Lecture-1-Staphylococcus.. .

Staphylococci
The staphylococci are gram-positive spherical cells, usually arranged in grape-like irregular clusters. They grow readily on many types of media and are active metabolically, fermenting carbohydrates and producing pigments that vary from white to deep yellow. Some are members of the normal flora of the skin and mucous membranes of humans; others cause suppuration, abscess formation, a variety of pyogenic infections, and even fatal septicemia. The pathogenic staphylococci often hemolyze blood, coagulate plasma, and produce a variety of extracellular enzymes and toxins. The most common type of food poisoning is caused by a heat-stable staphylococcal enterotoxin. Staphylococci rapidly develop resistance to many antimicrobial agents and present difficult therapeutic problems. The genus staphylococcus has at least ! species. The three main species of clinical importance are StaphylococcuS. aureus, Staphylococcus epidermidis, and Staphylococcus saprophyticus. Staphylococcus aureus is coagulase-positive, which differentiates it from the other species. S. aureus is a ma"or pathogen for humans. #lmost every person will have some type of S aureus infection during a lifetime, ranging in severity from food poisoning or minor skin infections to severe life-threatening infections. The coagulase-negative staphylococci are normal human flora and sometimes cause infection, often associated with implanted appliances and devices, especially in very young, old, and immunocompromised patients. #pproximately $%& of these infections caused by coagulase-negative
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Lecture-1-Staphylococcus.. .

staphylococci are due to S epidermidis. S saprophyticus is a relatively common cause of urinary tract infections in young women. Morphology & Identification A. TYPICAL ORGANISMS Staphylococci are spherical cells about ' (m in diameter arranged in irregular clusters. Single cocci, pairs, tetrads, and chains are also seen in li)uid cultures. Staphylococci are nonmotile and do not form spores. *nder the influence of drugs like penicillin, staphylococci are lysed. . C!LT!R" Staphylococci grow readily on most bacteriologic media under aerobic or microaerophilic conditions. They grow most rapidly at $ +, but form pigment best at room temperature -.!/.% +,0. ,olonies on solid media are round, smooth, raised, and glistening. S. aureus usually forms gray to deep golden yellow colonies. S epidermidis colonies usually are gray to white on primary isolation; many colonies develop pigment only upon prolonged incubation. 1o pigment is produced anaerobically or in broth. 2arious degrees of hemolysis are produced by S. aureus and occasionally by other species. C. GRO#T$ C$ARACT"RISTICS The staphylococci produce catalase, which differentiates them from the streptococci. 3athogenic staphylococci produce many extracellular substances, which are discussed below. Staphylococci are relatively resistant to drying, heat, and 4& sodium chloride but are readily inhibited by certain chemicals. Staphylococci are variably sensitive to many antimicrobial drugs.

Lecture-1-Staphylococcus.. .

Antigenic Str%ct%re Staphylococci contain antigenic polysaccharides and proteins as well as other substances important in cell wall structure. 3eptidoglycan, a polysaccharide polymer containing linked subunits, provides the rigid exoskeleton of the cell wall. Teichoic acids, which are polymers of glycerol or ribitol phosphate, are linked to the peptidoglycan and can be antigenic. 3rotein # is a cell wall component of many S. aureus strains that binds to the 5c portion of 6g7 . The 5ab portion of 6g7 bound to protein # is free to combine with a specific antigen. 3rotein # has become an important reagent in immunology and diagnostic laboratory technology; for example, protein # with attached 6g7 molecules directed against a specific bacterial antigen will agglutinate bacteria that have that antigen &'coagglutination80. Some S aureus strains have capsules, which inhibit phagocytosis. 9ost strains of S. aureus have coagulase, or clumping factor, on the cell wall surface; coagulase binds nonenzymatically to fibrinogen, yielding aggregation of the bacteria. "n(y)e* & To+in*. Staphylococci can produce disease both through their ability to multiply and spread widely in tissues and through their production of many extracellular substances. A. CATALAS" Staphylococci produce catalase, which converts hydrogen peroxide into water and oxygen. The catalase test differentiates the staphylococci, which are positive, from the streptococci, which are negative.
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Lecture-1-Staphylococcus.. .

