Streptococci and Other

Streptococci-like Organisms

Gram-Positive Cell Wall

Gram-Negative Cell Wall

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
oxidasenegative

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 () 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

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 Lpyrrolidonylnapthlyamide (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, MunchPetersen (CAMP) test

Detects the production

of enhanced hemolysis
that occurs when -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

One virulence factor is

the fibronectin-binding
protein Sfbl.
This protein is involved in
the adherence and
internalization processes
of GAS isolates.
Sfbl interacts with
extracellular matrix (ECM)
proteins, particularly
fibronectin, using it as a
bridging molecule to
efficiently attach to and
invade host respiratory
endothelial cells.

S.pyogenes is generally an extracellular pathogen

that uses its secreted products, the streptococcal
extracellular products, to mediate bacterial
invasion of the host.
The invasins and exotoxins interact with host blood
and tissue components in ways that kill host cells
and result in damaging inflammatory responses.
Of the invasins, streptolysin O and S are
leukocidins, meaning they destroy phagocytes.
Hyaluronidase digests host connective tissue, and
the streptodornases degrade DNA.
Hyaluronidase also digests the bacterial capsule,
made of hyaluronic acid, which allows the bacterial
proteins involved in the internalization process to
be readily accessible for interaction with host cell
proteins .

The streptokinases are involved in fibrin lysis. Fibrin is a

critical protein involved in blood clotting, so
streptokinase activity can lead to hemorrhaging.
Taken together, streptococcal invasins lyse host cells,
including blood and immune cells, and allow S.pyogenes
to spread among host tissues by dissolving fibrin and
other intercellular substances.
The exotoxins include the three SPEs, types A, B, and C,
which act as superantigens. In necrotizing fasciitis,
these SPEs stimulate T cells by binding to the MHC class
II molecules.
The T cells are thus activated, and release a large
amount of cytokines, triggering an inflammatory
cascade.

Hyaluronic Acid Capsule

Non-antigenic

Adhesin

Prevents opsonized
phagocytosis

Amount of encapsulation
varies between GAS
strains

Highly encapsulated strains with

lots of M protein are associated
with invasive GAS diseases
The capsule of S.pyogenes also
acts as an adhesin by binding to
CD44 on human epithelial cells,
which leads both to cytoskeletal
rearrangements and to the
opening of intercellular junctions.
These events facilitate bacterial
access to deeper host tissues .

A Bacterial Capsule
Preventing Receptors on
Phagocytes from Binding to
Bacterial Cell Wall

M Protein

Major virulence factor

Composed of 3 regions:

Hypervariable (N-terminus)
Variable (A- and B-repeats)
Conserved (C-repeats)

Antigenic differences in the

hypervariable region
constitute the basis for the
Lancefield serological
classification of GAS

Over 120 types

Antibodies against one type

confer no protection against
others

M Protein Contd

Involved in colonization and

resistance to phagocytosis

Mediates antiphagocytic effect by

inhibiting activation of alternate
complement pathway

Confers resistance to phagocytosis

because it acts as an adhesin

Shares sequence homology with

mammalian fibrillar proteins,
providing a structural basis for
induction of autoimmunity
following GAS infection

Extracellular Virulence Factors (cont.)

Enzymes:
Nucleases:

Four antigenic types (A,B,C,D)

Facilitate liquefication of pus generating growth substrates
Nucleases A, C have DNase activity
Nucleases B, D also have RNase activity

Streptokinases: Two different forms

Lyse blood clots: catalyze conversion of plasminogen to plasmin, leading to
digestion of fibrin

C5a Peptidase: destroys C chemotactic signals (C5a)

Hyaluronidase: hydrolyzes hyaluronic acid
Others: Proteinase, NADase, ATPase, phosphatase, etc.

Diseases Contd

Image taken
from:

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

Differential Features of Group A

Streptococcus (GAS) and Viral
Findings Suggestive of
Findings Suggestive of
Pharyngitis
GAS Infection

SYMPTOMS

Sore throat
Dysphagia
Fever
Headache
Abdominal pain
Nausea/vomiting

SIGNS

Viral Infection

Soft palate petechiae

Anterior cervical
lymphadenopathy
Scarlet fever rash

SYMPTOMS

Cough
Running nose
Hoarse voice
Diarrhea

SIGNS

Stomatitis
Conjunctivitis

Erysipelas
NOTE:
erythema
bullae
Erysipelas: Acute
superficial cellulitis
of skin with
lymphatic
involvement; face
and lower
extremities, skin
and subcutaneous
tissues

Streptococcal Skin Infections

Erysipelas

Impetigo

infects the dermal layer

reddish patches
Can progress to local tissue destruction
Enter the bloodstream
isolated pustules

