2

 
1.5b GRAM (+) COCCI: STREPTOCOCCI
  MICROBIOLOGY
1ST
  Dr. Sia-Qunco | July 3, 2013 2013-2014

 
OUTLINE   • Does  not  produce  gas  
I.  Genus  Streptococcus   o Facultative  anaerobe  with  fermentative  metabolism  
A.  Classification  
B.  Biochemical  reactions  
o Usually  needs  blood  enriched  medium  to  grow  
II.  Streptococcus  pyogenes    
A.  Typical  organism  
B.  Cultural  Characteristics  
C.  Antigenic  Structure  and  Determinants  of  Pathogenicity  
D.  Toxins  and  Enzymes  
E.  Pathogenesis  and  Clinical  Findings  
F.  Diagnosis  
G.  Treatment  
H.  Prevention  and  Control    
III.  Streptococcus  Agalactiae   Figure  1.  Streptococcus  dividing  in  1  plane  
IV.  Group  C  Streptococci   resulting  in  pairs  and  chains  
V.  Group  D  Streptococci    
A.  General  Characteristics  
B.  Clinical  Infection   A.  Classification  
C.  Treatment   1.  Hemolytic  pattern  on  BAP    
D.  S.  anginosus-­‐milleri  group  
• α  hemolysis:  greenish  discoloration  
E.  Viridans  streptococci  
F.  Streptococcus  pneumonia/Pneumococcus   o due   to   incomplete   lysis   and   green   metabolite   of   reduced  
G.  Laboratory  identification   haemoglobin,  methemoglobin  
H.  Pathogenesis   • β  hemolysis:  clear  zone  of  hemolysis;  complete  lysis  of  RBCs  
I.  Pathology   • γ  hemolysis:  non-­‐hemolytic  
J.  Clinical  findings  
K.  Diagnostic  Laboratory  test  
 
 
Objectives:    
At  the  end  of  the  lecture  period  the  student  should  be  able  to:  
-­‐  Discuss  the  following  about  Streptococcus  bacteria:  
• general  characteristics  
• methods  of  classifying    
• Differentiate  between  the  types  of  hemolysis  patterns  on  BAP  
-­‐  Discuss  the  following  about  S.  pyogenes:  
 
• general  characteristics   Figure  2.  Hemolysis  patterns  on  BAP  
• antigenic  structure      
• enzymes  and  toxins   2.  Lancefield  Classification  
• pathogenesis  and  clinical  findings  of  diseases  due  to  S.pyogenes  
• Based   on   antigenic   composition   of   cell   wall   carbohydrates   in  
• State  the  diagnostic  methods  used  for  the  said  diseases  
• treatment  prevention  and  control  of  the  said  diseases  
beta  haemolytic  streptococcus  
-­‐  Discuss  the  following  about  S.  pneumonia:     • Serogroups  A-­‐H,  K-­‐U  
o general  characteristics   • Groups  A,  B,  C,  D,  G  –  associated  with  human  infection  
o culture  characteristics   • Capsular  polysaccharides  –  antigenic  specificity  is  used  to  classify  
• pathogenesis  and  clinical  findings  in  diseases  due  to  S.pneumoniae   S.  pneumonia  into  90  types  
• diagnostic  methods  in  S  pneumoniae  infection  
 
• treatment  methods  in  S  pneumoniae  infection  
-­‐  Discuss  the  general  characteristics,  pathogenesis  and  treatment  of  enterococcus  
Table  1.  Serogroups  associated  with  human  infections  
-­‐  Discuss  the  general  characteristics  of  S.viridans  and  pathogenesis  of  illness  due  to   Lancefield   Hemolysis   Representative   Major   Clinical  
the  species   Serogroup   on   Blood   Species   Symptoms  
-­‐  Discuss  the  characteristics  of  other  Streptococci     agar  
  A   Β   S.  pyogenes   Pharyngitis,   scarlet  
References:   fever,   septicemia,  
Medical  Microbiology,  25th  ed.  Jawetz,  Melnick,  Adelberg.   erysipelas,   impetigo,  
Zinsser  Microbiology,  20th  ed.  Joklik,  Willett,  et  al.   rheumatic   fever,   acute  
Clinical  Microbiology  Made  Ridiculously  Simple.  Gladwin  &  Trattler.   glomerulonephritis    
Microbiology  &  Immunology:  Appleton  &  Lange  Outine  Review.  WW.  Yotis   B   β   S.  agalactiae   Neonatal   sepsis   &  
Lippincott’s   Illustrated   Review   Microbiology,   3rd   ed.   Lippincott,   William   &   meningitis,   urinary  
Wilkins.  
tract   infection,  
Microbiology   &   Immunology   for   the   Boards   &   Wards.   Lippincott,   William   &  
puerperal  sepsis  
Wilkins.  
  C   β     Pharyngitis  
Legend:     highlighted  part  –  possible  questions  that  might  be  asked  on  exam   D     E.  faecalis   Genitourinary   tract  
  infections,  endocarditis    
I.  GENUS  STREPTOCOCCUS   G   Β     Pharyngitis  
• Strepto  –  “twisted”;  coccus  –  “grain  or  berry”    
• Gram  (+),  spherical,  in  chains  or  pairs   B.  Biochemical  Reactions  
• Divides  in  1  plane  so  there  will  be  elongation  only   • Strep  ferments  carbohydrates  and  is  Catalase  (-­‐)  
• Catalase  (-­‐)  –  to  differentiate  it  from  Staphylococcus  sp.   • Optochin  sensitivity  –  an  antibiotic,  quinine  derivative  

