COMPREHENSIVE REVIEW

OF MEDICAL
MICROBIOLOGY

Martin Miguel I. Amor, MD

UP College of Medicine
Class 2009

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 CLINICAL BACTERIOLOGY
GRAM POSITIVE COCCI
Staphylococci
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 STAPHYLOCOCCI

Coagulase Typical Important

Species
Production Hemolysis Features
Protein A on
S. aureus + Beta
surface
Sensitive to
S. epidermidis – None
novobiocin
Resistant to
S. saprophyticus – None
novobiocin

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 Staphylococcus aureus
CHARACTERISTICS

• Gram-positive cocci in clusters

• -hemolytic yellow or golden
colonies on blood agar
• Catalase-positive
• Coagulase-positive
• Salt-tolerant on MSA

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 Staphylococcus aureus

• HABITAT
– human nose (ANTERIOR
NARES) and skin

• TRANSMISSION
– direct contact (hands)
– fomites
– contaminated food

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 Staphylococcus aureus
VIRULENCE FACTORS: Immunomodulators

• Protein A: prevents complement activation

• Coagulase: builds an insoluble fibrin capsule
• Hemolysins (cytotoxins): toxic to
hematopoietic cells
• Leukocidin: specific for white blood cells
• Catalase: detoxifies hydrogen peroxide
• Penicillinase: inactivates penicillin derivatives

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 PRETEST REVIEW

Which virulence enzyme of Staphyloccus aureus

prevents complement activation?
A. Protein A***
B. Coagulase
C. Catalase
D. Leukocidin
E. Penicillinase

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 Staphylococcus aureus
VIRULENCE FACTORS: Tissue Penetrance

• Hyaluronidase: hydrolyzes hyaluronic acid

• Fibrinolysin (staphylokinase): dissolves fibrin
clots
• Lipase: spread in fat-containing areas of the
body

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 Staphylococcus aureus
VIRULENCE FACTORS: Toxins

• Exfoliatin: causes epidermal separation

• Enterotoxins (heat-stable): superantigens
causing food poisoning
• Toxic shock syndrome toxin (TSST-1):
superantigen leading to toxic shock syndrome

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 Staphylococcus aureus
SPECTRUM OF DISEASE: Pyogenic

• SKIN and SOFT TISSUE INFECTIONS

– folliculitis, furuncles, carbuncles, cellulitis,
hidradenitis suppurativa, mastitis, surgical site
infections

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 Staphylococcus aureus
SPECTRUM OF DISEASE: Pyogenic

• ACUTE ENDOCARDITIS
– most common cause of acute endocarditis
– native valve (tricuspid valve) in IV drug abusers

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 PRETEST REVIEW

Staphyloccus aureus is the most common cause of

which type of endocarditis?
A. subacute endocarditis
B. acute endocarditis***
C. culture-negative endocarditis
D. prosthetic valve endocarditis
E. native valve endocardits

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 Staphylococcus aureus
SPECTRUM OF DISEASE: Pyogenic

• PNEUMONIA
– nosocomial pneumonia, necrotizing pneumonia,
complicated by empyema, abscess or
pneumatocele
– post-viral pneumonia

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 PRETEST REVIEW

Necrotizing pneumonia with empyema and

pneumatocoele formation is most likely caused by?
A. Klebsiella pneumoniae
B. Pseudomonas aeruginosa
C. Staphyloccus aureus***
D. Bacillus anthracis
E. Mycoplasma pneumoniae

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 Staphylococcus aureus
SPECTRUM OF DISEASE: Pyogenic

• OSTEOMYELITIS and SEPTIC ARTHRITIS

– from hematogenous spread or local introduction at
wound site

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 Staphylococcus aureus
SPECTRUM OF DISEASE: Toxigenic

• GASTROENTERITIS
– acute onset (4 hrs) of vomiting and
diarrhea due to ingestion of
preformed heat-stable enterotoxin
– source: salad made with mayonnaise
(potato or tuna salad)

