‫ﻣﺮﻛﺰ اﻟﺸﺎﻣﻞ‬

Dr. Noor .M. Affara

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 There are two medically important genera of gram-positive cocci:
staphylococci and streptococci.
 They are distinguished by two main criteria:
 Microscopically, in Gram stained smear staphylococci appear in
grapelike clusters, whereas streptococci are in chains.
 All staphylococci are catalase positive whereas streptococci are
catalase negative.

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 The genus Staphylococcus consists of >40 species,
 The 3 species of medical importance which are S. aureus, S. epidermidis,
and S. saprophyticus. Of the three, S. aureus is the most important
human pathogen.

 Gram-positive cocci, arranged in grapelike clusters.

 Facultative anaerobes.
 Grow in simple media.
 Opaque colonies (endopigment).
 Non-motile and non-spore forming.
 Catalase positive. 3 / 39
Base on coagulase production the staphylococci classify in to two group:

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 Gram-positive cocci arranged in grapelike clusters.
 Some strains are capsulated.
 Non-motile and non-spore forming.

 Facultative anaerobes.
 Can grow on nutrient agar producing golden yellow colonies (aureus= golden)
 Beta hemolytic colonies on blood agar. (the colonies are large, round, smooth&
raised), except MRSA strain produce (white & smaller colonies, week or no
hemolysis on blood agar.
 Coagulase and catalase positive.
 Mannitol fermenter on mannitol salt agar.
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 Virulence factors include:
A) Cell wall components.
B) Extracellular factors (Enzymes & Exotoxins)

 Clumping factor (bound coagulase-fibrinogen binding protein, or protein

of adhesion): a surface protein in S. aureus responsible for adherence of
organisms to fibrinogen and fibrin leading to their clumping or
aggregation and promoting their attachment to blood cloths and
traumatized tissues.
 Protein A: is the major protein in the cell wall it binds to the FC portion
of IgG thereby preventing opsonization and phagocytosis of the
organism 7 / 39
 Peptidoglycan: has endotoxin-like activity. That explains the ability of S.aureus
to cause septic shock without possessing an endotoxin.
 Teichoic Acid: mediate adherence of organisms to mucosal Surfaces.
 Capsule: some strains of S. aureus possess polysaccharide microcapsule that is
inhibit phagocytosis by polymorphonuclear leukocytes (anti-phagocytic).

