Dr.
Oruba Khalid Abbas
Streptococci
Classification of Streptococci based on
(1) - Hemolysis reactions on blood agar) (Brown in 1903)
The type of hemolytic reaction on blood agar has long been used to classify the streptococci.
Beta -hemolysis
complete lysis of red cells surrounding the colony
appearance as Clear zone
Streptococcus pyogenes are beta-hemolytic
alpha-hemolysis
partial hemolysis (Greenish Discoloration) associated with reduction of red cell
hemoglobin.
S. pneumoniae are alpha-hemolytic (but can cause ß-hemolysis during anaerobic
incubation).
gamma-hemolytic
Non hemolytic colonies.
Enterococcus faecales
Most of oral streptococci and enterococci are non- hemolytic.
The property of hemolysis is not very reliable for the absolute identification of streptococci,
but it is widely used in rapid screens for identification of S. pyogenes & S. pneumoniae.
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Groups of Streptococci (1- Hemolysis on blood agar)
Streptococcus
α- Hemolytic β- Hemolytic γ-Hemolytic
Green- (Partial) Clear-( Complete) ( No
hemolysis)
S. pneumonia S. viridans S. pyogenes S. agalacteae Enterococcus faecales
- Optichan Sensetive -Optichan resistant - grow on macconkey
- lansifield ( A) -Lancifield (B)
-has capsule -no capsule - Lancifield (D)
-Bacitracin sensitive -Bacitracin resistant
-not grow in bile salt -grow in bile salt
(2) - Antigenic types of carbohydrate (Serology)
The cell wall of Streptococci is composed of repeating units of N-acetylglucosamine and
Nacetylmuramic acid, (standard peptidoglycan).
The identification of streptococci based on the serologic reactivity of "cell wall"
polysaccharide antigens described by Lancefield classification.
Lancefield developed serotyping system for classification of beta-hemolytic streptococci or
gamma based on the antigenic composition of
specific cell wall carbohydrates (C- Carbohydrates) or C- Substrate
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Viridians streptococci & Strep. pneumonia are not grouped under Lancefield
Classification (have no group-specific antigen).
18 group-specific antigens (Lancefield groups) were known.
The clinically important streptococci are grouped under A, B, C, D, F and G.
The main species and groups of medical importance :
–Group A Streptococci (GAS): Streptococcus pyogenes
The cell surface structure Strep. pyogenes is the most studied of any streptococi bacteria.
Group A polysaccharide (C substance or group carbohydrate antigen) is a polymer of
Nacetylglucosamine and rhamnose.
–Group B Streptococci (GBS): Strep. agalactiae
–Group D Streptococci: Enterococcus faecalis
(3)- Biochemical /Physiological properties
Bergeys manual of bacteriology, classified Streptococci based on growth at 6.5 %
NaCl, 10 and 45 degree centigrade .
Growth in 6.5% NaCL Temperature Group
45 °C 10° C
- - - Strep. pyogenes
- + - Strep. Viridans
+ + + Enterococcus
- - + Lactic acid bacteria
Streptococcus pyogenes (Group A streptococcus)
General characteristics
Gram-positive
Coccus, occurs in chains of varying lengths
Catalase negative
Oxidase negative
Nitrate negative
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Facultative anaerobic (the metabolism of S. pyogenes is fermentative ) Requires
enriched medium containing blood to grow.
Group A streptococci have a capsule composed of hyaluronic acid
Beta hemolysis on blood agar
Non-motile
Non spore-forming.
S. pyogenes is usually an exogenous secondary invader, following viral disease or
disturbances the normal flora.
Gram stain of Strep. pyogenes in a
clinical specimen and from pure
culture.
Pathogenesis of Strep. pyogenes
It is a major success pathogen to its ability to colonize, rapidly multiply and spread in host
while evading phagocytosis and confusing the immune system.
It is found usually in the respiratory tract, without signs of disease. Strep. pyogenes can infect
when defenses are compromised or when its able to penetrate the constitutive defenses.
Streptococcal diseases are associated in respiratory tract (pharyngitis or tonsillitis),
bloodstream, or the skin (pyoderma).
Summary of diseases caused by Strep. pyogenes
Suppurative infections (associated with pus occur in the throat, skin & systemically).
