1.

4 GRAM POSITIVE COCCI MICROBIOLOGY

Dr. Sia - Cungco| July 1, 2013 1ST 2013-2014

OUTLINE  Ferments mannitol (as distinguished from S. epidermidis and S.

I.Pyogenic cocci III. Genus Streptococcus
II. Genus Staphylococcus A. S. pyogenes saprophyticus)
A. S. aureus B. Group B Strep  Catalase positive – one feature that distinguishes them from the
B. S. epidermidis C. Group C Strep
C. S. saprophyticus D. Group D Strep catalase-negative streptococci
E. Viridans Group Strep  Coagulase positive – an enzyme that causes citrated plasma to clot
F. S. pneumoniae/ Pneumococci
G. Other Streptococci  Golden yellow colony on blood agar plate
IV. Appendix
 Found in nasal passages, skin, inguinal area and mucous membranes
Objectives:
 Define pyogenic cocci
 Resistant to drying, can withstand 50⁰C for 30 min and thus can
Staphylococci persist for long periods on fomites (inanimate objects), which can
 Discuss the characteristics of The Genus Staphylococcus then serve as sources of infection.
o S. areus:
1. Discuss the general characteristics of S.aureus o Example: A boil covered by a gauze – When removed, that gauze
2. Discuss the culture characteristics of S. aureus is infectious because Staph. aureus can survive or is viable for an
3. Discuss the antigenic structure of S. aureus
4. Discuss the determinants of pathogenicity of S. aureus average of 14 days.
5. Discuss the different clinical infections of S. aureus
6. Discuss the methods of laboratory diagnosis of S.aureus
 Resistant to 9% NaCl but inhibited by certain chemicals
7. State the basic principle of treatment of S. aureus infection (hexachlorophene)
8. Discuss the techniques of preventing spread of S.aureus infection.
o Discuss the general characteristics of S. epidermidis
 Β-Lactamase production is common – resistant to Penicillin (PCN;
o Discuss the general characteristics of S. saprophyticus plasmid controlled)
Streptococci  Nafcillin, Methicillin, Oxacillin resistance: in genes independent of
 Discuss the general characteristics of Streptococcus
 Discuss methods of classifying Streptococcus plasmids
 Differentiate between the types of hemolysis patterns on BAP  May be susceptible to Vancomycin (drug of choice now in hospitals)
o S. pyogenes:
1. State the general characteristics of S. pyogenes
2. Discuss the antigenic structure of S.pyogenes
3. Discuss the enzymes and toxins elaborated by S.pyogenes
1. Cultural Characteristics
4. Discuss the pathogenesis and clinical findings of diseases due to S.pyogenes  Grows well on routine media like Nutrient Agar or Blood Agar
5. State the diagnostic methods used in diseases due to S.pyogenes
6. Discuss treatment prevention and control of diseases due to S. pyogenes Plate (BAP)
o S. pneumoniae:  On BAP: Smooth, opaque, round, convex golden yellow colonies
1. Discuss the general characteristics of S.pneumoniae
2. Discuss culture characteristics of S.pneumoniae surrounded by β-hemolysis (complete hemolysis of RBCs; Fig. 1)
3. Discuss the pathogenesis and clinical findings in diseases due to S.pneumoniae
4. Discuss diagnostic methods in S. pneumoniae infection
5. Discuss treatment methods in S. pneumoniae infection
o Discuss the general characteristics, pathogenesis and treatment of Enterococci
o Discuss the general characteristics of S.viridans and the pathogenesis of illness due to S. viridans
o Discuss the characteristics of other Streptococci

References: Dr. Sia-Cungco’s lecture ppt., Katzung, Micribiology BRS

I. Pyogenic Cocci
 Pus producing cocci
 Staphylococcus, Streptococcus, Gram (-) Neisseria Figure 1. Staphylococcus on blood agar plate

II.Genus Staphylococcus 2. Antigenic Structure

 Spherical cells in clusters (because they divide spontaneously in  Peptidoglycan (Cell Wall )(Gram + has thick layer)
different planes) o Can be protective but destroyed by acids or lysozyme (found in
 Natural habitat: Mammalian body surfaces, i.e. skin and mucosa tears and saliva)
 Pathogenic when surface barrier is breached (e.g. wounds) and o Elicits production of pyrogens and opsonic antibodies
organisms gain access to tissues o Chemoattractant for polymorphonuclear cells (PMN)
 All are Catalase (+)  Teichoic Acids – binds the peptidoglycan
o Can produce catalase enzyme (H2O2 → H2O + O2) o Stimulates production of antibodies
o This is the biochemical test for staphylococci (Versus the o Extracellular teichoic acid consumes early reacting
streptococci, which are catalase negative) complement components in the serum and protects the
 Only S. aureus is Coagulase (+) organism from complement mediated opsonization (lysis)
o Being coagulase (+) is synonymous with virulence  Protein A (only S. aureus contains protein A, negative (-) for S.
 Three important Staphylococcus species: epidermidis and S. saprophyticus)
o S. aureus: “golden (Au)” o Called Microbial Surface Component Recognizing Adhesive
o S. epidermidis: “over the skin” Matrix Molecules (MSCRAMM) – nice to know
o S. saprophyticus: “rotten plants” o Antiphagocytic: Attaches to the Fc part of IgG instead of Fab
 Fibronectin-binding protein (FnBP) – promote binding to
A.Staphylococcus aureus fibronectin in mucosal cells and tissue matrices (Fig. 2)
 Clumping Factor – causes clumping of S. aureus when mixed with
 Gram-positive, round, cluster-forming coccus plasma (aggregated bacteria is antiphagocytic )
 Nonmotile, nonsporeforming facultative anaerobe (can ferment o Aggregated bacteria cannot be phagocytosed
sugar with or without oxygen)  Capsular polysaccharide – antiphagocytic
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Group 10: Candeloza (09158901078), Canlas, Canta, Cara, Carandang, Carpio, Casas
 MICROBIOLOGY 1.3

