Staphylococcus,

Streptococcus
and
Enterococcus

Dulnie Wijeweera
27.01.2025
1. Staphylococcus
Staphylococci
• Commonly found on the skin of healthy individuals

• Staphyle = a bunch of grape

• Gram-positive cocci in clusters

• Facultative anaerobes

• 1µm in diameter

• Non-motile, non-capsulated

• Usually catalase positive

• Many species

• Staphylococci most frequently associated with human infection

are
1. Staphylococcus aureus – the major pathogen
2. Staphylococcus epidermidis
3. Staphylococcus saprophyticus
Habitat
• Staphylococci are ubiquitous colonizers of the skin

• In humans, S. aureus has preference for the anterior nares, especially

in adults
Shed onto healthy skin, including axilla and perineum

• Nasal carrier rate varies from 10% to 40% (community and the
hospital environment)

• Nasal carriage of S. aureus can be persistent

Virulence factors
1. Cell wall polymers
2. Cell surface proteins
3. Exoproteins

• Refer Table 12.2 in 19th Edition, Medical Microbiology: A guide to

microbial infections by Michael R. Barer, Will L Irving, Andrew Swann,
Nelun Perera
 How is it acquired?

Infected lesions
Healthy carries Animals
Disseminated in pus and dried exudate

From patients with pneumonia Environment

 Laboratory diagnosis
• Grow readily on standard laboratory media

• Gram-positive cocci in clusters

• Catalase positive

• Staphylococcus produces an extracellular enzyme

coagulase
- Converts plasma fibrinogen to fibrin
- Has a laboratory diagnostic value because they help
rapidly discriminate between coagulase-positiv (S.
aureus) and coagulase-negative staphylococci (CoNS)

• DNAase test positive

 Staphylococci
Coagulase-positive Coagulase-negative

CoNS
S. aureus S. epidermidis
S.Saprophyticus
a) Staphylococcus aureus
• Aureus = golden yellow
Blood agar MacConkey agar
 Friedrich Julius Rosenbach

Staphylococcus Staphylococcus
aureus epidermidis
 MSSA Vs MRSA

• Identified in the laboratory by using

Cefoxitin disc
Cefoxitin resistant = MRSA
• MSSA (Methicillin-sensitive S. aureus)
- sensitive to cefoxitin

• MRSA (Methicillin-resistant S. aureus)

- Cefoxitin resistance/ growth up to
the disc
Infections caused by S. aureus

Toxin mediated Pyogenic infections

• Scalded skin syndrome/ • Boils, carbuncles

pemphigus neonatorum • Surgical site infections
• Abscesses
• Toxic shock syndrome
• Impetigo
• Food poisoning • Mastitis
• Blood stream infections
• Osteomyelitis
• Pneumonia
• Endocarditis
Staphylococcal toxins and associated diseases
Enterotoxins
• A to E, G, H, I & J
• Withstand 100℃ for several minutes
• Ingestion of preformed toxins causes food poisoning within a few hours

Toxic shock syndrome toxin

• Associated with highly absorbent tampons in menstruating women

• But non-menstrual cases are also common
• Multi-systemic disease
• Due to TSST or Enterotoxins or both that act as superantigens
 Toxic shock syndrome
Menstrual Non-menstrual
 Colonization of the
 Post-surgical
Vagina and Cervix with
TSST-1 producing  Influenza associated
strains of S. aureus  Contraceptive
(vaginal infection in device associated
menstruating women
(Diaphragm)
using tampons)
 Postpartum

• sudden onset of high fever, vomiting, diarrhea, Erythematous rash, shock

• followed 1-2 weeks later by desquamation (palms of the hands and the
soles of the feet)
 Epidermolytic toxins

• Toxin A & B

• Induce intra-epidermal
blisters

• Cause of scalded skin

syndrome in small children
lacking antitoxin
Panton-Valentine Leukocidin (PVL)
• Leukocidin – cause leucopenia by toxin damage

• Described in the context of community acquired infections (CA-

MRSA)

• Associated with necrotizing pneumonia and complicated skin and

soft tissue infections
Skin and Soft Tissues Infections
• Infection of the epidermis –impetigo

• Infection of the superficial dermis – folliculitis

• infection of deep dermis—furuncles, carbuncles, and hidradenitis

suppurativa

• infection of subcutaneous cellular tissues—erysipelas, cellulitis,

fasciitis, and pyomyositis

“Hallmark is suppuration (pus production)”

