STREPTOCOCCI

 Gram-positive spherical bacteria which form pairs or chains during growth

 Widely distributed in nature as members of the normal human flora and as causative agents of important
human diseases.
 Large heterogeneous group of bacteria but there is no one system to classify them

Classification of streptococci
 Major categories
1. Colony morphology and hemolytic reactions on blood agar
2. Serologic specificity of the cell wall group specific substance and other cell wall or capsular antigens
3. Biochemical reactions and resistance to physical and chemical factors
4. Ecologic features

 Characteristics of medically important streptococci

Name Group-specific Hemolysis Habitat Important Laboratory Common and
substance Criteria Important
Diseases
S. pyogenes A β Throat, skin Large colonies, PYR(+), Pharyngitis,
inhibited by bacitracin Impetigo, RF, GN
S. agalactiae B β Female Hippurate hydrolysis, Neonatal sepsis
genital tract CAMP(+) and meningitis
S. dysgalactiae, C, G β (human Throat Large colonies Pharyngitis,
subspecies infections), pyogenic infections
equisimilis; others α, none
E. faecalis and D none, α Colon Growth in presence of bile Abdominal
other enterococci esculin (+); Growth in 6.5% abscess, UTI,
NaCl; PYR(+) endocarditis
S. bovis (non- D none Colon Growth in presence of bile, Endocarditis,
enterococcus) hydrolyze esculin, no growth common blood
in 6.5% NaCl, degrades isolate in colon CA
starch
S. anginosus group F (A, C, G) and α, β, none Throat, Small colonies variants of β- Pyogenic
untypable colon, hemolytic sp. Grp A are infections,
female bacitracin resistant and including brain
genital tract PYR(-), carbohydrate abscess
fermentation patterns
Viridans Usually not α, none Mouth, Optochin resistant, bile Dental caries (S.
streptococci typed or throat, insoluble colonies, mutans),
untypable colon, carbohydrate fermentation endocaridits,
female tract patterns abscess (mixed)
S. pneumoniae None α throat Susceptible to optochin, Pneumonia,
bile-soluble colonies, Meningitis,
Quellueng (+) Endocaridits
Peptostreptococcus None none, α Mouth, Obligate anaerobes Abscess
(many species) colon,
female
genital
tract

 Patterns of Hemolysis
 o Many species are able to hemolyze erythrocytes in vitro
o Beta hemolysis (β): complete destruction of erythrocytes with clearing of the blood around the bacterial growth
o Alpha hemolysis (α): incomplete lysis of erythrocytes with reduction of hemoglobin and formation of green
pigment
o Gamma hemolysis (γ): nonhemolytic
 Group specific substance (Lancefield classification)
o Carbohydrate contained in the cell wall of many species
o Forms the basis of serologic grouping into Lancefield groups A-H and K-U
o Serologic specificity of group specific carbohydrate is determined by an amino sugar
Group A streptococci Rhamnose-N-acetylglucosamine
Group B Rhamnose-glucosamine polysaccharide
Group C Rhamnose-N-acetylglucosamine
Group D Glycerol teichoic acid containing D-alanine and
glucose
Group F Glucopyranosyl-N-acetylgalactosamine
 Capsular polysaccharide
o Antigenic specificity of capsular polysaccharides is used to classify
 S. pneumoniae into more than 90 types
 Group B streptococci (S. agalactiae)
 Biochemical reaction
o Sugar fermentation reactions
o Tests for presence of enzymes
o Tests for susceptibility to or resistance to certain chemical agents

Streptococci of Particular Medical Interest

 Streptococcus pyogenes
o Contain group A antigen
o Prototypical human pathogen, associated with:
 Local or systemic invasion
 Poststreptococcal immunologic disorders
o Forms large (1 cm diameter) zones of β-hemolysis around colonies of more than 0.5mm in diameter
o Pyrrolidonyl-β-naphthylamide (PYR) (+): hydrolysis of L-pyrrolidonyl-2-naphthylamide
o Susceptible to bacitracin
o Morphology and Identification
 Typical organism
 Spherical or ovoid cocci arranged in chains
 Divide in a plane perpendicular to long axis of the chain
 Length of chain varies considerably
 Striking diplococcal appearance
 Rod like forms are occasionally seen
 Gram (+) although the lose gram positivity and become gram (-) with age and death of bacteria
 Most group A strains produce capsules composed of hyaluronic acid
 Impedes phagocytosis
 Hair-like pili project through the capsule which consists of M protein and is covered with lipoteichoic acid
 Cell wall components: M, T, R antigens (proteins), group-specific carbohydrates, and peptidoglycans
 Culture
 Forms discoid colonies of about 1-2 mm of diameter
 β-hemolytic
 Growth characteristics
 Growth tends to be poor on solid media or in broth unless enriched with blood or tissue fluids
 Growth and hemolysis are aided by incubation in 10% CO2
  Most pathogenic streptococci grow best at 37°C, therefore they love to live in human beings as that is the
normal body temperature.