Acute diseases:
• Respiratory tract infections
Throat: S. pyogenes is the leading cause of pharyngitis (strep throat). It is acquired by
inhaling aerosols by infected individuals. The symptoms reflect the inflammatory events at
the site of infection.
sinusitis, otitis, and pneumonia.
• Skin
Impetigo (superficial) infection of epidermal layers of skin.
Cellulitis (deep) occurs when the infection spreads subcutaneous tissues.
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Necrotizing fasciitis (destructive wound infections) infection of the fascia & may proceed
rapidly to underlying muscle. It is severe invasive infections, prompting descriptions of
"flesh eating bacteria".
• Systemic
Scarlet fever (rash); a severe complication of streptococcal infection, but now, because of
antibiotic therapy, it is little more than streptococcal pharyngitis accompanied by rash. It
caused by erythrogenic toxin.
Toxic shock; caused by a few strains that produce a toxic shock toxin (Superantigens).
Scarlet fever & streptococcal toxic shock syndrome are systemic responses to circulating
bacterial toxins.
Invasive, toxigenic streptococci cause joint or bone infections, and myositis, meningitis and
endocarditis, Bacteremia, Puerperal sepsis
Non-suppurative Sequelae:
Two post streptococcal sequelae rheumatic fever & glomerulonephritis, may follow
streptococcal disease, and occur in 1-3% of untreated infections.
Due to immunological reactions to Strep. pyogenes antigens. Some of the antibodies produced
during the above infections cross-react with certain host tissues. These can indirectly damage
host tissues after the organisms cause non suppurative complications.
Rheumatic fever. M protein cross reacts with sarcolemma.- Antibodies cross-react with
heart tissue, fix complement, and cause damage.
Glomerulonephritis. Antigen-antibody complexes may be deposited in kidney, fix
complement, and damage glomeruli- Only a few M-types are nephritogenic.
Virulence Factors of S. pyogenes
Strep. pyogenes produces a wide array of virulence factors, include:
(1) Protein M (major virulence factor) , fibronectin-binding protein (Protein F) and
lipoteichoic acid for adherence (inhibit phagocytosis).
(2) T substance:
This antigen has no relation to the virulence of streptococci.
T-substance is acid labile and heat labile and it’s obtained from
streptococci by proteolytic digestion. On basis of this antigen
certain types of streptococci are differentiated by agglutination. It’s
type specific, permits differentiation of certain types of
streptococci. It’s used in epidemiological studies as “typing
marker”.
(3) Nucleoprotein:
Antigens associated with streptococcal cell body.
(4) hyaluronic acid capsule (non antigenic) as an immunological disguise and to inhibit or
prevent opsonized phagocytosis by neutrophils or macrophages.
(5) invasins such as Haemolysins, streptokinase, hyaluronidase and streptolysin
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(streptolysin O, streptolysin S ) (ASO test)
Hemolysin Streptolysin O Streptolycin S
Stability of Oxygen No yes
Antigenic Yes No ( small)
(6) Exotoxins, such as pyrogenic (erythrogenic) toxin; causes the rash in scarlet fever and
systemic toxic shock syndrome.
7-DNAase (streptodornase- 4 types)
8-Protease
9. Amylase
10. C5a peptidase (evasion of pahgocytosis)- C5a enhances chemotaxis of phagocytes
. Streptolysin O *sensitive to oxygen
* antigenic ASO
Streptolysin O is a protein that is hemolytically active in the
reduced state but rapidly inactivated in the presence of oxygen its
antigenic and combines quantitively with antistreptolysin O (ASO)
this antibody blocks hemolysis by streptolysin O.
Streptolysin O +RBCs = hemolysis
Streptolysin O+ASO+ RBCs = no hemolysis
The ASO titer can be applied in the diagnosis of streptococcal
infections.
Serum titer >200 I.U. is considered abnormal.
streptolysin S * Not sensitive to oxygen
* Not an antigenic
It’s responsible for hemolysis around streptococcal colonies on
blood agar surface.
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Treatment and prevention
Penicillin is still effective in treatment of GAS disease and to prevent sequelae.
No effective vaccine has been produced, but specific M-protein vaccines are being tested.