Impetigo

• Mainly in children

• Highly contagious

• Initially clear vesicles , later filled

with pus

• Secondory spread due to

scratching
Furuncles Carbuncle
Treatment of MSSA
• 90% resistance to penicillin – by development of penicillinase

• MSSA: Rx with a penicillinase stable penicillin – cloxacillin,

flucloxacillin

• Other antibiotics with staphylococcal cover

• Doxycycline
• Erythromycin
• Clindamycin
• Co-trimoxazole
• vancomycin, teicoplanin ( penicillin allergy)
• Rifampicin – for special indications
Methicillin-resistant Staphylococcus aureus (MRSA)
• Mediated by mecA gene (mainly)

• Resistant to almost all β-lactam agents

• Causes the same range of infections – but higher morbidity and

mortality due to difficulty in treatment

• Spread easily in the hospitals Hospital acquired MRSA (HA-MRSA)

• Community acquired MRSA (CA-MRSA) also seen

• Treatment:
- Glycopeptides (vancomycin or
teicoplanin) are the agents of
choice in the treatment of systemic
infection with MRSA

• Prevention:
- Need surveillance
- Isolation
- Decolonization
- Hand hygiene
- Antibiotic stewardship
b) Coagulase- negative Staphylococci
• Comprises of a large group of related species

• Commonly found as skin commensals in healthy individuals

• Morphologically similar to S. aureus

- but they do not coagulate plasma

• Rare cause of infection in immunocompromised (eg neonates, cancer

patients) and patients with prosthetic material/devices
Staphylococcus epidermidis
• Common skin contaminant isolated from clinical specimens

• However, can cause implant (intravascular lines, cannulae, cardiac

valves etc) associated infections

• Patients at risk are those who have

Prosthetic heart valves
 CSF drains EVDs
Those who undergo peritoneal dialysis
 Immunocompromised patients
ICU patients with multiple devices
Staphylococcus saprophyticus

• Cause of urinary tract infection in young females

• Differentiated from the other CoNS by novobiocin resistance

Staphylococcus epidermidis
sensitive
CoNS treatment
• Antibiotic resistance is higher and unpredictable

• Need removal of the device/implant in device associated infections

• Vancomycin, teicoplanin can be given

• S. saprophyticus –
• Treated with cotrimoxazole
• Alternative nitrofurantoin
Streptococci and Enterococci
Classification of Streptococcus by Haemolysis
 Streptococcus species
Group Species haemolysis

1. Pyogenic group S. pyogenes β

S. agalactiae
2. Mitis group S. pneumoniae α
3. Anginosus group S. anginosus Variable (α/β or
S. Intermedius none)
S. constellatus

4. Bovis groip S. equinus α or none

5. Mutans group S. mutans None
Lancefield grouping
• β-haemolytic streptococci are further characterized via Lancefield
serotyping

• Based on group-specific carbohydrates antigen present on the

bacterial cell wall

• Clinically significant are A, B, C, D, F and G

Species Lancefield group

Streptococcus pyogenes A
Streptococcus agalactiae B
Streptococcus canis G
Streptococcus dysgalactiae subspecies dysgalactiae C

Streptococcus dysgalactiae subspecies equisimilis C, G, A and L

Streptococcus anginosus group A, C, F and G or

ungroupable

Streptococcus bovis group D

Enterococcus species D
Other Streptococcus species such as S. pneumoniae and Viridans
streptococci are classified as 'non-Lancefield streptococci'
Pyogenic β haemolytic group
i) Streptococcus pyogenes
Streptococcus pyogenes (group A strep/GAS)
• Exclusive human pathogen

• Causes a wide range of suppurative infections

• Most common route of entry – upper

respiratory tract

• β-hemolytic streptococcus

• More than 150 different strains have been

identified based on different M-protein types
Virulence factors of S. pyogenes:
1. Adhesins (F protein, M protein)

2. M protein – resists phagocytosis

3. Hyaluronic acid capsule - resists phagocytosis

4. Hyaluronidase - breakdown hyaluronic acid of connective tissue,

- Facilitate spread of infection among fascial planes

5. Streptokinase/ fibrinolysin - binds plasminogen and converts to

plasmin, resulting in the spreading of infection

6. Streptococcal pyrogenic exotoxin – induces fever, Causes skin rash

Transmission

• Directly through respiratory droplets and contact with infected

wounds/secretions
• Indirectly through fomites (contaminated objects such as towels
Streptococcal infections

