M.
09 GRAM-POSITIVE COCCI: GENUS
STAPHYLOCOCCUS (PART 2)
Dr. Gallardo | October 15, 2018
OUTLINE
I. Staphylococcus aureus
II. Coagulase-Negative Staphylococcus spp.
III. Laboratory Diagnosis for Staphylococcus spp.
IV. Treatment
V. Prevention
I. Staphylococcus aureus (cont’d)
A. TOXIGENIC/TOXIN-MEDIATED DISEASES
1. STAPHYLOCOCCAL FOOD POISONING
 Due to preformed heat-stable enterotoxins
o Not a form of infection but an intoxication
o The food will not show any signs of being contaminated
which is quite dangerous
 The toxins will not make the food look or taste bad
 Common contaminated food include:
o processed meats, e.g. ham, salted pork
o custard-filled pastries, e.g. cream puffs
o mayonnaise-containing food, e.g. potato salad, left at
room temperature
o ice cream
 Characterized by short incubation period (1-8 hours)
 Violent nausea, vomiting, and diarrhea, with no associated
fever
 Symptoms last less than 24 hours; rapid recovery
2. STAPHYLOCOCCAL TOXIC SHOCK SYNDROME (STSS)
 Multisystem disease occurring within 5 days after onset
of menses in young women who use tampons
o Hyper-absorbent culture media for the growth of the
organism
 Also occurs in children or men with staphylococcal wound
infections
 Abrupt onset of high fever, vomiting, diarrhea, myalgia,
scarlatiniform (scarlet fever like) rash, hypotension, cardiac
and renal failure.
3. STAPHYLOCOCCAL SCALDED SKIN SYNDROME (SSSS)
 Characterized by generalized painful erythema and
bullous desquamation of large areas of skin
 Primarily affects neonates (Ritter’s disease) and children
<4 years of age
 Due to the production of exfoliatin
 Epidermis starts to regenerate after about 7-10 days as the
human host start to develop antibodies against the toxin.
 Only a surface type of lesion involving the stratum
granulosum that heal without scarring.
 (+) Nikolsky sign
o Do gentle stroking of the skin and be able to desquamate
areas of it
MICRO | 1 of 3
Fig 1. Staphylococcal Scalded Skin Syndrome.
II. COAGULASE-NEGATIVE STAPHYLOCOCCI (CONS)
 Catalase-positive
 Coagulase-negative
 Gram-positive cocci arranged in clusters
 Normal flora of human skin and mucosal surfaces
 Relatively avirulent
 Produce the “slime layer” or biofilm
A. Staphylococcus epidermidis
 Member of normal flora of human skin, respiratory, and
gastrointestinal tracts
 Nonpathogenic, noninvasive
 Coagulase-negative, non-hemolytic
 Rarely produce suppuration
 May infect foreign devices (orthopedic or cardiovascular
prostheses, catheters, grafts, shunts, peritoneal dialysates) or
cause disease in immunocompromised hosts
 Infections are almost always hospital acquired
2 Phases Involved in the association of S. epidermidis to
plastic surfaces:
1. Adherence Phase
o Cells adhere to plastic surface
o May involve polysaccharide factors and surface proteins
2. Intercellular Phase
o Adhere to each other
o Mediated by a polysaccharide, PIA (Polysaccharide
Intercellular Adhesion Molecule)
o Forms multilayered clusters that become embedded in an
exopolysaccharide matrix
 Biofilm is formed on surfaces on intravascular
catheters and foreign devices
o Biofilm
 Protects the embedded organisms from the
phagocytic cell of the host
 Decreases the ability for some antimicrobial agents
to eradicate adherent staphylococcal micro-colonies.
 Isolation of this organism may not require treatment because:
o Normal flora
o Break of aseptic technique: indicative of contamination
when the growth is within 3-5 days
SOFLA, TORRES
 Clinically we treat Staphylococcus epidermidis infections if: B. CULTURE
o The growth is occurring very quickly within 24 hrs.  Definitive diagnosis
o The growth is appearing in more than one sterile body  Gold standard for diagnosis of Staphylococcus spp.
site (considering that we do the culture aseptically). For  Test for the following parameters:
instance we do a blood culture and a urine culture and a. Colonial morphology
with all these cultures, we isolate S. epidermidis. b. Hemolysis and pigment production
o The patient has risk factors. c. Catalase and coagulase production
d. S. aureus: ferments mannitol
B. Staphylococcus saprophyticus
 Coagulase-negative
 Non-pigmented
 Novobiocin resistant
 Non-hemolytic
 Second most common cause of UTI in sexually active
young women
o E. coli is the most common cause of UTI in any age
group
 Infections are almost always community-acquired
 Produces a number of proteins that may be responsible for
propensity to cause UTI.