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 MICROBIOLOGY 1.5b
 

o Viridans  streptococcus  is  resistant   genes    of    different    M    types.    Both    group    C    and    group    G       str
o  Streptococcus  pneumonia  is  sensitive  to  optochin   eptococci    have    genes    homologous    to    the    genes    for    M       prot
• PYR  Disk  –  ability  to  hydrolyze  pyrrolidonyl  to  β  naptilamide   ein    of    group    A,    and    M    protein    has    been    found    on       group    
o (+)  change  to  Red  –  S.pyogenes  and  Group  D  Enterococcus   G    streptococci.      
o (-­‐)  remains  yellow  –  no  change;  Viridans  strep     • has    a    rodlike    coiled    structure      that    separates    functional    domains  
• Oxidase   test   –   presence   of   cytochrome   oxidase   in   certain   o allows       for    a    large    number    of    sequence    changes    while      
bacteriam   maintaining    function,    and    the    M    protein  
o (+)  Violet  blue  –  Neisseria  and  Moraxella  catarrhalis   immunodeterminants,    therefore,    can    readily    change  
  • Type   I   M:   induces   antibodies   that   react   with   human   cardiac  
II.  STREPTOCOCCUS  PYOGENES   muscle  (determinant  of  Rheumatic  Fever)  
o The  type  1  M  protein  here  has  a  cross  reaction  with  human  
A.  Typical  Organism    
cardiac  muscle  and  heart  valve  antigens  so  its  not  recognized  
•Group  A  strep  (GAS),  β  hemolytic   by  the  body  as  self  and  it  is  being  recognized  as  a  non-­‐self  so  
•Lancefield  Grp  A,  Gm  (+),  spherical,  in  chains   there  would  be  destruction  of  your  heart  valves.  (rheumatic  
•Facultative  anaerobe,  catalase  (-­‐),  Oxidase    (-­‐),  PYR  (+)   heart  fever  or  rheumatic  heart  disease)  
•Bacitracin  (an  antibiotic  disk)  sensitive:  95%  accurate   • Type  II  M:  no  consequences  
o the  definitive  test  for  strep  pyogenes    
o put   it   in   a   plate   culture   of   strep   pyogenes   and   there   would  
be  zone  of  inhibition  
• Killed  in  30  min  at  60⁰  C  
 
B.  Cultural  Characteristics  
• Primary  isolation  of  specimens:  use  blood  media  (BAP)  
• Clinical   specimens   can   be   processed   by   pour   or   streak   plate  
techniques.  
• Optimal  pH  7.4-­‐  7.6  at  37⁰.    
• Culture  growth  is  enhanced  by  a  low  O2  tension  or  by  increased  
CO2    
• Discoid   colonies,   domed,   grayish   to   opalescent   with   a   zone   of   Figure  4.  M  protein  structure  
beta  hemolysis    
• Utilizes  glucose  w/  Lactic  Acid  as  product  
o Most    streptococci    that    contain    the    group    A    antigen    are    
S.      pyogenes.    It    is    a    prototypical    human    pathogen.                S.    
pyogenes    is    the    main    human    pathogen    associated    with    l
ocal    or       systemic    invasion    and    post streptococcal    immun
ologic       disorders    (ex:    Rheumatic    fever    and  
Glomerulonephritis).    S.       pyogenes    typically    produces    large
   (1    cm    in    diameter)    zones    of       hemolysis    around    colonies  
 greater    than    0.5    mm    in    diameter.      
• PYR-­‐positive    (hydrolysis    of    L-­‐pyrrolidonyl-­‐2-­‐
naphthylamide)      and    usually    are    susceptible    to    bacitracin  
   
Figure  5.  M  protein  and  schematic  diagram  of  a  bacterial  wall  
 
2.  T  substance  
• Permits       differentiation       of       certain       types  
of       Streptococci       by       agglutination       with       specific   antisera,  
while      other      types      share      the  same  T  substance.    
• Heat-­‐labile,  acid-­‐labile,  non-­‐virulence  factor    
• Used  for  typing  GAS  that  cannot  be  serotyped  with    anti    M    sera.            
• Obtained  from  streptococci   by  proteolytic   digestion,   which  
  rapidly    destroys    M    proteins  
Figure  3.  (Left)  S.  pyogenes  seen  as  gram  (+)  cocci  in  chains.    
(Right)  S.  pyogenes  on  BAP  exhibiting  beta  hemolysis.   3.  Lipotheichoic  Acid  
 