 Facultative anaerobes: grows under aerobic and anerobic conditions; Peptostreptococci are obligate
anaerobes
 Variation
 Different colony forms- seen with variant strains of the same species
 Matte colonies- with organisms that produce much M protein; generally virulent
 Glossy colonies- less M protein; less virulent
o Antigenic structures
 M Protein
 Major virulence factor of Group A S. pyogenes
 Hair-like projections of the streptococcal cell wall
 Indicates virulence: enables bacteria to resist phagocytosis by PMN
leukocytes
 150 types; repeated infections with group A S. pyogenes can happen
 Rod-like coiled structure that separates the functional domains which
allows a large number of sequence changes while maintaining function
and immunodeterminants can readily change
 Important role in pathogenesis of rheumatic fever
 T substance
 Antigen with no relation to virulence
 Acid labile; heat labile
 Obtained by proteolytic digestion which rapidly destroys M proteins
 Permits differentiation of certain types of streptococci by agglutination with specific antisera
 R protein- another surface antigen
 Nucleoproteins
 P substances: little serologic specificity and makes up most of the streptococcal cell body
o Toxins and enzymes
 Streptokinase (fibrinolysin)
 Produced by many strains of group A β-hemolytic streptococci
 Transforms the plasminogen into plasmin:
 Active proteolytic enzyme that digests fibrin and other proteins
 Countered by antistreptokinase
 Given intravenously for treatment of pulmonary emboli, coronary artery and venous thromboses
 Streptodornase (streptococcal deoxyribonuclease)
 Depolymerizes DNA
 Enzymatic activity measured by the decrease of viscosity of known DNA solutions
 Helps to liquefy exudates
 Facilitates removal of pus and necrotic tissue
 Giving antimicrobials better access and Speeding up recovery of infected surfaces
 Antibody to DNAse develops after streptococcal infections, especially skin infections
 Hyaluronidase
 Splits hyaluronic acid- important component of the ground substance of connective tissue
 Spreading factor: aids in spreading infecting microorganism
 Antigenic
 Specific for each bacterial or tissue source
 Pyrogenic Exotoxins (erythrogenic toxins)
 3 antigenically distinct toxins (Spe): A, B, and C
 Associated with streptococcal toxic shock syndrome and scarlet fever
 Act as superantigens, stimulating MHC II molecules that activate T cells, which in turn releases cytokines that
mediate shock and tissue injury
 Exotoxin A: most widely studied, and produced by Group A streptococci that carry a lysogenic phage
  Diphosphorydine nucleotidase
 Play a role in the organism ability to kill leukocytes
 Proteinases and amylase are produced by some strains
 Hemolysins
 Streptolysin O
 Molecular weight: 60,000
 Hemolytically active in the reduced state
 Rapidly activated in the presence of oxygen
 Combines quantitatively with antistreptolysin O (ASO) titer of more than 160-200 unit is abnormally high
 Streptolysin S
 Elaborated in the presence of serum; not antigenic
 May be inhibited by a nonspecific inhibitor
o Pathogenesis and Clinical Findings
A. Diseases Attributable to Invasion by Streptococcus Pyogenes, β-hemolytic Group A Streptococci
1. Erysipelas
 Portal of entry: skin- massive brawny edema, raised lesion
 Rapidly advancing margin of infection
2. Cellulitis
 Acute, rapidly spreading infection of the skin and subcutaneous
 Follows infection associated with mild trauma, burns, wounds or surgical
incisions
 Painful, tenderness, erythema
 Lesion is not raised, indistinct margins of infection
3. Necrotizing fasciitis (Streptococcal gangrene)
 Infection of the subcutaneous tissues and fascia
 Extensive and rapidly spreading necrosis
 Flesh eating bacteria
4. Puerperal fever
 Septicemia originating from infected uterine lining (endometritis) following vaginal delivery
5. Bacteremia or sepsis
 Infection of traumatic or surgical wounds; rapidly fatal
B. Diseases Caused by Local Infection with S. Pyogenes
1. Streptococcal sore throat or Pharyngitis
 Most common infection due to β-hemolytic S. pyogenes
 Bacteria adheres to the pharyngeal epithelium with lipoteichoic acid covered surface pili
