suppurative complications - are seen infrequently since the advent of e ffective antibiotic therapy. Among them are cited: peritonsillar abscess and cel lulitis, otitis media, sinusitis. Nonsuppurative complications - rheumatic fever (RF) and acute diffuse glomerulonephritis (GNDA), that we will review later. Et iologic diagnosis: is made by culture of throat swab. In case of scarlet fever s imultaneously facilitates the diagnosis. Treatment: It is aimed at preventing th e FR and suppurative complications. Prevention of rheumatic fever requires the e radication of infection of the pharynx by SGA, which depends on long-term treatm ent rather than high doses of antibiotic. SGA is to present homogeneously sensit ive to penicillin, an antibiotic with proven efficacy in the prevention of RF. P enicillin G benzathine is used 1.2 million units and for children weighing less than 30 kg, 600,000 U. In patients allergic to penicillin are given erythromycin . According to current data may also be useful new macrolides (azithromycin, cla rithromycin).€Oral regimens should be kept for 10 days. Approximately 15% of ind ividuals are as carriers after treatment. Piodermitis: This term collectively de signating localized streptococcal infections of the skin. Impetigo: a superficia l skin infection is characterized by the appearance of vesicles, 1-2 mm, which r apidly evolve into amber-colored crust, itchy and accompanied by lymphadenopathy 3 satellites. The most common location is in the extremities. USG, which causes im

petigo, differs from those that cause sore throat, belonging to different seroty pes M. The isolates from skin lesions are primarily group A, but is occasionally found as responsible for other serogroups (C and G). The immune response to ski n infections AELO differs from the response in cases of pharyngeal infection, be ing weaker. There is experimental evidence that suggest this may be due to local inactivation of streptolysin 0 by skin lipids. By contrast, the response anti-D Nase and anti-hyaluronidase are preserved and are useful for serological diagnos is. Treatment and Prophylaxis: There are a large number of oral antibiotics effe ctive in the treatment of impetigo. These include: Penicillin V, 1st generation cephalosporins, erythromycin. Topical treatment with mupirocin has high cure rat es, but is expensive. No less important is personal hygiene measures, which are the most important prophylactic measure. Other agents can cause cellulite, but most cases are due to SGA and S.aureus. Al though penicillin is a good choice for streptococcal etiology, because in the ea rly stages is difficult etiological differentiation from a clinical standpoint, we recommend the use of semisynthetic penicillins resistant to penicillins or va ncomycin. Necrotizing fasciitis (streptococcal gangrene) is an infection of deep fascia and subcutaneous tissues, characterized by rapid and extensive necrosis. In typically begins with a traumatic injury, often trivial, which may present a s an erythematous area, which over a period of 24-72 hours a rapid evolution. Th e inflammation spreads and intensifies, the skin darkens and becomes purple, bul lae appear hemorrhagic content. Is often accompanied by bacteremia and metastati c abscesses can occur. The process has an inexorable course to the gradual worse ning unless specific and swift action to contain it. Mortality rates are high ev en with appropriate treatment. Proper management of this entity depends on a cor rect early diagnosis. The study by Gram stain of exudates serosanguineous of inj uries can be useful if it reveals Gram + cocci in a chain. The differential diag nosis of cellulitis and necrotizing fasciitis is crucial, because although both require antibiotic treatment the second also requires surgical treatment, extens ive debridement in some cases. Streptococcal toxic shock syndrome: have been rep orted in recent years several cases of TSS, in different areas of the world, obs erved primarily in adults and then children. SGA strains that cause TSS are tran smitted quickly from person to person and is a high rate of transmission to cont acts. Pathogenesis: We found a higher frequency of certain M serotypes in TSS. A lthough not yet elucidated the pathogenic mechanisms, studies now focus on the s treptococcal pyrogenic exotoxin (SPE). In addition to causing the rash in scarle t fever, the SPEs have a variety of adverse biological effects observed in anima l models, such as changes of different organs and shock. Amino acid homology was found between the SPE and staphylococcal enterotoxin B and C. SPE is a superant igen, and is a potent inducer of tumor necrosis factor. In addition to the M ser otype, other factors have been found associated with SGA strains responsible for TSS as quality and quantity of SPE and, recently, synthesis of a protease. Thes e INVASIVE INFECTIONS OF SKIN AND SOFT PARTS Since the mid-80s, an epidemiological shift