Summary: Streptococcus pyogenes (Group A)

BOX 19-1
Biology, Virulence, and Disease
Rapidly growing gram-positive cocci arranged in chains;
group-specific carbohydrate (A antigen) and type-specific
proteins (M protein) in cell wall
Virulence determined by ability to avoid phagocytosis
(mediated primarily by capsule, M and M-like proteins,
C5a peptidase), adhere to and invade host cells (M
protein, lipoteichoic acid, F protein), and produce toxins
(streptococcal pyrogenic exotoxins, streptolysin S,
streptolysin O, streptokinase, DNases)
Responsible for suppurative diseases (pharyngitis, softtissue
infections, streptococcal toxic shock) and
nonsuppurative diseases (rheumatic fever,
glomerulonephritis)
Epidemiology
Transient colonization in upper respiratory tract and skin
surface with disease caused by recently acquired strains
(before protective antibodies are produced)
Pharyngitis and soft-tissue infections typically caused by
strains with different M proteins
Person-to-person spread by respiratory droplets
(pharyngitis) or through breaks in skin after direct
contact with infected person, fomite, or
arthropod vector
Individuals at higher risk for disease include children 5 to
15 years old (pharyngitis); children 2 to 5 years old with
poor personal hygiene (pyoderma); patients with
soft-tissue infection (streptococcal toxic shock
syndrome); patients with prior streptococcal pharyngitis
(rheumatic fever, glomerulonephritis) or soft-tissue
infection (glomerulonephritis)
Diagnosis
Microscopy is useful in soft-tissue infections but not
pharyngitis or nonsuppurative complications
Direct tests for the group A antigen are useful for the
diagnosis of streptococcal pharyngitis, but negative
results must be confirmed by culture or molecular assays
Isolates identified by catalase (negative), positive PYR
(L-pyrrolidonyl arylamidase) reaction, susceptibility to
bacitracin, and presence of group-specific antigen (group
A antigen)
Antistreptolysin O test is useful for confirming rheumatic
fever or glomerulonephritis associated with streptococcal
pharyngitis; anti-DNase B test should be performed for
glomerulonephritis associated with pharyngitis or
soft-tissue infections
Treatment, Prevention, and Control
Penicillin V or amoxicillin used to treat pharyngitis; oral
cephalosporin or macrolide for penicillin-allergic patients;
intravenous penicillin plus clindamycin used for systemic
infections
Oropharyngeal carriage occurring after treatment can be
re-treated; treatment is not indicated for prolonged
asymptomatic carriage because antibiotics disrupt normal
protective flora
Starting antibiotic therapy within 10 days in patients with
pharyngitis prevents rheumatic fever
For patients with a history of rheumatic fever, antibiotic
prophylaxis is required before procedures (e.g., dental)
that can induce bacteremias leading to endocarditis
For glomerulonephritis, no specific antibiotic treatment or
prophylaxis is indicated
Streptococcal Diseases: Clinical Summaries
BOX 19-2
Streptococcus pyogenes (Group A)
Suppurative Infections
Pharyngitis: reddened pharynx with exudates generally
present; cervical lymphadenopathy can be prominent
Scarlet fever: diffuse erythematous rash beginning on the
chest and spreading to the extremities; complication of
streptococcal pharyngitis
Pyoderma: localized skin infection with vesicles progressing
to pustules; no evidence of systemic disease
Erysipelas: localized skin infection with pain, inflammation,
lymph node enlargement and systemic symptoms
Cellulitis: infection of the skin that involves the
subcutaneous tissues
Necrotizing fasciitis: deep infection of skin that involves
destruction of muscle and fat layers
Streptococcal toxic shock syndrome: multiorgan systemic
infection resembling staphylococcal toxic shock
syndrome; however, most patients bacteremic and with
evidence of fasciitis
Other suppurative diseases: variety of other infections
recognized including puerperal sepsis, lymphangitis, and
pneumonia
Nonsuppurative Infections
Rheumatic fever: characterized by inflammatory changes of
the heart (pancarditis), joints (arthralgias to arthritis),
blood vessels, and subcutaneous tissues
Acute glomerulonephritis: acute inflammation of the renal
glomeruli with edema, hypertension, hematuria, and
proteinuria
Streptococcus agalactiae (Group B)
Early-onset neonatal disease: within 7 days of birth,
infected newborns develop signs and symptoms of
pneumonia, meningitis, and sepsis
Late-onset neonatal disease: more than 1 week after birth,
neonates develop signs and symptoms of bacteremia with
meningitis
Infections in pregnant women: most often present as
postpartum endometritis, wound infections, and urinaryFigure 19-1 Gram stain of Streptococcus
pyogenes.