. COAG!LAS" AN, CL!MPING -ACTOR S aureus produces coagulase, an enzyme-like protein that clots oxalated or citrated plasma. ,oagulase binds to prothrombin and initiate fibrin polymerization. ,oagulase may deposit fibrin on the surface of staphylococci, perhaps altering their ingestion by phagocytic cells or their destruction within such cells. ,lumping factor is a surface S aureus compound that is responsible for adherence of the organisms to fibrinogen and fibrin. :hen mixed with plasma, S aureus forms clumps. ,lumping factor is distinct from coagulase. C. OT$"R "N.YM"S ;ther enzymes produced by staphylococci include a hyaluronidase, or spreading factor; a staphylokinase resulting in fibrinolysis but acting much more slowly than streptokinase; proteinases; lipases; and <-lactamase. ,. "/OTO/INS The alpha toxin is a heterogeneous protein that acts on a broad spectrum of eukaryotic cell membranes. The alpha-toxin is a potent hemolysin. The <etatoxin degrades sphingomyelin and therefore is toxic for many kinds of cells, including human red blood cells. The gamma-toxin lyses red blood cells from humans and animals. The delta-toxin is heterogeneous and dissociates into subunits in nonionic detergents. 6t disrupts biologic membranes and may have a role in S aureus diarrheal diseases. ". PANTON0 1AL"NTIN" L"!2OCI,IN This toxin of S. aureus has two components. 6t can kill white blood cells of humans and rabbits. The two components act synergistically on the white blood cell membrane to form pores and increase cation permeability.
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Lecture-1-Staphylococcus.. .

-. "/-OLIATI1" TO/INS These epidermolytic toxins of S. aureus are two distinct proteins of the same molecular weight. =pidermolytic toxin # is a chromosomal gene product and is heat-stable -resists boiling for .! minutes0. =pidermolytic toxin > is plasmid-mediated and heat-labile. The epidermolytic toxins yield the generalized des)uamation of the staphylococcal scalded skin syndrome. The toxins are superantigens. G. TO/IC S$OC2 SYN,ROM" TO/IN 9ost S. aureus strains isolated from patients with toxic shock syndrome produce a toxin called toxic shock syndrome toxin-' -TSS0, which is the same as enterotoxin 5. TSS is the prototypical superantigen. TSS binds to 9?, class 66 molecules, yielding T cell stimulation, which promotes the protean -different forms0 manifestations of the toxic shock syndrome. The toxin is associated with fever, shock, and multisystem involvement, including a des)uamative skin rash. $. "NT"ROTO/INS There are multiple -#/=, 7/6, @/90 enterotoxins. #pproximately %!& of S. aureus strains can produce one or more of them. Aike TSS, the enterotoxins are superantigens. The enterotoxins are heat-stable and resistant to the action of gut enzymes. #n important cause of food poisoning, enterotoxins are produced when S. aureus grows in carbohydrate and protein foods. 6ngestion of .% (g of enterotoxin > results in vomiting and diarrhea. The emetic effect of enterotoxin is probably the result of central nervous system stimulation -vomiting center0 after the toxin acts on neural receptors in the gut

Lecture-1-Staphylococcus.. .

