MEDICAL MICROBIOLOGY I

Lesson 8
Staphylococci and Diseases

Staphylococcus
Staphylococcaceae contains 4 genera, the
most important of which is the genus
Staphylococcus
Staphylococcus (from Greek: staphyl, bunch
of grapes and KKKO,
kkkos, granule) is a
genus of Gram positive bacteria
Under microscope they appear round (cocci)
and form in grape-like clusters

Staphylococcus

Staphylococcus
The Staphylococcus genus includes 32 species
and 8 sub-species
Members of this genus are facultatively
anaerobic, non-motile, Gram positive cocci
that usually form irregular clusters
They are catalase positive, oxidase negative,
ferment glucose, and have teichoic acid in
their cell walls

Staphylococcus
Organisms in clinical material may also appear
as single cells, pairs, or short chains
Most staphylococci are 0.5 - 1 m in diameter
Grow in medium containing 10% NaCl and at a
temperature ranging from 18 - 40C

Staphylococcus
Staphylococci are normally associated with
the skin, skin glands, and mucous membranes
of warm-blooded animals
Staphylococcus can cause a wide variety of
diseases in humans and other animals through
either toxin production or penetration
Staphylococcal toxins are a common cause of
food poisoning, as it can grow in improperly
stored food

Staphylococcus
Staphylococcus are responsible for many
human diseases
Staphylococcus cause a wide spectrum of life
threatening systemic diseases; infections of
the skin, soft tissues, bones, and urinary tract;
and opportunistic infections

Staphylococcus
Sometimes responsible for endocarditis and
infections of patients with lowered resistance
(e.g. wound infections, surgical infections,
urinary tract infections, body piercing)
S. aureus is the most important human
staphylococcal pathogen and cause boils,
abscesses, wound infections, pneumonia,
toxic shock syndrome, and other diseases

Physiology and Structure

Capsule
A loose-fitting, polysaccharide layer (slime
layer)
The capsule protects the bacteria by inhibiting
the chemotaxis and phagocytosis of the
organisms by polymorphonuclear leukocytes ,
as well as by inhibiting the proliferation of
mononuclear cells after mitogen exposure
It also facilitates the adherence of bacteria to
catheter and other synthetic material

Physiology and Structure

Peptidoglycan
Half of the cell wall by weight is peptidoglycan
The peptidoglycan consists of layers of glycan
chains built with 10 - 12 alternating subunits of
N-acetylmuramic acid and N-acetylglucosamine
The peptidoglycan has endotoxin-like activity,
stimulating the production of endogenous
pyrogens, activation of complement and the
production of interleukin-1 monocytes, and
aggregation of polymorphonuclear leukocytes
( a process responsible for abscess formation)

Physiology and Structure

Teichoic acid
Species-specific, phosphate-containing
polymers that are bound covalently to the
peptidoglycan layer or through lipophilic
linkage to the cytoplasmic membrane
Mediate the attachment of staphylococci to
mucosal surfaces through their specific
binding to fibronectin

Physiology and Structure

Teichoic acid
Although the teichoic acids are poor
immunogens, a specific antibody response is
stimulated when they are bound to
peptidoglycan
The monitoring of this antibody response has
been used to detect systemic staphylococcal
disease although this is less sensitive than are
other diagnostic tests

Physiology and Structure

Protein A
The surface of most S. aureus (but not the
coagulase-negative staphylococci) is uniformly
coated with protein A
Extracellular protein A can also bind to
antibodies, thereby forming immune
complexes with the subsequent consumption
of the complement

Physiology and Structure

Coagulase and other surface proteins
The outer surface of most strains of S. aureus
contains clumping factor (or bound coagulase)
This protein binds fibrinogen, converts it to
insoluble fibrin, causing the staphylococci to
clump or aggregate
Detection of this protein is the primary test for
identifying S. aureus

Physiology and Structure

Cytoplasmic membrane
Made up of a complex of proteins, lipids, and
a small amount of carbohydrates
Serves as an osmotic barrier for the cell and
provides an anchorage for the cellular
biosynthesis and respiratory enzymes

Classification
The main classification of staphylococci is
based on their ability to produce coagulase,
an enzyme that causes blood clot formation
2 classification:
Coagulase positive
Coagulase negative

Classification
Coagulase Positive
S. aureus - can produce coagulase
Some may be atypical in that they do not
produce coagulase
S. aureus is also catalase-positive, able to
convert hydrogen peroxide (H2O2) to water
and oxygen, which makes the catalase test
useful to distinguish staphylococci from
enterococci and streptococci.