Figure 19-2 Streptococcus pyogenes (group A) typically appear as
small colonies with a large zone of hemolysis.
tract infections; bacteremia and disseminated
complications may occur
Infections in other adult patients: most common
diseases include bacteremia, pneumonia, bone
and joint infections, and skin and soft-tissue
infections
Other -Hemolytic Streptococci
Abscess formation in deep tissues: associated with
S. anginosus group
Pharyngitis: Associated with S. dysgalactiae; disease
resembles that caused by S. pyogenes; can be
complicated with acute glomerulonephritis
Viridans Streptococci
Abscess formation in deep tissues: associated with
S. anginosus group
Septicemia in neutropenic patients: associated with
S. mitis group
Subacute endocarditis: associated with S. mitis and
S. salivarius groups
Dental caries: associated with S. mutans group
Malignancies of gastrointestinal tract: associated with
S. bovis group (S. gallolyticus subsp. gallolyticus)
Meningitis: associated with S. gallolyticus subsp.
pasteurianus, S. suis, and S. mitis group
Streptococcus pneumoniae
Pneumonia: acute onset with severe chills and sustained
fever; productive cough with blood-tinged sputum; lobar
consolidation
Meningitis: severe infection involving the meninges, with
headache, fever, and sepsis; high mortality and severe
neurologic deficits in survivors
Bacteremia: more common in patients with meningitis than
with pneumonia, otitis, media, or sinusitis; overwhelming
Summary: Streptococcus agalactiae (Group B)
Biology, Virulence, and Disease
Rapidly growing gram-positive cocci arranged in chains;
group-specific carbohydrate (B antigen) and typespecific
capsular carbohydrates (Ia, Ib, II-VIII)
Virulence determined primarily by ability to avoid
phagocytosis (mediated by capsule)
Responsible for neonatal disease (early-onset and
late-onset disease with meningitis, pneumonia,
bacteremia), infections in pregnant women
(endometritis, wound infections, urinary tract
infections), and other adults (bacteremia, pneumonia,
bone and joint infections, skin and soft-tissue
infections)
Epidemiology
Asymptomatic colonization of the upper respiratory tract
and genitourinary tract
Early-onset disease acquired by neonates from mother
during pregnancy or at time of birth
Neonates are at higher risk for infection if (1) there is
premature rupture of membranes, prolonged labor,
preterm birth, or disseminated maternal group B
streptococcal disease, and (2) mother is without
type-specific antibodies and has low complement levels
Women with genital colonization are at risk for
postpartum disease
Men and nonpregnant women with diabetes mellitus,
cancer, or alcoholism are at increased risk for disease
No seasonal incidence
Diagnosis
Microscopy useful for meningitis (cerebrospinal fluid),
pneumonia (lower respiratory secretions), and wound
infections (exudates)
Antigen tests are less sensitive than microscopy and
should not be used
Culture most sensitive test; a selective broth (i.e., LIM)
is needed for optimal detection of vaginal carriage
Polymerase chain reactionbased assays to detect vaginal
carriage in pregnant women are commercially available,
as sensitive as culture and rapid
Isolates identified by demonstration of group-specific
cell wall carbohydrate or positive nucleic acid
amplification test
Treatment, Prevention, and Control
Penicillin G is the drug of choice; empiric therapy
with broad-spectrum antibiotics (broad-spectrum
cephalosporin plus aminoglycoside) used until specific
pathogen identified; combination of penicillin and
aminoglycoside is used in patients with serious
infections; a cephalosporin or vancomycin is used
for patients allergic to penicillin
For high-risk babies, penicillin is given at least 4 hours
before delivery
No vaccine is currently available
Summary: Bacillus anthracis
Biology, Virulence, and Disease
Spore-forming, nonmotile, nonhemolytic gram-positive
rods
Polypeptide capsule consisting of poly-D-glutamic acid
observed in clinical specimens
Virulent strains also produce three exotoxins that
combine to form edema toxin (combination of
protective antigen and edema factor) and lethal toxin
(protective antigen with lethal factor)
B. anthracis primarily infects herbivores, with humans as
accidental hosts
Rarely isolated in developed countries but is prevalent in
impoverished areas where vaccination of animals is not
practiced
The greatest danger of anthrax in industrial countries is
the use of B. anthracis as an agent of bioterrorism
Three forms of anthrax are recognized: cutaneous (most
common in humans), gastrointestinal (most common in
herbivores), and inhalation (bioterrorism)
Diagnosis
Organism is present in high concentrations in clinical
specimens (microscopy typically positive) and grows
readily in culture
Preliminary identification is based on microscopic
(gram-positive, nonmotile rods) and colonial
(nonhemolytic, adherent colonies) morphology;
confirmed by demonstrating capsule and either lysis
with gamma phage, a positive direct fluorescent
antibody test for the specific cell wall polysaccharide,
or positive nucleic acid amplification assay
Treatment, Prevention, and Control
