Foundations in

Microbiology
Sixth Edition
Chapter 18
The Cocci of Medical
Importance
Lecture PowerPoint to accompany
Talaro
Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
2
General Characteristics of the
Staphylococci
Common inhabitant of the skin and mucous
membranes
Spherical cells arranged in irregular clusters
Gram-positive
Lack spores and flagella
May have capsules
31 species
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Staphylococcus aureus
Grows in large, round, opaque colonies
Optimum temperature of 37
o
C
Facultative anaerobe
Withstands high salt, extremes in pH, and
high temperatures
Carried in nasopharynx and skin
Produces many virulence factors
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Virulence factors of S. aureus
Enzymes:
Coagulase coagulates plasma and blood;
produced by 97% of human isolates; diagnostic
Hyaluronidase digests connective tissue
Staphylokinase digests blood clots
DNase digests DNA
Lipases digest oils; enhances colonization on
skin
Penicillinase inactivates penicillin
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Virulence factors of S. aureus
Toxins:
Hemolysins (, , , ) lyse red blood cells
Leukocidin lyses neutrophils and macrophages
Enterotoxin induce gastrointestinal distress
Exfoliative toxin separates the epidermis from the
dermis
Toxic shock syndrome toxin (TSST) - induces
fever, vomiting, shock, systemic organ damage


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Epidemiology and Pathogenesis
Present in most environments frequented by humans
Readily isolated from fomites
Carriage rate for healthy adults is 20-60%.
Carriage is mostly in anterior nares, skin,
nasopharynx, intestine.
Predisposition to infection include: poor hygiene and
nutrition, tissue injury, preexisting primary infection,
diabetes, immunodeficiency.
Increase in community acquired methicillin resistance
- MRSA
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Staphylococcal Disease
Range from localized to systemic
Localized cutaneous infections invade skin through
wounds, follicles, or glands
folliculitis superficial inflammation of hair follicle; usually
resolved with no complications but can progress
furuncle boil; inflammation of hair follicle or sebaceous
gland progresses into abscess or pustule
carbuncle larger and deeper lesion created by aggregation
and interconnection of a cluster of furuncles
impetigo bubble-like swellings that can break and peel
away; most common in newborns

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Staphylococcal Disease
Systemic infections
osteomyelitis infection is established in the
metaphysis; abscess forms
bacteremia - primary origin is bacteria from
another infected site or medical devices;
endocarditis possible

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Staphylococcal Disease
Toxigenic disease
food intoxication ingestion of heat stable
enterotoxins; gastrointestinal distress
staphylococcal scalded skin syndrome toxin
induces bright red flush, blisters, then
desquamation of the epidermis
toxic shock syndrome toxemia leading to
shock and organ failure


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Other Staphylococci
Coagulase-negative staphylococcus; frequently involved
in nosocomial and opportunistic infections
S. epidermidis lives on skin and mucous membranes;
endocarditis, bacteremia, UTI
S. hominis lives around apocrine sweat glands
S. capitis live on scalp, face, external ear
All 3 may cause wound infections by penetrating
through broken skin.
S. saprophyticus infrequently lives on skin, intestine,
vagina; UTI
17
Identification of Staphylococcus in
Samples
Frequently isolated from pus, tissue exudates,
sputum, urine, and blood
Cultivation, catalase, biochemical testing,
coagulase
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Clinical Concerns and Treatment
95% have penicillinase and are resistant to
penicillin and ampicillin.
MRSA methicillin-resistant S. aureus
carry multiple resistance
Abscesses have to be surgically perforated.
Systemic infections require intensive
lengthy therapy.
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Prevention of Staphylococcal Infections
Universal precautions by healthcare providers
to prevent nosocomial infections
Hygiene and cleansing

21
General Characteristics of Streptococci
Gram-positive spherical/ovoid cocci arranged in long
chains; commonly in pairs
Non-spore-forming, nonmotile
Can form capsules and slime layers
Facultative anaerobes
Do not form catalase, but have a peroxidase system
Most parasitic forms are fastidious and require
enriched media.
Small, nonpigmented colonies
Sensitive to drying, heat and disinfectants
25 species

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Streptococci
Lancefield classification system based on
cell wall Ag 17 groups (A,B,C,.)
Another classification system is based on
hemolysis reactions.
b-hemolysis A,B,C,G and some D strains
a hemolysis S. pneumoniae and others
collectively called viridans
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Human Streptococcal Pathogens
S. pyogenes
S. agalactiae
Viridans streptococci
S. pneumoniae
Enterococcus faecalis