• mediates  buccal  epithelial  cell  adherence  (adheres  to  fibronectin  
C.      Antigenic  Structure  and  Determinants  of  Pathogenicity  
on  epithelial  cells)  
1.  M  Protein     • Cytotoxic  to  host  cells  
• Hair-­‐like  projections  on  the  cell  wall  of    Grp  A  β  hemolytic  strep.    
• Major  virulence  factor;  Antiphagocytic  (inhibits  opsonization  and   4.  Capsular  Polysaccharide    
the  complement  system)   • Hyaluronic  acid  capsules  in  some  Grp  A  Strep  
• Immunity   to   Grp   A   infection   is   due   to   antibodies   against   M   • Antiphagocytic    because    it    has    no    receptor    for    macrophages  
Protein     • Mimics  the  ground  substance  of  animal  tissues-­‐-­‐-­‐-­‐antiphagocytic  
• 150  types  of  M  Pr    
o   a    person    can    have    repeated    infections    with    group    A    S       pyo  

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 MICROBIOLOGY 1.5b
 

5.  Protein  F  (Fibronectin-­‐binding  Protein)     7.  Diphosphopyridine  Nucleotidase  

• mediates   attachment   to   fibronectin   in   the   pharyngeal   • Ability  to  kill  Leukocytes  
epithelium.     • elaborated  into  the  enviroment  by  some  streptococci  
• M  proteins  and  lipoteichoic  acids  also  bind  to  fibronectin.   • may  be  related  to  the  organism’s  ability  to  kill  leukocytes  
   
D.  Toxins  and  Enzymes     E.  Pathogenesis  and  Clinical  Findings      
1.  Streptolysin  O  (SLO)    
• Oxygen  labile   DISEASES  DUE  TO  INVASION  OF  S.  Pyogenes    
• Cytolytic   activity   against   RBC,   PMN,   Platelets   and   is   the   reason   1.  Erysipelas    
for  the  Beta  hemolysis   • Skin   and   subcutaneous   tissue   infection   usually   on   the   face   or  
• Antigenic   and   stimulates   production   of   the   antibody   lower  extremities    
Antistreptolysin  O  (ASO)  in  10-­‐14  days   • with  brawny  edema  (elevated)  and  rapidly  advancing  margin  of  
• ASO  Titer  :  indicator  of  recent  infection  with  S.  pyogenes     infection  which  is  well  delinieated  
• (>200iu  =  positive)    
  2.  Streptococcal  Cellulitis  
2.  Streptolysin  S  (SLS)   • Rapidly   spreading   infection   of   the   of   the   skin   and   SC   tissues  
• Oxygen  stable   associated  with  trauma,  burns  or  wound  
• Lytic  for  red  and  white  blood  cells   • With  erythema,  pain  and  swelling  
• Not  antigenic   • Cellulitis  vs  Erysipelas  
• Responsible  for  the  surface  hemolysis  seen  on  BAP   o In  cellulitis,  the  region  is  not  raised  or  brawny  
  o In   cellulitis,   line   between   involved   and   uninvolved   tissue   is  
3.  Pyrogenic  Exotoxin  (Erythrogenic  Toxin)   indistinct  
• 90%  of  S.  pyogenes:  Exotoxin  A,  B,  C    
• Heat  labile  but  stable  to  acid,  alkali  and  pepsin  
• Exotoxin  A  
o Assoc.  w/  Toxic  Shock  Syndrome  &  Scarlet  Fever  
o Superantigen   producing   release   of   cytokines   that   mediate  
shock/tissue  injury  
• Exotoxin  B:  Necrosis  of  tissues  (Necrotizing  Fasciitis)  
• Exotoxin   C:   Causes   increased   permeability   of   the   Blood-­‐Brain-­‐
Barrier  to  toxins  and  bacteria  and  has  a  pyretic/febrile  effect  on  
the  hypothalamus.  
• Dick  test    
o (+):  The  toxin  causes  an  erythematous  reaction  in  the  skin  of   Figure  6.  (Left)  Erysipelas.  (Right)  Streptococcal  cellulitis.  
nonimmune  persons      
o (-­‐):  No  reaction  in  persons  with  immunity   3.  Necrotizing  Fasciitis  
• Schultz-­‐  Charlton  Rxn:  Antitoxin  injected  in  the  skin  of  a  patient   • A.k.a.  “Flesh-­‐Eating  bacteria”  
with  Scarlet  fever  produces  localized  blanching     • Rapidly   spreading   necrosis   of   the   skin,   SC   and   fascia   due   to   M  
  protein   and   necrotizing   Exotoxin   B   that   blocks   phagocytosis,  
4.  Streptokinase  (Fibrinolysin)   allowing  bacteria  to  move  rapidly  through  tissues  in  a  matter  of  
• Transform   plasminogen   into   plasmin,   a   proteolytic   enzyme   to   hours  
digest   fibrin   and   other   proteins   facilitating   the   rapid   spread   of   • Symptoms:   toxic   shock–like   syndrome,   fever,   hypotension,  
organism.   multi-­‐organ   involvement,   a   sunburn-­‐like   rash,   or   a   combination  
• Used   as   IV   treatment   for   pulmonary   emboli;   coronary   artery   &   of  these  symptoms.  
venous  thrombosis    (Streptokinase  of  Group  C)   • Must  be  recognized  early.    
  • Intervention:  surgical  debridement  plus  massive  antibiotics    
5.  Streptodornase    
• Helps  to  liquify  exudates.  DNAses  that  degrade  the  viscous  DNA  
in  necrotizing  tissue  or  exudates,  aiding  the  spread  of  infection.  
o because   the   pus   is   made   up   of   deoxyribonucleoprotein   so  
the  streptodornase    will  try  to  liquefy  this  to  facilitate  spread  
of  the  infection  
 