1. Suppurative 2.Non-suppurative
a)Non-invasive
• Pharyngitis • Acute glomerular nephritis
• Scarlet fever • Rheumatic fever
• Impetigo

b)Invasive soft tissue infections

• Necrotizing fasciitis
• Streptococcal toxic shock
syndrome
• Puerperal sepsis
1. Suppurative
a) non-invasive infections
Pharyngitis

• Most common clinical manifestation of GAS

• Most common bacterial cause of acute pharyngitis

• Most commonly observed in children 5–15 years of age

• Abrupt onset fever, headache, and sore throat

• Posterior pharynx may have exudate

• Complications:
- peritonsillar abscess
- otitis media
- Sinusitis
- mastoiditis
- scarlet fever
- rheumatic fever

“Group C streptococcus (GCS) and Group G streptococcus (GGS) can

also cause acute bacterial pharyngitis”
Scarlet fever

• Caused by Pyrogenic exotoxin producing

strains

• Rash after 1 to 2 days of pharyngitis

• Diffuse erythematous blanching rash of skin

and mucus membranes

• Palms, soles, and face spared

• “Strawberry tongue”
Impetigo Erysipelas
• Exposed areas of the face, arms or • Superficial layers of the skin and
legs lymphatics
• Initially with clear vesicles, become • Raised sharply demarcating boarders
pus filled (unlike cellulitis)
1.Suppurative
b) invasive infections
Necrotizing fasciitis

• Very rapid tissue destruction

• Following minor trauma

• The skin may have minimal

infective signs

• Systemic shock and rapid general

deterioration
Streptococcal toxic shock syndrome

• Occur in patients with invasive and bacteraemic infections

• Severe pain at the site of origin of infection, fever, and rash

• Similar to Staphylococcal TSS

2. Non- suppurative sequalae
1. Rheumatic fever

• a potential sequela to pharyngitis (including scarlet fever)

• Appear 1 to 5 weeks after infection

• Major manifestations:
• Polyarthritis, carditis, chorea, erythema marginatum, subcutaneous
nodules

• Due to autoreactive antibodies to M protein

- ‘’molecular mimicry “
2. Acute glomerular nephritis

• primarily, but not exclusively, associated with GAS skin infections

• Present with haematuria, edema, & AKI

• An “immune complex deposition” mediated disease

• However, several other mechanisms have been proposed.

Laboratory diagnosis
1. Small colonies with wide zone of β
haemolysis on blood agar

2. No growth on MacConkey agar

3. Catalase negative
GAS - bacitracin
sensitive
4. Bacitracin (0.04U) –sensitive

5. Antibodies against streptolysin O (ASO)

• Significant rise of antibody seen 3 to 4 weeks later
• important for rheumatic fever
Treatment of Streptococcus pyogenes
infections
• Universally sensitive to penicillin
-Resistance not detected yet

• Pharyngitis- penicillin V/ amoxicillin given for 10 days

To eradicate the organism from the pharynx
Allergy to penicillin: erythromycin/clarithromycin

• Severe skin and soft tissue infections (necrotizing fasciitis)

Need surgical debridement
Clindamycin is combined for toxin
Pyogenic β-haemolytic group
ii) Streptococcus agalactiae (GBS)
• Found in the GUT (primary habitat)

• Intermittently carried in the vagina

• Infections mainly in neonates, peripartum mothers and patients

with chronic medical conditions
Virulence factors of GBS
1. Haemolysins

2. capsule polysaccharide

3. C5a peptidase

4. hyaluronidase (not all strains)

5. adhesins
Neonatal infections

Early onset disease Late onset disease

• Present within 12 hours of birth • >7days to 3 months after birth

• Resulting from ascending spread • Resulting from spread of cross
from vagina infections to the baby by hospital
• Meningitis, pneumonia can staff, no vaginal colonization
occur • Meningitis is the common
• PROM, prolonged labour, manifestation
premature delivery, LBW, • Septic arthritis, osteomyelitis,
intrapartum fever are risk conjunctivitis, sinusitis, otitis media
factors can occur
• Higher risk for preterm babies
Early onset disease
Infection in the adults

Pregnant females Non-pregnant adult

• Ascending amniotic infection, • Sepsis, pneumonia, cellulitis,

chorioamnionitis, abortion, arthritis, UTI
endometritis • Occur in patients with DM,
• Can occur in previously healthy cirrhosis, renal failure, cancer
• OLD AGE – higher risk for GBS
infection
Laboratory diagnosis