is observed in invasive infections caused by SGA, coexisting with the rea ppearance of certain strains of SGA for certain M serotypes, with an increase in the severity and the same frequency. Usually affects adults, and the front door is usually skin. In some cases,€infection leading to shock and failure multipar enquimatoso resembling in some respects to Staphylococcal toxic shock syndrome. As this entity has designated as streptococcal toxic shock syndrome (TSS). Below is a brief overview of severe streptococcal infections of skin and soft tissue and TSS. Erysipelas: An acute inflammation of the skin, with marked impairment o f lymphatic drainage that is caused by EMS. Their frequency has increased in rec ent years. It can affect face, limbs or trunk. Syndrome is accompanied by toxiin feccioso. Treatment with penicillin is curative. Streptococcal Cellulitis: An ac ute and widespread inflammation of the skin and subcutaneous tissue, which can c ontinue to burns, wounds or surgical incisions. It differs from erysipelas becau se the injury is not limited and there is no demarcation between the area affect

ed and unaffected skin. 4 and other factors are responsible for the ability of these strains rapidly invad e the tissues and bloodstream, and trigger the release of factors mediating the cascade of inflammation, multiparenquimatosa at fault. The clinic can be intertw ined with aspects of necrotizing fasciitis is often associated. But what charact erizes it is rapid change in the shock preceded by a mild localized in a small i njury, characterized by local pain, erythema, which progresses to bullous lesion s, accompanied by intermittent fever. The shock is accompanied by acute failure of various organs: severe brain damage, kidney failure, respiratory distress, to xic cardiomyopathy, and liver dysfunction. From the laboratory point of view, th ere is a change multiparenquimatosa, unlike staphylococcal etiology of shock, bl ood cultures are positive in 60% of cases. For the treatment the patient require s intensive care and support must perform vital functions. From the microbiologi cal point of view should be instituted an early antimicrobial therapy, empirical at first, and after confirming the etiology Streptococcal Penicillin G is the a ntibiotic of choice, although it is relatively ineffective when the concentratio n of microorganisms is high. Is currently also investigating the effectiveness o f treatments that target the host component in the pathogenesis of the disease, ie, interacting with the inflammatory response (peripheral blocking action of in terleukins and tumor necrosis factor). Non-suppurative complications rheumatic f ever: Rheumatic fever (RF) is a disease characterized by producing non-suppurati ve inflammatory lesions that involve the heart, subcutaneous tissues and central nervous system. In its classic form is a disease of an acute, febrile, and self -limited. However, heart valve damage can occur, and this damage be chronic and progressive, leading to cardiovascular failure, disability and Pathogenesis: The FR is eventually death. post-streptococci sequel after an upper respiratory inf ection due to SGA. This is supported by several facts: "There is a temporal rela tionship between pharyngeal infection outbreaks and epidemics USG FR: - Most pat ients with FR have a recent history of faringlitis. - In patients with antibodie s detected antiestreptocóccicos FR reveal recent infection. - Continued use of p rophylactic antibiotics reduce recurrent pharyngitis by SGA, is accompanied by a decrease of RF in patients with a history of it. The FR is associated with pharyngeal infection by SGA but not by skin infections , and also with certain M serotypes that are commonly called "strains reumatógen as." These strains have the characteristic of not possessing opacity factor (OF) and possess a thick capsule. Although USG is the cause of the FR, is not entire ly clear the exact mechanism by which the organism induces the disease, and spaw ned several theories: 1. toxic effects of certain products of GHS, particularly streptolysin S and O 2. serum sickness-like reaction mediated by Ag-Ab complex, perhaps located at sites of tissue damage, 3. induced autoimmune phenomena, perh aps, because of the similarity or identity between certain streptococcal Ag and certain molecules in human tissues. Clinically has a varied presentation and the re is no specific diagnostic test. Is presented by a variety of symptoms and sig ns that can occur alone or in combination. According to their diagnostic criteri a are divided into major and minor. Major criteria: carditis, polyarthritis, cho rea,€subcutaneous nodules and erythema marginatum. Minor criteria: fever, arthra lgia, heart failure, acute phase reactants (C reactive protein, high VES, leukoc ytosis). From diagnostic point of view recently analyzed the criteria we must ad d the presence if there is evidence of recent streptococcal infection. Such evid ence may be an episode of bacteriologically documented estrptocóccica pharyngiti s or demonstration of a high titre of anti-streptococcal antibodies in serum. Th is latest study but does not allow diagnosis of FR, possible evidence of the exi stence of a recent infection SGA. Serum was performed AELO dosage being consider ed as an indicator of recent infection equal to or greater than 200 Todd units. They can also dispense anti-DNase and anti-hyaluronidase. Treatment and Prophyla xis: Treatment is designed to reduce inflammation, reduce fever and cardiovascul