6.  Hyaluronidase  
• Splits   hyaluronic   acid   in   the   ground   substance   of   connective  
 
tissue  
• Spreading  factor   Figure  7.  Necrotizing  fasciitis  
• antigenic      and      specific      for      each      bacterial      or      tissue      source.  
• Following   infection   with   hyaluronidase-­‐   4.  Puerperal    fever  
producing       organisms,       specific       antibodies       are       found    in    the    ser
• aka    “childbed    fever”        
um.  
• septicemia  secondary  to  endometritis  after  birth  
 
 
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 MICROBIOLOGY 1.5b
 

• symptoms:   chills,   fever,   abdominal   distention   and   tenderness,  

serosanguinous  vaginal  discharge  with  foul  smell  
• caused  high  mortality  rate  before  advent  of  antibiotics  
• may   be   introduced   by   healthcare   workers   (remember  
Semelweiss  =  institution  of  handwashing)  
 
5.  Bacteremia/sepsis/  Streptococcal  toxic  shock  syndrome  
• Defined   as   isolation   of   group   A   β-­‐hemolytic   streptococci   from  
blood  or  another  normally  sterile  body  site  in  the  presence  of  
 
shock  and  multiorgan  failure.     Figure  9.Streptococcal  sorethroat/Pharyngitis.  Enlarged  tonsils  
• Mediated   by   the   production   of   streptococcal   pyrogenic    
exotoxins   causing   massive,   nonspecific   T-­‐cell   activation   and   Note:  Rheumatic  Fever  (RF)  is  the  common  sequelae  of  a  respiratory  
cytokine  release   infection.  Acute  Glomerulonephritis  (GN)  is  the  common  sequelae  of  
• Flu-­‐like   symptoms,   followed   shortly   by   necrotizing   soft   tissue   streptococcal  skin  infection.  Although  both  diseases  may  crossover.    
infection,  shock,  acute  respiratory  distress  syndrome,  and  renal  
failure.   2.  Streptococcal  pyoderma/Impetigo  
• Follows  skin  infection   • Small  vesicles  progressing  to  weeping  lesions.  denuded  surfaces  
  with  pus.  
6.  Scarlet  Fever   • Grp   A   Streptococcus   skin   infection   may   precede  
• Associated   with   severe,   purulent   inflammation   of   the   posterior   Glomerulonephritis    
oropharynx   and   tonsillar   areas   with   a   sunburn-­‐like   rash   on   the   • Although  S.  aureus  is  recovered  from  most  contemporary  cases  
neck,   trunk   and   extremities   in   response   to   the   release   of   of  impetigo,  S.  pyogenes  is  the  classic  cause  of  this  syndrome.    
Pyrogenic/Erythrogenic   exotoxin   to   which   the   patient   does   not   • The  disease  begins  on  any  exposed  surface  (most  commonly,  the  
have  antibodies   legs).    
• “Strawberry  tongue”  due  to  the  erythrogenic  toxin   • Typically   affecting   children,   it   can   cause   severe   and   extensive  
• Patients   don’t   die   of   scarlet   fever,   they   die   because   of   the   septic   lesions  on  the  face  and  limbs    
shock  caused  by  scarlet  fever   • Treatment:   topical   agent   such   as   mupirocin,   or   systemically   with  
  penicillin  or  a  first-­‐generation  cephalosporin  
 

 
Figure  8.  Symptoms  associated  with  scarlet  fever:    
Rashes  (left)  and  Strawberry  tongue  (right)   Figure  10.  Impetigo  
   
