CLINICAL BACTERIOLOGY

MARK M. CALBAN, MD
CSU
College of Medicine & Surgery
GENUS STAPHYLOCOCCUS
 GRAM (+) COCCI

CATALASE TEST

(+) STAPHYLOCOCCUS (-) STREPTOCOCCUS

COAGULASE
MANNITOL SALT AGAR

S. AUREUS S. EPIDERMIDIS
Coagulase + S. SAPROPHYTICUS

NOVOBIOCIN

S. EPIDERMIDIS S. SAPROPHYTICUS
Sensitive Resistant 3
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 DISTINGUISHING CHARACTERISTICS

• Gram + Cocci
• Arranged in clusters

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 DISTINGUISHING CHARACTERISTICS

• Beta-hemolytic

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 DISTINGUISHING CHARACTERISTICS

• Yellow colonies
• Ferments MSA

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 DISTINGUISHING CHARACTERISTICS

• Coagulase +

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 DISTINGUISHING CHARACTERISTICS

• PYRtest +
• L-pyrrolidonyl-b-napthlyamide

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RESERVOIR

• ANTERIOR NARES
• Normal flora on nasal mucosa
and skin.

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TRANSMISSION

• Via the hands and sneezing

• Surgical wounds
• Lungs of cystic fibrosis patients

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TRANSMISSION

• Foods associated with food

poisoning:
• Ham or canned meats, custard
pastries, and potato salad

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PREDISPOSING FACTORS TO INFECTION

• Surgery or any break in skin,

surgical packing or sutures
or any foreign body (e.g.,
tampons); ventilators
• Severe neutropenia; cystic
fibrosis
• IV drug abuse
• Chronic granulomatous
disease (CGD)

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PATHOGENESIS

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I. PROTEINS THAT DISABLE IMMUNE DEFENSES

A. Protein A
- inhibits phagocytosis;
- binds Fc portion of antibody; inhibiting complement fixation,
OPSONIZATION and phagocytosis.

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B. Coagulase
I.- PROTEINS THAT DISABLE
convert fibrinogen IMMUNE
to a fibrin clot DEFENSES
thereby inhibiting
phagocytosis.

C. Hemolysin
- Alpha, beta, gamma, and delta.
• They destroy red blood cells, neutrophils, macrophages, and
platelets.

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I. PROTEINS THAT DISABLE IMMUNE DEFENSES

D. Leukocidin
• They destroy leukocytes (white blood cells).
E. Penicillinase
• Secreted form of beta-lactamase.
• It disrupts the beta-lactam portion of the penicillin molecule,
thereby inactivating the antibiotic.

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II. PROTEINS THAT TUNNEL THROUGH THE TISSUE

1) Hyaluronidase "Spreading Factor"

- protein breaks down proteoglycans in connective tissue.

2) Staphylokinase
- This protein lyses formed fibrin clots (like streptokinase).

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II. PROTEINS THAT TUNNEL THROUGH THE TISSUE

3) Lipase
• This enzyme degrades fats and oils, which often accumulate on the
surface of our body w/c facilitates colonization of sebaceous glands
PIMPLES
4) Protease
• destroys tissue proteins.

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III. EXOTOXIN ASSAULT WEAPONRY

1)Exfoliatin
- A diffusible exotoxin that causes
the
skin to slough off (scalded skin
syndrome).

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III. EXOTOXIN ASSAULT WEAPONRY

2) Enterotoxins (heat stable)

• Exotoxins which cause food
poisoning, resulting in vomiting
and diarrhea.

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III. EXOTOXIN ASSAULT WEAPONRY

3) Toxic Shock Syndrome toxin

(TSST-1):
• analogous to the pyrogenic
toxin produced by GABHS.
• Causes TSS
• 20% of isolates.

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III. EXOTOXIN ASSAULT WEAPONRY

3) Toxic Shock Syndrome toxin

(TSST-1):
• pyrogenic toxins
• are called superantigens and
bind to the MHC class II

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DISEASES CAUSED BY
EXOTOXIN RELEASE

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GASTROENTERITIS

• Ingestion of food containing the

pre-formed toxin
• N/V, diarrhea, abdominal pain,
and occasionally fever.
• The episode lasts 12 to 24
hours.
• ”mayonnaise”, PASTRY/DAIRY
PRODS

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TOXIC SHOCK SYNDROME

• “Woman who use Tampoons”

• penetrates the vaginal mucosa
and
• enhances susceptibility to
endotoxin.

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TOXIC SHOCK SYNDROME

• Cleaning the infected foci

• Removal of the tampon or
drainage of an infected wound
• Antibiotics

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SCALDED SKIN SYNDROME (SSS)

• Exfoliative toxin, establishes

a localized infection and
releases a diffusible toxin
that exerts distant effects.
• neonates with local
infection of the recently
severed umbilicus or older
children with skin infections.