M protein vaccines are a major candidate for use against rheumatic fever, but certain M
protein types cross-react antigenically with the heart and themselves may be responsible for
rheumatic carditis. This risk of autoimmunity has prevented the use of Group A streptococcal
vaccines.
Streptococcus agalactiae
Beat hemolytic
Lancefield group B
Regularly resides in human vagina, pharynx and large intestine
Can be transferred to infant during delivery and cause severe infection.
Streptococcus agalactiae—group
B strep: Bacitracin resistant,
Hippurate test ⊕, PYR ⊝, Produces
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CAMP factor which enlarges the area of hemolysis. (Note: CAMP stands for the
authors of the test, not cyclic AMP.).
causes: pneumonia, meningitis, and sepsis, mainly in babies.
Because it colonizes female genital tract it’s recommended to screen pregnant
women at 35–37 weeks of gestation with rectal and vaginal swabs, Patients with
⊕ culture receive intrapartum penicillin prophylaxis.
Groups A & B Streptococci are treated with penicillin/ Erythromycin.
No vaccines available
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2.Lancefield Group D Enterococcus – E. faecalis:
normal colonists of human large intestine
Causes; Nosocomial Infections, opportunistic urinary, wound and skin infections Grow
in the presence of 6.5% NaCl.
Grow on MacConkey agar
Usually non-hemolytic or α hemolytic
Naturally high levels of antibiotic resistance
Sensitivity testing needed for enterococci
Treatment ( Penicillin+ Gentamycin)
No vaccines available
Viridians streptococci
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They possess no Lancefield antigens.
Non haemolytic- alpha haemolytic.
Optochin resistant.
Not soluble in bile salts
Heterogeneous group of organisms
–Human commensals
–Pathogens
Causes; endocarditis, bacteremia
eg. Streptococcus mutans (dental caries)
Streptococcus salivarius
Streptococcus pneumoniae (Diplococcus pneumoniae)
Gram-positive, cocci. Usually, pairs of cocci (diplococci)
alpha hemolytic, cultured in media that contain blood (fastidious) - growing best in 5%
Co2.
Possess a capsule of polysaccharide that permits typing with specific antisera
Young colonies resemble dew-drops due to capsule- spontaneous autolysis of older bacteria.
Fermentative aerotolerant anaerobe
Special tests such as inulin fermentation, bile solubility, Quelling reacion, optochin antibiotic.
Like other streptococci, they lack catalase and ferment glucose to lactic acid. Do not
display C- substrate of cell wall composition. normal inhabitant of the human upper
respiratory tract can cause pneumonia, sinusitis, otitis media, meningitis- It also causes
osteomyelitis, septic arthritis, endocarditis, cellulitis and brain abscesses. usually secondary
to one of the former infections.
Strep. pneumoniae is currently the leading cause of invasive bacterial disease in children
and the elderly. do not form spores. non-motile.
sensitivity must be routinely employed to differentiate the pneumococcus from Strep.
viridans.
Pneumonia is a disease of the lung that is caused by a variety of bacteria including
Streptococcus, Staphylococcus, Pseudomonas, Haemophilus, Chlamydia & Mycoplasma,
several viruses, and certain fungi and protozoans.
The disease may be divided into two forms,
bronchial pneumonia and lobar pneumonia.
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Bronchial pneumonia: most prevalent in infants, young children and aged adults. It is
caused by various bacteria, including Strep. pneumoniae. produces Patchy Pneumonic
Consolidation
Lobar pneumonia: occur in younger adults. A majority (more than 80%) of the cases of
lobar pneumonia are caused by Strep. pneumoniae. causes consolidation of whole lobe.
Virulence factors of Strep. pneumoniae
1- Capsule (polysaccharide)
Completely envelops the pneumococcal cells.
The capsule is an essential determinant of virulence.
The capsule interferes with phagocytosis by preventing complement C3b opsonization of the
bacterial cells.
90 different capsule types of pneumococci have been identified and form the basis of
antigenic serotyping of the organism.
2- IgA protease
Treatment and vaccination
- Traditionally treated with
Amoxicillin
Chloramphenicol
Third generation Cephalosporins
- Anti-pneumococcal vaccines are based on formulations of various capsular
(polysaccharide) antigens derived from the highly-prevalent strains
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