1. Gram + Cocci: Staphylococcus & Streptococcus Nestor T. Hilvano, M.D., M.P.H.

2. Learning Objectives 1.Contrast Staphylococcus aureus with Staphylococcus epidermis in terms of virulence in humans. 2.Discuss the structural and enzymatic features and toxins of Staphylococcus that allow it to evade the body's defenses. 3.Describe cutaneous lesions and systemic diseases caused by Staphylococcus aureus. 4.Discuss briefly staphylococcal resistance to antimicrobial drugs 5.Describe two structures in Streptococcus pyogenes that allow this organisms to survive against the human defense mechanisms. 6.Identify the conditions under which Group A streptococci cause disease. 7.Discuss the epidemiology, diagnosis, treatment, and prevention of Group B (Streptococcus agalactiae ) infections. 8.Identify the normal location of viridans streptococci in the human body and describe three serious diseases they cause. 9.Describe how the structure of Streptococcus pneumoniae affects its pathogenicity. 10.Discuss the diagnosis, treatment, and prevention of pneumococcal diseases. 11.Describe Enterococcus as to pathogenicity and the diagnosis, treatment, and prevention of their diseases.

3. Staphylococcus Gram + in _____, facultative anaerobic yellow in culture Catalase positive SEM- grapelike S. aureus – virulent; coagulase +;1/3 pop. are colonized (no illness) & common source of germs to others S. epidermidis – normal flora of human skin; opportunistic pathogens

4. Pathogenicity of Staphylococcus Protein A – binds with IgG Bound coagulase – forms clot that hide bacteria from phagocytes Polysaccharide slime layers – facilitate attachment to surfaces (catheters, shunts, artificial heart valves) Enzymes – leukocidin, hyaluronidase, staphylokinase, lipase, and beta-lactamase Toxins – exfoliative toxins, TSS toxins, and enterotoxins

5. Epidemiology of Staph Infection Found in human skin Transmitted through - direct contact and via fomites 20% - 40% adults are carriers Prevention - proper hand washing, aseptic techniques, proper cleaning of wound, use of antiseptics

6. Staph. Cutaneous Diseases Folliculitis – infection of hair follicles; pus-filled vesicles Furuncle – commonly called _____; localized superficial Carbuncle – extends deeper Rx: antibiotics; drainage (I & D) What is the most common causative agent of boil?

7. Staph. Cutaneous Diseases Scalded skin syndrome – red skin; blisters; slough off within 2 days; caused by exfoliative toxin Impetigo – mostly in young children; red patches; pus-filled vesicles that crust; 80% caused by S. aureus Wound infections – surgical infection by contaminated personnel, equipment

8. Staphylococcus Food Poisoning Caused by enterotoxin-contaminated food (salad, processed meat, ice cream, pastries) Food remain at room temp. or warmer for several hours * Does reheating of (inoculated) food inactivate enterotoxins? Why? a) toxins are heat labile b) toxins are heat stable Symptoms appear within four hours after ingestion; self limiting; usually resolved about 24 hours (consumed staph do not continue to produce toxins)

9. Staph. Systemic Diseases Toxic Shock Syndrome - first described in 1978 - 1980 = 299 cases, 25 deaths, caused by tampons (fever, rash, hypotension, diarrhea, vomiting) - TSS toxin in wound or abraded vagina absorbed into blood; results to low BP/ inadequate O2 supply to vital organs - Penicillin resistant

10. Staph. Systemic Diseases Bacteremia Endocarditis Meningitis Pneumonia and Empyema (fluid with pus) Osteomyelitis

11. Diagnosis and Treatment of Staph. Infection Dx: - identify S. aureus in gram stain, ______; and coagulase _____. Only 5% susceptible to penicillin today; methicillin drug of choice (semi-synthetic) MRSA – resistant to beta-lactam antibiotics (penicillin, methicillin, and cephalosporins) - nosocomial infections - called “superbug”, discovered in UK (1961), now found worldwide - vancomycin used to Rx

12. Streptococcus Gram + cocci in ____ (a. chain b. clumps) Auxotrophs –requires complex media (Vit. B, aa., purines + pyrimidines) Catalase negative Facultative anaerobe

13. Group A β-hemolytic Streptococcus Streptococcus pyogenes Pathogenicity – protein M and Hyaluronic capsule (evades phagocytosis) - enzymes (streptokinase dissolves blood clot; hyaluronidase facilitates spread of organisms) - toxins (pyrogenic; pyogenic) White colonies sorrounded by zone of beta- hemolysis (clear zone) Infect the pharynx or skin

14. Group A Streptococcal Diseases Strep throat (pharyngitis) – spread via ___ (a. ingestion b. respiratory droplets). Scarlet fever – reaction to erythrogenic toxin; fever of 101˚F (38.3˚C), strawberry tongue, red rash (by capillary distensions) within 24 hrs. and fades in a week followed by peeling.

