STREPTOCOCCAL & STAPHYLOCOCCAL INFECTIONS STREPTOCOCCAL INFECTIONS Bacteriology Streptococci are Gram-positive bacteria arranged in chains.

. Most streptococci from human sources are aerobic. Lancefield distinguished streptococci according to group-specific cell-wall carbohydrate antigens into groups A to D. Streptococci can also be classified according to their property of haemolysis around colonies on blood-agar plates. -haemolytic- produce clear haemolysis e g Lancefields group A ! " streptococci !-haemolytic- produces a greenish #one around the colonies e g Streptococcus viridans No"haemolytic #tre$tococci - Streptococcus faecalis or enterococci$ which are common inhabitants of the gastrointestinal tract

%ro&$ A #tre$tococc&# i"'ectio"

e.g. Streptococcus pyogenes Streptococci are widely prevalent and infection can occur at any age and in both se%es during any season. &he nasopharyn% and the s'in are portals of entry. (ario&# )i#ea#e# ca&#e) *y Group A streptococcus infection S&$$&rati+e( pharyngitis$ tonsillitis Scarlet fever )rysipelas Streptococcal s'in infections Streptococcal pneumonia Myositis$ ga"gre"e, "ecroti-i"g 'a#ciiti# puerperal sepsis lymphangitis rheumatic fever acute glomerulonephritis

No" #&$$&rati+e(

Sore throat i"cl&)i"g $hary"giti#, to"#illiti# &he patient develops flushed facies$ and is febrile. &he throat is congested$ red and oedematous.

 Anterior cervical lymph nodes are enlarged and tender. Suppurative complications - paranasal sinusitis$ otitis media$ mastoiditis. *onsuppurative complications - acute rheumatic fever and acute glomerulonephritis. Moderate leucocytosis occurs and throat swabs often yield positive culture. Deferential diagnosis- viral pharyngitis$ diphtheria$ infectious mononucleosis. Treatme"t !en#athine penicillin G$ +., m- .M or penicillin /$ ,01 mg 23 tid or 011 mg 23 bid % +1 days for Pe"icilli" allergy patients azithromycin 011mg od % 0days * Scarlet 'e+er "omplication that occurs +-, days after symptoms of pharyngitis Diffuse erythematous rash that blanches when pressed$ disappears in 0-4 days "ircumoral pallor$ strawberry tongue 5ollowed by des6uamation Ery#i$ela# .t usually involves the face and head. &he s'in becomes red$ oedematous and firm to hard in consistency due to cuticular lymphangitis. .nitially locali#ed$ tends to spread to ad7acent parts and may involve large areas. &he margins of the erythematous areas are raised and sometimes vesicles are also seen. &he patient is often sic'. )rysipelas of the face has to be differentiated from cellulitis. As cellulitis involves subcutaneous tissues$ it stops short of the e%ternal ear which has no subcutaneous tissue$ while facial erysipelas spreads to involve the pinna 8Millians sign9. Treatme"t -3ral penicillin / in doses of +,0 mg :DS for ten days is often sufficient in mild cases. "ecroti-i"g 'a#ciiti# infection enters via a brea' in s'in cellulitis gangrene and e%tensive destruction of muscle and tissue multiorgan failure aggressive treatment with surgical debridement and antibiotics is needed

%ro&$ B #tre$tococci
"ommonly coloni#e the female genital tract. "ommon infections ; .n neonates( sepsis and meningitis .n adults - puerperal infection$ urinary tract infection$ diabetic ulcer infection$ endocarditis$ bacteremia$ pneumonia$ bone and 7oint infections$ s'in and soft tissue infections &he ma7ority of G!S infections in otherwise healthy adults are related to pregnancy and parturition

 .nfections in adults that are not associated with the peripartum period generally involve individuals who are elderly or have an underlying chronic illness$ such as diabetes mellitus or a malignancy. 2enicillin is the agent of choice for all group ! streptococcal infections

%ro&$ C a") %
).g. S. dysgalactia "ommon diseases - "ellulitis$ bacteremia$ endocarditis

(iri)a"# Stre$tococci 8< hemolytic9

commensals of mouth and upper respiratory tract infections( abscess$ septicemia in neutropenic patients$ SA!)$ dental caries

