Streptococcus

Group A Streptococcus: Streptococcus

pneumoniae:
Sore throat Pneumonia,
Scarlet fever Meningitis,
Necrotizing fasciitis, Recurrent otitis
Post-streptococcal Group B Enterococcus
complications Streptococcus: spp.:

New – borns meningitis Wound infections,

Urinary Tract Infections,
Sepsis
Streptococcal pharingitis
Scarlet fever
Necrotizing fasciitis

Flesh-eating bacteria
Gram-Positive Cocci
Genus Streptococcus
 I. General presentation
• Minidefinition:
– Gram positive cocci grouped in chains
involved in suppurative infections, toxinoses
(e.g.scarlet fever) and poststreptococcal
complications
Gram stain of Streptococcus
II. Taxonomy and classification
Bergey Manual 2004:
Domain: Bacteria
Phylum: B XIII, Firmicutes
Class: III, Bacilli
Order: Lactobacilalles
Family: Streptococcaceae
Genus Streptococcus

Related with staphylococci, enterococci, Bacillus

spp.
 III. Habitat
– Group A Streptococcus
• Pharynx
• Skin – carriers, surgical wounds, burns
• Environment, antiseptic solutions (nosocomial
transmission –  -hemolytic streptococcus)
– Group B Streptococcus – genital tract
– Enterococcus – digestive tract (microorganism
isolated from man and animals = zoonotic)
– Str. pneumoniae and viridans – nose and
pharynx, there from may disseminate
IV. Streptococci of medical
importance. Classification
– Serological (based on group specific sera
against cell wall polysaccharide C)

– Based on hemolysis type:

• beta (complete),
• alpha (incomplete, greenish = viridans),
• alpha ‘ (incomplete)
• gamma (absent on sheep erythrocytes)
 Serological classification
• Groupable streptococci:
– Lancefield groups: A to W groups, except I and J
– A, B, D – most important; C, G, F – rare
– One or more species/group
– Based on the structure of bacterial cell wall
C polysaccharide

• Non-groupable streptococci:
- Str. pneumoniae
» Pneumonia, meningitis, recurrent otitis
- Str. mutans
- Str. viridans
» Dental caries
Classification based on hemolysis
• Beta
– Complete hemolysis
– Group A, C, G
• Alpha: partial hemolysis,
greenish colour:
– Str. pneumoniae, Str.
viridans
• Alpha’: partial hemolysis
– Group D (may be alpha’ or
gamma)
• Gamma
– Absence of hemolysis
Diseases caused by Streptococci
- Suppurative infections:
- Non invasive:
- Sore throat (Group A Streptococcus),
- Impetigo, erizipelus
- Invasive:
- New born meningitis (Group B Streptococcus),
- Necrotizing fasciitis (Group A streptococcus – flesh eating bacteria)
- Hospital acquired infections (Enterococcus);
- Pneumonia (Streptococcus pneumoniae) etc.
- Toxinoses: Scarlet fever, streptococcal toxic shock (pyrogenic toxin)
- Generalized infections: Bacteremia/septicemia/endocarditis (Enterococcus, Str.
pneumoniae, Str. viridans)
- Poststreptococcal complications - of medium or high severity
 Pyrogenic toxin
• Superantigen
• Polyclonal Mitogen for T
lymphocytes
• Activates immunity system
causing delivery of pro-
inflammatory cytokines
 Scarlet fever

• Group A acute pharyngitis

•Rash (erithema)
•Erythrogenic toxin produced by
group A streptococcus
Scarlet Fever

CLINICAL FEATURES
-2-4 incubation period
- Headache and tonsillitis appear after

Rash:
- develops within 2 hours, spreads rapidly over trunk and neck
- With increased density in the neck, axillae and groins.
- A fine punctuate erythematous appearance
- A “sand papery” feel and blanching on pressure.
-Rash lasts about 6 days followed by peeling

Tongue:
- white first then “red strawberry”
Poststreptococcal complications
– early and late
• Acute Rheumatic Fever (ARF)
• Early – 2 to 4 weeks after the throat
infection: rheumatic arthritis (light): big
articulations, moving arthritis without
sequelae
• Rheumatic Heart Disease
• Usually after several episodes of ARF:
heart damage (severe) – damaged valves –
fibrillation, infection, heart failure,
thrombotic accidents
– Chronic sequelae, life threatening!!!
Rheumatic fever- mechanism
 Streptococcal M Protein
– Cross-react with myosin
– Autoimmunity

 Cell wall antigens

– Difficult to be cleared in vivo
– Persist indefinitely
 Rheumatic fever licks
articulations and bites heart

• Sore throat therapy

— Mandatory Penicillin in
severe clinical forms
• Prevent carditis
 Acute Poststreptococcal
Glomerulonephritis (APSGN)
•immune
complexes
kidney disease
(type III
hypersensitivity)
 V. Streptococci:
– Microscopy:
• Shape: ovoid cocci, 0,5 – 1m dimensions
• Tinctoriality: Gram positive
• Arrangement:
- characteristic, in chains or pairs
- extracellular in prelevates
• Non-sporulated, non mobile
• Oxydase and catalase negative
• Facultatively anaerobic
• Cultivability:
- cultivate on simple
nutritive media with blood
supplement (enriched)
- hemolyse –
classification

Group B streptococcus - GBS Group A streptococcus - GAS

 Metabolic type and enzymes

●HETEROTROPHIC type (growing only in

the presence of organic substances)

Catalase negative;
Facultatively anaerobic bacteria
Resistence to physical, chemical
and biological agents