1. Small colonies with small zone of β haemolysis on blood agar

2. Grows on MacConkey agar

3. Catalase negative

4. CAMP test positive

Positive CAMP test

Treatment of Streptococcus agalactiae
infections:
• Susceptible to Penicillin

Prevention of early on-set Streptococcus

agalactiae infections in neonates:
• Screening for GBS
• Give intrapartum penicillin prophylaxis to mothers who carry GBS
Streptococcus pneumoniae
Pneumococcal virulence factors

Polysaccharide capsule

Autolysin

Pneumolysin IgA protease

 Oropharyngeal microbiota in 50-70%

 Person to person spread is uncommon

• Usually occur when the upper respiratory colonizing flora is aspirated to the lower
tract

• Patients with glottic reflex and mucociliary escalator impairment are at high risk

 Altered consciousness – General anaesthesia, convulsions, alcoholism, epilepsy, trauma

 Respiratory viral infections – when the mucociliary layer is damaged
 Chronic bronchitis
Other risk factors:
 Valvular heart disease,
 chronic renal failure
 DM
 bronchial malignancy
 old age
 Immune defects (hypogammaglobulinaemia, asplenia, multiple myeloma, HIV
Pneumonia

• Commonest cause of
pneumonia
• Leads to lobar pneumonia
mainly, but multilobar
involvement can occur
• Can lead to empyema
• Complications,
• lung abscess
• bacteraemia
• meningitis
• infective endocarditis
• pericarditis
Meningitis
• Among the most important causes of meningitis
• Pneumococci in the pharynx travel via the blood stream to
meninges
• Very high mortality

Otitis media
• Commonly seen in children 6 months to 3 years age

Conjunctivitis
• Among the common causes of conjunctivitis
 Draughtsman colonies

Laboratory diagnosis
• α-haemolytic colonies with central autolysis
(draughtsman colonies) on blood agar

• No growth on MacConkey agar

• Gram stain- Gram positive diplococci with

lanceolate shape
Viridans Streptococci Optochin sensitivity of S.
optochin resistant pneumoniae
• Catalase negative

• Opthochin sensitive
- this differentiates pneumococci from
viridans group streptococci

• Bile solubility test positive

Streptococcus pneumonia: Viridans Streptococci:
Gram-positive diplococci, with a halo Gram-positive cocci in long chains
(capsule)
Treatment of Streptococcus pneumoniae infections:
• Resistance to penicillin is increasing in many regions
• Ceftriaxone, cefotaxime (3rd generation cephalosporins)

Prevention of Streptococcus pneumoniae infections

• Pneumococcal vaccines
• 2 types
Viridans Streptococci
Viridans Streptococci (VGS)
• Colonize oropharynx and the GI tract

• Many species classified in to 6 major groups

 mitis, mutans, salivarius, sanguinis, aniginosus & bovis groups

• S. mutans cause dental caries

• VGS can enter the blood stream during dental procedures

• In high-risk patients cause infective endocarditis

• rheumatic heart disease
• congenital heart disease
• prosthetic valves
• previous endocarditis
Anginosus group Bovis group

• Includes • Found in the human gut

Streptococcus anginosus,
Streptococcus intermidius
 Streptococcus constellatus
• Can cause bacteraemia,
endocarditis
• Found on tooth surfaces
• Associated with bowel
carcinoma
• Cause deep abscesses
Treatment of IE due to VGS:
• Penicillin in combination with an aminoglycosides are given for synergy in
endocarditis treatment
• “Aminoglycosides are intrinsically resistant to Streptococci”

Prevention of IE due to VGS:

• Antibiotic Prophylaxis is given for dental procedures that lead to
bleeding
Enterococci
 Enterococci
• Found in the human intestines

• Most react with Lancefield group D

sera

• Hydrolyse bile aescilin

• Two common species causing

human infections are
 Enterococcus faecalis
 Enterococcus faecium are

• Cause UTI, bacteraemia,IE, biliary

tract infections, pus forming
abdominal infections, peritonitis Gram positive elongated cocci
Treatment of Enterococcus infections
• Intrinsically resistant to many antibiotics including cephalosporins

• Sensitivity varies widely

• E faecalis – mostly amoxicillin sensitive

• E faecium – mostly resistant to amoxicillin
- treated with vancomycin/teicoplanin

• Vancomycin resistant Enterococci (VRE) – a rising problem of around the

world