PROTEINS RESPONSIBLE FOR UTI

PROTEIN FUNCTION
Protein Mediates attachment to
Hemagglutinin uroepithelial cells
Surface Fibrillar Plays a separate role in attachment Fig 2. MSA inoculated with Staphylococcus aureus.
Protein
Urease Implicated in invasion of organism  Mannitol salt agar (MSA) is selective for staphylococci
into urinary bladder by breaking because of the high salt concentration
down urea to ammonia creating an  Acid from mannitol fermentation causes the pH indicator
alkaline environment for the (phenol red) to turn from red (alkaline) to yellow (acid)
microorganism to thrive in
C. NOVOBIOCIN SENSITIVITY DISC
C. Staphylococcus haemolyticus  Differentiates coagulase-negative Staphylococci
 Coagulase-negative
 Diseases: Bacteremia, endocarditis, bone and joint infections, NOVOBIOCIN TEST RESULTS
UTI, wound infections, opportunistic infections in RESISTANT SUSCEPTIBLE
immunocompromised hosts S. saprophyticus S. epidermidis
D. Staphylococcus lugdunensis
 Coagulase-negative, non-pigmented, non-hemolytic
 Staphylococcal species most commonly associated with
native valve endocarditis
o Most commonly involved organism with native valve
endocarditis is still Streptococcus
o Most common staphylococcal organism associated with
artificial valve endocarditis is S. epidermidis.
 Also cause arthritis, bacteremia, UTI, and opportunistic
infections
 Reported increasingly worldwide in the literature

III. LAB DIAGNOSIS FOR STAPHYLOCOCCUS SPP.

A. GRAM STAIN Fig 3. Novobiocin Susceptibility Test.
 Presumptive diagnosis
 Gram-positive cocci in clusters D. NUCLEIC ACID-BASED TEST
 Specimen:  Nucleic acid amplification tests are now commercially
o Scrape base of abscess; not really an aspirate available for direct detection and identification of S. aureus in
o Blood is rarely gram stained due to a very small amount clinical specimens.
of organism in the blood  Useful for detecting MSSA (Methicillin Susceptible S. aureus)
and MRSA (Methicillin Resistant S. aureus) in wound
specimens and screening nasal specimens for carriage of
these microorganisms.

MICRO | 2 of 3 SOFLA, TORRES

IV. TREATMENT CHECKPOINT
A. DEFINITIVE
Identify what is being asked:
1. Disease characterized with generalized painful erythema
DRUGS FOR THE TX OF STAPHYLOCOCCI
and bullous desquamation of large areas of skin.
ORGANISM ANTIBIOTIC 2. Neonatal form of your answer in #1.
DOC (due to the -lactamase or Penicillinase- 3. DOC for VRSA
ability of the resistant Penicillin: 4. pH indicator in MSA.
organism to -Oxacillin 5. Most commonly associated staphylococcal organism with
elaborate - -Nafcillin artificial valve endocarditis.
lactamase) -Methicillin
S. -Cloxacillin True or False:
aureus Oxacillin-resistant Vancomycin 1. S. saprophyticus is almost always community acquired.
and Methicillin- 2. S. lugdonensis is the most common cause of native valve
resistant strains endocarditis.
(ORSA, MRSA) 3. Surface fibrillar proteins are secreted by S. epidermidis
Vancomycin- -Linezolid (Oxazolidinones) for attachment to the uroepithelial cells.
resistant strains -Daptomycin (Newer types) 4. Infections from CONS immediately require antibiotic
(VRSA) -Tigecyclines treatment.
S. epidermidis Vancomycin ± 5. Scrapings from the base of the abscess is the ideal
(highly antibiotic resistant, Rifampin/Aminoglycosides sample to visualize abundant microorganisms from a
regardless of susceptibility (for synergism) suspected Staphylococcal infection.
testing)
Quinolone
Tigecycline, (4) Phenol Red, (5) S. epidermidis; TFFFT
ANSWERS: (1) SSSS, (2) Ritter’s Disease, (3) Linezolid, Daptomycin, or
S. saprophyticus Trimethoprim-
Sulfamethoxazole (TMP-SMX)

B. SUPPORTIVE
 Incision and Drainage – cornerstone of abscess
treatment in order for antibiotics to better penetrate
 Toxic Shock Syndrome – correction of shock
 S. epidermidis – removal of foreign body

V. PREVENTION
 No vaccine available
 Perform strict aseptic techniques at all times.
 Persistent colonization of nose with S. aureus may be
reduced by intranasal application of Mupirocin
o MOA: cessation of incorporation of isoleucine into
bacterial proteins; primarily effective against Gram-
positive bacteria
 Avoid indiscriminate use of antibiotics to prevent
development and spread from resistant strain

MICRO | 3 of 3 SOFLA, TORRES