SUPERANTIGEN EXOTOXIN
o The toxins have an affinity for T cell receptor–major histocompatibility
complex Class II antigen complex. They stimulate enhanced T-
lymphocyte response (Fig. 3).
o This major T-cell activation can cause toxic shock syndrome, by release
into the circulation of large amounts of T-cell cytokines, such as
interleukin-2 (IL-2), interferon-γ (IFN-γ), and tumor necrosis factor-α
(TNF-α).
o An antigen in small amounts will produce profound effects

Figure 2. Action of fibronectin-binding protein

3. Determinants of Pathogenicity Figure 3. Superantigen mechanisms

 Extracellular Enzymes
1.Coagulase – causes clotting of plasma
 Toxic Shock Syndrome Toxin (TSST-1) – binds to MHC Class II on T
o Deposits fibrin on the surface of the staphylococcus- cells causing the release of cytokines that mediate shock, such as
antiphagocytic (“like an armor”) IL-2, TNF, and INF
o Synonymous with invasive potential
2.Lipase – hydrolyzes lipids including the oil on body surfaces
o For invasion of cutaneous & subcutaneous tissues
o Correlated with ability to produce BOILS (Pigsa)
3. Catalase – converts H2O2 to O2 and H2O
o A positive(+) catalase test will show bubbles
4.Hyaluronidase/Spreading Factor
o Hydrolyzes hyaluronic acid in the ground substance of
connective tissue, facilitating spread of infection.
5.Staphylokinase/ Fibrinolysin – converts plasminogen to plasmin
o Produces dissolution of clots (plasmin is an anticoagulant)
o Prevents walling off, aiding in the spread of the organism
6.Nuclease – can cleave either DNA or RNA
o Viscosity of pus is due to deoxyribonucleoprotein
o Facilitates spread of the organism
Figure 4. Effects of septic shock
 Toxins
 Pathogenesis
o Cytolytic Exotoxins: α, β, γ, and δ toxins attack mammalian cell
o Anterior nares – major reservoir of infection
(including RBC) membranes (can act as hemolysins)
o The perineum is another carriage site
1. Alpha Toxin (α hemolysin) – hemolytic and dermonecrotic
o Lesions with draining pus can disseminate the organism through
 Injures the circulatory system, muscles, renal cortex tissues,
the hands
damages macrophages and platelets
o Abscess – characteristic of a staphylococcal infection. Organisms
 Polymerizes into tubes that pierce membranes, resulting in
penetrate a sebaceous gland or a hair shaft.
the loss of important molecules and osmotic lysis
o Skin/Mucous membrane is an excellent protective barrier.
2. Βeta Toxin (Staphylococcal Sphingomyelinase)
Destruction of the integrity of these surfaces predisposes to
 Damages sphingomyelin on RBC membrane producing
infection (e.g burns)
hemolysis
3.Delta Toxin
 Damages RBC, Macrophage, Lymphocytes, Neutrophils,
4. Clinical Infection
Platelets  Folliculitis
4.Gamma Toxin – hemolytic activity o Infection of the hair follicles
5.Leukocidin (Panton-Valentine Leukocidin) o Old Treatment: Clamping of hair using hemostat, rolling hair into
 This pore-forming toxin lyses PMNs and macrophages tip of clamp, and then pulling hair out. A long stream of pus
 Production of this toxin makes strains more virulent comes with the hair. Drawback: It hurts patients SO MUCH.
6.Enterotoxin - heat stable exotoxin resistant to gut enzymes  Furuncle
 Stimulates the vomiting center and increases fluid o Folliculitis extending to the subcutaneous tissue
transudation into the intestine o Focal suppurative lesion
 A ,B, C, C2, D, E, G-J, K-R, U, V. Enterotoxin A is the most o Old belief: Anesthetizing an abscess before incision and drainage
frequently associated toxin with Staphylococcal Food would aid the spread of infection thus there was use of an oral,
Poisoning. rubber anesthetic which doctors let patients bite, as lesions are
7.Exfoliative Toxin – epidermolytic toxin which dissolves the matrix cross-incised and probed to break loculations. Now, anesthesia is
of the epidermis producing generalized desquamation. used directly on the lesion.
 Causes Staphylococcal Scalded Skin Syndrome
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 Carbuncle – multiple foci; extends to the deeper fibrous tissues
 Impetigo
o Encrusted pustules on the superficial skin in infants and children
o When crusts are removed, a red denuded surface is exposed
 Highly contagious
 Staphylococcal Scalded Skin Syndrome – due to Exfoliative Toxin
o Generalized painful erythema & bullous desquamation of large
areas of the skin (Fig. 5)
 Staphylococcal Food Poisoning
o Most common form of bacterial food poisoning
o Preformed toxin in food contaminated by hands of food workers
o Food with enterotoxin are normal in odor and taste
o Abdominal pain, vomiting and diarrhea 4-6 hours after ingestion
o Antibiotics will not work the culprit is the toxin, treatment should
be hydration (via IV fluid) or antiemetic
 Osteomyelitis
o Follows a hematogenous spread from a furuncle or carbuncle
o Localizes at the diaphysis of long bones with accumulation of pus
o Fever, chills, pain over the bone
 Septicemia
o Generalized infection with sepsis or bacteremia that may be
associated with a known focus like a septic joint
a. Acute Endocarditis
 Associated with intravenous drug abuse caused by injection
of contaminated preparations or by needles contaminated
with S. aureus.
 S. aureus also colonizes the skin around the injection site,
and if the skin is not sterilized before injection, the bacteria
can be introduced into soft tissues and the bloodstream.
 Subacute endocarditis: caused by Streptococcus pyridans
b. Pneumonia
 Common in hospitalized debilitated immuno-compromised
patients. Follows a viral influenza infection.
 Rapid destruction of lung parenchyma resulting in cavitation
 Usually seen in staphylococcal bronchopneumonia in X-ray
which includes the entire lung with patchy infiltrates instead
of lobar pneumonia which involves one lobe of the lung
 Common in malnourished post-measles children
 Measles death rate is index of malnutrition in the Philippines
 Septic arthritis
o Invasion of synovial membrane resulting in a closed infection of
the joint cavity