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b-hemolytic S. pyogenes
Most serious streptococcal pathogen
Strict parasite
Inhabits throat, nasopharynx, occasionally
skin
27
Virulence Factors of b-hemolytic
S. pyogenes
Produces surface antigens:
C-carbohydrates protect against lysozyme
Fimbriae - adherence
M-protein contributes to resistance to
phagocytosis
Hyaluronic acid capsule provokes no
immune response

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Virulence Factors of b-hemolytic
S. pyogenes
Extracellular toxins:
streptolysins hemolysins; streptolysin O (SLO)
and streptolysin S (SLS) both cause cell and
tissue injury
pyogenic toxin (erythrogenic) induces fever
and typical red rash
superantigens strong monocyte and
lymphocyte stimulants; cause the release of
tissue necrotic factor



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Virulence Factors of b-hemolytic
S. pyogenes
Extracellular enzymes
streptokinase digests fibrin clots
hyaluronidase breaks down connective tissue
DNase hydrolyzes DNA
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Epidemiology and Pathogenesis
Humans only reservoir
Inapparent carriers
Transmission contact, droplets, food, fomites
Portal of entry generally skin or pharynx
Children predominant group affected for
cutaneous and throat infections
Systemic infections and progressive sequelae
possible if untreated


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Scope of Clinical Disease
Skin infections
Impetigo (pyoderma) superficial lesions that break
and form highly contagious crust; often occurs in
epidemics in school children; also associated with
insect bites, poor hygiene, and crowded living
conditions
Erysipelas pathogen enters through a break in the
skin and eventually spreads to the dermis and
subcutaneous tissues; can remain superficial or become
systemic
Throat infections
Streptococcal pharyngitis strep throat
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Scope of Clinical Disease
Systemic infections
Scarlet fever strain of S. pyogenes
carrying a prophage that codes for
pyrogenic toxin; can lead to sequelae
Septicemia
Pneumonia
Streptococcal toxic shock syndrome
36
Long-Term Complications of Group
A Infections
Rheumatic fever follows overt or subclinical
pharyngitis in children; carditis with extensive
valve damage possible, arthritis, chorea, fever
Acute glomerulonephritis nephritis,
increased blood pressure, occasionally heart
failure; can become chronic leading to kidney
failure
37
Group B: Streptococcus agalactiae
Regularly resides in human vagina, pharynx
and large intestine
Can be transferred to infant during delivery
and cause severe infection
most prevalent cause of neonatal pneumonia,
sepsis, and meningitis
15,000 infections and 5,000 deaths in US
Pregnant women should be screened and treated.
Wound and skin infections and endocarditis in
debilitated people
38
Group D Enterococci and Groups C and
G Streptococci
Group D:
Enterococcus faecalis, E. faecium, E. durans
normal colonists of human large intestine
cause opportunistic urinary, wound, and skin
infections, particularly in debilitated persons
Groups C and G:
common animal flora, frequently isolated from
upper respiratory; pharyngitis, glomerulonephritis,
bacteremia

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Identification
Cultivation and diagnosis ensure proper
treatment to prevent possible complications.
Rapid diagnostic tests based on monoclonal
antibodies that react with C-carbohydrates
Culture using bacitracin disc test, CAMP test
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Treatment and Prevention
Groups A and B are treated with penicillin.
Sensitivity testing needed for enterococci
No vaccines available
43
a-Hemolytic Streptococci:
Viridans Group
Large complex group
Streptococcus mutans, S. oralis, S. salivarus,
S. sanguis, S. milleri, S. mitis
Most numerous and widespread residents of the
gums and teeth, oral cavity and also found in
nasopharynx, genital tract, skin
Not very invasive; dental or surgical procedures
facilitate entrance

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Viridans Group
Bacteremia, meningitis, abdominal infection,
tooth abscesses
Most serious infection subacute endocarditis
blood-borne bacteria settle and grow on heart
lining or valves
Persons with preexisting heart disease are at high
risk.
Colonization of heart by forming biofilms
45
Viridans Group
S. mutans produce slime layers that adhere
to teeth, basis for plaque.
Involved in dental caries
Persons with preexisting heart conditions
should receive prophylactic antibiotics
before surgery or dental procedures.