 Coagulase (free coagulase): causing plasma to clot by converting fibrinogen to

fibrin. Fibrin deposits on the surface of S.aureus forming a wall around the
bacteria this lead to protection from phagocytic cell and localization of infection.
 Catalase: degrades H2O2 into water and oxygen (bubbles).catalase is an
important virulence factor because H2O2 is a microbicidal and its degradation
limits the ability of phagocytic cells to kill bacteria.
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 Structure of Staphylococcal cell wall
Protein A 9 / 39
 Staphylokinase (Fibrinolysin):breaks down fibrin clots and allowing S.aureus
to free it self from cloths and spread.
Hyaluronidase or spreading factor: Splits hyaluronic acid in ground
substance of connective tissue and enabling the bacteria to spread between
the cells .
 Deoxyribonucleases (DNAase): a heat-stable nuclease, hydrolyze the DNA
and is a unique characteristic component of S. aureus in the genus.
 Beta-lactamase (Pencillinase): Splits beta-lactam ring in pencilline and
some cephalosporine. causing the organism resistance to beta-lactam
antibiotics.
 Other enzymes: lipase(splits fat and help the organism in infecting skin and
subcutaneous tissues) and proteinase (splits protein).
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1. Cytotoxins or membrane-damaging toxins:
 Including several toxins as alpha, beta, gamma, delta and
Leucocidin or Panton-Valentine [P-V] leukocidin). Of these the most
important are alpha toxin and P-V leukocidin)
 Many of cytotoxins are pore-forming toxins (PFT), which are able to
cause cytolysis of many cells as erythrocytes, fibroblasts,
leukocytes, macrophages, and platelets by producing pores on the
cytoplasmic membrane.
 alpha toxin causes marked necrosis of the skin and hemolysis.
 P-V leukocidin toxin kills cells, especially leukocytes and cause
necrosis of tissues.
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2. Enterotoxins: a superantigen, at least 10 antigenic types of
enterotoxins (A,B,C1,C2,C3, D, E, G,H and I), produced by 50% of
S.aureus strains. Type A is most common to cause food poisoning. The
toxins are heat stable and resistance to the action of gut enzyme and
causes food poisoning.
3. Toxic shock syndrome toxins- 1 (TSST-1): a superantigen, causes
toxic shock syndrome (TSS) due to infection or colonization by TSST-1
producing S.aureus.
4. Epidermolytic/Exfoliatin Toxins (ET): causes Staphylococcal
scalded Skin Syndrome (SSSS). It is “epidermolytic” and acts as a
protease that cleaves desmosomes, leading to the separation of the
epidermis from the underlying tissues. They are superantigen.
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1. Are potent antigens. Superantigens
(SAgs):
2.No need for intracellular–procession.
3.They interact to class II major
histocompatibility complex (MHC II)
molecules on macrophages out side the
peptide- binding groove. On the T cell
side, SAgs bind to the variable regions of
the β chain only. But not to α chain of the
T cell receptors (TCR).
4. Induce a massive activation of helper T
cell and release of large amounts of
cytokines interleukin 1 (IL-1) ,interleukin 2
(IL-2 ) and tumor necrosis factor(TNF)by
both macrophages and T cells that may
cause systemic toxicity of SAgs.
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 S. aureus is the most virulent Staphylococcus species.
 It is responsible for both nosocomial and community-based infections that
range from relatively minor skin and soft tissue infections to lifethreatening
systemic infections.
 Transmission of infection: staphylococci are found primarilyin the normal
human flora. S.aureus is often found in the nose and sometimes on the skin,
and nasal carriage of S aureus occurs in 40-50% of humans .
 The source of infection: A. Exogenous from patients or healthy carriers or
 B. Endogenous: own strains that colonized site.
 Mode of transmission: A. Contact: direct or indirect (through fomites)
B. Inhalation of air borne droplets
 The organisms are introduced into the 14tissues
/ 39 as a result of minor abrasions or
 S. aureus can produce disease both through their ability to multiply and
invade tissues and through the production of extracellular enzymes and
toxins .
 Two types of diseases causes by S. aureus :
A. Pyogenic disease.
B. Toxigenic disease.

1. Localized Skin and Soft Tissue Infection

 The typical lesion of S. aureus infection is an abscess such as:
• Folllculltis: infection of hair follicles.
• Furuncle (boil): large, painful, pus-filled cutaneous lump.
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• Carbuncle: a cluster of furuncles or boils with extension into
subcutaneous tissues and evidence of systemic disease (fever, chills,
bacteremia) occurs usually on the back of the neck.
• Cellulitis: (inflammation of skin and subcutaneous tissue).
• Impetigo: Superficial infection of abraded skin and is highly
communicable among children, begins as a cluster of small blisters
expand and rupture within 24 hrs. and a thin yellow fluid drain from
ruptured blisters quickly dries and form honey colored crusts usually
appears on the face.
• Mastitis and breast abscess (in nursing mothers).
• Wound infection (Post-traumatic or Post-surgical wound infection)
• Hidradenitis: infection of axillar apocrine –sweat glands.
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 Pyogenic disease of S.aureus

Boil

Folliculitis: Note the multiple, small pustules on the chin and neck

Carbuncle. Note a drop of yellowish pus near the center

of the lesion
Abscess on foot: Note central raised area of whitish pus surrounded
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by erythema. An abscess is the classic lesion caused by S. aureus.
 Pyogenic disease of S.aureus

Impetigo: Stye Paronychia

Folliculitis : a Group of pustules affecting

areas of moist skin with hair. Boils Carbuncle
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• A stye is a bacterial infection involving one or more of the small
glands near the base of eyelashes.
• Paronychia: infection of the proximal and the lateral folds of nail.
2. Staphylococus pneumonia: frequent complication of prior viral infection
( measles or influenza).
3.Invasive diseases: are more serious & usually occur in
immunocompromised herein the ,organisms invade the blood stream cause
(bacteremia) and spread to many body site result in osteomyelitis, septic
arthritis, pneumonia, empyema, endocarditis, meningitis, and urinary tract
infection.
4.Septicemia (sepsis) can originate from any localized lesion, especially
wound infection, or as a result of intravenous drug abuse. Sepsis caused by S.
aureus has clinical features similar to those of sepsis caused by certain gram-
negative bacteria, such as Neisseria meningitides.
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 Pyogenic disease of S.aureus