 Fibronectin (glycoprotein) on epithelial cells act as ligand
 Infants and small children: subacute nasopharyngitis
 Older children and adults: more intense nasopharyngitis, tonsillitis, intense redness and
edema of mucous membranes and high fever
 20% are asymptomatic
2. Streptococcal Pyoderma
 Impetigo: local infection of superficial layers of the skin especially in children
 Consists of superficial vesicles and eroded areas whose denuded surface is covered with pus and is later
encrusted
 Spreads by continuity and is highly communicable especially in hot humid climates
 Associated with S. pyogenes M types: 49, 57, and 59-61
 May proceed to glomerulonephritis in the future
C. Invasive Group A Streptococcal Infections, Toxic Shock Syndrome, and Scarlet Fever
 Shock, bacteremia, respiratory failure, and multiple organ failure; causing death in 30% of cases
 Infections follow minor trauma in otherwise healthy persons with soft tissue infection- Necrotizing fasciitis,
myositis
  S. pyogenes M types 1 and 3 make exotoxin A or B- associated with severe
infections
 Pyrogenic exotoxins A-C cause scarlet fever
 Rash on the trunk appears after 24 hrs of illness and spreads to involve the
extremities
D. Poststreptococcal Diseases
 Follows a latent period of 1-4 weeks following S. pyogenes infection
 Diseases are not due to direct effect of bacteria but due to hypersensitivity response
 Nephritis usually follows skin infection. Rheumatic fever usually follows infection of the respiratory tract
1. Acute glomerulonephritis
 Develop 3 weeks after pyoderma or impetigo
 Nephrogenic strains with M types 12, 4, 2, and 49
 Initiated by Ag-Ab complexes on the glomerular basement membrane on the kidney
 Hematuria, proteinuria, edema, hypertension, and urea nitrogen retention
 Few patients die or develop chronic glomerulonephritis; Majority recover completely
2. Rheumatic fever
 Most serious sequela of S. pyogenes leading to damage to heart muscle and valves
 Follows 1-4 weeks after strep throat infection
 Fever, malaise, migratory polyarthritis, carditis. Thickening and deformation of cardiac valves
 May be reactivated by recurrent streptococcal infections
o Diagnostic Laboratory Tests
A. Specimens
 Depends on the nature of infection
 Culture: throat swab, pus or blood; antibody determination: serum
B. Smears
 Pus: single cocci or pairs (instead of chains)
 Nonviable organisms lose ability to retain blue dye: Gram (-)
 If smears of pus show streptococci but cultures are negative, then anaerobic organisms should be
suspected.
 Smears of throat swabs are rarely contributory because of cross-contamination with viridans streptococci
C. Culture
 Done using blood agar plates. If anaerobes are suspected to contaminate, use anaerobic media.
 Incubation in 10% CO2 often speeds hemolysis.
 Slicing the inoculum into the blood agar makes O2 unable to inactivate streptolysin O- hastens hemolysis
D. Antigen Detection Tests
 Rapid detection of group A streptococcal antigen from throat swabs; 60-90% sensitive, 98-99% specific
 Use enzymatic or chemical methods, then enzyme immunoassay (EIA) or agglutination tests to
demonstrate presence of antigen.
E. Serologic Tests
 Estimates the rise in the titer of antibodies to many group A streptococcal antigens
 Antistreptolysin (ASO)- respiratory disease (most widely used)
 Anti-DNAse and antihyaluronidase- skin infection
 Antistreptokinase
 Anti-M type-specific antibodies
o Immunity
 Resistance to strep throat and other streptococcal pyogenes infection is M type-specific
 Recovery from infection of one group A streptococcal M type renders insusceptibility to reinfection of that
same type but not to others
 Antibody to streptolysin O blocks hemolysis but does not indicate immunity. High titers (greater than 250
units) indicate recent or repeated infections; seen in rheumatic individuals
o Treatment
 Penicillin G, Erythromycin (if patient is allergic to Penicillin); Resistance to Tetracyclines seen in some
  Rapid eradication of streptococci should be done following acute streptococcal infections to prevent
poststreptococcal disease and eliminate antigenic stimulus before day 8.