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SCALDED SKIN SYNDROME (SSS)

• Causes cleavage of the middle

epidermis, with fine sheets of
skin peeling off to reveal moist
red skin beneath.
• Ddx: Drug allergy

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DISEASES RESULTING FROM
DIRECT ORGAN INVASION

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PNEUMONIA
• Severe cause of CAP –
Nosocomial
• “Post-Viral Pneumonia”
• Abrupt onset of fever,
chills, and lobar
consolidation of the lung,
with rapid destruction of
the lung parenchyma,
resulting in cavitations
(holes in the lung) >>>>
causes effusions and
empyema.

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MENINGITIS, CEREBRITIS, BRAIN ABSCESS

• high fever, stiff neck, headache,

obtundation, coma, and focal
neurologic signs.

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OSTEOMYELITIS

• bone infection
• Boys <12 Y/O
• Hematogenous spread
• CM: warm, swollen tissue over
the bone and with systemic
fever and shakes.

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ACUTE ENDOCARDITIS

• destructive infection of the

heart valves
• CM: sudden onset of high fever
(103-105 F°), chills, and
myalgias (like a bad flu).

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ACUTE ENDOCARDITIS
• Pathology: Vegetations grow
rapidly on the valve, causing
valvular destruction and
embolism of vegeta- tions to
the brain (left heart valve
involvement) or lung
• (right heart valve infected).

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ACUTE ENDOCARDITIS

• IV DRUG USE – right- TVE and

may present with pneumonia
caused by bacterial
embolization from this infected
valve.
• Other causes: Grp D Strep,
Viridans Strep

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SEPTIC ARTHRITIS

• Invasion of the synovial

membrane resulting in a closed
infection of the joint cavity.

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SEPTIC ARTHRITIS

• CM: acutely painful red swollen

joint with decreased range of
motion.
• MC pathogen in the pediatric
age group and in adults over the
age of 50.

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SEPTIC ARTHRITIS

• Dx: Examination of the synovial

fluid,
a.yellowish and turbid
b.neutrophils (>100,000)
c.positive Gram stain or culture.

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SKIN INFECTIONS

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IMPETIGO

• contagious infection usually

occurs on the face, especially
around the mouth.
• Small vesicles lead to pustules,
which crust over to become
honey-colored, wet, and flaky.

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CELLULITIS

• is a deeper infection of the cells.

• The tissue becomes hot, red,
shiny and swollen.

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• ABSCESS is a collection of pus. Infection of a hair follicle produces a
single pus-filled crater with a red rim.
• FURUNCLE - infection can penetrate deep into the subcutaneous
tissuE
• CARBUNCLE – multiple contiguous, painful lesions communicating
under the skin called carbuncles.
• TX: I & D

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MRSA

• Penicillinase >>> Alternatives: Methicillin, Nafcillin

• tend to develop in the hospital, where broad- spectrum antibiotics
are used.
• MOT: from patient to patient by the hand contact of health care
workers
• Tx: Vancomycin

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TREATMENT

• Early on S. aureus (now known as methicillin-sensitive S. aureus,

MSSA) acquired a multiple drug resistant plasmid with resistance to
early beta-lactams (via a beta- lactamase) and most other antibiotics.

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TREATMENT

• Methicillin & nafcillin were developed.

• Methicillin-resistant S. aureus (MRSA) (due to changes in major
penicillin-binding proteins) is commonly resistant to all antibiotics
except VANCOMYCIN & FUSIDIC ACID.

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TREATMENT

• TOPICAL MUPIROCIN used to reduce nasal colonization (Carriers)

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PREVENTION

• Basic hospital infection control

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Staphylococcus epidermidis

• Gram +, Catalase +, Cocci, Coagulase -, Novobiocin Sensitive

• Immunocompromised – Nosocomial
Infects PROSTHETIC DEVICES and IV & FOLEY CATHETERS by producing
adherent biofilms.
• Component of normal skin flora; contaminates blood cultures.

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Staphylococcus saprophyticus

• Gram +, Catalase +, Cocci, Coagulase -, Novobiocin R

• 2ND MCC (second only to E. coli) of urinary tract infections in
SEXUALLY ACTIVE YOUNG WOMEN.
• It is most commonly acquired by females (95%) in the community
(NOT in the hospital)

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Organism Virulence Disease Distinguishing Impt. Feature
factor characteristic

S. aureus ProteinA Folliculitis, furuncles, Catalase (+) B-lactamase

TSST-1 carbuncles, impetigo, Coagulase (+)
Exfoliatin cellulitis MSA (+)
Enterotoxin SSS, TSS, Novobiocin (S)
osteomyelitis
Food poisoning