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 Staphylococcus aureus
SPECTRUM OF DISEASE: Toxigenic

• SCALDED SKIN SYNDROME

– exfoliatin cleaves desmoglein in
desmosomes
• separation of epidermis at zona
granulosa
– characterized by fever, large
bullae, and an erythematous
macular rash

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 Staphylococcus aureus
SPECTRUM OF DISEASE: Toxigenic
• TOXIC SHOCK SYNDROME
– due to TSST-1
– fever, hypotension, strawberry
tongue, desquamating rash and
multi-organ involvement (>3)
– usually no site of pyogenic
inflammation; blood CS negative
– usual scenario: tampon-using
menstruating women or in patients
with nasal packing for epistaxis

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 Staphylococcus aureus
TREATMENT

• methicillin-sensitive SA (MSSA)
– Penicillinase-resistant penicillins (nafcillin, oxacillin,
and dicloxacillin)
• methicillin-resistant SA (MRSA)
– contain altered PBP; DOC is vancomycin
• vancomycin-resistant SA (VRSA)
– DOC is linezolid

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 Staphylococcus epidermidis
CHARACTERISTICS

• Gram-positive cocci in clusters

• Catalase-positive
• Coagulase-negative
• Novobiocin-sensitive
• Whitish, non-hemolytic colonies
on blood agar

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 Staphylococcus epidermidis

• HABITAT
– normal skin flora

• TRANSMISSION
– autoinfection
– direct contact (hands)

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 Staphylococcus epidermidis
PATHOGENESIS

• low-virulence organism
• glycocalyx adheres well to foreign bodies
– prosthetic heart valves
– prosthetic joints
– ventriculoperitoneal shunts
– indwelling catheters

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 Staphylococcus epidermidis
SPECTRUM OF DISEASE

• most common cause of

– prosthetic valve endocarditis
– septic arthritis in prosthetic joints
– ventriculoperitoneal shunt infections

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 Staphylococcus epidermidis
TREATMENT

• removal of prosthetic device

• over 50% are methicillin-resistant and thus
require vancomycin

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 Staphylococcus saprophyticus
CHARACTERISTICS

• Gram-positive cocci in clusters

• Catalase-positive
• Coagulase-negative
• Novobiocin-resistant
• Whitish, non-hemolytic colonies
on blood agar

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 Staphylococcus saprophyticus
SPECTRUM OF DISEASE

• epidemiology
– 2nd most common cause of UTIs in
sexually active women
• clinical findings
– dysuria, pyuria, and bacteriuria

• treatment
– TMP-SMX, quinolones

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 CLINICAL BACTERIOLOGY
GRAM POSITIVE COCCI
Streptococci
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 STREPTOCOCCI
Lancefield Typical
Species Diagnostic Features
Group Hemolysis
S. pyogenes A Beta Bacitracin-sensitive
Bacitracin-resistant; hippurate
S. agalactiae B Beta
hydrolyzed
Alpha or beta
E. faecalis D Growth in 6.5% NaCl
or none
Alpha or
S. bovis D No growth in 6.5% NaCl
none
S. pneumoniae NA Alpha Bile-soluble; inhibited by optochin
Not bile-soluble; not inhibited by
Viridans group NA Alpha
optochin

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 Streptococcus pyogenes
CHARACTERISTICS

• Gram-positive cocci in chains

• Catalase-negative
• Beta-hemolytic
• Bacitracin-sensitive
• Lancefield group A

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 Streptococcus pyogenes

• HABITAT
– human throat (oropharynx)
– skin

• TRANSMISSION
– respiratory droplets

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 Streptococcus pyogenes
PATHOGENESIS: Virulence Enzymes

• Hyaluronidase
– degrades hyaluronic acid (spreading factor)
• Streptokinase (fibrinolysin)
– activates plasminogen
• DNase (streptodornase)
– degrades DNA in exudates or necrotic tissue