o Epidemiology, Prevention, and Control
 Nasal discharges- most dangerous source for spread of S. pyogenes
 Humans can be asymptomatic nasopharyngeal or perineal carriers
 Other streptococci are known members of the normal flora of the human body
 Produced disease only when established in parts of the body where they do not normally occur
 Heart valves and viridans streptococci
 Control Procedures
1. Detection and early antimicrobial therapy of respiratory and skin infections with Group A streptococci
 Maintain adequate Penicillin levels in tissues for 10 days;
 Benzathine Penicillin G x 1 dose intramuscularly; Erythromycin if patient is allergic to Penicillin
2. Antistreptococcal chemoprophylaxis in persons who have had rheumatic fever.
 Benzathine Penicillin G x 1 dose IM every 3-4 weeks or daily oral penicillin or oral sulfonamide
3. Eradication of S. pyogenes from carriers.
 Streptococcus agalactiae
o Group B streptococci are β-hemolytic
o Produce zones of hemolysis that are only slightly larger than the colonies (1-2 mm in diameter)
o Hydrolyze sodium hippurate
o CAMP (Christie Atkins Munch-Peterson) test (+)
o Part of normal vaginal flora in 5-25% of women
o Group B streptococcal infection (GBS) in neonates (day 0-30)- fulminant sepsis, meningitis or respiratory
distress syndrome
o IV ampicillin is given to mothers who are GBS carriers and are in labor
 Group C and G Streptococci
o Sometimes occur in the nasopharynx; may cause pharyngitis, sinusitis, bacteremia, or endocarditis
o Look like group A S. pyogenes on blood agar medium; β-hemolytic
o Group G- have hemolysis and may have M protein similar to S. pyogenes
 Streptococcus bovis
o Nonenterococcal group D streptococci; part of enteric flora
o May cause endocarditis in the heart and bacteremia in patients with colonic carcinoma
o Nonhemolytic; Pyrrolidonyl-β-naphthylamide (PYR) (-)
o Grow in the presence of bile and hydrolyze esculin; do not grow in 6.5% NaCl
o Often classified as viridans streptococci
 Streptococcus anginosus group
o S. Anginosus
 Includes S. constellans and S. intermedius; Referred to as the S. milleri group
 Part of normal flora; may be classified as viridans streptococci
 Group N Streptococci
o Rarely found in human disease states o Produce normal coagulation (“souring”) of milk
 Group E, F, G, H, & K-U
o Occur primarily in animals
o S. canis Group G- Skin infection of dogs
 Viridans Streptococci
o Include S. mitis, S. mutans, S. salivarius, S. sanguis. Some are α-hemolytic or non-hemolytic
o Optochin resistant and insoluble in deoxycholate
o Most are prevalent members of the normal flora of the upper respiratory tract and may
reach the blood stream following trauma
o Principal cause of endocarditis of normal heart valves
o S. mutans- cause of dental caries; synthesizes dextran or levans from sucrose
 Nutritionally Variant Streptococci
o
Previously known as S. defectives and S. adjacens; both are pyridoxal-dependent streptococci
 Require pyridoxal or cysteine for growth on blood agar
 Grows as satellite colonies around colonies of staphylococci and other bacteria
o Either α-hemolytic or non-hemolytic; part of the normal flora
o Clinically similar to viridans streptococci
 Peptostreptococcus (Many Species)
o Grow only under anaerobic or microaerophilic conditions and variably produce hemolysis
o Part of the normal flora of the mouth, upper respiratory tract, bowel and female genital tract
o Often part of mixed anaerobic infections in wounds, breast, postpartum endometritis
o Pus- foul odor
 Streptococcus pneumoniae
o Morphology and Identification
 Typical organisms
 Gram (+), lancet-shaped diplococci; Sputum or pus: single cocci or chains also seen
 Becomes gram (-) with age and undergo spontaneous lysis
 Autolysis is enhance by surface active agents
 Ox bile (10%), Na deoxycholate (2%), viridans streptococci do not lyse
 Optochin sensitive and Quellung reaction positive
 Culture
 Small round colonies: dome shaped and central plateau with an elevated rim
 α-hemolytic on blood agar and growth is enhanced by 5-10% CO2
 Growth characteristics
 Energy is obtained from fermentation of glucose, with rapid production of lactic acid (limits growth)
 Neutralization of broth cultures with alkali leads to massive growth
 Variation
 Capsule formation- associated with large mucoid colonies
o Antigenic structure
A. Component Structures
 Peptidoglycan and teichoic acid
 Capsular polysaccharide is covalently bound to the peptidoglycan and to the cell wall
polysaccharide
 Immunologically distinct for more than 90 types (there are more than 90 repeated infections with S.