S. epidermidis Adherence: Catheter and Catalase (+) Predominant

biofilm prosthetic devices Coagulase (-) skin flora
Endocarditis in i.v. Novobiocin (S)
drug abusers
S. saprophyticus UTI in newly sexually Catalase + Normal flora
active females Coagulase (-)
Novobiocin (R)

S. aureus – resistance to penicillin

• beta lactamase – plasmid
• altered PBP – chromosomal (e.g., MRSA)
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 Frequency Coagulase Color of Mannitol Novobiocin
colonies fermentation resistance

S. Aureus Common + Golden yellow + -

S. Epidermidis Common - White - -

S. Occasion - Variable - +
Saprophyticus al

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THANK
YOU!
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GENUS STREPTOCOCCUS
 GRAM (+) COCCI

CATALASE TEST

(+) STAPHYLOCOCCUS (-) STREPTOCOCCUS

β-streptococcus α-streptococcus γ-streptococcus

S. pyogenes S. agalactiae S. pneumoniae Viridans Strep

Bacitracin S CAMP test +
S Optochin R
Gp A Hippurate HOH
+ Bile solubility -
Gp B
+ Quellung -
+ Animal patho -
Gp D

Enterococcus S. bovis
Grow 6.5% NaCl No Grow
R penicillin S
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LANCEFIELD CLASSIFICATION

• C-CHO present in the cell wall

• Group A – Strep. pyogenes
• Group B – Strep. agalactiae
• Group C
• Group D – Enterococci & Non-Enterococci

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STREPTOCOCCUS PYOGENES
Streptococcus pyogenes

• GABHS - Lancefeld group A

antigen
• “Pus-producing
• "Strep throat," scarlet fever,
rheumatic fever, and PSGN.

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M PROTEIN

• 80 types
• MAJOR VIRULENCE FACTOR - Inhibits
the activation of
complement and protects the organism from
phagocytosis.

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PATHOGENECITY

STREPTOLYSIN O STREPTOLYSIN S
• O2 labile • O2 stable
• Destroys RBC & WBC >>> Beta • Destroys RBC & WBC >>> Beta
Hemolysis Hemolysis
• Antigenic  ASO • NOT Antigenic
• Measure Titer in Todd Units

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PATHOGENECITY

PYROGENIC EXOTOXIN
• “Erythrogenic toxin"
• SCARLET FEVER

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PATHOGENECITY

STREPTOKINASE OTHER ENZYMES:

• activates the proteolytic • Hyaluronidase
enzyme plasmin, which breaks • DNAases
up fibrin blood clots
• Anti-C5a peptidase

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PATHOLOGY

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STREPTOCOCCAL PHARYNGITIS

• CM: red swollen tonsils and

pharynx, a purulent exudate on
the tonsils
• high temperature, & swollen
lymph nodes.
• It lasts 5 days
• Tx: Penicillin

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• Folliculitis
• Cellulitis - red, swollen skin
which is hot to the touch
• Impetigo - vesicular, blistered,
eruption, becomes crusty and
flaky; mouth
• Tx: Penicillinase resistant
penicillin like dicloxacillin

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NECROTIZING FASCIITIS

• "Flesh-eating Streptococcus"
• Pathology: M proteins that block
phagocytosis, allowing the
bacteria to move rapidly through
tissue.
• MOT: break in the skin caused by
trauma to the fascia
• CM: skin color changes from red
to purple to blue, and large
blisters (bullae) for  (myositis).
• Tx: PenG or Clindamycin
• **Staph & Clostridium

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 SCARLET FEVER
• Pyrogenic toxin or ery- throgenic
toxin.
• Acquired by lysogenic conversion
• CM: fever, scarlet-red, rash begins
on the trunk and neck, and then
spreads to the extremities, sparing
the face. The skin may peel off in
fine scales during healing.

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 STREPTOCOCCAL TSS
• Mediated by the release of
pyrogenic toxin.
• Tx: PenG & Clindamycin

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 RHEUMATIC FEVER
• Untreated Strep Throat • “Molecular Mimicry” 
• CM: Myocarditis  VHD
1.Fever • Mitral V > Aortic V
2.Myocarditis • Permanent & Irrev  PenG
3.Joint swelling • Amoxicillin - dental or surgical
procedure.
4.Chorea
5.Subcutaneous nodules
6.Erythema marginatum

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 APSGN
• ADCC mediated inflammatory
disease of the glomeruli of the
kidney  Ag + Ab  GBM 
Complement Activation 
GBM destruction.
• It occurs about one week after
infection of either the pharynx
OR skin by nephritogenic
• “Child w/ a Puffy face”
• Hematuria - tea or coca-cola
colored
• Hypertension

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Group A Streptococci
(Streptococcus pyogenes)

TEST:
1. Bacitracin Disk Test / TAXO A: (0.04 units)
 presumptive test for B-hemolytic strep.
 (+) result = any zone of inhibition
 group A

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TAKE NOTE…..

