Tille: Bailey & Scott’s Diagnostic Microbiology, 14th Edition

Chapter 13: Staphylococcus, Micrococcus, and Similar Organisms

Answers to Case Studies and Review Questions

Case Studies

Case Study 13-1

1. PYR, β-galactosidase, and VP will differentiate among the tube coagulase-positive

staphylococci. Staphylococcus intermedius is VP-negative and PYR-positive and is a pathogen in
dogs. This isolate was S. intermedius, which was probably acquired by the mother while working
in the veterinarian’s office and then transmitted to her son.
2. An ornithine decarboxylase test should be performed on PYR-positive staphylococci from
significant normally sterile sites to identify Staphylococcus lugdunensis, which is among the few
staphylococci that have a positive reaction for this test. S. lugdunensis can be problematic to
identify because it can be slide coagulase-positive but is always tube coagulase-negative.
Fortunately, it does not have the typical β-hemolysis of S. aureus. However, S. aureus has been
identified that no longer expresses the β-hemolytic phenotype, resulting in misidentification as S.
lugdunensis. The identification of S. lugdunensis is important, because this organism is highly
associated with infectious endocarditis, a complication of bacteremia. Treatment must be long
and aggressive. Because more than half of S. lugdunensis are β-lactamase–negative, the
laboratory should include this result in the report, so that penicillin can be considered for therapy.
3. The only known mechanism of resistance is mediated by the mecA gene in staphylococci,
which produces penicillin-binding protein 2a (PBP2a). This protein does not bind well to either
penicillin or the penicillinase-resistant penicillins (i.e., oxacillin, dycill [dicloxacillin], nafcillin).
Thus this protein is available to the cell to complete the formation of the cell wall. Direct
detection of the gene or its protein product is an excellent method to detect resistance in
coagulase-negative staphylococci.
4. Surprisingly, the agent is cefoxitin, a drug that would not generally be considered to treat
staphylococcal infections. The disk test is recommended by the Clinical and Laboratory
Standards Institute (CLSI) as the best predictor of both susceptibility and resistance, having a
high sensitivity and specificity.1
1
Clinical and Laboratory Standards Institute: Performance standards for antimicrobial
susceptibility testing; M100-S23, Wayne, PA, 2013, CLSI.

Case Study 13-2

1. Gram-positive cocci in clusters, many white blood cells (WBCs).

2. Blood cultures, as well as a culture and sensitivity of the joint fluid, would be recommended to
ensure that the patient was not developing a bacteremia. Blood cultures in this case were
negative at 48 hours in both the aerobic and anaerobic cultures. Joint fluid demonstrated the
growth of a coagulase-negative staphylococcus.
3. The patient has developed a septic arthritis as a result of an infection with a coagulase-

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Answers to Case Studies and Review Questions 13-2

negative staphylococcus.
4. Additional testing would include a biochemical panel and antibiotic sensitivity profile to
confirm the identity of the organism and proper treatment of the patient. The joint was replaced
with an antibiotic impregnated prosthesis. A peripherally inserted central catheter (PICC) line
was inserted, and she was treated for 6 weeks with intravenous (IV) antibiotics. Eventually, the
patient received a new permanent joint replacement.

Review Questions

Multiple Choice

1. b; 2. d; 3. b; 4. a; 5. c

True/False

F, F, F, T, T

Matching

e, f, i, j, k, b, h, d, g, a, c, l

Short Answer

1. Methicillin-sensitive S. aureus, as evidenced by oxacillin sensitivity and negative cefoxitin

screen; β-lactamase–positive staphylococci are considered resistant to all penicillins.
2. Methicillin-resistant S. aureus, as evidenced by oxacillin resistance and positive cefoxitin
screen; all β-lactamase–positive, oxacillin-resistant staphylococci are considered resistant to
cephems, β-lactam and β-lactamase inhibitor combinations, carbapenems, and penicillins.
3. Methicillin-sensitive S. aureus, as evidenced by oxacillin sensitivity and negative cefoxitin
screen; β-lactamase–positive staphylococci are considered resistant to all penicillins.

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