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 Streptococcus pyogenes
PATHOGENESIS: Toxins
• Erythrogenic toxin
– produces scarlet fever
• Streptolysin O (oxygen-labile)
– highly antigenic, causes AB formation
• Streptolysin S (oxygen-stable)
• Pyogenic exotoxin A
– superantigen similar to TSST
• Exotoxin B
– protease that rapidly destroys tissue
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 Streptococcus pyogenes
SPECTRUM OF DISEASE: Pyogenic

• SKIN and SOFT TISSUE INFECTIONS

– Impetigo: perioral vesicular/blistered lesions with
honey-colored crust

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 PRETEST REVIEW

Which among the following diseases caused by GABHS

has a pyogenic etiology?
A. impetigo***
B. rheumatic fever
C. glomerulonephritis
D. necrotizing fasciitis
E. toxic shock syndrome

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 Streptococcus pyogenes
SPECTRUM OF DISEASE: Pyogenic

• SKIN and SOFT TISSUE INFECTIONS

– Erysipelas: superficial infection extending into
dermal lymphatics

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 Streptococcus pyogenes
SPECTRUM OF DISEASE: Pyogenic

• SKIN and SOFT TISSUE INFECTIONS

– Cellulitis: deeper infection involving
subcutaneous/dermal tissues
• facilitated by hyaluronidase (spreading factor)

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 Streptococcus pyogenes
SPECTRUM OF DISEASE: Toxigenic

• SKIN and SOFT TISSUE INFECTIONS

– Necrotizing fasciitis: rapidly progressive infection
of deep subcutaneous tissues
• facilitated by exotoxin B

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 Streptococcus pyogenes
SPECTRUM OF DISEASE: Toxigenic
• streptococcal toxic shock
syndrome
– clinically similar but milder
than S. aureus TSS
– due to pyogenic exotoxin A
– recognizable site of pyogenic
inflammation
– blood cultures are often
positive

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 Streptococcus pyogenes
SPECTRUM OF DISEASE: Pyogenic

• PHARYNGITIS
– most common bacterial
cause of sore throat
– inflammation, exudate,
fever, leukocytosis, and
tender CLAD
– pyogenic complications:
abscess, otitis, sinusitis,
meningitis

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 Streptococcus pyogenes
SPECTRUM OF DISEASE: Toxigenic

• SCARLET FEVER
– postpharyngitic
– due to erythrogenic toxin, seen
in lysogenized strains
– fever, strawberry tongue,
centrifugal rash (sandpaper-
like), Pastia’s lines,
desquamation
– Dick test for susceptibility

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 PRETEST REVIEW

Which test evaluates for susceptibility to scarlet fever?

A. Elek test
B. Dick test***
C. Frei test
D. Pastia test
E. PPD test

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 Streptococcus pyogenes
SPECTRUM OF DISEASE: Immunologic

• ACUTE RHEUMATIC FEVER

– postpharyngitic
– cross-reacting antibodies to M
proteins and antigens of joint,
heart, and brain tissue
– JONES CRITERIA:
• migratory polyarthritis
• pancarditis
• erythema marginatum
• Sydenham chorea
• subcutaneous nodules
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 Streptococcus pyogenes
SPECTRUM OF DISEASE: Immunologic
• GLOMERULONEPHRITIS
– post-impetigo OR
postpharyngitic
– M protein incites immune
complex deposition on the
glomerular basement membrane
– ssx: hypertension, periorbital
edema, hematuria

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 Streptococcus pyogenes
TREATMENT

• Penicillin G

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 Streptococcus agalactiae
CHARACTERISTICS

• Gram-positive cocci in chains

• Catalase-negative
• Beta-hemolytic
• Bacitracin-resistant
• Lancefield group B
• hydrolyze hippurate
• CAMP test–positive

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 Streptococcus agalactiae
HABITAT and TRANSMISSION

• HABITAT
– Vagina

• TRANSMISSION
– Transvaginal
– Transplacental

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 Streptococcus agalactiae
SPECTRUM OF DISEASE: Pyogenic