ar control. As far as prophylaxis is important to note that patients who have RF are at high risk for repeat episodes with each pharyngeal infection by SGA, so that these patients require continuous prophylaxis to prevent recurrent infectio ns by these microorganisms. This involves the administration of 1.2 million unit s of benzathine penicillin G given every 4 weeks. In patients allergic to penici llin are given erythromycin stearate 250mg twice daily. 5 Regarding the duration of continuous prophylaxis there is great controversy. Som e groups believe that it should not be discontinued until the patient age of 20. Other groups recommend that this be maintained indefinitely. On the other hand, is investigated intensively in the development of a safe and effective vaccine based on M protein to prevent infection by SGA. It should be versatile and posse ss antigenic determinants that confer type-specific immunity and do not contain antigens cross with human tissue. Acute diffuse glomerulonephritis: The GNDA is an acute condition of the renal glomeruli is anatomically characterized patholog ically by diffuse proliferative lesions of the glomeruli and clinically by edema , hypertension, hematuria and proteinuria. It is a sequel suppurative throat or skin infections caused by certain strains of EMS calls "nefritógenas" belonging to certain serotypes, different from those associated with FR, the most common s erotype 12. As in the FR, do not know the exact mechanism by which the condition occurs. Given the time between infection and development of GNDA, the presence of hypocomplementemia, and that immunoglobulins and complement components are pr esent in the kidney from the onset of the condition, there is strong evidence fo r an immunological mechanism to award the cause of renal injury. The most accept ed hypothesis suggests that about kidney damage would be caused by deposition of immune complexes composed of streptococcal antigens and antibodies of the host, at the glomerulus. The diagnosis is made based on clinical evidence and recent streptococcal infection. The latter, based on previous history of scarlet fever, throat infection by SGA or by demonstration of high values of Ac antiestreptocó ccicos. It should be remembered that the GNDA associated with pyoderma the AELO do not rise, so should the owner or anti-DNAse antihialuronidasa. Treatment and prophylaxis: From the microbiological point of view patients should receive peni cillin G benzathine for the eradication nefritógenas strains, this treatment onl y epidemiological purposes and not to modify the course of preexisting GNDA. Unl ike FR prophylaxis is not recommended because they are rare continuous episodes of recurrent GNDA. Streptococcus agalactiae Streptococcus agalactiae or group B Streptococcus (GBS), was described as a human pathogen in 1935 by Fry in three c ases of puerperal fever. MICROBIOLOGICAL CHARACTERISTICS SGB are Gram + cocci, facultative anaerobes, demanding that blood on solid media with grayish grow into colonies 3-4 mm in diameter, surrounded by a halo betahe mólisis Strait. SGB have two antigens on the cell wall polysaccharide nature, on e is the group-specific C antigen, and another is type-specific S substance that allows the classification into five serotypes: Ia, Ib, Ic, II and III. Outside the wall is surrounded by a natural polysaccharide capsule, which inhibits phago cytosis. The capsule of serotype III in particular, inhibits the activation of t he alternative pathway of complement, which participates in the process of opson ophagocytosis of these bacteria.€Sialic acid is the terminal residue of serotype s la and III and is responsible for newly appointed effect. CLINICAL FEATURES Th e association between maternal genital tract colonization at the time of deliver y and neonatal infection with GBS early invasive is well established. Are descri bed in the newborn respiratory distress syndrome, meningitis, sepsis, otitis, em pyema. In adults, it may be the etiologic agent of urinary tract infections, vag inal, and it is very important as an agent of puerperal sepsis. The microbiologi cal diagnosis is made by isolation of GBS from blood cultures, CSF, and / or foc i of suppuration. There are rapid diagnostic methods that involve the detection of capsular antigen in CSF. GBS is uniformly susceptible to penicillins and thes e are the treatment of choice once established the diagnosis. Prevention of colo