Classification
Coagulase Positive
Inhabits and sometimes infects the skin of
domestic dogs and cats
Carry the genetic material that imparts
multiple bacterial resistance
Optical-rectalitis is caused by a coagulasepositive organism

Classification
Coagulase Negative
S. epidermidis - a commensal of the skin, but
can cause severe infections in
immunosuppressed patients and those with
central venous catheters
S. saprophyticus - part of the normal vaginal
flora, is predominantly implicated in
genitourinary tract infections in sexually-active
young women

Classification
Coagulase Negative
In recent years, several other Staphylococcus
species have been implicated in human
infections, notably S. lugdunensis, and S.
caprae
Common abbreviations for coagulase-negative
Staphylococcus species are CoNS and CNS

Pathogenesis and Immunity Staphylococcal Toxins

S. aureus produces many virulence factors,
including at least 5 cytolytic or membranedamaging toxins (alpha, beta, delta, gamma,
and Pantovalentine [P-V] leukocidin); 2
exfoliative toxin; 8 enterotoxins (A-E, G-I), and
toxic shock syndrome toxin-1 (TSST-1)
The cytolytic toxins have also been described as
haemolysins, but this is misnomer because the
activities of the first 4 toxins are not restricted
solely to red blood cells and P-V leukocidin is
unable to lyse erythrocytes

Pathogenesis and Immunity Staphylococcal Toxins

The enterotoxins and TSST-1 belong to a class
of polypeptides known as superantigens
Type of toxins:

Alpha toxins
Beta toxins
Delta toxins
Gamma toxins
Panton-Valentine [P-V] leukocidin
Exfoliative toxins
Enterotoxins
Toxic Shock Syndrome Toxin-1 (TSST-1)

Pathogenesis and Immunity Staphylococcal Toxins

Types:
Coagulase
Catalase
Hyaluronidase
Fibrinolysin
Lipases
Nuclease
Penicillinase

Clinical Diseases Staphylococcus aureus

It causes diseases through the production of
toxin or through the direct invasion and
destruction of tissue
The clinical manifestations of some
staphylococcal diseases are almost exclusively
the result of toxin activity, whereas other
diseases result from the proliferation of the
organisms, leading to abscess formation and
tissue destruction

Clinical Diseases Staphylococcus aureus

In the presence of a foreign body, significantly
fewer staphylococci are necessary to establish
disease
Patients with congenital diseases associated
with an impaired chemotactic or phagocytic
response (e.g. Job-Buckley syndrome, WiskottAldrich syndrome, chronic granulomatous
disease) are more susceptible to
staphylococcal diseases

Clinical Diseases Staphylococcus aureus

Staphylococcal Scalded Skin Syndrome (SSSS)
Ritters disease or SSSS - characterised by the
abrupt onset of a localised perioral erythema
(redness and inflammation around the mouth)
that covers the entire body within 2 days
Slight pressure displaces the skin and large
bullae or cutaneous desquamation of the
epithelium

Clinical Diseases Staphylococcus aureus

Staphylococcal Scalded Skin Syndrome (SSSS)
The epithelium becomes intact again within 7 10 days when the protective antibodies appear
Scarring does not occur because only the top
layer of epidermis is sloughed
Low mortality; death does occur as a result of
secondary bacterial infection of the denuded
skin areas
Bullous impetigo - localised form of SSSS

Staphylococcal Scalded Skin Syndrome

Bullous Impetigo

Clinical Diseases Staphylococcal Food Poisoning

One of the most common food-borne illness, is an
intoxication rather than an infection
Caused by bacterial toxin present in food,
especially in processed meats (e.g. ham and salted
pork, custard-filled pastries, potato salad, and ice
cream)
Staphylococcal food poisoning results from
contamination of the food by a human carrier and
not animal
Food preparation by individual with obvious infection
or with asymptomatic nasopharyngeal colonisation

Clinical Diseases Staphylococcal Food Poisoning

Heating of food will kill the bacteria but not
inactivate the heat-stable toxin
After ingestion of contaminated food, the
onset of disease is abrupt and rapid, with a
mean incubation period of 4 hours and
symptoms generally lasting fewer than 24
hours
Symptoms: severe vomiting, diarrhoea, and
abdominal pain or nausea

Clinical Diseases Staphylococcal Food Poisoning

Contaminated food can be tested for toxins at
a public health facility
Treatment is for the relief of the abdominal
cramping and diarrhoea and for the
replacement of fluids
Antibiotic therapy is not indicated because the
disease is mediated by preformed toxin and
not by replicating organisms

