(Module 202)

Cardiac infections

Endocarditis Myocarditis Pericarditis

Endocarditis is infection Myocarditis is infection of Inflammation of the fibrous sac
of the valves of the heart the heart muscle surrounding the heart due to
autoimmune disease, infection,
trauma or malignancy
• Staph. epidermidis
• Coxsackie viruses
• Staphylococcus aureus
• Cytomegalovirus
• Streptococci Viridans group • S. aureus
• Epstein-Barr virus
• Enterococci • S. pneumoniae
• Parvovirus B19
• Candida • Mycobacterium tuberculosis
• Influenza virus
• Coxsackie virus
• Echovirus

Staphylococci
STAPHYLOCOCCI general characters
Staphylococci are Gram positive cocci arranged in grape-like clusters

Staph. aureus Staph. epidermidis Staph. saprophyticus

• Coagulase positive
• Mannitol positive
• Coagulase negative
• Causing haemolysis of RBCs
• Normal human microbiota
in vitro
• Sometimes cause infections, often associated
with implanted appliances and devices

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 STAPH. AUREUS
Morphology

Stain Arrangement Shape Capsule

Spore forming Motility
Gm +ve Grape like Cocci Non capsulated
Non spore forming Non motile
clusters

Culture

Yellow colonies on On nutrient agar Beta haemolytic Facultative anaerobes

mannitol salt agar producing colonies on
golden yellow colonies blood agar

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 Pathogenesis and virulence factors
Protein A
• Binds to the Fc portion of
IgG at the complement
binding site.
• Preventing complement
activation
• Opsonization and
phagocytosis of the
organism is reduced
• Immune evasion by
Staph. aureus
Coagulase
• Enzyme-like protein.
• Causes coagulation of
plasma with fibrin
deposition around the
lesions as well as on the
surface of staphylococci
rendering them more
resistant to phagocytosis
• Invasive pathogenic potential
Cell wall components
Teichoic acid
Mediates its
adherence to
mucosal surfaces
Enzymes and proteins
Clumping factor
• Is a surface compound
• Responsible for adherence
(adhesin) of the organism to
fibrinogen and fibrin in
plasma leading to their
aggregation and promoting
their attachment to blood
clots and traumatized
tissues.
• It is immunogenic
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Polysaccharide Peptidoglycan
microcapsule
Endotoxin-like
Microcapsule that
properties
is anti-phagocytic
Catalase Panton-Valentine
leukocidin
Limits the ability of
phagocytic cells to • Produced mainly by
kill bacteria by community acquired
degrading H2O2 CA-MRSA.
• It is encoded on a
mobile phage
• It causes lysis of
leukocytes, releasing
inflammatory mediators
leading to necrosis and
severe inflammation

Exfoliative toxin
• Two distinct proteins A and B
• Epidermolytic and cause the
desquamation seen in
staphylococcal "scalded skin
syndrome" in young children
• They are superantigens
• Genes for these toxins are
located on a chromosomal
element called a pathogenicity
island
Toxins
Toxic shock syndrome toxin
• This is produced by strains that
cause the toxic shock syndrome.
• Manifested by fever, diffuse
macular rash, shock, and
multisystem involvement
• Superantigen
• Genes for these toxins are located
on a chromosomal element called
a pathogenicity island
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Enterotoxins
• Multiple (A-E, G-J, K-R and U, V)
• Produced by 50% of Staph.
aureus strains
• The toxins are heat stable and
resistant to the action of gut
enzymes
• They cause the diarrhoea and
vomiting associated with
staphylococcal food poisoning
• They act as superantigens
• Genes for these toxins are located
on a chromosomal element called
a pathogenicity island
 Diseases caused by Staph. aureus
Pyogenic staphylococcal diseases

Focal suppuration Invasive conditions Outbreaks

* Abscess formation is characteristic
of Staph. aureus lesions
* This is due to coagulase which
deposits fibrin around the lesions
forming a wall, which is reinforced
by inflammatory cells
* e.g. folliculitis, boils, abscesses &
carbuncles
* From any focus or after trauma,
organisms may spread via the
lymphatics or blood (bacteraemia) to commonly occur due to antibiotic
other parts of the body causing deep
seated lesions
* e.g. osteomyelitis, necrotizing
pneumonia, empyema, endocarditis,
meningitis, multiple abscesses in
tissues and septicaemia
* Outbreaks of hospital acquired
post-operative wound infections
resistant staphylococci
* Foreign bodies, such as sutures
and intravenous catheters
predispose to these infections.

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 Toxigenic staphylococcal diseases
Food poisoning
• Ingestion of the preformed
enterotoxin in contaminated
food that is improperly cooked
and kept unrefrigerated for
some time
• The source of contamination
of food is the hands or the
nose of a cook or food
handlers (carriers)
• The type of food involved in
staphylococcal food poisoning
is carbohydrate rich food, e.g.
cakes, pastry, koskosi, koshari
(popular Egyptian food) as well
as milk and milk products
• The incubation period is short
(1-8 hrs) followed by nausea,
vomiting, watery non-bloody
diarrhoea and general malaise
with no fever.
Differences between CA-MRSA and HA-MRSA
CA-MRSA
Less resistant
Not hospitalized
PVL
More transmissible
Toxic shock syndrome (TSS) Scalded skin syndrome
• This is associated with TSST-1 • It is due to the exfoliative
• TSS was first described in toxin
menstruating women using • The syndrome occurs in
tampons babies and young children
• The syndrome also occurs with • It is characterized by large
wound or localized infections areas of desquamation of
the skin and generalized
• TSS has an abrupt onset of fever,
vomiting, diarrhoea, muscle pains bullae formation
and rash
• Hypotension, heart failure and
renal failure may occur in severe
cases.
• TSST-1 can be detected in the
blood by ELISA
HA-MRSA
More resistant
Hospitalized
No PVL
Less transmissible
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 Diagnosis