LOCAL  INFECTIONS  WITH  S.  Pyogenes   POST  STREPTOCOCCAL  DISEASE  
1.  Streptococcal  sorethroat/Pharyngitis  (acute  tonsillitis)   • 1  to  4  weeks  after  acute  infection  
• In   children   there   is   nasopharyngitis   and   sorethroat   that   may   • Not  directly  related  to  the  bacteria  but  due  to  a  hypersensitivity  
extend  to  middle  ear  (causing  otitis  media)  and  mastoid.   response  (antibiotics  won’t  work)  
o Presence  of  “Luga”    
• In   adults   there   is   intense   nasopharyngitis,   tonsillitis,   purulent   1.  Acute  Glomerulonephritis  :  due  to  nephritogenic  strains  
exudates,   enlarged   lymph   nodes   (in   submandibular   area)   and   • Preceded   by   skin   infection   or   respiratory   infection   (but   mostly  
fever.     by  skin  infection)  
o Odaynophagia:  painful  swallowing   • Due   to   Ag-­‐Ab   complexes   on   the   basement   membrane   producing  
o Dysphagia:  difficult  swallowing   inflammation  
• Seen  as  whitish  deposits  on  tonsils  (pus  due  to  pyogenes).   • Edema,  Hypertension,  Azotemia,  Hematuria  &  Proteinuria    
• Symptoms:  Sore  throat  and  fever   • Some  go  into  chronicity  leading  to  Renal  failure  
• Pharynx  may  be  beefy  red  with  or  without  exudates.     • Patients  will  undergo  dialysis  if  it  becomes  chronic    
• Rheumatic  Fever  may  be  a  sequelae      
o It   is   caused   by   cross   reactions   between   antigens   of   the   heart   Table  2.  Clinical  mnemonic  for  GN  signs  
and  joint  tissues,  and  the  streptococcal  antigen  (M  protein).     CLINICAL  MNEMONIC:  CHEAP  BUN  
o Antibodies  against  M  protein  will  destroy  the  heart  valves   C-­‐  Creatinine  is  elevated  
o It  is  characterized  by  fever,  rash,  carditis,  and  arthritis.   H-­‐   Hematuria   (coffee/tea/cola   colored   urine;   hemolyzed   blood)   ,  
Hypertension  (both  adults  and  children)  
E-­‐  Edema  
A-­‐  Azotemia  
P-­‐  Proteinuria  
BUN  is  elevated  
 
 
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 MICROBIOLOGY 1.5b
 

2.  Rheumatic  Fever   G.  Treatment  

• Certain  Grp  A  Strep  contain  membrane  antigens  that  react  with   • PCN  (Penicillin)  :  Amoxicillin  or  Cephalexin  
human  heart  tissue  antigens   • Erythromycin  (But  it  causes  gastric  irritation)  
• The   patient   produces   antibodies   that   damage   heart   muscles   and   • Antimicrobials-­‐   NO   Effect   on   established   GN   or   RF   (prophylaxis  
valves,  as  well  as  joints   is  done  in  RF  to  prevent  reinfection)  
• Preceded  by  respiratory  infection   • Eradicate  strep  immediately  to  prevent  Post  Strep  Diseases  
• Fever  ,  malaise,  arthritis,  carditis      
• Tendency   to   be   reactivated   by   recurrent   strep   infection   H.  Prevention  and  Control  
producing  cumulative  heart  damage.    
o If   patients   get   6   attacks   of   tonsillitis   a   year   for   the   last   3   or   4   • Nasal  discharges  are  the  most  dangerous  source  for  spread  
years,  tonsillectomy  is  recommended   • Prophy   antibiotics   for   surgery   Pxs   w/   known   heart   valve  
• Treatment:  Prophylaxis  by  benzatine  penicillin  every  28  days  1.2   deformity  or  prosthetic  heart  valves  
million  units;  erythromycin  250  mg  2x  a  day  until  Px  is  28  y/o   • Eradicate  Grp  A  Strep  in  Pxs  with  respiratory  or  skin  infections  
  • Prophylaxis  for  those  who  have  suffered  an  attack  of  RF  
F.  Diagnosis    
1.  Specimens  
III.  STREPTOCOCCUS  AGALACTIAE  
• Definitive   Dx   :   Direct   culture   of   posterior   pharynx   and   tonsils.   • Group   B   streptococcus,   β   hemolytic   strep   in   diplococci   or   in  
Swabs  are  inoculated  on  broth  or  blood  agar.   short  chains  
• Vesicular  or  pustular  fluid  (pyoderma):  used  if  there  is  impetigo   • Normal  flora  of  the  pharynx,  GIT,  vagina    
• Cellulitis  and  Erysipelas  material:  Aspiration  of  tissue  fluids  from   • Forms  large  mucoid  colonies;  hydrolyzes  sodium  hippurate  
the   advancing   border   of   erysipelas   or   by   SC   injection   of   sterile   • (+)   CAMP   or   Christie   Atkins   Munch   Peterson   -­‐   complete  
saline  followed  by  reaspiration.   hemolysis  zone  when  inoculated  perpendicular  to  a  streak  of  S.  
• Serum   for   antibody   determination   (   ASO   ):   Used   if   there   is   an   aureus  
AGN  or  if  Strep  is  the  problem   • Common   cause   of   neonatal   septicemia   and   meningitis   (other  
  one  is  E.coli)    
2.  Smears  from  Pus  :  Gm  (+)  in  chains  or  pairs  (cocci)   o Remember:  Group  B  is  for  Baby  (  infant  diseases)  
  • Acquired  from  the  mother  during  delivery.    
3.   Smears   from   Throat   swab:   rarely   contributory   ;   Viridans   (normal   • Higher   incidence   in   prolonged   labor,   premature   rupture   of  
flora)   have   the   same   appearance   as   S.   pyogenes   which   leads   the   membranes(PROM)  or  obstetric  manipulation  
necessity  of  culture   • May  cause  bacteremia,  skin  and  soft  tissue  infections  in  people  
  with  DM,  elderly/immunocompromised  
4.  Culture   • May  also  cause  endocarditis  and  puerperal  infection  
• S.  Pyogenes  :  Β  hemolysis  (complete  hemolysis)  on  BAP;  PYR(+)(   • Pen  G  is  the  drug  of  choice    
red  color  ),  Inhibited  by  Bacitracin     o other   drugs:   erythromycin,   chloramphenicol   (not   used  
o Bacitracin  is  the  most  definitive  test  for  S.  Pyogenes.  All  the   because   it   causes   aplastic   anemia),   cephalosporin,  
other  Streptococcus  sp.  are  negative  to  Bacitracin.   vancomycin,  imipenem,  clindamycin  
• S.   viridans   :   Alpha   hemolytic   (incomplete   hemolysis)   on   BAP;    
PYR(-­‐)   (   no   change   remains   to   be   in   yellow   color   );   Bacitracin   IV.  GROUP  C  STREPTOCOCCI  
negative   • S.  equisimilis,  S.  zooepidemicus,  S.  dysgalactiae  
  • all  are  beta  hemolytics  except  S.  dysgalactiae  
Table  3.  Test  results  to  differentiate  pyogenes  and  viridians  infection   • S.  equisimilis  
Pyogenes   Viridans  
o source  of  streptokinase  for  thrombolytic  therapy  (for  stroke  
B  hemolysis  on  BAP   Alpha  hemolysis  on  BAP  
or  MI  and  if  the  patient  comes  in  within  golden  period  of  less  
Pyr  (+):  red   Pyr  (-­‐):yellow  
than  3  hours)  
Bacitracin  (+)   Bacitracin  (-­‐)  
o may   cause   pharyngitis,   puerperal   sepsis,   endocarditis,  
 