15. Group A Streptococcal Diseases Necrotizing fasciitis – flesh-eating strep (1994 England; 1998 Texas); enter thru breaks in skin; toxins destroy muscle and fat tissues, toxemia, organ failure, > 50% die; spread along fascia of muscle Post-streptococcal Glomerulonephritis – autoimmune, anti-strep antibodies cross-react w/ antigens in glomerular b.m.; obstruct blood flow, HPN, and low urine output; transplant

16. Rheumatic Fever Autoimmune; cardiac valve diseases Major criteria include: carditis; polyarthritis; chorea; subcutaneous nodules (small, painless bumps); rash (a red, irregular rash on the trunk) Minor criteria include: fever; arthralgia; previous rheumatic carditis; changes in the ECG pattern; abnormal sedimentation rate or C-reactive protein (laboratory tests performed on blood) Diagnosis - made when two of the major criteria, or one major criterion plus two minor criteria, are present along with evidence of a strep infection.

17. Diagnosis and Rx of Streptococcal Infection Identify organisms in skin Identify Group A strep Antigens Penicillin; susceptible to topical bacitracin Erythromycin or cephalosporin – penicillin-sensitive patients

18. Group B Strep: Strep. agalactiae Gram + cocci, in chains, beta-hemolytic 25% in normal vaginal flora of women; can cause UTI and endometritis in women Cause neonatal disease (bacteremia, meningitis, pneumonia) through birth canal or health care workers Dx – ELISA and agglutination tests Pen G drug of choice

19. Alpha-Hemolytic Strep. viridans Produce a green pigment (incomplete) Inhabit the mouth, pharynx, GIT, urinary, and genital tracts Opportunists; one cause of dental caries; subacute endocarditis with vegetative growths on valves Susceptible to penicillin

20. Streptococcus pneumoniae Gram + cocci in short chain, commonly in pairs (lancet-shaped diplococci) Polysaccharide capsules and phosphorylcholine in cell walls confer virulence. Pharyngeal microbiota Can colonize lungs, sinuses, and middle ear 85% of cases of pneumonia Dx: Gram stain of sputum, quellung reaction (anticapsular antibodies caused swelling of capsules), optochin test (differentiate S. pneumonia from other alpha-hemolytic strep, inhibition around the disc) agglutination test

21. Enterococcus under Group D Strep unencapsulated; prod. gas on sugar fermentation; nonhemolytic Harbor normally in intestinal tracts of human and animals E. faecalis and E. faecium – can be pathogenic in human; secrete bacteriocins (proteinaceous toxins produced by bacteria to inhibit growth of other bacteria) Serious disease to urinary tract and bloodstream Dx. – not sensitive to bile, lack capsule= which distinquishes from S.pneumoniae Prev. – good hygiene and aseptic technique

22. Homework 1.Define terms – pyrogenic, pyogenic, furuncle, carbuncle, folliculitis, bacteriocins, nosocomial infection, optochin test, and Quellung reaction. 2.Differentiate staphylococcus and streptococcus as to morphology in gram stain (+/-, clusters/chain) and reaction to catalase test (+/-). 3.Identify microbes: a) gram + cocci, coagulase +; b) gram + cocci, group A beta hemolytic; c) gram + cocci, alpha hemolytic; d) gram + cocci lancet-shaped 4.Discuss staphylococcal toxic shock syndrome. 5.Identify the most common causative bacteria of : __scalded skin syndromea. streptococcus viridans __sore throat (pharyngitis)b. enterococcus faecalis __lung infectionc. staphylococcus aureus __commonly isolated in GITd. streptococcus pneumonia __ dental caries opportunist e. streptococcus pyogenes