Clinical Diseases Staphylococcal Food Poisoning

Certain strains of S. aureus can also cause
enterocolitis, which is manifested clinically by
watery diarrhoea, abdominal cramps, and
fever
Enterocolitis occurs primarily in patients who
have received broad-spectrum antibiotics,
which suppress the normal colonic flora and
permit the growth of S. aureus

Clinical Diseases Toxic Shock Syndrome

The disease is initiated with the localised
growth of toxin-producing strains of S. aureus
in the vagina or a wound, followed by release
of the toxin into the bloodstream
Clinical manifestations starts abruptly and
include fever, hypotension, and a diffuse
macular erythematous rash

Clinical Diseases Toxic Shock Syndrome

Multiple organ systems are also involved, and
the entire skin including the palms and soles
desquamates
The risk of recurrent disease is as high as 65%
50% of patients with TSS fail to develop
protective antibodies after their disease
dissolves

Toxic Shock Syndrome

Clinical Diseases Cutaneous Infections

Localised, pyogenic staphylococcal infections
include impetigo, folliculitis, furuncles, and
carbuncles
Impetigo, a superficial infection affecting
mostly young children, occurs primarily on the
face and limbs
Folliculitis is a pyrogenic infection in the hair
follicles

Folliculitis and Impetigo

Clinical Diseases Cutaneous Infections

Furuncles (boils) - an extension of folliculitis,
are large, painful, raised nodules with an
underlying collection of dead and necrotic
tissue
Carbuncles occur when furuncles coalesce
and extend to the deeper subcutaneous
tissue. Multiple sinus tracts are usually
present. Patients presented with chills and
fevers, indicating the systematic spread of
staphylococci via bacteremia to other tissues

Furuncles and Carbuncles

Clinical Diseases Bacteremia and Endocarditis

Although bacteremias caused by most other
organisms originate from an identifiable focus
of infection, such as an infection of the lungs,
urinary tract or GI tract, the initial foci of
infection in approximately of patients with
S. aureus bacteremias are not known
Hospital acquired through surgical procedure
or result from the continued use of a
contaminated IV catheter

Clinical Diseases Bacteremia and Endocarditis

S. aureus bacteremias, particularly prolonged
episodes are associated with dissemination to
other body sites, including the heart
Acute endocarditis caused by S. aureus is a
serious disease with a mortality rate
approaching 50%
Initial symptoms: non-specific influenza-like
symptoms. Patients condition can deteriorate
rapidly and include disruption of cardiac output
and peripheral evidence of septic embolisation

Endocarditis

Clinical Diseases Pneumonia and Empyema

S. aureus respiratory disease can develop after
the aspiration of oral secretions or from the
haematogenous spread of the organism from
a distant site
Aspiration pneumonia is seen primarily in the
very young, the aged, and patients with cystic
fibrosis, influenza, chronic obstructive
pulmonary disease, and bronchiectasis

Clinical Diseases Pneumonia and Empyema

Haematogenous pneumonia is common for
patients with bacteremia or endocarditis
Empyema occurs in 10% of patients with
pneumonia, and S. aureus is responsible for
of all cases

Empyema and Pneumonia

Clinical Diseases Osteomyelitis and Septic Arthritis

Osteomyelitis can result from the
haematogenous dissemination to bone, or it
can be a secondary infection resulting from
trauma or the extension of disease from an
adjacent area
The haematogenous osteomyelitis that is
seen in adults commonly occurs in the form of
vertebral osteomyelitis and rarely in the form
of infection of the long bones

Clinical Diseases Osteomyelitis and Septic Arthritis

Brodies abscess is a sequestered focus of
staphylococcal osteomyelitis that arises in the
metaphyseal area of a long bone and occurs
only in adults
S. aureus is the primary cause of septic
arthritis in young children and in adults who
are receiving intra-articular injections or who
have mechanical abnormal joints

Osteomyelitis and Septic Arthritis

Clinical Diseases
Staphylococcus epidermidis and other
coagulase-negative staphylococci

Endocarditis
Catheter and shunt infections
Prosthetic joint infections
Urinary tract infections

Laboratory Diagnosis
Microscopy - Gram positive cocci (clusters on
agar media and appear as single cells or small
groups in clinical specimens)
Culture - blood agar (haemolysis cause by
cytotoxins, particularly toxins)
Serology - antibodies to cell wall teichoic acids
Identification - biochemical tests (positive
reactions for coagulase [clumping factor],
heat-stable nuclease, alkaline phosphatase
and mannitol fermentation)

Question
What are the special characteristics of
Staphylococcus?
What are the virulence factors of
Staphylococcus?
What are the diseases that can be caused by
Staphylococcus?