Streptococcus, Enterococcus, and Similar Organisms CHAPTER 15 251

TABLE 15-2 Pathogenesis and Spectrum of Diseasecontd

Organism Virulence Factors Spectrum of Diseases and Infections

Enterococcus spp.
Abiotrophia spp. (nutritionally variant
streptococci)
Leuconostoc spp., Lactococcus spp.,
Globicatella sp., Pediococcus
spp., Aerococcus spp., Gemella
spp., Helcococcus sp.
Facklamia spp.
Ignavigranum ruoffiae
Dolosigranulum pigrum
Dolosicoccus paucivorans
Alloiococcus sp.
Little is known about virulence; adhesions,
cytolysins, and other metabolic capabilities
may allow these organisms to proliferate as
nosocomial pathogens; multidrug resistance
also contributes to proliferation
Unknown
Unknown; probably of low virulence;
opportunistic organisms that require impaired
host defenses to establish infection; intrinsic
resistance to certain antimicrobial agents (e.g.,
Leuconostoc spp. and Pediococcus spp.
resistant to vancomycin) may enhance survival
of some species in the hospital setting
Unknown
Most infections are nosocomial and include
urinary tract infections, bacteremia,
endocarditis, mixed infections of abdomen and
pelvis, wounds, and occasionally, ocular
infections; CNS and respiratory infections are
rare
Endocarditis; rarely encountered in infections of
other sterile sites
Whenever encountered in clinical specimens,
these organisms should first be considered as
probable contaminants; Aerococcus urinae is
notably associated with urinary tract infections
Chronic otitis media in children

mediated by antigen-antibody complexes that deposit in
glomeruli, where they initiate damage.
The organism adheres and invades the epithelial cells
through the mediation of various proteins and enzymes.
Internalization of the organism is believed to be impor-
tant for persistent and deep tissue infections. Additional
virulence factors are included in Table 15-2.
S. pyogenes is also a powerful modulator of the host
immune system, preventing clearance of the infection.
The M protein is able to bind beta globulin factor H, a
regulatory protein of the alternate complement pathway
involved in the degradation of C3b. The M protein also
binds to fibrinogen blocking complement alternate
pathway activation. In addition, all strains produce a C5a
peptidase, which is a serine protease capable of inactivat-
ing the chemotactic factor for neutrophils and mono-
cytes (C5a).
S. agalactiae, group B, infections usually are associated
with neonates and are acquired before or during the
birthing process (see Table 15-2). The organism is known
to cause septicemia, pneumonia, and meningitis in new-
borns. Although the virulence factors associated with the
other beta-hemolytic streptococci have not been defini-
tively identified, groups C, G, and F streptococci cause
infections similar to those associated with S. pyogenes (i.e.,
skin and soft tissue infections and bacteremia) but are
less commonly encountered, often involve compromised
patients, and do not produce postinfection sequelae.
STREPTOCOCCUS PNEUMONIAE AND
VIRIDANS STREPTOCOCCI
S. pneumoniae contains the C polysaccharide unrelated to
the Lancefield grouping and is still one of the leading
causes of morbidity and mortality. The organism is the
primary cause of bacterial pneumonia, meningitis, and
otitis media. The antiphagocytic property of the
polysaccharide capsule is associated with the organisms
virulence. There are more than 90 different serotypes of
encapsulated strains of S. pneumoniae. Nonencapsulated
strains are avirulent. The organism may harmlessly
inhabit the upper respiratory tract with a 5% to 75% car-
riage rate in humans. S. pneumoniae is capable of spread-
ing to the lungs, paranasal sinuses, and middle ear. In
addition, this organism accesses the bloodstream and
the meninges to cause acute, purulent, and often life-
threatening infections.
S. pneumoniae is capable of mobilizing inflammatory
cells mediated by its cell wall structure, including pepti-
doglycan, teichoic acids, and a pneumolysin. The pneu-
molysis activates the classical complement pathway. The
pneumolysin mediates suppression of the oxidative burst
in phagocytes providing for effective evasion of immune
clearance. In addition, the organism contains phosphor-
ylcholine within the cell wall, which binds receptors for
platele- activating factor in endothelia cells, leukocytes,
platelets, and tissue cells of the lungs and meninges pro-
viding for entry and spread of the organism.
The viridans (greening) streptococci and Abiotrophia
spp. (formally known as nutritionally variant strepto-
cocci) are a heterogenous group consisting of alpha
hemolytic and nonhemolytic species generally consid-
ered to be opportunistic pathogens of low virulence. The
organisms colonize the gastrointestinal and genitouri-
nary tract. These organisms are not known to produce
any factors that facilitate invasion of the host. However,
when access is gained, a transient bacteremia occurs and
endocarditis and infections at other sites in compro-
mised patients may result.
ENTEROCOCCI
Enterococci, previously classified as group D strepto-
cocci, commonly colonizes the gastrointestinal tract.