Streptococci and Other Streptococci-like Organisms By:Dr. Aghaei
Case Study 9-year-old boy complains of fever and sore throat On examination, his pharynx is red and his tonsils are swollen His cervical lymph nodes are also swollen A throat culture is taken
Points to Consider Clinical symptoms presented by the patient The serious complications that may result from this type of infection How to recover and identify the infecting organism What other species are involved in clinical infections Other points to consider
Streptococcus and Enterococcus: General Characteristics Gram-positive, facultatively anaerobic cocci Most are typically spherical; some may appear elongated
Streptococcus and Enterococcus: General Characteristics Appear in chains when smears are prepared from broth cultures Catalase-and oxidase-negative
Streptococcus and Enterococcus: Habitat and Clinical Infections Habitat Indigenous respiratory tract microbial flora of animals and humans Certain species are also found in the gastrointestinal and urogenital tracts of humans Clinical infections Upper and lower respiratory tract infections Urinary tract infections Wound infections Endocarditis
Streptococcus and Enterococcus: Cell Wall Structure Thick peptidoglycan layer Teichoic acid C=carbohydrate layer present except in viridans group Capsule in S. pneumoniae and in young cultures of most species
Streptococcus and Enterococcus: General Characteristics Hemolytic Patterns Beta (ß) a clear, colorless zone around the colony caused by complete hemolysis of the red blood cells in the agar
Streptococcus and Enterococcus: Hemolytic Patterns Alpha (a):hemolysis showing a greenish discoloration around the area surrounding the colony due to incomplete hemolysis of the red blood cells in the agar
Streptococcus and Enterococcus: Hemolytic Patterns No hemolysis (gamma): colonies show no hemolysis or discoloration
Classification of Streptococcus and Enterococcus Species Hemolysis Group Antigen Common Terms S.pyogenes ß A Group A streptococci S.agalactiae ß B Group B streptococci S. equisimilis ß C Group C streptococci E. faecalis Alpha or no D Enterococci E. faecium hemolysis E. durans ( rarely ß ) S. bovis S. equinus Alpha ( )or none (rarely ß) D Nonenterococci Disease Association(s) Pharyngitis; scarlet fever pyoderma; rheumatic fever; AGN Neonatal sepsis; puerperal fever; pyogenic infections; pneumonia; meningitis Pharyngitis; impetigo; pyogenic infections Urinary tract infections Wound infections Bacteremia; Endocarditis Urinary tract; pyogenic infections; Endocarditis infections S. pneumoniae Alpha ( ) hemolysis Pneumococcus Bacteremia; pneumonia; meningitis; Viridans and Nonhemolytic S. sanguis S. salivarius S. mitis or nonhemolytic S. milleri S. mutans Other species Alpha ( ) hemolysis or no hemolysis - Viridans strep Endocarditis Dental caries
Biochemical Identification Susceptibility tests Bacitracin (0.04 units) or A disk Identifies Group A streptococci Group A streptococcus is susceptible to A disk (left)
Biochemical Identification Susceptibility test Trimethoprim sulfamethoxazole (SXT) Inhibits beta-hemolytic streptococcal groups other than A and B Group A streptococcus growing in the presence of SXT
Biochemical Identification Susceptibility test Optochin P disk Differentiates S. pneumoniae from other alpha-hemolytic streptococci (Viridans group) Bile solubility test S pneumoniae lyses in a suspension of sodium deoxycholate while other viridans streptococci do not lyse
Biochemical Identification PYR hydrolysis Substrate L-pyrrolidonylb-napthlyamide (PYR) is hydrolyzed by Group A Streptococci and Enterococcus sp. As specific as 6.5% NaCl broth for Enterococcus sp. More specific than Bacitracin for Group A streptococci PYR test for Group A streptococci and enterococci. Both are positive for this test (right); left is a negative result
Biochemical Identification Hydrolysis Hippurate hydrolysis Differentiates Group B streptococci from other beta hemolytic streptococci Group B streptococci hydrolyzes sodium hippurate
Biochemical Identification Christie-Atkins, Munch- Petersen (CAMP) test Detects the production of enhanced hemolysis that occurs when b-lysin and the hemolysins of Group B streptococci come in contact Group B streptococci showing the classical arrow-shaped hemolysis near the staphylococcus streak
Biochemical Identification Bile Esculin hydrolysis Ability to grow in 40% bile and hydrolyze Esculin are features of streptococci that possess Group D antigen Growth in 6.5% NaCl broth Differentiates Group D streptococci from enterococci Both Group D streptococci and enterococci produce a positive (left) bile Esculin hydrolysis test.
