Staphylococcus Streptococcus

S. pneumoniae
S. pyogenes
S. aureus
S. agalacaiae
Pneumonia Ear,
Skin Sinus
infections
Skin
Neonatal Non-neonatal
infections
Throat meningitis Meningitis
infections

TSST
Systemic
infections Food poisoning
Lecture objectives:

• Characterize the structure of S. aureus

• Describe the media used to isolate S. aureus
• List the virulence factors for S. aureus
• Describe the infections causes by S. aureus
• Describe the steps in diagnosing S. aureus
 Staphylococcus aureus
• Carried in the normal flora (skin and mucosa),
but breaking the natural barriers can lead to
disease.
• The anterior nares are the main site of
colonization
• Other sites of colonization include:
– axilla, rectum, and perineum
– The vaginal carriage rate is approximately 1-10%
in premenopausal women
• The rate is higher during menses
Staphylococcus aureus

Gram + Cocci
Facultative anaerobe
Catalase +
Coagulase + (converts fibrinogen to fibrin,
which walls bacteria from immune response)
 Pyogenic or Pus-Forming
Bacteria
• Common Gram-negative examples:
– Neisseria spp., Escherichia coli,
Pseudomonas aeruginosa
• Common Gram-positive examples:
– Streptococcus pyogenes
– Staphylococcus aureus
• Responsible for most pus forming infections
Lecture objectives:

• Characterize the structure of S. aureus

• Describe the media used to isolate S. aureus
• List the virulence factors for S. aureus
• Describe the infections causes by S. aureus
• Describe the steps in diagnosing S. aureus
 Staphylococcus aureus
NUTRIENT AGAR
• Colonies are golden (aureus)

MANNITOL SALT AGAR

• High salt concentrations

(haloduric)

• Produces a yellow color when

mannitol fermented to acid

• Phenol red indicator turns

yellow

BLOOD AGAR
 Hemolysis of Staph on blood agar

Partial RBC Complete RBC

hemolysis hemolysis
Staph aureus

No hemolysis

• Beta-hemolytic species - completely rupture the red blood cells (visible

as a halo in culture). Caused by hemolysins.
• Alpha-hemolytic species- oxidize the iron in the hemoglobin (turning it
dark green in culture). Caused by peroxidases.
• Gamma-hemolytic species - do not cause hemolysis and rarely cause
illness.
Lecture objectives:

• Characterize the structure of S. aureus

• Describe the media used to isolate S. aureus
• List the virulence factors for S. aureus
• Describe the infections causes by S. aureus
• Describe the steps in diagnosing S. aureus
 Virulence Factors

• Protein A- binds Fc regions and blocks Ab

• Alpha-toxin - makes pores in cells

• Exfoliative toxins - separate dermis and epidermis

• Superantigen-like toxins

• Toxic shock syndrome toxin 1 (TSST-1)

• Activates of T cells and APC without antigen
specificity causing massive cytokine release

• Staph enterotoxin B (SEB)

• Causes GI symptoms – not absorbed from GI to
blood
Virulence Factors Biological Effects
Structural components
Protein A Binds Fc portion of IgG and prevents
Ab-mediated clearance of Ag

Toxins
Cytotoxin (alpha) Lyses many cells. Alpha toxin is
secreted by most S. aureus strains.

Exfoliative toxins Splits intracellular bridges stratus

granulosum epidermis
Super-antigen toxins

Enterotoxins (ex. SEB) sAg, and causes direct effect in the

gut-intestinal fluid loss with diarrhea
and vomiting
TSS toxin (TSST-1) sAg, as well as direct lysis of
endothelial cells, and causes
leakage
 Virulence Factors – protein A

No protein A Protein A
Lecture objectives:

• Characterize the structure of S. aureus

• Describe the media used to isolate S. aureus
• List the virulence factors for S. aureus
• Describe the infections causes by S. aureus
• Describe the steps in diagnosing S. aureus
Staphylococcal diseases.

Isolation of staphylococci from sites

of infection:

1+, Less than 10% positive cultures;

2+, 10% to 50% positive cultures;
3+, 50% to 90% positive cultures;
4+, more than 90% positive cultures.
 Staphylococcal diseases

SKIN NON SKIN

Toxin mediated Non-toxin mediated

Toxin mediated Non-toxin
mediated

• Staphylococcal • Staphylococcal • Wound

scalded skin food poisoning infections
syndrome • Toxic shock • Endocarditis
Purulent Non-
(SSSS) syndrome (TSS) • Pneumonia
(abscess) Purulent
• Osteomyelitis
• Septic arthritis
• Impetigo • Cellulitis
• Folliculitis (furuncles) • Erysipelas
• Carbuncles • Necrotizing fasciitis
 Staphylococcal diseases