o Painful, red, swollen joint with a limited range of motion
 Toxic Shock Syndrome (TSS)
o Common in menstruating women who use tampons or anybody
who has a staphylococcal wound infection
o TSS results in high fever, rash with diffuse erythema followed by
desquamation, vomiting, diarrhea, hypotension, and multiorgan
involvement (especially GI, renal, and/or hepatic damage)
Figure 5. Left: Scalded skin syndrome. Center: Carbuncle. Right: Impetigo.
MICROBIOLOGY 1.3
5. Laboratory Diagnosis
 Gram stain of pus/sputum: Gram (+) cocci in clusters is a
presumptive diagnosis of staphylococci
 Culture (Pus, Blood, Tracheal Aspirate, CSF)
o Blood Agar Plate: yellow colonies with beta hemolysis
o Mannitol Salt Agar: Only S. aureus ferments mannitol; the acid
produced changes color of the agar from red to yellow (Fig. 6)
 Catalase Test: 3% H2O2 + specimen = bubbles indicate a (+) test
 Coagulase Test: Citrated plasma + equal volume of broth culture is
incubated. If a clot forms in 1-4 hrs, the test is (+)
 All Staphylococci are Catalase (+). Streptococci are Catalase (-).
Only Staphylococcus aureus is Coagulase (+), other staphylococci
are Coagulase (-)
Figure 6. Mannitol Salt Agar Plate
6. Treatment
 Basic principle: Adequate drainage, foreign substance or object
should be removed
 Antimicrobials are less effective for Staph within the abscess
 Oral Cloxacillin, IV Nafcillin, Vancomycin
 Cloxacillin Capsule 500mg every 6 hours for 10 days
 Pediatrics: Cloxacillin at 50mg/Kg/Day
 Methicillin Resistant S. aureus (MRSA)
o Resistant to all β Lactam antibiotics including cephalosporins
o Vancomycin has been the agent of choice for empiric treatment
of life-threatening MRSA
o Vancomycin resistance has increased steadily, prompting the use
of alternative drugs such as quinupristin-dalfopristin,linezolid,
and daptomycin
7. Prevention
 Proper disposal of discharge-contaminated fomites
 Washing of hands before and after patient contact
 Mupirocin to nasal and perineal carriage sites
 Anti-Staphylococcal Drug with Rifampicin provides long-term
suppression
B.Staphylococcus epidermidis
 Identification
o White colonies on BAP. Catalase (+) but Coagulase (-)
o Does not ferment mannitol
 Epidemiology
o Normal skin flora
o Infection is usually the contamination of a surgical site from
patients’ or others skin or nasopharynx
 Pathogenesis
o Low virulence for the normal host; life threatening infection
when host defenses are breached
o Predilection for prosthetic devices (Total hip replacement)
o Vancomycin sensitivity remains the rule, but resistant isolates
have been reported
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C. Staphylococcus saprophyticus
 Characteristics
o Coagulase (-)
o Occurs on the (N) skin and periurethral area and as a transient
urethral flora
o Common cause of symptomatic Urinary Tract Infection in
sexually active young women
o Novobiocin Resistant
*Refer to the appendix for summary of differentiation of Staph species.
II. Genus Streptococcus
 27 recognized species
 Streptococci are gram positive, nonmotile, and catalase negative
 They are ovoid to spherical in shape and occur as pairs or chains
 Most are facultative anaerobes because they grow fermentatively
even in the presence of oxygen.
 Because of their complex nutritional requirements,
 Blood enriched medium is generally used for their isolation.
 Does NOT produce gas.
 Spherical, in chains or pairs because growth occurs by elongation
on the axis parallel to the chain (divides in one plane, Fig. 7)
Figure 7. Morphology of Genus Streptococcus
 Classifications of Streptococci
1. Hemolysis Patterns on BAP (Fig. 8)
o β Hemolysis: clear zone of hemolysis due to complete lysis of RBC
o α Hemolysis: greenish discoloration due to incomplete hemolysis
o γ Hemolysis: non-hemolytic
Figure 8.Patterns of hemolysis
2. Lancefield Classification
o System based on the antigenic composition of cell wall
carbohydrates in beta hemolytic strep
o Groups A,B,C,D & G: Associated w/ human infection (Fig. 9)
MICROBIOLOGY 1.3
Figure 9. Serogroups associated with human infections
3. Capsular Polysaccharides
o Antigenic specificity is used to classify S. pneumoniae into 90
types
4. Biochemical Reactions
o Streptococci ferment carbohydrates and are catalase (-)
 Optochin Sensitivity
– Optochin is an antibiotic disk
– Viridans streptococci is resistant
– S. pneumoniae is sensitive
 PYR Disk – ability to hydrolyze pyrrolidonyl
– Positive: Red Color (S. pyogenes & Group D Enterococci)
– Negative: Yellow (No Change)- Viridans
 Oxidase Test– presence of cytochrome oxidase in certain
bacteria. Organism will react to it and will change the color of
the paper into:
– Positive: Violet Blue (Neisseriae)
– Negative: S. pyogenes
A.Streptococcus pyogenes
 Group A Β-Hemolytic Streptococci
 Typical Organism
o Lancefield Group A, Gm (+), spherical and in chains
o Facultative anaerobe, Catalase(-), Oxidase (-), PYR(+)
o Killed in 30 min at 60⁰ C
o Bacitracin sensitive - 95% accurate
 S. pyogenes is the only one sensitive to bacitracin. If there is a
culture of streptococci and a bacitracin disk is put in, and there
is inhibition of growth then definitely it can be said that the
organism is S. pyogenes.
 Culture
o Primary isolation of specimens: use blood agar plate
o Clinical specimens can be processed by POUR or STREAK PLATE
techniques.
o Optimal pH 7.4- 7.6 at 37⁰C
o Since it is facultative, culture growth is enhanced by a low O2
tension or by increased CO2
o Discoid colonies, domed, grayish to opalescent with a zone of
beta hemolysis
o Utilizes glucose w/ Lactic Acid as product
Figure 10. Left. S. pyogenes seen as gram (+) cocci in chains. Right. S. pyogenes
on BAP culture producing beta hemolysis
1. Antigenic Structure and Determinants of Pathogenicity
a. M Protein
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 MICROBIOLOGY 1.3
f. Nucleoproteins
 Extraction of streptococci with weak alkali yields mixture of
proteins and other substances of little serologic specificity, called
P substances, which probably makes up most of the strep cell
body