pneumoniae possible for an individual)
B. Quellung Reaction
 Pneumococci mixed with specific anti polysaccharide serum of the same type→ capsule swells markedly→
organisms agglutinate by cross-linking of antibodies (Positive Quellung reaction as seen in S. pneumoniae)
o Pathogenesis
A. Types of Pneumococci
 Adults: types 1-8 are clinically important; 75% of cases of pneumococcal pneumonia, 50% of fatalities are
pneumococcal bacteremia
 Children: types 6, 14, 19 & 23 are most important
B. Production of Disease
 Produce disease due to their ability to multiply in tissues
 Do not produce toxins of significance
 Virulence is due to their capsule- prevents or delay ingestion by phagocytes
C. Loss of Natural Resistance (factors that predispose to pneumococcal infections)
1. Viral and other respiratory tract infections that damage surface cells, abnormal mucus accumulation,
bronchial obstruction, irritants that disturb mucociliary function
2. Alcohol or drug intoxication- depresses phagocytic activity, depresses the cough reflex, facilitates aspiration
of foreign material
 3. Abnormal circulatory dynamics
4. Other mechanism- malnutrition, general debility, sickle cell anemia, hyposplenism, nephrosis, complement
efficiency
o Pathology
 Infection causes outpouring of fibrinous edema fluid into alveoli→ accumulation of red cells and
leukocytes→ consolidation of portions of lungs→ pneumococci found in the exudate; may reach bloodstream
via lymphatic drainage→ mononuclear cells later phagocytose the debris + pneumococci
o Clinical findings (Pneumococcal Pneumonia)
 Sudden onset; with fever, chills, and sharp pleural pain
 Bloody or rusty-colored sputum
 Early: bacteremia in 10-20% of cases; Consolidation/fibrosis of lung is prevented with early antimicrobial
therapy
 Late: Empyema (pus in pleural space)- complication of pneumonia, requires aspiration and drainage by a
surgeon\
 Sinuses or middle ear- most frequent affected by pneumococci next to respiratory tract. Infections may
extend to the meninges
 Triad of complications- (bacteremia from pneumonia): Meningitis, Endocarditis, and Septic arthritis
o Diagnostic laboratory tests
 Blood is drawn for culture
 Serum antibody test- impractical
 CSF and Sputum- demonstration of pneumococci by smear and culture
 Stained smears- Gram stain of rusty red sputum shows typical organisms, many PMN leukocytes and
erythrocytes
 Capsule swelling test- Fresh emulsified sputum mixed with antiserum causes capsule swelling (called
quelling reaction)
 Culture- Created by sputum culture on blood agar, incubated in CO2 or a candle jar; blood culture is also
taken
o Immunity
 Type specific
 Depends on: antibodies to capsular polysaccharide and intact phagocytic function
 Vaccines induce production of antibodies to capsular polysaccharides, however is given only for extremes of
age (0-2 and 65↑)
o Treatment
 Early treatment leads to rapid recovery
 Penicillin G- drug of choice; but around 10-15% of pneumococci are Penicillin-resistant
 Cross resistance with cefotaxime
 Resistance to tetracycline, erythromycin, and fluoroquinolones also occurs. Pneumococci remain susceptible
to vancomycin.
o Epidemiology, Prevention, and Control
 Pneumococcal pneumonia- 60% of all bacterial pneumonia
 Predisposing factors are more important than exposure to infectious agent
 Vaccines can provide 90% protection against bacteremic pneumonia
 Enterococci
o Group D group-specific substance
o Part of normal enteric flora
o Nonhemolytic but occasionally α-hemolytic
o Pyrrolidonyl-β-naphthylamide (+); bile esculin (+)
o Grows in 6.5% NaCl and grows well at 10°C-45°C
o More resistant to penicillin (β-lactamase production). Vancomycin-resistance also known
o 12 species
o Enterococcus faecalis- most common: causes 85%-90% pf enterococcal infections
o E. facium- causes 5-10% of enteroccal infections
o Most frequent cause of nosocomial infections (hospital-acquired infections)
o Most common sites: urinary tract, wounds, biliary tract, and blood
o In neonates: meningitis and bacteremia
o In adults: endocarditis