SKIN NON SKIN

Toxin mediated Non-toxin mediated

Toxin mediated Non-toxin
mediated

• Staphylococcal • Staphylococcal • Wound

scalded skin food poisoning infections
syndrome • Toxic shock • Endocarditis
Purulent Non-
(SSSS) syndrome (TSS) • Pneumonia
(abscess) Purulent
• Osteomyelitis
• Septic arthritis
• Impetigo • Cellulitis
• Folliculitis (furuncles) • Erysipelas
• Carbuncles • Necrotizing fasciitis
S. aureus:
Skin & Soft
Tissue
Infections
Epidermis (squamous epithelial):
• Impetigo

Dermis (dense irregular connective):

• Furuncles/Boils/Folliculitis
• Carbuncles (fused boils)
• Erysipelas

Subcutaneous layer:
• Cellulitis
• Fasciitis
CUTANEOUS INFECTIONS

Impetigo:
Superficial infection that causes the production of pus-filled vesicle
CUTANEOUS INFECTIONS

Furuncles//boils/folliculitis

Painful raised nodules that have underlying collection of necrotic

tissue/pus. Extends deeper than hair follicle.
Furuncles/folliculitis/boils

Stye
CUTANEOUS INFECTIONS

Carbuncles:

Coalescence of furuncles with invasion of deeper subcutaneous

tissue; patients have chills and fever which suggests a systemic
infection
CUTANEOUS INFECTIONS

Erysipelas:

• Lesion with sharply demarcated raised edge

• Red, swollen, warm, hardened and painful
• No effect on subcutaneous tissue
• No release of pus, only serum or serous fluid
• Rapid invasion and spread through lymphatic vessels
• Produces overlying skin "streaking" and regional lymph node
• swelling and tenderness.
CUTANEOUS INFECTIONS - (subcutaneous level)

Cellulitis:

• Inflammation of the connective tissue below dermis as well as

other subcutaneous tissue.
• Cellulitis results in fever and chills in addition to skin infection.
 Staphylococcal diseases

SKIN NON SKIN

Toxin mediated Non-toxin mediated

Toxin mediated Non-toxin
mediated

• Staphylococcal • Wound
• Staphylococcal
food poisoning infections
scalded skin
• Toxic shock • Endocarditis
syndrome Purulent Non- syndrome (TSS) • Pneumonia
(SSSS) (abscess) Purulent
• Osteomyelitis
• Septic arthritis
• Impetigo • Cellulitis
• Folliculitis (furuncles) • Erysipelas
• Carbuncles • Necrotizing fasciitis
Scalded skin syndrome (Ritter’s disease)–
Usually in babies
• Results from exfoliative toxin production in lesions
• Blistering of skin
• Few bacteria in lesions – Caused by toxin
• Few leukocytes present in lesions
• Slight pressure on the skin displaces it
• Disease symptoms look bad – But no scarring
• Lack of syndrome in adults – Presence of antibodies
specific for exotoxins, improved renal clearance of
toxins
 Staphylococcal diseases

SKIN NON SKIN

Toxin mediated Non-toxin mediated

Toxin mediated Non-toxin
mediated

• Staphylococcal • Wound
• Staphylococcal
food poisoning infections
scalded skin
• Toxic shock • Endocarditis
syndrome Purulent Non- syndrome (TSS) • Pneumonia
(SSSS) (abscess) Purulent
• Osteomyelitis
• Septic arthritis
• Impetigo • Cellulitis
• Folliculitis (furuncles) • Erysipelas
• Carbuncles • Necrotizing fasciitis
NONCUTANEOUS INFECTIONS

Bacteremia and Endocarditis

• Often hospital acquired, and is associated with bacteria from the skin getting into
the blood stream
• surgical procedure
• contaminated intravascular catheter
• IV drug use

• Endocarditis needs to treated promptly, otherwise the patient has very poor
prognosis.

Osteomyelitis can result from trauma that spreads the bacterial infection to the bone
esp in children where growing bones are highly vascularized. The disease is
characterized by localized pain, high fever and purulent discharge from the sinus
tract overlying the infected bone.