Pathogene*i* Staphylococci, particularly S epidermidis , are members of the normal flora of the human skin and respiratory and gastrointestinal tracts. 1asal carriage of S. aureus occurs in .!/%!& of humans. Staphylococci are also found regularly on clothing, bed linens, and other fomites in human environments. The pathogenic capacity of a given strain of S. aureus is the combined effect of extracellular factors and toxins together with the invasive properties of the strain. #t one end of the disease spectrum is staphylococcal food poisoning,attributable solely to the ingestion of preformed enterotoxin; at the other end are staphylococcal bacteremia and disseminated abscesses in all organs. 3athogenic, invasive S. aureus produces coagulase and tends to produce a yellow pigment and to be hemolytic. 1onpathogenic, noninvasive staphylococci such as S epidermidis are coagulase-negative and tend to be nonhemolytic. Such organisms rarely produce suppuration but may infect orthopedic or cardiovascular prostheses or cause disease in immunosuppressed persons. S saprophyticus is typically nonpigmented, novobiocin-resistant, and nonhemolytic; it causes urinary tract infections in young women. Pathology The prototype of a staphylococcal lesion is the furuncle or other localized abscess. 7roups of S. aureus established in a hair follicle lead to tissue necrosis -dermonecrotic factor0. ,oagulase is produced and coagulates fibrin around the lesion and within the lymphatics, resulting in formation of a wall
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that limits the process and is reinforced by the accumulation of inflammatory cells and, later, fibrous tissue. :ithin the center of the lesion, li)uefaction of the necrotic tissue occurs -enhanced by delayed hypersensitivity0, and the abscess Bpoints8 in the direction of least resistance. Crainage of the li)uid center necrotic tissue is followed by slow filling of the cavity with granulation tissue and eventual healing. 5ocal suppuration -abscess0 is typical of staphylococcal infection. 5rom any one focus, organisms may spread via the lymphatics and bloodstream to other parts of the body. Suppuration within veins, associated with thrombosis, is a common feature of such dissemination. S. aureus may cause pneumonia, meningitis, empyema, osteomyelitis, endocarditis, or sepsis with suppuration in any organ. Staphylococci of low invasiveness are involved in many skin infections -eg, acne, pyoderma, or impetigo0. #naerobic cocci -peptostreptococcus0 participate in mixed anaerobic infections. Staphylococci also cause disease through the elaboration of toxins, without apparent invasive infection. >ullous exfoliation, the scalded skin syndrome, is caused by the production of exfoliative toxins. Toxic shock syndrome is associated with toxic shock syndrome toxin-' -TSS0. Clinical -inding* # localized staphylococcal infection appears as a Bpimple,8 hair follicle infection, or abscess. There is usually an intense, localized, painful inflammatory reaction that undergoes central suppuration and heals )uickly when the pus is drained.

Lecture-1-Staphylococcus.. .

S. aureus infection can also result from direct contamination of a wound, eg, postoperative staphylococcal wound infection or infection following trauma -chronic osteomyelitis subse)uent to an open fracture, meningitis following skull fracture0. 6f S. aureus disseminates and bacteremia ensues, endocarditis, acute hematogenous osteomyelitis, meningitis, or pulmonary infection can result. 5ood poisoning due to staphylococcal enterotoxin is characterized by a short incubation period -'/D hours0; violent nausea, vomiting, and diarrhea; and rapid convalescence. There is no fever. Toxic shock syndrome is manifested by an abrupt onset of high fever, vomiting, diarrhea, myalgias, a scarlatiniform rash, and hypotension with cardiac and renal failure in the most severe cases. 6t often occurs within % days after the onset of menses in young women who use tampons, but it also occurs in children or in men with staphylococcal wound infections. The syndrome can recur. Toxic shock syndrome-associated S. aureus can be found in the vagina, on tampons, in wounds or other localized infections, or in the throat but virtually never in the bloodstream. ,iagno*tic La3oratory Te*t* A. SP"CIM"NS Surface swab, pus, blood, tracheal aspirate, or spinal fluid for culture, depending upon the localization of the process. . SM"ARS Typical staphylococci are seen in stained smears of pus or sputum. 6t is not possible to distinguish saprophytic -S epidermidis0 from pathogenic -S. aureus0 organisms on smears.
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Lecture-1-Staphylococcus.. .