Streptococcal toxic shock syndrome

M proteins
Complex with fibrinogen
Binds to neutrophils
Activates neutrophils
Release of damaging enzymes
Shock and organ damage
Figure 21.6, 7

Scarlet fever

Scarlet fever, characterized by a diffuse,

erythematous, blanching, fine papular rash that
resembles sandpaper on palpation, is another
manifestation of GAS infection.
Scarlet fever is caused by erythrogenic toxinproducing strains of GAS and may manifest
desquamation after the rash starts to fade.
Exudative pharyngitis may occur, but this finding also
is common with viral pharyngitis.
In children younger than 3 years, an atypical symptom
complex known as streptococcosis may occur,
consisting of persistent nasal congestion, rhinorrhea,
low-grade fever, and anterior cervical
lymphadenopathy.
In infants, the only symptoms may be low-grade fever,
fussiness, and decreased feeding.

PostGroup-A
Streptococcal Infections

Rheumatic fever from pharyngeal infections

only

Fever
Inflammation of the heart, joints, blood vessels, and
subcutaneous tissues inflammatory reaction
characterized by arthritis, carditis, chorea (disorder of CNS
with involuntary spastic movements), erythema
marginatum (skin redness with defined margin), or
subcutaneous nodules
Chronic, progressive damage to the heart valves

Jones criteria for the Diagnosis of Acute

Rheumatic Fever
Jones Criteria for the Diagnosis of Acute Rheumatic Fever

Diagnosis: Requires 2 major criteria or 1 major and 2 minor criteria

plus evidence of recent group A streptococcal infection
Major
Minor
Evidence of Recent GAS
Infection
Carditis
Fever
Positive throat culture or RADT
Polyarthritis
Arthralgia
or
Chorea
Elevated acute phase
Elevated or rising
Erythema
reactants
antistreptococcal antibody
marginatum
Prolonged PR interval
titers
Subcutaneous
nodules

RADT_rapid antigen detection test

PostGroup-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

Necrotizing fasciitis: ( flesh-eating bacteria):

Infection deep in subcutaneous tissues that spreads along fascial

planes, destroying muscle and fat; Initially cellulitis followed by
bullae (fluid filled blisters; bulla is singular), gangrene, systemic
toxicity, multiorgan failure and mortality in more than 50% of patients

Laboratory Diagnosis:
Group A Streptococcus

Grams stained wound smear showing grampositive cocci in chains with numerous polys

Laboratory Diagnosis:
Group A Streptococcus

Colony morphology

Transparent, smooth,
and well-defined zone
of complete orhemolysis

Laboratory Diagnosis:
Group A Streptococcus

Identification

Catalase-negative
Bacitracin-susceptible
PYR-positive
Bile-esculinnegative
6.5% NaCl-negative

Group A streptococci is
susceptible to Bacitracin disk
(left); The right shows resistance

Group 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

Epidemiology of Neonatal Group B

Streptococcal 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 -Hemolytic Streptococcus

Colony morphology

Grayish-white, mucoid,
creamy, narrow zone of
-hemolysis

Presumptive
Identification tests

Catalase-negative
Bacitracin-resistant

Laboratory Diagnosis:
Group B -Hemolytic Streptococcus

Presumptive
identification tests

Bile-esculin-hydrolysis
negative
Does not grow in 6.5%
NaCl
CAMP-testpositive

S. agalactiae shows the arrowshaped hemolysis near the

staphylococcus streak,
showing a positive test for
CAMP factor

CAMP Factor Test

Group B
Streptococcus

S. aureus
(Spingomyelinase C)

(CAMP Factor)

Group A
Streptococcus

Enhanced
Zone of
Hemolysis

Hippurase NEG

Grp B Streptococci
and
Campylobacter

Hippurase POS

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

 Important nosocomial pathogen

Vancomycin resistant Enterococcus (VRE)

Laboratory Diagnosis: Streptococcus

Group D and Enterococcus Species

Microscopic morphology

Cells tend to elongate

Colony morphology

Most are nonhemolytic, although

some may show or,
rarelyhemolysis
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

Enterococcus
Group D Streptococcus

Bile Esculin Agar

Bile Esculin Agar
NEG

POS

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

Virulence factors

Inhabits the nasopharyngeal areas of healthy

individuals
Typical opportunist
Possess C substance
Polysaccharide capsule

Clinical infections

pneumonia
meningitis
bacteremia
sinusitis/otitis media

Laboratory Diagnosis:
Streptococcus pneumoniae

Microscopic
morphology

Gram-positive cocci
in pairs; lancetshaped

S. pneumoniae
Diplococcus

S. pneumoniae Virulence Factors

Transformation (In vivo) (Griffith)

Laboratory Diagnosis:
Streptococcus pneumoniae

Colony
morphology

Smooth,
glistening, wetlooking, 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