Pneumonia – Consolidation and abscess formation in the lungs seen in very young,
elderly and in patients with
underlying pulmonary disease.
 Staphylococcal diseases

SKIN NON SKIN

Toxin mediated Non-toxin mediated

Toxin mediated Non-toxin
mediated

Ex.Staphylococcal Exs: impetigo, • Staphylococcal Exs: wound

scalded skin folliculitis, furuncles, food poisoning infections,
syndrome (SSSS) carbuncles endocarditis,
• Toxic shock pneumonia,
syndrome (TSS) osteomyelitis,
septic arthritis
 Food Poisoning
• Most common form of food poisoning in US
• Food is contaminated by someone whose skin or nasopharyngeal fluid is
infected with the enterotoxin-carrying S. aureus strain
Toxin mediated

• Extensively prepared food

• If food remains at room temp, bacteria can grow
• Common foods include: salads, such as ham, egg, tuna, chicken, potato; cream-
filled pastries, cream pies
• Other sources include milk and dairy products, as well as meat, poultry,
eggs, and related products.
• Bacteria release enterotoxin into food
• Toxin is ingested and is not readily destroyed by gut
• While bacteria can be killed by reheating, toxin is heat resistant
 Toxic Shock Syndrome
• 1980s – Increase cases in menstruating women
 < 1% of women carry Staph. strain producing TSST-1 in vaginal
flora
 Menstruation appears to facilitate toxin production
Toxin mediated

 Certain types of hyperadsorbant tampons trap oxygen and

further facilitate growth
 Tampons later recalled - ↓ disease incidence
• Since the early 1990s, at least half of the cases have not been
associated with TSST-1 but with SEB in wounds, abscesses etc

• Disease - Release of toxin into blood causes massive cytokine

release
• Fever, hypotension, diffuse rash, sloughing of skin
• Multiple organs can stop functioning (kidney, liver, CNS,
platelets dysregulation)
• Blood is usually negative for bacteria
• The pathophysiology mimics that of endotoxic (LPS) mediated shock
 Toxic Shock Syndrome (TSS)
• Increased understanding of disease
• Death rate ↓ to 5%

• TSS can occur post various Staph infections

including pneumonia, abscess, skin/wound
infection, septicemia, osteomyelitis
TSS

Vaginal cases – Non- vaginal cases

toxin crosses mucosa

50% TSST-1 50% SEB

100% TSST-1
Toxic shock syndrome (cutaneous and soft tissue involved)
Toxic Shock Syndrome
Model Loses Leg to Toxic Shock Syndrome, Sues
Tampon Maker
By Nick Sanchez | Friday, 19 Jun 2015
A Vogue cover model is suing tampon
maker Kotex after she lost a leg to toxic
shock syndrome (TSS), a severe
bacterial infection associated with
tampons.

Most major tampon manufacturers

make tampons with either mixes of
viscose rayon and cotton, or pure
viscose rayon, and in either case those
tampons provide optimal physical-
chemical conditions necessary to cause
the production of the TSST-1 toxin. ….
whereas 100 percent cotton tampons
provide the lowest risk
Lecture objectives:

• Characterize the structure of S. aureus

• Describe the media used to isolate S. aureus
• List the virulence factors for S. aureus
• Describe the infections causes by S. aureus
• Describe the steps in diagnosing S. aureus
Diagnosis:
Stain
• Gram staining of the lesion illustrates G(+) cocci in clusters

Culture
• Lesions usually contain many bacteria that can be easily cultured overnight in aerobic
environment. When lesions cannot be accessed directly (ex. deep tissue infections)
blood cultures can be done.
• Lesions also often contain numerous neutrophils.
• Blood agar - Staph. produces hemolysin which causes beta (complete) hemolysis
of RBC.
• MSA agar - To select the growth of Staph aureus, the agar should be supplemented
with 7.5 % NaCl (inhibits growth of most organisms but not Staph genus), and
mannitol (fermented mainly by Staph aureus, not other organisms).

Biochemical test
• Colonies can be tested for coagulase and catalase
Mannitol salt agar is
selective for
staphylococci because
of the high salt
concentration. Acid from
mannitol fermentation
causes the pH indicator
phenol red to turn from
red (alkaline) to yellow Staphylococcus aureus grown on a sheep blood agar plate. Note
(acid). the colonies are large and ß hemolytic.
• For food poisoning and TSS, diagnosis is made based on clinical history.

• Many Staph aureus strains are now resistant to penicillin, methicillin and
some are even resistant to the last resort antibiotic, vancomycin. Most
resistance genes are plasmid-encoded.
 MRSA

HA-MRSA
CA-MRSA
Usually due
to devices in Usually due to
hospitals immune
suppression;
chemo, etc
causes MRSA
to come out
 STATS
 Mortality rate for patients with Staph bacteremia ranges from 11%-
43%.

 25-35% of Staph complications are from endocarditis, with a

mortality rate of 20-44%.

 70% of nosocomial strains are resistant to at least one antibiotic

used to treat them.

 Greater than 95% of patients worldwide with staph infections do not

respond to first line antibiotics (penicillin or ampicillin).

 MRSA—Methicillin Resistant Staphylococcus aureus is wide-spread,

if a strain is a MRSA, it is likely to be resistant to many other
antibiotics.

 More than 30% of S. aureus infections are classified as MRSA.

 The rate of MRSA infections doubled between 1987 and 1997 in

intensive care units.