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TAKE NOTE…..

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STREPTOCOCCUS AGALACTIAE
STREPTOCOCCUS AGALACTIAE/GBS

• Bacitracin resistant, B-hemolytic,

• colonizes vagina
• causes pneumonia, meningitis, and sepsis, mainly in
babies.
• (+) CAMP factor; Hippurate test (+)
• Screen pregnant women at 35-37 weeks.
• Patients with positive culture receive intrapartum
penicillin prophylaxis.

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 STREPTOCOCCUS AGALACTIAE/GBS
• Pathology: Neonatal (< 3 months of age) meningitis
(-) brudzinski sign, pneumonia, and sepsis.
• Fever, vomiting, poor feeding, and irritability.
• Dx: Lumbar Puncture (E. coli, L. monocytogenes,
GBS)

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VIRIDANS STREPTOCOCCI
VIRIDANS STREPTOCOCCI

• NO LANCEFIELD CLASSIFICATION
• Streptococcus salivarius, S. sanguis, S. mitis, S. intermedius, S. mutans
• Dental Infections, Endocarditis

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TAKE NOTE…….

• ACUTE INFECTIVE ENDOCARDITIS – Staphylococcus epidermidis (Drug

Use)

• SUBACUTE BACTERIAL ENDOCARDITIS – Viridans streptococci

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TAKE NOTE…

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GROUP D STREPTOCOCCI
-Enterococci
-Non-Enterococci
GROUP D STREPTOCOCCI

• Enterococci: Enterococcus faecalis & Faecium

• Non-Enterococci:Strep. Bovis & Strep. equinus
• Gram (+) cocci, Catalase –

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Enterococci

• (faecalis and faecium)

• Reservoir: human intestines; normal bowel flora.
• alpha hemolytic
• Grow well in 40% bile or 6.5% NaCl.
• Pathology: UTI, biliary tract infections, SBE
• Resistance: Ampicillin & Vancomycin
• Tx: ciprofloxacin, chloramphenicol, and doxycycline

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NON-ENTEROCOCCI (S. bovis & equinus)

• (+) growth in 40% bile (but not in 6.5% NaCl).

• Reservoir: G.I. tract
• “colon cancer” BOWEL Cancer

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STREPTOCOCCUS PNEUMONIAE/
PNEUMOCOCCUS
STREPTOCOCCUS PNEUMONIAE/
PNEUMOCOCCUS

• MCC of bacterial pneumonia and meningitis in adults

• MCC of otitis media in children
• NO lancefield classification.
• “lancet-shaped” diplococci
• VF: polysaccharide capsule

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TAKE NOTE……..

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 STREPTOCOCCUS PNEUMONIAE/
PNEUMOCOCCUS

• When
QUELLUNG REACTION on a slide
pneumococci
smear are mixed with a small
amount of antiserum (serum with
antibodies to the capsular
antigens) and methylene blue,
the capsule will appear to swell.
This tech- nique allows for rapid
identification of this organism.

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 STREPTOCOCCUS PNEUMONIAE/
PNEUMOCOCCUS
OPTOCHIN SENSITIVITY
• Streptococcus pneumoniae is
alpha-hemolytic (partial
hemolysis-greenish color) but
Streptococcus viridans is also
alpha-hemolytic!
• The growth ofStreptococcus
pneumoniae will be inhibited,
while Streptococcus viridans will
continue to grow.

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Optochin test

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PNEUMOVAX VACCINE

• HIV
• ASPLENECTOMY
• Heptavalent: Serotypes 4, 6B,
9V, 14, 18C, 19F, and 23F

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Organism Virulence Disease Distinguishing Impt. Feature
factor characteristic
S. pyogenes M protein Sore throat Beta hemolytic No penicillin
(Group A) Pyrogenic Scarlet fever Catalase (-) resistance
(GABS) exotoxin Pyoderma Bacitracin (+) M12 strain –
Erysipelas PYR test positive assoc with AGN
Rheumatic fever, ASO
AGN
S. agalactiae Neonatal sepsis Beta hemolytic Vaginal flora,
(Group B) Neonatal meningitis Catalase (-) URT
(GBS) CAMP test
Hippurate HOH
E. fecalis UTI, peritonitis, Alpha, beta or Flora colon, URT
(Group D) biliary tract infection, gamma hem.,
etc Growth 6.5% NaCl
Penicillin R
PYR test positive
S. pneumoniae Capsule, Meningitis (adult) Alpha hemolytic No toxin
(lancet- IgA Pneumonia (rusty Optochin (+) Vaccine:
shaped) protease sputum) Bile solubility (+) capsular
Sinusitis Quellung rxn
Viridans strep Dextran Dental caries Alpha hemolytic Normal flora
Endocarditis

PYR test – pyrrolidonyl arylamidase 96

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TAKE NOTE……

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