bacteremia,   osteomyelitis,   brain   abscess,   post-­‐op   wound  
5.  Serologic  Test:  Estimates  rise  in  antibody  titer  (ASO  Titer)  
infection  and  pneumonia  
 
 
6.  Rapid  antigen  detection  test  
• Rapid   detection   of   Grp   A   antigen   from   a   throat   swab   using   IV.  GROUP  D  STREPTOCOCCI  
agglutination   • Enterococcal   species:   Enterococcus   faecalis,   Enterococcus  
o (+):   the   latex   particles   clump   together   giving   it   a   rough   faecium,  Enterococcus  durans  
appearance   • Non-­‐Enterococcal  species:  Streptococcus  equines,  Streptococcus  
o (-­‐):  the  latex  particles  remain  separate,  giving  the  suspension   bovis  
a  milky  appearance  (exhibited  by  S.  pyogenes)    
  A.  General  Characteristics  
• Grow  as  diplococcic  or  short  chains  
• Part   of   the   normal   enteric   flora,   inhabits   the   skin,   upper  
resipiratory  &  GUT  
• Gamma   to   alpha   haemolytic,   PYR   (+),   Grows   in   40%   bile,   can  
hydrolyze  Esculin  (+  turns  black)  
 
Figure  11.  Rapid  antigen  test   • Distinguishing  feature  of  Enterococci  (E.  faecium):  Can  grow  in  
  the  presence  of  6.5%  NaCl  
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 MICROBIOLOGY 1.5b
 

• Distinguishing  feature  of  S.  bovis:  Lysed  in  the  presence  of  6.5%   • Cultural  characteristics  
NaCl   o Complex  nutritional  requirements  
  o Has  absolute  nutritional  requirement  for  Choline  
B.  Clinical  Infection   o α  hemolytic  on  BAP,  facultative  anaerobe  
• Most   commonly   E.   faecalis:   UTI,   biliary   infection,   septicaemia,   o For  primary  isolation:  Tryptic  soy  or  Brain  heart  infusion  broth  
endocarditis,  wound  infection,  intra-­‐abdominal  abscess   enriched  with  5%  defibrinated  blood  
§ Young   cultures   of   encapsulated   pneumococci   produce  
• Streptococcus   bovis:   endocarditis   or   bacteremia   may   be  
circular,   glistening,   dome-­‐shaped   colonies   1   mm   in  
associated  with  GI  malignancy  (colonic  CA)  
diameter;  later  center  of  colonies  collapse  
• Presence   of   S.   bovis   in   the   blood   should   alert   the   clinical   to   a  
§ Encapsulated  strain  produce  rough  colonies    
possible  occult  malignancy  
 