C. C!LT!R" Specimens planted on blood agar plates give rise to typical colonies in 'D hours at $ +,, but hemolysis and pigment production may not occur until several days later and are optimal at room temperature. S. aureus but not other staphylococci ferment mannitol. Specimens contaminated with a mixed flora can be cultured on media containing $.%& 1a,l; the salt inhibits most other normal flora but not S. aureus. 9annitol salt agar is used to screen for nasal carriers of S. aureus. ,. CATALAS" T"ST # drop of hydrogen peroxide solution is placed on a slide, and a small amount of the bacterial growth is placed in the solution. The formation of bubbles -the release of oxygen0 indicates a positive test. The test can also be performed by pouring hydrogen peroxide solution over a heavy growth of the bacteria on an agar slant and observing for the appearance of bubbles. ". COAG!LAS" T"ST ,itrated rabbit -or human0 plasma diluted 'E% is mixed with an e)ual volume of broth culture or growth from colonies on agar and incubated at $ +,. # tube of plasma mixed with sterile broth is included as a control. 6f clots form in '/F hours, the test is positive. ,oagulase-positive staphylococci are considered pathogenic for humans; 6nfections of prosthetic devices can be caused by organisms of the coagulase-negative S epidermidis group. -. S!SC"PTI ILITY T"STING >roth microdilution or disk diffusion susceptibility testing should be done routinely on staphylococcal isolates from clinically significant infections.
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Lecture-1-Staphylococcus.. .

Gesistance to penicillin 7 can be predicted by a positive test for <-lactamase; approximately 4!& of S. aureus produce <-lactamase. Gesistance to nafcillin -and oxacillin and methicillin0 occurs in about .!& of S. aureus and approximately $%& of S epidermidis isolates. G. S"ROLOGIC AN, TYPING T"STS Serologic tests for diagnosis of S. aureus infections have little practical value. 9olecular typing techni)ues have been used to document the spread of epidemic disease-producing clones of S. aureus. Treat)ent 9ost persons harbor staphylococci on the skin and in the nose or throat. =ven if the skin can be cleared of staphylococci -eg, in eczema0, reinfection by droplets will occur almost immediately. >ecause pathogenic organisms are commonly spread from one lesion -eg, a furuncle0 to other areas of the skin by fingers and clothing, scrupulous local antisepsis is important to control recurrent furunculosis. Serious multiple skin infections -acne, furunculosis0 occur most often in adolescents. Similar skin infections occur in patients receiving prolonged courses of corticosteroids. 6n acne, lipases of staphylococci and corynebacteria liberate fatty acids from lipids and thus cause tissue irritation. Tetracyclines are used for long-term treatment. #bscesses and other closed suppurating lesions are treated by drainage, which is essential and antimicrobial therapy. 9any antimicrobial drugs have some effect against staphylococci in vitro. ?owever, it is difficult to eradicate pathogenic staphylococci from infected persons, because the organisms
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Lecture-1-Staphylococcus.. .

rapidly develop resistance to many antimicrobial drugs and the drugs cannot act in the central necrotic part of a suppurative lesion. 6t is also difficult to eradicate the S. aureus carrier state. >acteremia, endocarditis, pneumonia, and other severe infections due to S. aureus re)uire prolonged intravenous therapy with a <-lactamase-resistant penicillin. "pide)iology & Control Staphylococci are ubi)uitous human parasites. The chief sources of infection are shedding human lesions, fomites contaminated from such lesions, and the human respiratory tract and skin. ,ontact spread of infection has assumed added importance in hospitals, where a large proportion of the staff and patients carry antibiotic-resistant staphylococci in the nose or on the skin. #lthough cleanliness, hygiene, and aseptic management of lesions can control the spread of staphylococci from lesions, few methods are available to prevent the wide dissemination of staphylococci from carriers. #erosols -eg, glycols0 and ultraviolet irradiation of air have little effect.

Dr. Shama M.J Saadaldin Al-Shadidi 3 rd grade / College of Medicine Mustansiryah University 12/ Nov. /2013 Updated 2013 11