• Physical agents:
– Less resistant than Staphylococcus to:
• cold
• dryness
• pH variations
 Major pathogenity factors
Cell wall antigens:
• Lipoteichoic acid/F protein
– Fimbria
– Attach to epithelium cells
• M Protein
– Anti-phagocytic
– Involved in natural and adaptive immunity (Ab)
– Several M types – reinfection is possible with a different
M type strain
• Capsule
– Anti-phagocytic
Str. pyogenes
lipoteichoic acid
F-protein

fibronectin

epithelial cells
 Protein M
Complement IMMUNE

IgG

r
r r
M protein
peptidoglycan NON-IMMUNE
fibrinogen

r
r r
 VII. Pathogenesis:
• Colonize skin and mucosal surfaces
(special superficial structures)
• Invazion and infectious process
• Toxins: erithrogenic, pyrogenic
• Structures to avoid immune response:
– Capsule
– Protein M
 VIII. Immune response
• Main mechanism: fagocytosis
• Neutralising anti-toxic antibodies
• Antibody dependent Opsonisation
Bacteria resist by:
- Capsule and M protein, which interfere the
phagocytosis
Antigens cross-reacting with myosin are
responsible for autoimmunity (post-
streptococcal complications)
IX. Epidemiology and prophylaxis
- Humans are the reservoir for strep A
- Transmitted mainly by drops, less by direct contact
- Asymptomatic colonization in 20% of population
- Poststreptococcal complications: outbreak investigation;
Penicillin emergency treatment in severe streptococcal sore
throat and scarlet fever
- Enterococcus – zoonotic agent, nosocomial infections
- In toxic shock – fatality rate 30%
• Prophylaxis and treatment:
– Group A streptococcus severe infections – mandatory
Penicillin; hypersensitivity to Penicillin – test for
erythromycin and cephalosporines
 Laboratory diagnostic
1. Sampling and transport:

– samples: nose and pharynx exsudate, wound

secretion, blood (in str. viridans endocarditis,
pneumonia, sepsis ); CSF – in new born
meningitis or Str. pneumoniae meningitis
Precautions: before starting antimicrobial
therapy
2. Direct examination (left side)
 3. Isolation and identification
 hemolytic colonies
Complete hemolysis caused by streptolysin O
(Oxygen sensitive) ǂ streptolysin S (Oxygen Stable)
– Oxygen sensitive – inoculation on the medium by
introducing the loop inside the medium helps by
protecting haemolytic activity from Oxygen

– serogrouping: group A
 Catalase
Bacterial culture + H2O2

Negative = no bubbles = Streptococci

Positive = bubbles present = Staphylococci

www. biochemicaltestproject.blogspot.com
  Hemolytic colonies
• Developed by Streptococcus group A
(SGA), G and C
• Identification of SGA
– Bacitracin test: inhibition of growth =
SGA
– Serological identification using group
specific sera
Bacitracin test for GAS
identification
Commercial agglutination test

Grup A streptococcus Non Grup A streptococcus

 Rapid “Strep” Test
Extract from nose secretion
(+/- streptococcal antigen)
-

+
Antibody
Liposome

Streptococcal antigen
 GAS Serotyping

 M types
Scope:
-Epidemiology:
 T types
-To find the source and
 R types
transmission pathway
Based on
-To differentiate a reinfection
cell wall
proteins -Case management:
structure -to evaluate the potential of
the strain to cause
poststreptococcal injury
 Indirect diagnostic
Serological
• Antistreptolysin O (ASO)
• Important for monitoring
of strep A elimination and
poststreptococcal
disease
• Normal values: under 200
– 250 UI (for Romania)
 Group B streptococcus
• Meningitis in new
borns
• Septicemia
• Transmission
– from vaginal flora of
the mother
– before or during birth
 Group B Streptococcus
(Streptococcus agalactiae) identification

• α’ hemolysis (incomplete hemolysis)

• Hippurate test positive
• CAMP test:
– Incomplete group B streptococcus
hemolysis + incomplete hemolysis of S.
aureus = complete hemolysis
Obs. In S. aureus it is the beta hemolysin that
gives incomplete hemolysis and alpha
hemolysin that gives complete hemolysis!
 CAMP test

CAMP test positive – Streptococcus agalactiae

 Enterococcus ǂ Group D
Streptococcus
• Enterococcus and
Group D Streptococcus grow
on agar with bile and esculin
– Black aspect
• Medium with 6.5% salt
Grow
– enterococci
Don’t grow
– group D streptococci
Enterococcus Group D
Streptococcus
 Streptococci with viridans
incomplete hemolysis
• Oral species
– Dental caries
– Viridans hemolysis and negative for other tests
(optochin etc.)
– Non-groupable
– Endocarditis after dental extraction
• Str. pneumoniae
– Viridans hemolysis and positive for other tests
(optochin etc.)
– Non-groupable
– Pneumonia, meningitis, recurrent otitis
Str. pneumoniae – viridans hemolysis
Streptococcus pneumoniae
In diplo, intra and extracellular, capsule
 Streptococcus pneumoniae
-
• Optochin test positive
(# str.viridans) +

• Lysed by bile (#
str.viridans)

• Inuline positive (#
str.viridans)
 Antimicrobial susceptibility
testing
• Usually not for SGA, because always
susceptible to Penicillin; test only for
Penicillin allergic patients, to Macrolides
and Cephalosporins
• Pneumococci usually susceptible to
Penicillin, Macrolides. For Penicillin
resistant strains test Cephalosporins and for
Cephalosporin resistant give Vancomycin
 Key words Streptococcus:
• Gram positive, arranged in chains
• Sore throat, postinfectious complications, new born
meningitis, scarlet fever, pneumonia (Str.
pneumoniae)
• Catalase negative
• Lancefield groups, hemolysis; M types
• Group A – bacitracin test
• ASO test; Mandatory Penicillin in severe GAS
infections
• Group B – new born meningitis
• Viridans hemolysis + optochin positive = Str.
pneumoniae