nization of the fetus can be achieved by Ampicillin prophylaxis during delivery to carrier mothers. But the solution in the near future may lie in the active im munization with purified polysaccharide preparations. Beta-haemolytic Streptococ cus Group C and G have been isolated in human throat and skin infections similar to those of group A. Have also been isolated cases of puerperal infection, seps is, endocarditis and pneumonia. They are sensitive to penicillin, but tolerant s trains have been described. Enterococcus and Streptococcus Group D Enterococcus: Enterococci are Gram + cocci grouped in pairs or short chains. Belonged to grou p D of the Lancefield classification along with enterococci not remain in the ge nus Streptococcus. MICROBIOLOGICAL CHARACTERISTICS 6 They are facultative anaerobes, capable of developing in extreme conditions such as 6.5% NaCl, pH 9.6 and temperatures between 10-45 º C. They can survive 30 mi n at 60 ° C and developed in the presence of 40% of bile salts. The most frequen tly isolated in the clinic is E.faecalis in 80-90% of the isolates, followed by E.faecium, which is increasing its impact on hospitals especially multi-resistan t strains. It is found in the environment and the most important habitat is the gastrointestinal tract of humans and other animals. Pathogenesis: Although not d escribed a classic virulence factor, the resistance of enterococci to multiple a ntimicrobial agents allows it to survive and proliferate in patients receiving a ntimicrobial therapy. This accounts for the ability of enterococci to superinfec tion patients receiving broad-spectrum antimicrobial. The enterococci can adhere to heart valves and kidney epithelial cells, properties that undoubtedly contri bute to its ability to cause endocarditis and urinary tract infections. As a par t of the intestinal flora enterococci are capable of producing infections in out patients or hospitalized, and was previously thought that most infections caused by these agents were endogenous. However, most infections occur in hospitalized patients, or under treatment with peritoneal dialysis or hemodialysis, in which the agent is exogenous strains found in the environment and in the hands of sta ff. Has in some countries the 2nd or 3rd place in frequency as a cause of hospit al infections. Enterococci have been isolated from urinary tract infections, bac teremia and endocarditis, pelvic infections, and abdominal wounds. The most stri king attribute of enterococci is their relative and absolute resistance to antim icrobial drugs most commonly used in Gram + infections. Enterococci have acquire d a variety of resistance mechanisms, most of which are mediated by genes encode d in plasmids or transposons. It is very important high-level resistance to amin oglycosides acquired resulting in resistance to the synergistic combination of a minoglycosides with beta-lactam agents, widely used therapeutic partnership and for which consideration should be sensitive to a serious infection with enteroco cci. In the late 80s was described in Europe the resistance to Vancomycin (antib iotic only useful against strains resistant to other agents) currently causing i mpacts on other parts of the world. It is also in this decade that is the 1st lactamase-producing strain. Treatment of infections enterocóccicas is complicate d by the special patterns of sensitivity or resistance as they show the need for evidence of special sensitivity study to show its true susceptibility in the la boratory. For example,€standard procedures do not allow the study of the synergy between beta-lactams and aminoglycosides, or determine the high-level resistanc e to aminoglycosides. Streptococcus Group D: S.bovis is the most common species isolated in human pathology within the group. They are classified in group D on the basis of wall antigen (Lancefield). The major clinical manifestations are ca used by S.bovis bacteremia and endocarditis. The front door is usually the gastr ointestinal tract, although the biliary or urinary tract have also been implicat ed as probable sources. There is a striking association between S.bovis and bact eremia caused by underlying colon cancer, so that all patients with bacteremia d ue to S.bovis should be subjected to a comprehensive study to rule out the possi bility that underlying pathology. At issue is whether S.bovis plays some role in this neoplasm or is only a marker. S.bovis bacteremia is accompanied by 25-50%

