STREPTOCOCCI

Antigenic properties (group

Introduction specific cell wall antigens)

 Gram positive cocci, arranged in chains or pairs

 Catalase negative
 This forms the basis of Lancefield serological
grouping.
 Part of normal flora
 Serological specificity of the group specific
 Important species: Streptococcus pyogenes & Streptococcus carbohydrate is determined by an amino sugar.
pneumoniae
 Lancefield grouping is based on the
 Cause pyogenic infections - which spread as opposed to classification of beta-haemolytic streptococcal
staphylococcus lesions (localized) bacteria. This grouping is based on the
carbohydrate composition of bacterial antigens
found on the cell wall of these bacteria.
Classification of Strep from Humans
Species Lancefield Hemolytic Comments
S. pyogenes A β
S. agalactiae B β, γ Group B Strep
S. dysgalactiae subsp. C, G β Formerly S. equisimilis; pyogenic;
equisimilis respiratory, SSTI

S. pneumoniae None α Pneumonia, otitis media, meningitis

S. bovis species group D α, γ Viridans; associated with colon cancer;

IE

S. mutans group not useful α, γ, rarely β Viridans; dental caries and IE

S. salivarius group not useful α, γ Viridans; opportunistic

S. mitis group not useful α Viridans; IE, opportunistic
S. anginosus group A, C, F, G, or α, β, γ Viridans; formerly known as S. milleri; 3
no detectable species S. anginosus, S. constellatus,
and S. intermedius; purulent infxns
Morphology

Streptococci
 Gram positive cocci about 0.05-0.75 micro meters
 Arranged in chains, usually 10 or more
 Strept.pneumonia is found appearing as diplococci
 Catalase negative
 Oxidase negative
 Some strains possess Hyaluronic acid capsule others posses polysaccharide capsule.
 Facultative anaerobes
 Use Enriched media
 Most grow well in 37 degrees Celsius
 Colonies on blood agar are either: 1. alpha haemolytic
2. beta haemolytic
3. non-haemolytic
Streptococcus Pyogenes
 Background

 Known as GAS (Group A Streptococcus)

 Causes a wide varieties of diseases in humans.
 S. pyogenes is the most common bacterial cause of acute pharyngitis, accounting for 15-30% of cases in children and 5-10% of cases in
adult.
 During more temperate climates e.g. winter and spring there are up to 20% of asymptomatic school-aged children.
 These infection are often secondary infections seen after infection of influenza.
 Understanding the diversity of this organism and its complications is an important cornerstone of paediatric medicine.
 Among infections of the upper respiratory and skin, this organism causes invasive systemic infections.
 Along with Staphylococcus areus, group A strep is the one of the most common pathogens responsible for cellulitis.
 Other important complications include nonsuppurative: acute rheumatic fever and acute glomerulonephritis.
 Also it is seen important in causing Toxic Shock Syndrome and of life- threatening skin and soft tissue infections- especially necrotizing
fasciitis.
 Cellular Structure of Group A
Type Specific Proteins
Strept: S. pyogenes

 Major classes (consist of two) the M and the T proteins

 Group specific carbohydrates (A-polysaccharide)  Minor classes are F, R and M associated (MAP) antigens

 Approximately 10% of dry weight of the cell. It  M proteins

consists of polymer of L-rhamnose and N-acetyl-  Fimbriae like “hairy extensions”

D-glucosamine (2:1 ratio)  Heat resistant and acid resistant

Trypsin sensitive
Antigenic components; linked by phosphate


containing bridges to peptidoglycan composed of  More than 80 M serotypes are due to diversity among antigenicity of the M protein’s amino

N-glutamic acid, L-Lysine and D- and L- alanine. (-NH2) terminus which is exposed to the surface.