Inhalation or gastrointestinal anthrax or bioterrorismassociated
anthrax should be treated with ciprofloxacin
or doxycycline, combined with one or two additional
antibiotics (e.g., rifampin, vancomycin, penicillin,
imipenem, clindamycin, clarithromycin)
Naturally acquired cutaneous anthrax can be treated with
amoxicillin
Vaccination of animal herds and people in endemic areas
can control disease, but spores are difficult to eliminate
from contaminated soils
Animal vaccination is effective, but human vaccines have
limited usefulness
Alternative treatments interfering with the activity of
anthrax toxins are under investigation
Bacillus Diseases: Clinical Summaries
Bacillus anthracis
Cutaneous anthrax: painless papule progresses to
ulceration with surrounding vesicles and then to eschar
formation; painful lymphadenopathy, edema, and
systemic signs may develop
Gastrointestinal anthrax: ulcers form at site of invasion
(e.g., mouth, esophagus, intestine) leading to regional
lymphadenopathy, edema, and sepsis
Inhalation anthrax: initial nonspecific signs followed by
the rapid onset of sepsis with fever, edema, and
lymphadenopathy (mediastinal lymph nodes);
meningeal symptoms in half the patients, and most
patients with inhalation anthrax will die unless
treatment is initiated immediately
Bacillus cereus
Gastroenteritis: emetic form characterized by a rapid
onset of vomiting and abdominal pain and a short
duration; diarrheal form characterized by a longer onset
and duration of diarrhea and abdominal cramps
Ocular infections: rapid, progressive destruction of the
eye after traumatic introduction of the bacteria into
the eye
Severe pulmonary disease: severe anthrax-like pulmonary
disease in immunocompetent patients
Summary: Listeria
Biology, Virulence, and Disease
Gram-positive coccobacilli, often arranged in pairs
resembling enterococci and Streptococcus pneumoniae
Facultative intracellular pathogen that can avoid antibodymediated
clearance
Virulent strains produce cell attachment factors
(internalins), hemolysins (listeriolysin O, two
phospholipase C enzymes), and a protein that mediates
actin-directed intracellular motility (ActA)
Ability to grow at 4 C, in a wide pH range, and in the
presence of salt can lead to high concentrations of the
bacteria in contaminated foods
Epidemiology
Isolated in soil, water, and vegetation and from a variety
of animals, including humans (low-level gastrointestinal
carriage)
Disease associated with consumption of contaminated
food products (e.g., contaminated milk and cheese,
processed meats, raw vegetables [especially cabbage])
or transplancental spread from mother to neonate;
sporadic cases and epidemics occur throughout the
year
Neonates, elderly, pregnant women, and patients with
defects in cellular immunity are at increased risk
for disease
Diagnosis
Microscopy is insensitive; culture may require incubation
for 2 to 3 days or enrichment at 4 C
Motile at room temperature, weakly -hemolytic, and
capable of growth at 4 C and at high-salt
concentrations
Treatment, Prevention, and Control
The treatment of choice for severe disease is penicillin or
ampicillin, alone or in combination with gentamicin
People at high risk should avoid eating raw or partially
cooked foods of animal origin, soft cheese, and
unwashed raw vegetables

Table 22-1 Listeria and Erysipelothrix

Organism Historical Derivation
Listeria Listeria, named after the English surgeon
Lord Joseph Lister
L. monocytogenes monocytum, a blood cell or monocyte;
gennaio, produce (monocyte producing;
membrane extracts stimulate monocyte
production in rabbits, but this is not seen
in human disease)
Erysipelothrix erythros, red; pella, skin; thrix, hair (thin,
hairlike organism that produces a red or
inflammatory skin lesion)
E. rhusiopathiae rhusios, red; pathos, disease (red disease)
Summary: Erysipelothrix
Biology, Virulence, and Disease
Slender, pleomorphic, gram-positive rods that form long
(i.e., 60m) filaments
Production of neuraminidase believed to be important for
attachment and penetration into epithelial cells, and
polysaccharide-like capsule protects the bacteria from
phagocytosis
Disease in humans most commonly a localized cutaneous
infection or septicemia associated with endocarditis
Epidemiology
Colonizes a variety of organisms, particularly swine
and turkey
Found in soil rich in organic matter or groundwater
contaminated with wastes from colonized animals
Uncommon pathogen in the United States
Occupational disease of butchers, meat processors,
farmers, poultry workers, fish handlers, and
veterinarians
Diagnosis
Long, filamentous gram-positive rods seen on Gram
stain of a biopsy collected at the advancing edge of
the lesion
Grows well on blood and chocolate agars incubated in
5% to 10% carbon dioxide
Treatment, Prevention, and Control
Penicillin is drug of choice for both localized and
systemic diseases; ciprofloxacin or clindamycin can
be used for localized cutaneous infections for patients
allergic to penicillin, and ceftriaxone or imipenem
can be considered for disseminated infections
Workers should cover exposed skin when handling
animals and animal products
Swineherds should be vaccinated