Impetigo: Stye Paronychia

Folliculitis : a Group of pustules affecting

areas of moist skin with hair. Boils Carbuncle
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1- Food Poisoning:
 The commonest type of bacterial food poisoning.
 Caused by ingestion of preformed enterotoxin in contaminated food that is
improperly cooked and kept unrefrigerated for some time.
 The source of food contamination is the (carriers) such as cooks or food
handlers harboring's S.aureus on their hands or nose.
 The incubation period is short (1-6 hrs) followed by violent vomiting,
diarrhea without fever.
 It is usually self- limited within 24 hours.
2- Toxic Shock Syndrome:
 It was first described in menstruating women using tampons. The syndrome
also occurs with wound or localized infection.
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2-Toxic Shock Syndrome:
 The disease characterized by sudden onset of high fever, vomiting, diarrhea,
myalgia, skin rash. Hypotension, heart and renal failure may occur in severe
cases.
3- Staphylococcal Scalded Skin Syndrome (SSSS):
 Occur in neonate & children under five years of age.
 Followed infection caused by S. aureus that produces Exfoliatin toxins.
 The superficial layers of the epidermis slough in response to the presence of
Exfoliatin toxin.
 Large bullae are formed under the skin that rupture
and leaving moist, red and scalded dermis.
 Full recovery without scar formation is the rule.
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1. Specimens: swab from lesion e.g. pus ,sputum, urine, CSF and blood (in
case of bacteremia, septicemia, endocarditis)…etc.
2. Smears prepared directly from specimens and stained by Gram-stained
and examine by microscope will show Gram- positive cocci in grape-like
clusters among pus cells.
Note: microscopy cannot distinguish Staphylococcus species.
3. Culture: S.aureus colonies will show complete hemolysis (β-hemolysis)
on Blood agar and golden yellow colonies better seen on nutrient agar.
When grown on Mannitol salt agar, yellow colonies are produced due to
fermentation of mannitol.
4. Colonies are further identified by gram staining and tested for:
a.Catalase production: staphylococci are catalase positive, which
differentiate them from streptococci that are catalase negative.
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 Nutrient agar: Golden
yellow colonies.

Blood agar: Golden yellow colonies surrounded

by clear zones of hemolysis (β-hemolysis)

Mannitol salt agar :S. aureus (below). ferment

mannitol and give yellow colonies and the
normally pink medium will turn yellow.
Staphylococcus epidermidis (above) doesn’t
ferment mannitol and consequently the medium
remain pink (Unchanged)..
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Catalase test ; By mixing a drop of 3% hydrogen peroxide (H2O2) with a
colony of the test bacteria on slide or pouring H2O2 on plate. Producing air
bubbles = positive (+), without air bubbles = negative (+)

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B. Coagulase production: S. aureus is coagulase positive which
differentiate it from other Staphylococcus species that are coagulase
negative.
 Coagulase test
 It is the most important marker for identifying S.aureus.
 Coagulase cause plasma to clot by converting fibrinogen to fibrin.
 Two types of coagulase are produced by S.aureus bound coagulase
and Free coagulase and can be detected by 2 methods:
• Slide method detects the bound coagulase or the clumping
factor. it is rapid, the result obtain within 10 to 15 seconds.
• Tube method detects the Free coagulase which is an
extracellular enzyme produce by S.aureus.
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 Tube coagulase test:
A. Negative test result (no clot produced).
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Laboratory Diagnosis
5. PCR may be used for identification.
6. Phage typing is required in epidemiological studies of outbreaks of S.
aureus disease as food poisoning & surgical wound infections
7. Antimicrobial Susceptibility Test
- As S. aureus develops resistance to antibiotics readily,
drugs should be prescribed according to the antimicrobial
susceptibility test done on Mueller Hinton agar.