 
G.  Laboratory  Identification  
C.  Treatment  
• Optochin  Sensitivity  
• Enterococcus  
o Disc   with   a   quinine   derivative   that   inhibits   the   growth   of  
o PCN  +  Gentamycin  or  Streptomycin  
pneumococci  but  not  Viridans  Strep  
o Vancomycin  &  Erythromycin  
o Used   to   distinguish   the   2   organisms   because   both   are   α  
o E.  faecium  is  more  likely  to  be  vancomycin  or  multiply  resistant  
haemolytic  
than  E.  faecalis  
 
• S.  faecalis  and  S.  bovis  
o PCN  G  
o Azithromycin,  Clarithromycin  (&  other  macrolides)  
 
D.  S.  anginosus-­‐milleri  Group  
• S.  constellatus,  S.  intermedius,  S.  anginosus,  S.  milleri  
• normal  flora  of  the  oral  cavity  and  the  gingival  crevices  
• May   be   classified   as   Viridans   strep   because   they   are   also   α-­‐  
Figure  13.  Optochin  Sensitivity  Test  –  leftmost:  S.  Pneumonia  
hemolytic  
 
• Dental,  brain,  lung  and  intra-­‐abdominal  abscess  
• Bile  Solubility  
 
o Autolytic   amidase   or   Autolysin   that   cleaves   the   peptidoglycan  
E.  Viridans  Streptococci  
is  present  in  pneumococci  but  not  in  Viridans  Strep  
• Group  of  streptococci   o The   amidase   is   activated   by   bile   &   bile   salts,   β   lactam  
• S.  mitis,  S.  mutans,  S.  salivarius,  S.  sanguis   antibiotics  &  remaining  in  a  stationary  phase  resulting  in  lysis  
• α  haemolytic,  PYR  (-­‐),  Bacitracin  (-­‐)   of  the  organism  
• Not  inhibited  by  Optochin,  not  bile  soluble    
• Most   prevalent   member   of   the   (N)   flora   of   the   mouth   and   the  
upper   respiratory   tract.   Found   also   in   the   GIT   &   female   genital  
tract  
• Pathogenesis  
o May   reach   the   bloodstream   because   of   dental   manipulation,  
trauma  or  GIR  or  GU  instrumentation  &  cause  endocarditis  
o Wound   infection,   meningitis,   biliary   &   intra-­‐abdominal  
infections  may  occur  
o S.   sanguis:   most   frequent   single   species   causing   bacterial    
endocarditis   Figure  14.  Bile  Solubility  Test  
o S.  mutans:  dental  caries  &  dental  plaque    
  • Quellung  Reaction  
F.  Streptococcus  pneumonia/Pneumococcus   o Pneumococci  +  Polyvalent  Antiserum  =  capsule  swelling  
o Most  useful  &  rapid  method  for  ID  of   pneumococci  in   sputum,  
CSF,  exudates  
o Polyvalent  antiserum  or  “Omniserum”  contains  antibodies  for  
all  types  
 

 
Figure  12.  Streptococcus  pneumonia  
• Most   common   cause   of   community   acquired   pneumonia   &  
meningitis  in  adults  
• Cause  of  otitis  media,  septicaemia,  sinusitis    
Figure  15.  Quellung  Reaction.  Notice  the  paired  arrangement  of  the  cells.  The  
• Normal  inhabitants  of  upper  respiratory  tract  
capsule  has  been  made  more  apparent  by  the  reaction  of  specific  pneumococcal  
• Gm   (+)   diplococcic,   encapsulated,   non-­‐motile,   lancet   shaped,   in   antiserum  that  makes  S.  pneumoniae  appear  to  swell.  
chains  or  pairs    
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 MICROBIOLOGY 1.5b
 

• Animal  Inoculation   • Complications:  

o Infected  sputum  is  injected  intraperitoneally  to  a  mouse     o Pleural  effusion  that  can  lead  to  emphysema  
o The  mouse  succumbs  to  a  fatal  infection  in  48hours   o Meningitis,  pericarditis,  endocarditis  
   
H.  Pathogenesis   2.  Otitis  Media  
• Types  of  Pneumococci   • The  most  common  bacterial  infection  of  children.  
o Adults:  Type  1-­‐8  (75%  of  Pneumococci  cases)  
o Children:  Types  6,  14,  19,  23  
• Determinants  of  pathogenecity  
o Polysaccharide  capsule  
§ 91  types;  Pneumococcus  damages  host  tissue  as  long  as  
it  is  outside  the  phagocytic  cell.  Capsule  is  antiphagocytic  
antigenic  
o Pili  
§ Enable  the  attachment  of  encapsulated  pneumococci  to  
the  epithelial  cells  of  the  upper  respiratory  tract  
 