of cases of endocarditis, which has a subacute course and is clinically indistin guishable from that produced by viridans group streptococci, with rare periphera l septic complications and excellent response to antimicrobials. S.bovis is very susceptible to penicillin. While the association Penicillin-aminoglycoside syne rgy has been shown against S.bovis, the course of treatment for 4 weeks only pen icillin was equally effective. Vancomycin is a reasonable alternative in patient s allergic to penicillin. Streptococcus viridans or ALFA GROUP HEMOLYTIC The Vir idans Streptococcus are a heterogeneous group composed of different microorganis ms with different ecological niches and pathogenicity. Although agencies are par t of the normal flora of the respiratory and digestive tract, may under certain circumstances, invade sterile sites and can cause serious illness. They share th e general characteristics of the genre and are characterized by producing a halo around their colonies alfahemólisis. Nutritional requirements are variable and from the point of view of most air requirements are facultative anaerobes, with some strains and other microaerophilic capnófilas. 7 Although some isolates may react with Lancefield antisera are not grouped. Sever al species are distinguished in this group, requiring identification of a variet y of biochemical tests. Among its virulence factors are: a. the presence of lipo teichoic acid which promotes the adherence of the organism (important in the adh erence to heart valves when causing endocarditis); b. abundant production of ext racellular polysaccharides (slime) involved in the pathogenic mechanisms of prod uction of caries and provides adhesion between them, important mechanism in endo carditis. Group A streptococci isolated from different pathological processes: d ental caries, surgical infections, bloodstream infections, endocarditis (which i s responsible for 50-75% of patients in the healthy valves), deep abscesses, etc . Most Streptococcus Viridans group are susceptible to penicillin G, but recentl y are being reported moderate and highly resistant strains in some areas of the world. Have also been reported that some strains exhibit the phenomenon of toler ance, in which microorganisms can be inhibited by low concentrations of the anti microbial, but there is a level 32 times higher to achieve bactericidal activity . STREPTOCOCCUS PNEUMONIAE S. pneumoniae is an important human pathogen recogniz ed etiologic agent of pneumonia, meningitis, sinusitis and otitis media, is less often the source of endocarditis, arthritis, and peritonitis. MICROBIOLOGICAL C HARACTERISTICS coconut is a Gram + channels are collected in liquid form. It is catalase - demanding from a nutritional standpoint and requires for optimal deve lopment of an atmosphere enriched with 5-10% CO2. Alpha-hemolysin has a hemoglob in-degrading giving a green color around the colony when developing on blood aga r. The peptidoglican and teichoic acids are major constituents of the cell wall. The next figure shows a schematic representation of the capsule, cell wall and cell membrane. The integrity of the wall depends on the presence of numerous sid e peptide chains that are interlinked by enzymes (trans and carboxypeptidases), with the active site of these enzymes the junction beta-lactam antibiotics. A un ique component is the pneumococcal polysaccharide C,€teichoic acid composed of p hosphate covalently bound to peptidoglican hill in the outer layer of the cell w all. Outside the wall is a natural polysaccharide capsule present in virtually all cl inical isolates. Approximately 80 are recognized S. pneumoniae serotypes based o n antigenic differences in capsular polysaccharides. Pathogenic mechanisms bacte rial adherence is the first step in the production of infection. Recently discov ered a pneumococcal adhesin allowing it to bind to specific receptors on epithel ial cells. The chemical nature of these adhesins has not yet been clarified. Onc e colonization has occurred, the infection will result if the organisms are carr ied to places where the defensive mechanisms (specific and inespecífcos) host no t removed. S. pneumoniae has the ability to cause disease by their ability to es cape phagocytosis and killing by host phagocytic cells. SGA Unlike the S. pneumo niae produces few toxins, so it produces disease because of its ability to repli

cate in host tissue and generate an intense inflammatory response. a. Evasion of phagocytosis: pneumococci are poorly ingested by phagocytic cells in the absenc e of capsular antibodies and complement. It has been observed experimentally by mutagenic transposition, that the interruption in the production of capsule beco mes a virulent strain avirulent. The mechanisms by which the capsule inhibits ph agocytosis are not yet fully clarified, there are several possibilities: - the a bsence of phagocytic cell receptors that recognize the capsular polysaccharides - the presence of electrochemical forces that repel the phagocytic cells - antib ody masking non-specific and complement are deposited on the bacterial surface a nd become inaccessible to phagocytosis. 