28 / 39 Pattern method of bacteriophage typing

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 Abscesses require surgical drainage and antibiotic therapy to prevent
dissemination.
 Systemic infection require vigorous antibiotic therapy.
 S.aureus shows marked ability to develop resistance to antibiotics
specially in hospitals. Sensitivity testing is therefore essential for the
choice of antibiotic.
 Therapy is faced with the following antibiotic resistance pattern of
S.aureus:
1. Penicillin resistant S.aureus.
2. Methicillin-resistant S.aureus (MRSA).
3. Vancomycin resistant S.aureus
- (VRSA) Vancomycin resistance S. aureus
- (VISA) Vancomycin intermediate
30 / 39 S. aureus
1. Penicillin resistant S.aureus
 About 95% of S. aureus strains are resistance to (penicillin G or
amoxicillin and ampicillin).
 Resistance due to the production of β-lactamase (penicillinase).
 Resistance rate is highest among hospital stains of S.aureus.
 Resistance stains remain susceptible to penicillinase- resistant penicillins
e.g (methicillin, oxacillin , cloxacillin or naficillin and some
cephalosporin).
2. Methicillin resistant S. aureus (MRSA)
 About 20% of S. aureus strains are Methicillin resistance (MRSA).
 More serious type of resistance.
 Resistance due to alteration of penicillin-binding protein (PBPs)
present on S. aureus cell membrane to PBP-2a. This is due to the
acquisition of mec A gene on the chromosome of MRSA.
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 The altered PBP2a of MRSA strains has less affinity for β-lactam
antibiotics; hence, MRSA strains are resistance to all β-lactam
antibiotics.
 Vancomycin is the drug of choice for MRSA.
 For skin and soft tissue infections caused by MRSA, oral therapy with
(Trimethoprim-sulfamethoxazole (brand name: Bactrim),
Clindamycin, Doxycycline and Linezolid) are useful.
3. Vancomycin-resistant S.aureus
 Unfortunately during the last few years some strains of MRSA
displayed intermediate (VISA) or complete (VRSA) resistance to
vancomycin. This situation is very serious.
 Quinupristin-dalfopristin (Synercid) and Linezolid (Zyvox) are useful
choice for treatment of infection not responding to vancomycin.
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Morphology and Culture Characteristics:
S. epidermidis is similar to S.aureus except in the following:

 It gives white-nonhemolytic colonies  It is non-mannitol fermenter

on blood agar.

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Habitat and Transmission:
 Normal flora of the human skin and mucous membranes. It is probably the
patient's own strains that cause infection(endogenous infection), but
transmission from person to person via contact may occur.
Pathogenesis:
 The organisms produce extracellular polysaccharide (glycocalyx or slime
layer) that allows its adherence to prosthetic devices and facilitate
formation of biofilm on device surface. Biofilm appears to act as a barrier,
protecting bacteria from host defence mechanisms as well as from antibiotics.
 It is a low-virulence organism that causes disease primarily in
immunocompromised patients and in those with implants. It is a major cause
of hospital-acquired infections. Unlike S. aureus, do no produce exotoxins.
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Diseases:
 Endocarditis on prosthetic heart valves, prosthetic hip infection,
intravascular catheter infection, cerebrospinal fluid shunt infection,
neonatal sepsis.
Laboratory Diagnosis
 S. epidermids is diagnosed by its morphological & culture characteristics
 it is sensitive to Novobiocin.
Treatment:
Vancomycin plus either rifampin or an aminoglycoside.
It produces β-lactamases and it is highly resistant to antibiotics.
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 Morphology and Culture Characteristics: S. saprophyticus is
similar to S.epdermidis.
 Disease :S. saprophyticus causes community-acquired urinary
tract infections in young sexually active women (second to
Escherichia coli).
 Laboratory Diagnosis: S. saprophyticus is similar to S.epdermidis
expect is being Novobiocin resistant.
 Treatment: quinolones are drugs of choice.

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Characters distinguishing species of staphylococcus

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 Prevention
 There is no vaccine against staphylococci.
 Cleanliness, frequent handwashing, and aseptic
management of lesions help to control spread of S. aureus.
 Persistent colonization of the nose by S. aureus can be
reduced by intranasal mupirocin or by oral antibiotics, such
as ciprofloxacin or trimethoprim-sulfamethoxazole..
 Shedders may have to be removed from high-risk areas
(e.g., operating rooms and newborn nurseries).
 Cefazolin is often used perioperatively to prevent
staphylococcal surgical-wound infections.

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