PNE./OCOCCAL INFECTIONS
Diplococcus pneumoniae 8Streptococcus pneumoniae9 is a Gram-positive lancetshaped encapsulated organism. .t is called Streptococcus pneumoniae because$ li'e other streptococci$ it grows in chains in li6uid medium and also it is catalase-negative and cause <-hemolysis on blood agar. .t is widely distributed as a commensal of the upper respiratory tract. 2neumonia is the most common presentation. Pathoge"e#i# 2athogenic strains of pneumococci are ac6uired through inhalation. &he subse6uent spread to the respiratory tract depends upon the efficiency of defence barriers of the lungs li'e cough refle% and phagocytic cells especially alveolar macrophages. !arriers may be impaired by coincidental virus infections such as influen#a or measles. &he pathogenic pneumococci are then aspirated into alveoli to cause alveolar inflammation and lung consolidation. 2neumococci can cause septicemia especially in children with sic'le cell disease$ after splenectomy$ or in patients suffering from hypogammaglobulinaemia. (ario&# i"'ectio"# ca&#e) *y P"e&mococci Site =espiratory tract I"'ectio"# 3titis media Acute sinusitis 2neumonia "entral nervous system Meningitis

Site Soft tissue>s'eletal "ellulitis

I"'ectio"# Septic arthritis

PNE./OCOCCAL PNE./ONIA Cli"ical 'eat&re# 2neumococcus is the commonest cause of lobar pneumonia. &he disease commonly occurs in young adults. &he onset is acute$ with fever and rigors$ chest pain on the side of inflammation$ and cough. .nitially$ the cough is dry but soon rusty sputum appears. &he patient is sic'$ and fever ranges from ?@.0A" to B+A". 3n e%amination$ the patient is dyspnoeic with accessory muscles of respiration wor'ing and will have signs of pneumonia 3ther physical signs will depend on the presence of complications such as empyema$ pyogenic meningitis or acute otitis media. Com$licatio"# *early +0C of cases develop pleural effusion with typical physical signs. .n some cases the effusion may become purulent and form an empyema. Treatme"t Ro&te, 0r&g Oral Thera$y Amo%icillin :uinolone$ e.g.$ levoflo%acin &elithromycin Pare"teral Thera$y 2enicillin Ampicillin "eftria%one Duration of therapy is 4-+1 days. Pre+e"tio" A polyvalent pneumococcal vaccine is now available. &his contains ,? antigenic capsular polysaccharides. .t is protective in nearly D1C of cases. .t should be administerd to all high ris' patients. ?;B m- 6Bh +;, g 6Eh + g 6+,;,Bh + g 6Dh 011 mg 6,Bh D11 mg 6,Bh 0o#e, Sche)&leb

P"e&mococcal me"i"giti# affects all ages$ primarily seen in children$ elderly$ post-splenectomy spreads to the "*S after bacteremia$ infections of ear>sinuses>lung or head trauma that causes communication between sub arachnoid space and nasopharyn% c>f( fever$ headache$ vomiting$ stiff nec'$ sei#ures$ impairment of conciousness mortality is higher than that caused by *. meningitidis or F. influen#a investigations( L2 8unless contraindicated9$ blood cultures$ "& 8to e%clude a mass lesion such as cerebral abscess9 &reatment( admit the patient and begin empirical treatment$ pneumococcal meningitis is treated with cefota%ime ,g i.v E hourly> ceftria%one ,g i.v. +, hourly for +1-+B days. "hloramphenicol- penicillin allergy. /ancomycin or>and rifampicin- resistant strains. 1111 Rea) $"e&mococcal me"i"giti# ENTEROCOCCAL INFECTIONS )nterococcus belong to lancefield Group 0 &wo species$ )nterococcus faecalis and )nterococcus faecium$ are responsible for most human enterococcal infections. )nterococci - cause +1C of all nosocomial infections Gound infections$ peritonitis$ intra abdominal abscess$ urinary tract infections especially in patients with indwelling catheters$ bacteremia$ overwhelming sepsis in asplenic patients and endocarditis. &reatment )nterococci are not reliably 'illed by penicillin or ampicillin alone at concentrations achieved clinically in the blood or tissues. )nterococcal should be treated with combination of penicillin or ampicillin with an aminoglycoside$ especially enterococcal endocarditis and meningitis. .f the patient is penicillin-allergic$ - vancomycin +0 mg>'g every +, hours. =esistance to vancomycin( line#olid is administered STAPHYLOCOCCAL INFECTIONS Bacteriology &he name Staphylococcus means Hbunch of grapesH Staphylococci are Gram-positive noncapsulated cocci. Staphylococci coagulase positive ; Staphylococci aureus "oagulase negative Staphylococci e.g. S. epidermidis &hree haemolysins$ a$ b$ and g are produced by pathogenic staphylococci.