 T protiens
 Not virulent

 Useful as an epidemiological marker

 Trypsin resistant

 Resistant to Heat and Acid

 F protein
 Binds to fibronectin

 Lipoteichoic acid (antigenic)

 Capsular polysaccharide: Composed of hyaluronic acid.
 Virulent Factors
 Hyaluronic acid capsule
 non antigenic – due to the same composition of host
connective tissue.
 Important factor because it allows the bacterium to hide its
own antigens and to go unrecognised by the host.
 Also it prevents opsonized phagocytosis by neutrophils or
macrophages.
 Adhesins
 There are three (lipoteichoic acids, M proteins, Fibronectin-
binding proteins)
 Lipoteichoic acid is anchored to proteins on the bacterial
surface .
 These acids are supported externally to cell wall on fimbriae
and mediate adherence to host epithelial cell.
 Hyaluronidase (spreading factor)-digest host connective tissue hyaluronic
acid as well as organism’s capsule.
 Streptokinases- they are fibrin lysis participants
 Proteases- causes soft tissue necrosis or Toxic Shock Syndrome.
 Pryogenic Extotoxin
 Consists of three Streptococcal pyrogenic exotoxins (Erythrogenic
toxins) A,B and C
 As antigens they don’t require processing by antigenic presenting cells
 They stimulate T cells binding to class II MHC directly and non-
specifically
 Invasins and Exotoxins
 Invasins and toxins they interact with blood and tissue components, that kill host
cells and provoke a damaging inflammatory response
 Streptolysin S- oxygen stable leukocidin
 Streptolysin O- oxygen labile leukocidin
Pathogenesis
Spectrum of Diseases

 Suppurative diseases-processing of discharge and pus.  Nonsupprative diseases- processing no

 Pharyngitis discharge or pus.
 Impetigo
 Rheumatic Fever
 Pneumonia
 Necrotizing fasciitis
 Acute glomerulonephritis
 Cellulitis  Scarlet Fever
 Streptococcal bacteremia
 Toxic Shock Syndrome
 Osteomyelitis
 Otitis media
 Sinusitis
 Meningitis or brain abscess
 Erysipelas
 Pictures of Clinical Manifestations

Picture showing Erysipelas Necrotizing fasciitis progressing Severe Necrotizing Picture showing Strept
GAS infection of the skin From erythema to bullae formation fasciitis of the left hand in Throat known as
and subcutaneous layer a patient pharyngitis.
Laboratory ID

 Specimen of choice: pharyngeal exudate, blood, tissue or body fluid.

 Culture
 Done on blood agar
 Shows clear zone of beta haemolysis, surrounding smack translucent to opaque colonies.
 Bacitracin sensitivity test
 Zone of inhibition around the colonies confirms presence of Streptococcus pyogenes.
 L-pyrolidonyl-beta-naphthylamide test
 Shows difference between S. pyogenes and other beta haemolytic strep
Laboratory ID Cont’d

 Direct Antigen Detection Test

 Detecting a group specific carbohydrate antigen A, by using throat swabs.
 Test done by method of direct fluorescent antibody test
 It is rapid, and specific
 Less sensitive.
 Serodiagnosis
Culture on blood
agar.
Laboratory ID
Antimicrobial Therapy

 Group A Streptococcus: sensitive to Penicillin and Ampicillin.

 For Toxic Shock , Necrotizing fasciitis- high doses of Penicillin and Clindamycin could
be used
 Persons with allergy to penicillin: alternative drug can be Erythromycin, other
macrolides and Cephalosporins.
 For skin infections:
 Prompt surgical drainage of abscesses or skin aspiration
 Surgical debridement of devitalized skin tissue
 Amputation.
Resistance

 Research article (Food for thought):

 In 2005
 Research that was done, they discovered that GAS had a pili
 It was found to be unusual, since normally gram negative bacteria were known only to contain
pili ( this organism is gram positive)
 The pilus was found to be long, and a surface exposed structure composed of members of a
family of extracellular matrix proteins.
 When a bacterium contains a pilus, it is often at times associated with virulence factors.
Resistance Cont’d

 In 2006
 An article reported in a reason for failure of antibiotics against streptococcus pyogenes was due
to biofilm formation.