Specimen Cultures Colony Typing methods for

Smears
s identification epidemiological purposes

Catalase Coagulase Clumping

Phage typing Antimicrobial Molecular
production production factor
susceptibility typing

Treatment and drug resistance

90% of staphylococci are 65% of staphylococci (VISA) or complete

resistant to penicillin G, resistant to Beta-lactams resistance to vancomycin
ampicillin (VRSA) were reported

Due to production of Penicillin-binding protein (PBP-2a)

Alteration in cell wall structure
Beta-lactamase not affected by these drugs

Treated by the beta

These strains are
lactamase resistant The drugs of choice for these
susceptible to linezolid
antibiotics such as organisms are the glycopeptides,
methicillin and oxacillin i.e. vancomycin

N.B.:
• Mupirocin is used as a topical antibiotic to reduce nasal carriage of the organism in hospital
personnel and in patients with recurrent staphylococcal skin infections
• Resistance to penicillin G, ampicillin and amoxicillin due to production of Beta-lactamase
(controlled by a plasmid) which breaks down the Beta-lactam ring in penicillin
• However, resistance to methicillin, nafcillin and oxacillin is due to acquisition of mecA gene
that codes for a penicillin-binding protein (PBP-2a) not affected by these drugs

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 Prevention

Shared exercise Treatment of nasal Aseptic

There are no Avoidance of Proper hygiene
carriers or their management
vaccines sharing personal equipment should be measures
wiped down between removal from high- of lesions and
items such as including
users risk areas, e.g. proper
towels and razors frequent hand
operating rooms, disposal of
washing
intensive care units bandages
and new-born
nurseries...etc.

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 STAPH. EPIDERMIDIS
General Characters

Staph. epidermidis present on normal skin It causes infections on top of prosthetic devices
and mucous membranes
e.g. prosthetic valves or artificial joints and
intravenous catheters

Morphology

Stain Arrangement Shape Capsule

Spore forming Motility
Gm +ve Grape like Cocci Non capsulated
Non spore forming Non motile
clusters

Culture

Pink colonies on On nutrient agar Non haemolytic Facultative anaerobes

mannitol salt agar producing colonies on
white colonies blood agar

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 Virulence Factors

A surface protein (adhesins) An exopolysaccharide (glycocalyx and slime)

• Participate in its adherence
• Lead to formation of a multi-layered biofilm on the
surface of devices and valves, causing infections that are
resistant to antibiotics

Diseases Caused

Most infections are hospital acquired It is also a major cause of sepsis in neonates
affecting immunosuppressed patients

Treatment

Most strains produce ℬ-lactamase The drug of choice is vancomycin to

& many are methicillin/nafcillin resistant which gentamicin is added

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 STAPH. SAPROPHYTICUS
General Characters

Staph. Second to E. coli as a Infection usually It produces urease It is novobiocin-

saprophyticus is cause of urinary occurs 24 hr after which may play a role in resistant
an opportunistic tract infection in intercourse its invasiveness in
pathogen while Staph.
sexually active urinary tract infections
epidermidis is
young women
novobiocin-
sensitive

Staph. Lugdunensis
Staph. Lugdunensis has emerged as a virulent organism
causing disease similar to Staph. aureus

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 Lecture Questions
- Complete :

1. ………………., ……………, ………………. act as superantigens, and their genes carried on chromosomal

element called ……………… While genes for ………………are carried on mobile phage.

2. Characters of staphylococcal enterotoxin …………………………… , ................................................... ,

………………………………..

3. Clinical Symptoms of Staph food poisoning ………, ………….., …………

4. Toxigenic staphylococcal diseases ………, …………..., ……….…..

5. Staphylococcal toxic shock syndrome caused by ………………….…… while scalded skin syndrome

caused by ………………..

6. Pyogenic staphylococcal diseases …………………, ……………., ………….

- Compare between coagulase and clumping factor

- Mention mechanism of Protein A action as virulence factor

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- MCQ:

1. Preventing complement activation, opsonization and phagocytosis are maintained by which

Staphylococcal cell wall component?
A. Techoic acid.
B. Peptidoglycan.
C. Protein A.
D. Microcapsule.

2. A family of four members had a delicious picnic lunch last Sunday. It was a warm day, and the
food sat in the sun for several hours. 3 hours later, everyone came down with vomiting and non-
bloody diarrhea. In the emergency room, it was found that the mother who prepared the food,
had a paronychia on her thumb. Which one of the following is the most likely causative
organism?
A. Enterococcus faecalis.
B. Staphylococcus aureus.
C. Staphylococcus epidermidis.
D. Streptococcus agalactiae.

3. You’re in the clinical lab looking at a Gram stain when the laboratory technician comes up to you
and says, “I think your patient has Staphylococcus epidermidis bacteraemia.” Which one of the
following sets of results did the tech. find with the organism recovered from the blood culture?
A. Gram-positive cocci in chains, catalase-positive, coagulase-positive
B. Gram-positive cocci in chains, catalase-negative, coagulase-negative
C. Gram-positive cocci in clusters, catalase-positive, coagulase-negative
D. Gram-positive cocci in clusters, catalase-negative, coagulase-positive
E.
4. Superantigen production by Staphylococcus aureus is involved in the pathogenesis of which one
of the following diseases?
A. Folliculitis
B. Bacteraemia
C. Glomerulonephritis
D. Toxic shock syndrome

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