2. Toxins and Enzymes

 Hair-like projections on the cell wall of Group A beta hemolytic
strep
 Antiphagocytic (inhibits opsonization and the complement
system)
 Immunity to Group A strep is due to antibodies against M Protein
but there are 150 types of M Protein so a patient can have
repeated infections with group A S. pyogenes of different M
types. (A person may be immune to 1 M protein but may not
immune to another M proteins)
 Type I-M induces antibodies that react with human cardiac
muscle (determinant of RF and heart bound antigen)
 There is a cross reaction with human cardiac muscle and heart
bound antigens → destruction of heart valves → Rheumatic
Fever and Rheumatic Heart Disease
o Type II-M : no consequence
1. Hemolysins
a. Streptolysin O (SLO)
o Oxygen labile
o Cytolytic activity against RBC, PMN, platelets (reason for β-
hemolysis)
o Antigenic and stimulates production of the antibody
Antistreptolysin O (ASO) in 10-14 days
o ASO Titer: indicator of recent infection with S. pyogenes
(>200iu = positive for S. pyogenes)
b. Streptolysin S (SLS)
o Oxygen stable
o Lytic for red and white blood cells
o Non-antigenic
o Responsible for the surface hemolysis seen on BAP
2. Pyrogenic Exotoxin (Erythrogenic toxin)
 90% of S. pyogenes: Exotoxin A, B, C
 Heat labile but stable to acid, alkali, and pepsin
a. Exotoxin A
o Associated with Toxic Shock Syndrome and scarlet fever
o Superantigen producing release of cytokines that mediate
shock/tissue injury
b. Exotoxin B
o Necrosis of tissues (Necrotizing Fasciitis)
c. Exotoxin C
o Causes increased permeability of the blood-brain barrier to
toxins and bacteria
o Has a pyretic effect on the hypothalamus