 289 Strept. pyogenes strains were isolated and abilities to form biofilms were analysed.
 Results proved that 90% of the strains were able to form biofilms.
 This showed that these organisms can make a biofilm to survive within the host.
Prevention and Control
Prevention and Control

 Chemoprophylaxis
 This is the most important way in prevention of Rhematic fever and other systematic infections from
GAS.
 This is the long term using of penicillin to prevent strept infections for people with a history of
streptococcal infections.
 Antibiotic prophylaxis prevents Strept reinfection and further damage to organs especially (the heart).
 Vaccines
 There are some multivalent streptococcal vaccines in the making, but they are still at animal trails
and not human
 They contain multiple M protein isotopes.
Streptococcus agalactiae
Background

 Group B streptococcus (Streptococcus agalactiae) it was once considered to be a pathogen only affecting
domestic animals.
 Affecting mainly cows causing mastitis.
 Now presently it is known as one of the causative agents causing postpartum infection and as the most common
cause of neonatal sepsis.
 This organism also can be seen causing pneumonia, sepsis and meningitis in new-borns.
 Colonizes the lower gastrointestinal tract and genitourinary tract.
 10-30% of pregnant women have this transient vaginal carriage as well as non pregnant patients
 60% infants might be born with this and contain the early onset of the infection.
 Risk of colonization at birth is higher if the mother is heavily colonized.
 Serotypes most commonly involved:
 Ia (35-40%)- also common in adult disease
 III (30%)
 V (15%
Cell Structure of Group B Strep
(Streptococcus agalactiae)

 Found existing in short chains (clinical specimen) and long chains (cultural specimen).
 Buttery grey white colonies with small zone of Beta hemolysis
 Three serological markers (cell wall polysaccharide antigens)
 Rhamose
 NAG (N-acetyglucosamine)
 Galactose
 Type specific capsular polysaccharides
Ia,Ia/c,II,IIc,III to VIII
 The surface protein is C protein.
Virulent Factors

 Virulence of this organism is related to the polysaccharide toxin it produces.

 Immunity is mediated by antibiotics to the capsular polysaccharide and is serotype-
specific.
 Thick peptidoglycan cell wall permits survival on dry surfaces.
 Capsular polysaccharides inhibit complement mediated phagocytosis.
 Hydrolytic enzymes may facilitate tissue destruction and systemic spread.
Pathogenesis

 Genital colonization it leads to prematurity (these infants are at greater risk)

 Classical and alternative pathway is needed to kill the organism.
 The capsular polysaccharides of type Ia, Ib and II have terminal residues of sialic acid
which inhibits activation of the alternative and complement pathway, interfering with
phagocytosis of these strains.
Spectrum of Disease
Spectrum of Diseases

 Early Onset Neonatal disease: which includes

 Bacteremia, pneumonia or meningitis in the first week of life of the neonate
 15-30 % of meningitis survivors have later neurological problems (blindness, deafness,severe
mental retardation)
 Risk factors may include:
 Ruptured membrane (less than 37n weeks of gestation)
 Multiple births, maternal fever and or amnionitis
 Maternal age is < 20, cases of previous miscarriage and preterm delivery
Spectrum of Diseases Cont’d

 Late Onset Neonatal Disease:

 Occurs 7 days to 3 months due to exogenous exposure from for e.g (mother, other child, care
giver, health care provider)
 Bacteremia, meningitis, late onset osteomyelitis or septic arthritis (onset involving the lower
limbs) but no functional lost of motion in extremities

 Pregnant women
 Suffer from UTI, endocarditis, meningitis, osteomyelitis(rare) and untreated bacteremia.
Spectrum of Diseases Cont’d

 Men and Non-pregnant females:

 Bacteremia, pneumonia, bone, joint, skin and soft tissue infections.
 Mortality rare seen between 15-32 %.
Laboratory ID

 Specimen of choice: blood, CSF, joint fluid, peritoneal fluid, plueral fluid, bone scrapping,
throat and rectal swabs.
 Culture
 Using nutritional enriched media
 Group specific antigen detection:
 Latex agglutination
 Enzyme immunoassay
 Indirect immunofluorescence
 Nucleic acid tests: PCR (screen pregnant women)
 Camp test
 Hippurate test (hydrolysis of hippurate)
Laboratory ID
Antimicrobial therapy

 Group B Streptococci- sensitive to penicillin and ampicillin

 Penicillin or ampicillin plus an aminoglycoside once the strain is sensitive to
aminoglycosides.
 Oral clindamycin remains an excellent agent to follow a course of parenteral therapy for
bone and soft tissue and lung infections if the organism is susceptible.
 Due to some resistance seen with Clindamycin, Vancomycin remains the initial
treatment choice for group B strept patients (those that are allergic to penicillin.
Prevention and Control