Clinically Significant Streptococci: Streptococcus pyogenes or Group A Beta-Hemolytic Streptococci Bacterial structure Fimbrae: attachment and adherence M protein: major virulence factor Hyaluronic acid capsule: prevents phagocytosis
Streptococcus pyogenes or Group A Streptococci: Additional Virulence Factors Hemolysins Streptolysin O Streptolysin S Erythrogenic toxin Enzymes Streptokinase DNases Hyaluronidase
Streptococcus pyogenes (Group A) Streptococcal Infections Acute bacterial pharyngitis Sore throat Malaise Fever/headache Scarlet fever Pyodermal infections Impetigo Erysipelas Erysipelas due to Streptococcus pyogenes
Post Group-A Streptococcal Infections Rheumatic fever from pharyngeal infections only Fever Inflammation of the heart, joints, blood vessels, and subcutaneous tissues Chronic, progressive damage to the heart valves
Post Group-A Streptococcal Infections Acute glomerulonephritis from either cutaneous or pharyngeal infections More common in children than adults Antigen-antibody complexes deposit in the glomerulus Inflammatory response causes damage to the glomerulus and impairs the kidneys
Invasive Group A Streptococcal Infections Streptococcal toxic shock syndrome Multi-organ system failure similar to staphylococcal toxic shock Initial infection may have been pharyngitis, cellulitis, peritonitis, or other wound infections
Invasive Group A Streptococcal Infections: Flesh-Eating Bacteria Cellulitis Severe form of infection that is life-threatening Bacteremia and sepsis may occur In patients necrotizing fasciitis, edema, erythema, and pain in the affected area may develop Streptococcal myositis resembles clostridial gangrene
Laboratory Diagnosis: Group A Streptococcus Grams stained wound smear showing gram-positive cocci in chains with numerous polys
Laboratory Diagnosis: Group A Streptococcus Colony morphology Transparent, smooth, and well-defined zone of complete or b- hemolysis
Laboratory Diagnosis: Group A Streptococcus Identification Catalase-negative Bacitracin-susceptible PYR-positive Bile-esculin negative 6.5% NaCl-negative Group A streptococci is susceptible to Bacitracin disk (left); The right shows resistance
Group B b-hemolytic Streptococcus (Staphylococcus agalactiae) Has been known to cause mastitis in cattle Colonize the urogenital tract of pregnant women Cause invasive diseases in newborns Early-onset infection Late-onset disease
Staphylococcus agalactiae: Invasive Infections Early-onset infection Occurs in neonates who are less than 7 days old neonates Vertical transmission of the organism from the mother Manifests in the form of pneumonia or meningitis with bacteremia Associated with a high mortality rate
Staphylococcus agalactiae: Invasive Infections Late-onset infection Occurs between 1 week and 3 months after birth Usually occurs in the meningitis form Mortality rate is not as high as early-onset In adults Occurs in immunosuppressed patients or those with underlying diseases Often found in a previously healthy adult who just experienced childbirth
Laboratory Diagnosis: Group B b-hemolytic Streptococcus Colony morphology Grayish-white, mucoid, creamy, narrow zone of b- hemolysis Presumptive Identification tests Catalase-negative Bacitracin-resistant
Laboratory Diagnosis: Group B b-hemolytic Streptococcus Presumptive identification tests Bile-esculin-hydrolysis negative Does not grow in 6.5% NaCl CAMP-test positive S. agalactiae shows the arrowshaped hemolysis near the staphylococcus streak, showing a positive test for CAMP factor
Identification Schema Schema to differentiate Group A and B from other b-hemolytic streptococci
Streptococcus Group D and Enterococcus Species Members of the gut flora Associated infections Bacteremia Urinary tract infections Wound infections Endocarditis
Laboratory Diagnosis: Streptococcus Group D and Enterococcus Species Microscopic morphology Cells tend to elongate Colony morphology Most are non-hemolytic, although some may show - or, rarely, b-hemolysis Possess Group D antigen
Laboratory Diagnosis: Streptococcus Group D and Enterococcus Species Identification tests Catalase: may produce a weak catalase reaction Hydrolyze bile esculin Differentiate Group D from Enterococcus sp. with 6.5% NaCl or PYR test
Identification Schema Schema to differentiate Enterococcus and Group D streptococci from other nonhemolytic streptococci
Other Streptococcal Species Viridans group Members of the normal oral and nasopharyngeal flora Includes those that lack the Lancefield group antigen Most are hemolytic but also includes nonhemolytic species The most common cause of subacute bacterial endocarditis (SBE)
Streptococcus pneumoniae General characteristics Inhabits the nasopharyngeal areas of healthy individuals Typical opportunist Possess C substance Virulence factors Polysaccharide capsule Clinical infections pneumonia meningitis bacteremia sinusitis/otitis media
Laboratory Diagnosis: Streptococcus pneumoniae Microscopic morphology Gram-positive cocci in pairs; lancet-shaped
Laboratory Diagnosis: Streptococcus pneumoniae Colony morphology Smooth, glistening, wet-looking, mucoid -Hemolytic CO2enhances growth
Laboratory Diagnosis: Streptococcus pneumoniae Identification Catalase negative Optochinsusceptibility-test susceptible Bile-solubility-test positive
Identification Schema Schema to differentiate S. pneumoniae from other - hemolytic streptococci
Streptococcus-Like Organisms Aerococcus Gram-positive cocci that tend to form tetrads -hemolytic; and may resemble viridans group May be confused with Enterococcus biochemically
Streptococcus-Like Organisms Leuconostoc Resemble streptococci microscopically; colonies resemble viridans group or Enterococcus Found in plants, vegetables, and dairy products Pediococcus Found in nature; used in bioprocessing and biopreservation of foods such as cheese, meats, and vegetables Rarely seen in human infections; has been associated with septicemia
Points to Remember General characteristics and hemolytic patterns of streptococcal and enterococcal species Infections produced by pathogenic species Microscopic and colony morphology Tests used to identify these species Emergence of resistant strains