FOR HISTORICAL COMPLETENESS

Figure 11. M protein structure.
b. Lipoteichoic Acid
 Attached to peplidoglycans and covers the pili which consists
partly of M proteins
 It mediates buccal epithelial cell adherence (adheres to
fibronectin on epithelial cells)
 Cytotoxic to host cells
c. Capsular Polysaccharide
 Made up of hyaluronic acid capsules in some Group A
streptococci
o Hyaluronic acid mimics the ground substance of connective
tissue, so the body will not act against it, and protects the
organism from being phagocytosed
d. Protein F (fibronectin-binding protein)
 Mediates attachment to fibronectin in the pharyngeal epithelium
 M proteins and lipoteichoic acids also bind to fibronectin
e. T Substance
 No relationship to virulence of streptococci
 Acid-labile and heat-labile
 Obtained from streptococci by proteolytic digestion, which
rapidly destroys M proteins and permits differentiation of certain
types of strep by agglutination with specific antisera
 Positive Dick Test - Causes an erythematous reaction in the
skin of non-immune persons
 Negative Dick Test - No reaction in persons with immunity
 Schultz-Charlton Reaction - Antitoxin injected in a skin of a
patient with Scarlet fever produces localized blanching
3. Streptokinase
 Transform Plasminogen into plasmin, a proteolytic enzyme to
digest fibrin and other proteins facilitating a rapid spread of the
organism
 Group C Streptokinase: Used as IV for treatment for Pulmonary
Emboli; Coronary artery and Venous thrombosis
4. Streptodornase
 Helps to liquefy exudates
 DNAses that degrade the viscous DNA in necrotizing tissue or
exudates, aiding the spread of infection
5. Hyaluronidase
 Splits hyaluronic acid in the ground substance of connective
tissue
 Spreading factor
6. Diphosphopyridine Nucleotidase
 Ability to kill Leukocytes

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 MICROBIOLOGY 1.3
3. Pathogenesis and Clinical Findings
A. Diseases due to invasion by S. pyogenes
1. Erysipelas
 Skin and subcutaneous tissue infection usually on the face or
the lower extremities
 With brawny/elevated edema and rapidly advancing margin of
infection, which is well-delineated
Figure14 . Left: Sunburn-like rash. Right: Strawberry tongue.

2. Streptococcal Cellulitis 6. Bacteremia/Sepsis/Streptococcal toxic shock syndrome

 Rapidly spreading infection of the skin and subcutaneous
tissues associated with trauma, burns, and wounds
 With erythema, pain, and swelling
 Cellulitis vs. Erysipelas
o Cellulitis: Region is not raised/elevated; line between
involved and uninvolved tissue is indistinct
 Isolation of Group A β-hemolytic streptococci from blood or
another normally sterile body site in the presence of shock
and multi-organ failure.
 Mediated by the production of streptococcal pyrogenic
exotoxins causing massive, nonspecific, T-cell activation and
cytokine release
 Flu-like symptoms, followed shortly by necrotizing soft tissue
infection, shock, acute respiratory distress syndrome, and renal
failure, followed by death

B. Local infection with S. pyogenes

1. Streptococcal Sore Throat/ Pharyngitis /Tonsillitis
 In children, there is nasopharyngitis and sore throat, and may
Figure 12. Left: Erysipelas. Right: Cellulitis. extend to the middle ear and mastoid (otitis media)
 In adults, there is intense nasopharyngitis, tonsillitis, purulent
exudate, enlarged lymph nodes around the submandibular
3. Necrotising Fasciitis
area, and fever
 Rapidly spreading necrosis of the skin, subcutaneous tissue,
 The pharynx may be beefy red with exudates
and fascia (hours) due to M protein and Exotoxin B that blocks
 Rheumatic Fever may be a sequelae
phagocytosis, allowing bacteria to move rapidly through tissues
o Caused by cross reactions between antigens of the heart and
 Symptoms may include a toxic shock-like syndrome, fever,
joint tissues, and the streptococcal antigen (M Protein)
hypotension, multi-organ involvement, as a sunburn-like
o Characterized by fever, rash, carditis, and arthritis
rash, or a combination of these symptoms.
 Must be recognized early. Surgically remove the fascia (Surgical
2. Streptoccocus pyoderma / Impetigo
debridement).
 Small vesicles progressing to weeping pustular lesions;
 “Flesh-eating bacteria” due to Necrotizing Exotoxin B
denuded surfaces with pus
 Group A Strep skin infection my precede glomerulonephritis
 Although S. aureus is recovered from most contemporary cases
of impetigo, S. pyogenes is the classic cause of this syndrome
 The disease begins on any exposed surface, most commonly
the legs
 Typically affecting children, it can cause severe and extensive
lesions on the face and limbs
 Treatment
o Topical agent such as mupirocin ointment
Figure 13. Necrotizing fasciitis.
o Systemically treated with penicillin or a first generation
cephalosporin
4. Puerperal Fever/ Childbed fever
 Septicemia secondary to an endometritis occurring after birth
 May be introduced by the healthcare workers (unhygienic
practices)
 Chills, fever, abdominal distention, and tenderness,
serosanguinous vaginal discharge
 High mortality rate before the advent of antibiotics