 Chemoprophylaxis
 Randomized and controlled clinical trials demonstrated intrapartum administration of itravenous
penicillin or ampicillin to GBS carries it protected the newborns.
 Due to these results, the CDC and they later published guidelines for the prevention of neonatal
GBS disease in 2002 and 2010
 The intervention was to administer intrapartum parental antibiotic prophylaxis of women whose
infants are at high risks of developing early onset GBS and also to administer the drugs if
maternal culture was positive on screening.
Prevention Method
Prevention method
Adverse effects of Chemoprophylaxis

 Antibiotic Allergies Including Anaphylaxis: this is seen rarely (morbidity associated

with anaphylaxis is greatly offset by reductions in the incidence of maternal and neonatal
invasive Group B Streptococcus.
• Since mother would be take intrapartum drugs and already in a hospital setting
Anaphylaxis intervention is readily available
 Click icon to add picture

Prevention Cont’d
Home screening kits are available in some
countries but efficiency is low and infection can
result post of the screening. Woman are told to test
at the 35 week gestation mark.
Application to Biotechnology

 This organism produces antibiotics in mouse or goats; known as mouse or goat anti-
streptococcus agalactiae monoclonal antibody.
 These antibiotics could prove useful, in aiding immunologists in studying the mechanism of S.
agalactiae and developing new antibiotics. Et al Abcam.
 Vaccination
 Several components of S.agalactiae can be used to make vaccines against itself.
 These vaccines could include a surface protein that elicits the host’s immune system and what is
present in all clinical strains.
 Vaccination containing two other surface proteins: (Rib &a and Sip protein)
o Rib & a- can give protection against most of S. agalactiae infection without adjuvant.
o Sip protein (ideal vaccine component) it is highly conserved and bring out an immune response against
different antigens from different type of strains of S. Agalactiae.
Streptococcus pneumoniae
 Background

 This species was isolated independently by Pasteur and Steinburg over 100 years ago.
 It is currently the leading cause of invasive bacterial disease in children and the elderly
 It is a normal inhabitant of the human upper respiratory tract.
 It is known medically as pneumonococcus.
 It is gram positive
 Lancet shaped cocci
 Usually seen appearing as Diplococci
 Nonmotile
 Non spore forming
 Catalase negative
 Can ferment glucose to lactic acid.
Structure

 Cell wall: the cell wall of this organism is  Pili

very thick.  This contributes to colonization of the upper
 Both teichoic acid and lipoteichoic acid respiratory tract.
contain phosphorylcholine (two choline  To increase the formation of large amounts of
residues may be covalently added to each TNF by the immune system during invasive
carbohydrate repeat. infection.
 This is an essential element in S.
pneumoniae since choline specifically
adheres to choline binding receptors that
are located on human cells.
Structure Cont’d

 Surface Proteins
 estimated to contain more than 500 surface proteins
 Some are membrane- associated lipoproteins.
 Some associated physically with the cell wall.
 Capsule
 Composed of polysaccharide completely
enveloped by pneumococcal cells.

 Lipoproteins associated physically with the cell wall;

 Includes five penicillin binding proteins, two
neuraminidases and an IgA protease.
 Proteins belonging to the family of choline-binding
proteins (CBP)
 The CPS family includes
PspA (protective antigen)
LytA,B and C (three autolysins)
CbpA (an Adhesin)
 An essential determinant of virulence
 It disrupts phagocytosis by preventing
complement C3b opsonization of the bacterial
cell.
 Uses the capsule types of pneumococci, to form
the basis of antigenic serotyping of the
organism.
Virulent factors

 Pili
 Capsule
 Cell wall components
 Haemolysins-
 Neuraminidase and IgA protease
 Choline Binding Proteins
Virulent Factors Cont’d

Choline Binding Proteins

 PspA:
 inhibits complement mediated opsonisation of pneumococci.
 Autolysin LytA:
 responsible for pneumococcal lysis in stationary phase as well as in the presence of antibiotics.
 CbpA:
 it is a major pneumococcal adhesion
 It has eight choline binding repeats
Pathogenesis
 Click icon to add picture

Spectrum of
Diseases
Pneumococcal pneumonia.
The onset is usually with sudden with fever, chills
and sharp pleural pain.
The sputum is characteristically bloody or rust
coloured
Mortality might be high, due to underlying medical
conditions and age of patient.
Spectrum of diseases Cont’d

 From the site of infection in the respiratory tract, pneumococci may disseminate to other
sites including;
 Sinuses
 Middle Ear
 Meninges
 This bacterium could also cause meningitis in children and adults
 Bacteremia can also occur
Laboratory ID

 Specimens of choice: blood, CSF, Sputum, bronchial washings, urine.