 Some strains produce a heat-stable enter to%in which is responsible for to%ic shoc' syndrome. E$i)emiology &he organism is present in normal persons- interior nacres$ s'in$ and perineal region. "oagulase-negative staphylococci 8S. epidermidis9 is the most common s'in commensal in humans Staph. aureus has$ perhaps more than any other organism$ shown the ability to develop resistance to antibiotic therapy. /eticilli"-re#i#ta"t Sta$h a&re&# 2/RSA3-- strains of Staph. aureus which are resistant to Meticillin or clo%acillin. =esistance to vancomycin has also been reported Cli"ical co")itio"# $ro)&ce) *y Sta$hylococc&# a&re&# S&$$&rati+e( +9 S4i"- 5uruncles$ "ellulitis$ .mpetigo$ "arbuncles ,9 L&"g#- Lung abscesses$ necroti#ing pneumonia$ emyema ?9 Heart- prosthetic valve )ndocarditis B9 Ce"tral "er+o&# #y#tem- meningitis in post operative and shunt surgeries$ !rain abscesses 09 Bo"e# a") 5oi"t#- 3steomyelitis$ esp in prosthetic devices$ septic arthritis E9 0&e to to6i"- Staphylococcal food poisoning$ &o%ic shoc' syndrome To6i" me)iate)( +9 to%ic shoc' syndrome ,9 food poisoning ?9 scalded s'in syndrome 8diffuse des6uamation of epithelium in infants9 F&r&"cle# ( An acute circumscribed abscess of the s'in and subcutaneous tissue is one of the most common manifestations of staphylococcal infection. 5uruncle of hair follicles 8folliculitis9 is common in oily s'in especially with poor hygiene. Deep Multiple recurrent furunculosis may occur on other areas such as the nec' and bac'$ buttoc's$ perineal region and scalp. 2ain and itching are the earliest symptoms of furunculosis. &he furuncle is initially red and oedematous and soon shows a core of yellowish necrotic debris which may drain spontaneously in ? to 0 days$ followed by healing. 3ccasionally$ in patients with poor resistance$ staphylococcal septicaemia may occur as a complication. Sta$hylococcal to6ic #hoc4 #y")rome 2TSS3

 &his serious and life-threatening disease is associated with infection by Staph. aureus which is producing to%ic shoc' syndrome to%in + 8&SS&+9. .t is most commonly seen in young women during$ or immediately after$ menstruation and is associated with the use of highly absorbent intravaginal tampons. &he to%in has an ability to penetrate mucosal barrier even though the infection remains localised in the vagina .t acts as a Isuper-antigenI$ triggering significant &-helper cell activation and very high peripheral polymorphonuclear leucocyte numbers. &SS has an abrupt onset with high fever$ generalised systemic upset 8myalgia$ headache$ sore throat and vomiting9$ a generalised erythematous blanching rash resembling scarlet fever$ and hypotension. .t rapidly progresses over a matter of hours to multisystem involvement with cardiac$ renal and hepatic compromise$ leading to death in +1-,1C. =ecovery is accompanied at 4-+1 days by des6uamation. Diagnosis of &SS still depends on a constellation of findings rather than one specific finding. And also absence of laboratory evidence of other illnesses that are often included in the differential 8e.g.$ =oc'y Mountain spotted fever$ rubeola$ leptospirosis9. Sta$hylococcal I"'ectio"#7 Treatme"t Surgical incision and drainage of all suppurative collections constitute the most important therapeutic intervention for staphylococcal infections 5or uncomplicated s'in and soft tissue infections$ the use of oral antistaphylococcal agents is usually successful. 5or other infections$ parenteral therapy is indicated Se"#iti+ity Sensitive to penicillinSensitive to methicillin =esistant to methicillin8M=SA9 A"ti*iotic 2enicillin G > *afcillin or o%acillin or "efa#olin /ancomycin> line#olid

3ther anti Sta$hylococcal a"ti*iotic# - &M2-SMJ$ ciproflo%acin> levoflo%acin 0&ratio" o' A"timicro*ial Thera$y Duration is based on indication endocarditis- E wee's 3steomyelitis or septic arthritis- Bwee's Shorter duration is re6uired for locali#ed s'in infection. Thera$y 'or To6ic Shoc4 Sy")rome

 Supportive therapy with reversal of hypotension is the mainstay of therapy for &SS. &ampons or other pac'ing material should be promptly removed. &he role of antibiotics is less clear. Foo) $oi#o"i"g( common cause of food poisoning source of infection( carriers with nasopharyngeal coloni#ation who handle food the to%in is stable to heat even at +11" for ?1 min and resistant to lysis by gastric acid and intestinal en#ymes rapid onset vomiting$ watery diarrhoea$ abdominal cramps resolves within ,B hours CNS Sta$hylococcal i"'ectio"#7 E")ocar)iti# of artificial valves K01C of all catheter a") #h&"t i"'ectio"#- persistent bacteremia is seen in these patients$ may cause immune mediated glomerulonephritis Pro#thetic 5oi"t i"'ectio"#Localised pain and mechanical failure of 7oint 5ever and leucocytosis may not be prominent and blood cultures may be negative &reatment( 7oint replacement and antibiotics &ri"ary tract i"'ectio"#- especially in patients with indwelling catheters