5. Scarlet fever
 Associated with severe, purulent inflammation of the posterior Figure 15. Left: Streptococcal sore throat. Right: Impetigo.
oropharynx and tonsillar areas with a sunburn-like rash on the
C. Post Streptococcal Disesae
neck, trunk, and extremities, in response to the release of
Pyrogenic/Eythrogenic exotoxin to which the patient does not  1-4 weeks after acute infection
have antibiotics  Not directly related to the bacteria but due to a
 “Strawberry tongue” due to an erythrogenic toxin hypersensitivity response

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1. Acute Glomerulonephritis (AGN)
o Due to nephritogenic strains
o Preceded mostly by skin infection, then respiratory infection
o Due to Ag-Ab complexes on the basement membrane
producting inflammation
o Edema, hypertension, azotemia (elevated BUN and serum
creatinine levels), hematuria, and proteinuria
o Some go into chronicity leading to Renal Failure
Mnemonic for AGN (by Dr. Sia-Cunco)
“CHEAP BUN”
C – Elevated creatinine
H – Hematuria / Hypertension
E – Edema
A – Azotemia
P – Proteinuria
BUN – Elevated BUN
2. Rheumatic Fever
o Certain Group A Strepcocci contain membrane antigens that
react with human heart tissue antigens
o The patient produces antibodies that damage heart muscles,
valves, and joints
o Preceded by a respiratory infection
o Fever, malaise, arthritis, carditis
o Tendency to be reactivated by recurrent strep infection
producing cumulative heart damage (valvular damage)
o “If a patient is getting 6 attacks of tonsillitis a year, for the
last 3 or 4 years, it is best recommended that the tonsils be
already taken out.”
o Prophylaxis is given: Benzathine Penicillin injection every
28 days, or Erythromycin tablets 250mg BID for life.
4. Diagnosis
A. Specimens
 Definitive diagnosis: Direct culture of posterior pharynx and
tonsils. Swabs are inoculated on broth or blood agar.
 Vesicular or pustular fluid
 Cellulitis and Erysipelas material: Aspiration of tissue fluids from
the advancing border of erysipelas or by subcutaneous injection
of sterile saline followed by reaspiration.
 Serum for antibody determination ( ASO )
B. Smears from Pus: Gm (+) in chains or pairs
 Smears from throat swab: rarely contributory ; Viridans have the
same appearance as S. pyogenes
C. Culture
 Streptococcus pyogenes: Βeta hemolysis on BAP; PYR(+)(red
color), Inhibited by Bacitracin
 Viridans streptococci: Alpha hemolytic on BAP; PYR(-) (yellow
color); Bacitracin negative
D. Serologic Test – estimates rise in antibody titer (ASO Titer )
E. Antigen Detection Test
 Rapid detection of Group A antigen from a throat swab using
agglutination
 In a positive test, the latex particles clump together, whereas in a
negative test, they stay separate,giving the suspension a milky
appearance
MICROBIOLOGY 1.3
Figure 16. Antigen detection test for S. pyogenes (left: positive clumping)
5. Treatment
 Penicillin, Erythromycin
 Antimicrobials – no effect on established glomerulonephritis or
rheumatic fever
 Eradicate immediately to prevent post-streptococcal diseases
6. Prevention and Control
 Nasal discharges are the most dangerous source for spread
 Prophylactic antibiotics for surgery patients with known heart
valve deformity or prosthetic heart valves
 Eradicate Group A Strep in patient with respiratory or skin
infections
 Prophylaxis for those who have suffered an attack of rheumatic
fever
B. Group B Streptococci
Streptococcus agalactiae
 Grow as diplococci or in short chains
 Normal flora of the pharynx, GIT and vagina
 β hemolytic and forms large, mucoid colonies
 Hydrolyzes Na Hippurate
 (+)CAMP (Christie, Atkins, Munch-Peterson) test: Complete
hemolytic zone when inoculated perpendicular to a streak of S.
aureus
 Leading cause of neonatal septicemia and meningitis
o Acquired from the mother during delivery
o Incidence is higher when there is prolonged labor, premature
rupture of membranes or obstetric manipulation.
o REMEMBER “B” IS FOR BABY
 Elderly/Immunocompromised: Bacteremia, skin & soft tissue
infections in diabetics
 May also cause endocarditis and puerperal infection
 Penicillin G is the drug of choice
 Other Drugs: Erythromycin, Chloramphenicol, Cephalosporins,
Vancomycin, Imipenem, Clindamycin
Figure 17. CAMP test for Group B streptococci
C. Group C Streptococci
 S. equisimilis, S. zooepidemicus, S. dysgalactiae
 All are beta hemolytic except S. dysgalactiae
 S.equisimilis is the source of streptokinase for thrombolytic therapy.
 S.equisimilis may cause pharyngitis, puerperal sepsis, endocarditis,
bacteremia, osteomyelitis, brain abscess, post-operative wound
infection and pneumonia
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 MICROBIOLOGY 1.3
D. Group D Streptococci Pathogenesis
 Enterococcal species  May reach the bloodstream because of dental manipulation, trauma
Enterococcus faecalis or GI or GU instrumentation, and cause endocarditis.
Enterococcus faecium  Wound infection, meningitis, biliary and intra-abdominal infections
Enterococcus durans may occur
 Non enterococcus  Dental Infections
Streptococcus equinus o Especially for S. mutans: dental caries and dental plaque
Streptococcus bovis o Bind to teeth, ferment sugar and produces acid and dental caries
 General  Endocarditis
o Grow as diplococci or short chains o S. sanguis: most frequent single species causing Bacterial
o Part of the normal enteric flora, inhabits the skin, the upper Endocarditis
respiratory and the GUT o Bacteria produce an extracellular dextran that allow them to bind
o Gamma to alpha hemolysis, PYR (+), grows in 40% bile, can to faulty cardiac valves (in cases like rheumatic fever, congenital
hydrolyze bile esculin ( + turns black) heart defect, mitral valve prolapse)
o Distinguishing Feature: Enterococci can grow in the presence of o Subacute bacterial endocarditis
6.5% NaCl  Piling up of bacteria on the heart valve
 Fever, anemia, heart murmurs secondary to valve destruction