 Culture
 Show glistening colonies about 1mm in diameter
 Shows alpha haemolysis
 Two serotypes show mucoid colonies type 3 and 37.
 Contains enzyme autolysin
 Autolysin- causes the culture to undergo a characteristic autolysis that kills the entire culture.
Laboratory ID Cont’d

 Biochemical tests
 Inulin test: this test is useful to
differentiate Pneumococci from Streptococci.
Streptococci do not ferment Inulin sugar but
pneumococci does.
 Bile solubility
 Optochin sensitive: this test is done to differentiate
between pneumococcus and streptococcus viridans.
Laboratory ID

 (Seotyping)Capsular swelling tests (Quellung reaction)

 Forms the basis of serotyping
 This reaction makes the capsule of this organism visible, resulting from exposure to specific,
agglutinating anticapsular antibodies.
 Antigen Detection:
 Pneumococcal polysaccharide is excreted in the urine and can be detected using a commercially
prepared immunoassay. Specificity is very low
Antimicrobial Therapy

 Pneumococci are sensitive to a number of drugs

 Penicillins are the drug of choice
 Athernative drugs of choice:
 Erythromycin
 Cephalosporins
 Chloramphenicol.
Prevention and Control

 Vaccination:
 Vaccine is under utilized; pneumococcus therefore remains the most common infectious agent
leading in hospitalization in all age groups.
 Polysaccharides of the 23 valent vaccine are not immunogenic in children under the age of 2.
This type of vaccine is recommended for children > 2 years and adults.
In the year 2000 in the U.S.A, a heptavalent pneumococcal conjugate vaccine has been
recommended for all children aged 2-23 months and for at risk children aged 24-59 months.
The four- dose series is given at 2,4,6 and 12-14months of age.
Protection covered is good against invasive pneumococcal infections including: septicaemia and
meningitis caused by the serotypes seen.
Streptococcus Viridans
Background on Streptococcus viridans

 Large group of commensals

 They are alpha haemolytic
 Laboratory ID- optochin resistant (often times it is compared to streptococcus pneumonia which is
optochin susceptible.
 Polysaccharide capsule- absent
 Fermentation of bile- insoluble
 Fermentation of inulin- not a fermenter
 Epidemiology- Found most abundant in the mouth, and can be later introduced into the blood
stream causing disseminated disease Endocarditis.
Pictures of Endocarditis due to Streptococcus
Viridans

Bacteria seen growing on a

section of the heart valve.
Streptococcus Viridans

 Streptococcus Viridans: contain a unique ability to synthesize dextrans from glucose,

which allows adherence to fibrin platelets aggregates at damaged heart valves.
 Dextrans (a complex glucan composed of chains of varying length. It is medical used to
reduce blood viscosity).
 Antimicrobial of choice: Penicillin, Ampicillin, if allergic to penicillin Clindamycin,
Erythromycin, Vancomycin.
 Prevention and Control: Proper dental care and management of teeth and mouth
infections.
Enterococcus

 Part of Streptococcus until 1984.

 Can grow in 6.5% NaCl and from 10°-45°C; hydrolyze esculin in presence of 40% bile
salts
 Most infections from E. faecalis or E. faecium; leading cause of nosocomial infxns
 Colonize GI tract; selected for by abx
Enterococcus: Clinical Manifestations

 Bacteremia +/- IE (1-32%)

 Frequent comorbidities
 IE subacute; fever, constitutional sx; 50% CHF; emboli 27-43%; death 11-35%
 UTI
 Meningitis
 0.3 to 4% of cases; usu severe comorbidities
 Neonatal
 Skin and Soft Tissue Infections
Enterococci: Challenges of Treatment

 Intrinsically resistant to many abx, with acquisition of additional resistance

 β-lactams not regularly bactericidal as monotherapy, requiring AG as synergy
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