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Streptococcus pneumoniae: The
Pneumococcus
Causes 60-70% of all bacterial pneumonias
Small, lancet-shaped cells arranged in pairs
and short chains
Culture requires blood or chocolate agar.
Growth improved by 5-10% CO
2
Lack catalase and peroxidases cultures die in
O
2
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S. pneumoniae
All pathogenic strains form large capsules
major virulence factor.
Specific soluble substance (SSS) varies among
types.
84 capsular types have been identified
Causes pneumonia and otitis media
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Epidemiology and Pathology
5-50% of all people carry it as normal flora in the
nasopharynx; infections are usually endogenous.
Very delicate, does not survive long outside of its
habitat
Young children, elderly, immune compromised, those
with other lung diseases or viral infections, persons
living in close quarters are predisposed to pneumonia
Pneumonia occurs when cells are aspirated into the
lungs of susceptible individuals.
Pneumococci multiply and induce an overwhelming
inflammatory response.
Gains access to middle ear by way of eustachian tube


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Cultivation and Diagnosis
Gram stain of specimen presumptive
identification
hemolytic; optochin sensitivity
Quellung test or capsular swelling reaction



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Treatment and Prevention
Traditionally treated with penicillin G or V
Increased drug resistance
Two vaccines available for high risk
individuals:
capsular antigen vaccine for older adults and
other high risk individuals-effective 5 years
conjugate vaccine for children 2 to 23 months



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Family Neisseriaceae
Gram-negative cocci
Residents of mucous membranes of warm-
blooded animals
Genera include Neisseria, Moraxella,
Acinetobacter.
2 primary human pathogens:
Neisseria gonorrhoeae
Neisseria meningitidis
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Genus Neisseria
Gram-negative, bean-shaped, diplococci
None develop flagella or spores.
Capsules on pathogens
Pili
Strict parasites, do not survive long outside of the host
Aerobic or microaerophilic
Oxidative metabolism
Produce catalase and cytochrome oxidase
Pathogenic species require enriched complex media
and CO
2.

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Neisseria gonorrhoeae:
The Gonococcus
Causes gonorrhea, an STD
Virulence factors:
pili, other surface molecules for attachment;
slows phagocytosis
IgA protease cleaves secretory IgG
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Epidemiology and Pathology
Strictly a human infection
In top 5 STDs
Infectious dose 100-1,000
Does not survive more than 1-2 hours on
fomites



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Gonorrhea
Infection is asymptomatic in 10% of males and 50%
of females.
Males urethritis, yellowish discharge, scarring
and infertility
Females vaginitis, urethritis, salpingitis (PID)
mixed anaerobic abdominal infection, common
cause of sterility and ectopic tubal pregnancies
Extragenital infections anal, pharygeal,
conjunctivitis, septicemia, arthritis
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Gonorrhea in Newborns
Infected as they pass through birth canal
Eye inflammation, blindness
Prevented by prophylaxis immediately after
birth
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Diagnosis and Control
Gram stain Gram-negative intracellular (neutrophils)
diplococci from urethral, vaginal, cervical, or eye
exudate presumptive identification
20-30% of new cases are penicillinase-producing
PPNG or tetracycline resistant TRNG
Combined therapies indicated
Recurrent infections can occur.
Reportable infectious disease


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Neisseria meningitidis: The
Meningococcus
Virulence factors:
capsule
pili
IgA protease
endotoxin
12 strains; serotypes A, B, C cause most
cases
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Epidemiology and Pathogenesis
Prevalent cause of meningitis; sporadic or epidemic
Human reservoir nasopharynx; 3-30% of adult
population; higher in institutional settings
High risk individuals are those living in close
quarters, children 6months-3 years, children and
young adults 10-20 years.
Disease begins when bacteria enter bloodstream, pass
into cranial circulation, and multiply in meninges
Very rapid onset; neurological symptoms; endotoxin
causes hemorrhage and shock; can be fatal

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Clinical Diagnosis
Gram stain CSF, blood, or nasopharyngeal
sample
Culture for differentiation
Rapid tests for capsular antigen
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Treatment and Prevention
Treated with IV penicillin G, chloramphenicol
Prophylactic treatment of family members,
medical personnel, or children in close contact
with patient
Vaccines exist for group A and C.

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Other Gram-negative Cocci and
Coccobacilli
Genus Branhamella
Branhamella catarrhalis found in nasopharynx:
significant opportunist in cancer, diabetes, alcoholism
Genus Moraxella
bacilli; found on mucous membranes
Genus Acinetobacter
Gram-negative bacilli; nonliving reservoir; source of
nosocomial infections