o Neuraminidase   Figure  16.  Otitis  Media  
§ Disrupts  cell  membranes;  contributes  to  invasiveness    
o Proteases   3.  Meningitis    
§ Immunoglobulin   degrading   extracellular   proteases;   • Pneumococcus  is  the  most  common  cause  of  meningitis  in  adults  
antiphagocytic   &  of  recurrent  meningitis  in  all  age  groups.  
§ Eliminate  IgA,  IgG,  IgM   • Usually   preceded   by   pulmonary   infection,   URTI,   sinusitis   or   otitis  
o Choline  binding  protein  A   media  
§ Major   adhesin   allowing   the   pneumococcus   to   attach   to    
TH
carbohydrates   on   epithelial   cells   of   the   human   NOTES  FROM  TORTORA,  FUNKE  &  CASE,  10  EDITION:  
nasopharynx   -­‐   At   present,   an   effective   Hib   vaccine   is   in   use;   recommended   for   infants   under  
o Pneumolysin  O  Toxin   2  y/o.  
§ Hemolysin;  most  important   -­‐  Diagnosis:  sample  of  CSF  obtained  by  spinal  tap/lumbar  puncture  
§ Inhibits  chemotaxis  of  PMN   -­‐  Portal  of  entry:  respiratory  tract  
-­‐  Method  of  transmission:  Aerosols  
§ Toxic   effect   on   respiratory   epithelium   producing   ciliary  
-­‐  Treatment:  Cephalosporin  
slowing  &  epithelial  disruption   -­‐  Prevention:  Polysaccharide  vaccine  
§ This   toxin   stimulates   production   of   pro-­‐inflammatory    
cytokines  
4.  Bacteremia/Sepsis  
• Predisposing  Factors  
• Common   in   individuals   who   are   functionally   or   anatomically  
o Viral/Other   Respiratory   infections:   Damages   respiratory   asplenic  (sickle  cell  disease)  
epithelium    
o Accumulated  secretions:  Protection  from  phagocytosis  
K.  Diagnostic  Laboratory  Test  
o Bronchial  obstruction  
o Irritants  that  disturb  mucociliary  action   • Specimens:  
o Alcohol,   Drugs,   Anesthesia,   Morphine:   Depresses   Nasopharyngeal  swab  
o
phagocytosis  &  the  cough  reflex  &  facilitates  aspiration   Blood  
o
o Pulmo  congestion,  CHF,  Prolonged  bed  rest   Pus  
o
o Malnutrition  &  Immunosuppression   Sputum  
o
  Spinal  fluid  
o
I.  Pathology   • Blood  should  be  drawn  for  culture  before  antibiotics  are  given.  
o Sputum  specimens:  from  the  lungs;  not  saliva  
• Outpouring   of   edema   fluid   in   the   alveoli   which   facilitates  
§ Gm   Stain:   (+)   lancet   shaped   diplococcic   –   a   presumptive  
microbial  multiplication  &  spread  to  other  alveoli  
diagnosis  of  pneumococcal  pneumonia  can  be  made  
• PMNs  &  RBCs  accumulate  in  the  alveoli  →  consolidation   § Culture:  BHI,  Trypticase  Soy  agar  &  broth  with  5%  blood  
• Pneumococci  reaches  bloodstream  via  the  lymphatics   Ø α  hemolytic  colonies    
• Later:  Phagocytes  take  up  &  digest  the  pneumococci   Ø Bile  soluble  
  Ø Optochin  sensitive  
J.  Clinical  Findings   Ø (+)  Quellung  
1.  Pneumococcal  Pneumonia/  Acute  Bacterial  Pneumonia   • Treatment  
• Rarely   a   primary   primary   infection.   Results   only   when   the   o PCN  G  
normal  defense  barriers  of  the  respiratory  tract  is  breached.   o Cephalosporin  (Cefotaxime,  Ceftriaxone)  
• Pneumonia   is   frequently   preceded   by   an   upper   or   middle   o Erythromycin  
respiratory   viral   infection,   which   predisposes   to   S.   pneumonia   o Chlorampenicol  for  meningitis  (crosses  the  blood  brain  barrier)  
infection  of  the  pulmonary  parenchyma   • Control  
• A   leading   cause   of   death,   especially   in   older   adults   &   those   o Vaccines  provide  90%  protection  
whose  resistance  is  impaired   o Pneumococcal   polysaccharide   vaccine   (PPV):   Immunizes  
• Acute  fever,  chills,  severe  pleuritic  pain   against  23  seroptypes.  For  adults.  
• Cough  with  “rusty”  mucopurulent  sputum  

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 MICROBIOLOGY 1.5b
 

o Pneumococcal   conjugate   vaccine   13   (PCV   13):   Effective   in    

infants  &  toddlers  (ages  6  wks-­‐5  yrs  old)    
   
TH
NOTES  FROM  TORTORA,  FUNKE  &  CASE,  10  EDITION:    
-­‐  Principal  Vaccine:  Purified  polysaccharide  from  7  strains  of  S.  Pneumonia    
-­‐   Recommendation:   For   adults   with   certain   chronic   diseases;   people   over   65;    
children  over  2-­‐23  months    
-­‐  Booster:  None  if  first  administered  ≥  24  months  
 

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