F. Streptococcus pneumoniae/Pneumococcus
 Most common cause of community acquired pneumonia and
meningitis in adults
 Cause of otitis media, septicemia, sinusitis
 Normal inhabitants of the upper respiratory tract
 Gram (+) diplococci, encapsulated, non-motile, lancet shaped, in
chains or pairs.

Figure 18. Bile esculin agar. (+) test: esculin is hydrolyzed to to glucose and
esculetin. Esculetin combines with ferric ions to produce a black complex.
 Clinical Infection
o Most commonly E.faecalis: UTI, Biliary infection, septicemia,
endocarditis, wound infection, intra-abdominal abscess
 Streptococcus bovis
o Grows in 40% bile, can hydrolyze bile esculin
o Distinguishing feature: Lysed in the presence of 6.5% NaCl
o Endocarditis or bacteremia may be associated with GI Malignancy
(colonic cancer)
o “The presence of S. bovis in the blood should alert the clinician to
a possible occult malignancy”
 Treatment
o Enterococcus
 Penicillin plus Gentamycin or Streptomycin
 Vancomycin and Erythromycin
 E. faecium is more likely to be vancomycin- or multiple-
resistant compared to E. faecalis
o S.bovis – Penicillin G
E. Viridans Group Streptococci
 Viridis = Latin word for green
 Alpha-hemolytic, PYR (-), bacitracin (-), produces greenish
discoloration on blood agar
 NOT inhibited by Optochin; NOT bile soluble
 No Lancefield antigen classifaction
 Most prevalent normal flora of the mouth and upper respiratory
tract (Human GI tract flora in nasopharynx and gingival cervices)
 Can travel to the endocardial surface via the bloodstream due to
vigorous brushing, dental operation, GI instrumentation, etc
 Will only cause a disease when immunocompetent
 Members include Streptococcus salivarius, S. sanguis, S. mitis, S.
intermedius, S. mutans
1. Cultural Characteristics
 Complex nutritional requirements
 Has an absolute nutritional requirement for choline.
 Alpha hemolytic on BAP, facultative anaerobe
 For primary isolation: Tryptic soy or Brain Heart Infusion broth
enriched with 5% defibrinated blood.
o Young cultures of encapsulated pneumococci produce circular,
glistening, dome-shaped colonies 1 mm in diameter
o Later, the center of colonies collapse
o Unencapsulated strain produce rough colonies
2. Laboratory Identification
 Optochin Sensitivity
o Disc with a quinine derivative that inhibits the growth of
pneumococci but NOT Viridans streptococci
o Used to distinguish the two organisms because both are alpha
haemolytic
 Bile Solubility
o Autolytic amidase or autolysin that cleaves the peptidoglycan is
present in pneumococci but NOT in Viridans streptococci
o The amidase is activated by bile and bile salts, β lactam
antibiotics and a stationary phase resulting in LYSIS of the
organism
 Quellung Reaction
o Pneumococci + Polyvalent Antiserum= capsule swelling
o Most useful and rapid method for identification of
pneumococci in sputum, CSF, Exudates
o Polyvalent antiserum or “Omniserum” contains antibodies for
all types
 Animal Inoculation
o Infected sputum is injected intraperitoneally to a mouse
o The mouse succumbs to a fatal infection in 48 hours