• urinary tract infection in pregnant women

• neonatal pneumonia, sepsis and meningitis
– most common cause
• endometritis

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 PRETEST REVIEW

What is the most common cause of neonatal

pneumonia?
A. GABHS
B. C. trachomatis
C. S. pneumoniae
D. S. pyogenes
E. S. agalactiae***

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 Streptococcus agalactiae
TREATMENT

• Penicillin G

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 group D streptococci
CHARACTERISTICS
• Gram-positive cocci in chains
• Catalase-negative
• Gamma hemolytic colonies
• Lancefield group D
• Grows in 6.5% NaCl
• hydrolyzes esculin in BEA
• positive pyrazine amidase (PYR)
test

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 group D streptococci
HABITAT and TRANSMISSION

• HABITAT
– human colon
– urethra and female genital tract
can be colonized

• TRANSMISSION
– may enter bloodstream during
GIT or GUT surgery

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 group D streptococci
SPECTRUM OF DISEASES

• UTIs due to indwelling urinary catheters and

urinary tract instrumentation
• biliary tract infections
• endocarditis in patients who underwent GIT
surgery due to E. faecalis
• marantic endocarditis in patients with
abdominal malignancy due to S. bovis

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 PRETEST REVIEW

A 54/M with colon cancer develops subacute onset of

fever with rigors and chills. Auscultation reveals a
holosystolic murmur. What is the most likely etiology of
infective endocarditis in this patient?
A. Enterococcus faecalis
B. viridans streptococci
C. Streptococcus bovis***
D. Staphylococcus aureus
E. Kingella kingae

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 group D Streptococci
TREATMENT

• Penicillin or vancomycin plus gentamicin

• Linezolid for vancomycin-resistant strains

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 Streptococcus pneumoniae
CHARACTERISTICS
• Gram-positive "lancet-shaped"
cocci in pairs or chains
• Catalase-negative
• Alpha-hemolytic
• Bile and optochin-sensitive
• positive Quellung reaction

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 Streptococcus pneumoniae
HABITAT and TRANSMISSION

• habitat is upper respiratory tract

• transmission via respiratory droplets

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 Streptococcus pneumoniae
PATHOGENESIS

• capsule retards phagocytosis

– encapsulated bacteria:
• S. pneumoniae
• H. influenzae
• N. meningitidis
• K. pneumoniae
• IgA protease for colonization
• c-substance reacts with CRP

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 Streptococcus pneumoniae
SPECTRUM OF DISEASES: Pyogenic

• PNEUMONIA
– most common cause of CAP
– sudden chill, fever, productive
cough, and pleuritic chest pain
– lobar pattern

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 Streptococcus pneumoniae
SPECTRUM OF DISEASES: Pyogenic

• otitis media, sinusitis,

meningitis
– most common cause
– skull fracture with spinal fluid
leakage from nose
predisposes to meningitis
• septic shock
– splenectomy predisposes to
sepsis

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 Streptococcus pneumoniae
TREATMENT and PREVENTION

• TREATMENT
– Penicillin G

• PREVENTION
– polyvalent (23-type) polysaccharide vaccine
– conjugated vaccine: pneumococcal polysaccharide
coupled with carrier protein (diphtheria toxoid)

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 Viridans streptococci
CHARACTERISTICS

• Gram-positive cocci in chains

• Catalase-negative
• Alpha-hemolytic
• Bile and optochin-resistant

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 Viridans streptococci
HABITAT and TRANSMISSION

• habitat is oropharynx
• enters bloodstream during dental procedures

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 Viridans streptococci
PATHOGENESIS

• glycocalyx enhances adhesion to damaged

heart valves
• protected from host defenses within
vegetations

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 Viridans streptococci
SPECTRUM OF DISEASE

• S. mutans, for dental caries

• S. sanguis, for subacute
bacterial endocarditis (SBE)
– most common cause of
subacute and native valve
endocarditis
• S. intermedius, for brain
abscesses

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 Viridans streptococci
TREATMENT

• Penicillin G with or without an aminoglycoside

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 END OF SECTION 2

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