8 b. Complement activation: the cell wall of pneumococci, appears to activate the alternative pathway of complement. Peptidoglican injection or teichoic acid sepa rately in the subarachnoid space causing an inflammatory reaction with features of bacterial meningitis. This activation is associated with release of C5a that attracts large numbers of polymorphonuclear cells into the medium. c. Other fact ors that contribute in the production of secondary disease. Among them are: - pn eumolysin, a toxin that inserts into the lipid bilayer of cell membranes through its interaction with cholesterol, causing a range of killer and cytotoxic effec ts, for example, inhibiting the bactericidal function of leukocytes polymorphonu clear and ciliary sweep. Perhaps more important is that the drug produces an int ense inflammation by activating the classical complement pathway. - Other: surfa ce proteins, autolysin (produces the disintegration of the bacterial cell wall r eleasing bacterial substances in the outbreak), alpha-hemolysin and finally, neu raminidase, which could contribute to bacterial adherence by cleavage of sialic acid on mucosal surfaces. DEFENSIVE MECHANISMS OF HOST There is ample evidence t hat the anticapsular antibody response provides effective protection against pne umococcal infection, specific anticapsular antibodies appear 5-8 days after the start of infection, which is the time when the fever if not treated half antimcr obiano. Pneumonia: S. pneumoniae is the most common agent of bacterial pneumonia in the community of origin. It is a very common disease that affects all ages, its inci dence is related to the season, and can cause death especially in people over 65 years. The diagnosis is clinical, radiological and microbiological. As for the final diagnosis is confirmed by the identification of S. pneumoniae in bronchial secretions and / or blood culture. ANTIMICROBIAL SUSCEPTIBILITY Penicillin was the drug of choice for treating pneumococcal infections until recent years, whic h has become gradually more resistant to it. This resistance reflects the select ion of spontaneous mutants, for which a higher concentration is required to satu rate the penicillin binding proteins (PBP). Even more recently, strains have app eared highly resistant to penicillin, more serious situation. Penicillin resista nce is only part of the problem, since strains that have also have increased res istance to other beta-lactam antibiotics. Vancomycin can be the last alternative at present€but should take into account the emergence of resistant enterococci to it, and the possibility of transmission of this resistance to S. pneumoniae. Treatment should be based on today in the susceptibility studies, so the clinica l laboratories should make the determination of the MIC for S. pneumoniae. PREVE NTION recommends vaccination of those groups at increased risk of pneumococcal i nfection: chronic lung disease, advanced cardiovascular disease, diabetes mellit us, cirrhosis, chronic renal failure, and those individuals over 65 years of age . A second group would consist of individuals who have a commitment to the immun e system: HIV infection, asplenia, lymphoma, myeloma, Hodgkin's disease, transpl ants, etc. The vaccine consists of the capsular polysaccharides of the 23 seroty pes most frequently isolated from infections. A recent study of effectiveness of the vaccine presented epidemiological data that showed that the vaccine's prote ctive effect persists for five years in young people, decreasing rapidly with in creasing age. Passive immunization with human immunoglobulin also protected agai

nst pneumococcal infection, and has been used in children with HIV infection and in adults with lymphoma, which is not expected to have an antibody response to vaccination. Factors that predispose to pneumococcal infection S. pneumoniae is the primary e xample of extracellular pathogenic bacteria. In these microorganisms the alterat ions in the main defensive elements (Ac and humoral factors such as complement a nd antiphagocytic cells) will lead to a predisposition of the host to repeated i nfection. CLINICAL PRESENTATION S. pneumoniae produces a wide variety of clinica l, standing out among them because of their severity and frequency of meningitis and pneumonia. Meningitis: S. pneumoniae with N.meningitidis is one of the most common agents in the adult. It is the result of bacteremia or extension of near by sources (sinuses, middle ear). The pathogenesis of meningitis is reviewed in another chapter. 9 Main Streptococcus serotypes in human disease serogroup A antigen specific group of cell wall Rhamnose-N-acetyl-glucosamine Clinical aspects pharyngitis, tonsil litis, scarlet fever, erysipelas, impetigo, cellulitis, nonsuppurative sequelae rheumatic fever, glomerulonephritis Corioamninitis, puerperal sepsis neonatal me ningitis neonatal respiratory tract infections genitourinary tract infections, w ounds, endocarditis, upper respiratory infections, cellulitis, sepsis B C D G Rhamnose Rhamnose-glucosamine-N-acetyl-galactosamine glycerol teichoic acid-gala ctosamine Rhamnose 1