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 MICROBIOLOGY 1.3
o Pneumonia is frequently preceded by an upper or middle
respiratory viral infection, which predisposes to S. pneumoniae
infection of the pulmonary parenchyma
o A leading cause of death, especially in older adults and those
whose resistance is impaired
o Acute fever, chills, severe pleuritic pain
o Cough with “rusty” mucopurulent sputum
o Complications:
 Pleural effusion that can lead to empyema
Figure 19. Left: Optochin senstitivty. Pneumococci growth is inhibited in  Meningitis, pericarditis, endocarditis
the lower left disc.
Center: Bile solubility. S. mitis in the left are not lysed, while S.
 Otitis Media
pneumoniae are lysed In the right test tube. o The most common bacterial infection in children
Right: Positive Quellung reaction.  Meningitis
o Pneumococcus is the most common cause of meningitis in
3. Pathogenesis adults and of recurrent meningitis in all age groups.
 Types of Pneumococci o Usually preceded by pulmonary infection, URTI, sinusitis or
o Adults: Types 1-8 (75% of Pneumonia cases) otitis media
o Children: Types 6, 14, 19, 23  Bacteremia/sepsis
 Determinants of pathogenicity o Common in individuals who are functionally or anatomically
o Polysaccharide Capsule: asplenic (sickle cell disease)
 91 Types; Pneumococcus damages host tissue as long as it is
outside the phagocytic cell. 6. Diagnostic Laboratory Tests
 Capsule is antiphagocytic  Specimens
 Antigenic o Nasopharyngeal swab
o Pili: enable the attachment of encapsulated pneumococci to o Blood - should be drawn for culture before antibiotics are given
the epithelial cells of the upper respiratory tract o Pus
o Neuraminidase: Disrupts cell membranes; contributes to o Spinal fluid
invasiveness o Sputum
o Proteases  From the lungs; not saliva
 Immunoglobulin degrading extracellular proteases  Gram stain: (+) lancet shaped diplococci - a presumptive
 Eliminate IgA, IgG, IgM diagnosis of pneumococcal pneumonia can be made.
o Choline binding protein A: Major adhesin allowing the  Culture: BHI, Trypticase Soy agar & broth with 5% blood, BAP
pneumococcus to attach to carbohydrates on epithelial cells of o α hemolytic colonies on BAP
the human nasopharynx. o Bile Soluble
o Pneumolysin O Toxin o Optochin Sensitive
 Hemolysin o (+) Quellung test
 Inhibits chemotaxis of PMN  Treatment
 Toxic effect on respiratory epithelium producing ciliary o PCN G
slowing and epithelial disruption. o Cephalosporin (Cefotaxime; Ceftriaxone )
 Stimulates production of proinflammatory cytokines o Erythromycin
 Predisposing Factors o Chloramphenicol for meningitis
o Viral/Other Respiratory infections: Damages respiratory  Control
epithelium o Vaccines provide 90% protection
o Accumulated secretions: protection from phagocytosis o Pneumococcal polysaccharide vaccine: (PPV)
o Bronchial obstruction  For adults; immunizes against 23 serotypes
o Irritants that disturb mucociliary action o Pneumococcal conjugate vaccine 13 (PCV 13)
o Alcohol, Drugs, Anesthesia, Morphine: Depresses phagocytosis  Effective in infants and toddlers (ages 6 weeks to 5 years)
and the cough reflex and facilitates aspiration
o Pulmonary congestion, CHF, prolonged bed rest G. Other Streptococci
o Malnutrition & Immunosuppression  S. anginosus-milleri Group
o S. constellatus, S. intermedius, S. anginosus, S. milleri
4. Pathology o Normal flora of the oral cavity and the gingival crevices
 Outpouring of edema fluid in the alveoli which facilitates o May be classified as Viridans because they are also α-hemoytic
microbial multiplication & spread to other alveoli. o Dental, brain, lung and intra-abdominal abscess
 PMN’s & RBC’s accumulate in the alveoli  consolidation  Peptostreptococcus
 Pneumococci reaches the bloodstream via the lymphatics. o Normal flora of the mouth, upper respiratory, bowel and female
 Later: Phagocytes take up & digest the pneumococci genital tract
o Mixed anaerobic infections in wounds, breast, post partum
5. Clinical Findings endometritis, rupture of viscus, brain, or chronic lung
 Pneumococcal Pneumonia/ Acute Bacterial Pneumonia suppuration.
o Rarely a PRIMARY infection. Results only when the normal
defense barriers of the respiratory tract is breached.

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 MICROBIOLOGY 1.3

III. Appendix
Table1.Differentiation of the different Staphylococcus species

Table 2. Summary of Important Staph spp.

Table 3. Summary of Important Strep spp.

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