THE STREPTOCOCCI

Streptococci are Gram-positive cocci (spherical or ovoid) often occurring in pairs and chains. On blood
agar, the species exhibit various degrees of haemolysis, which can be used as an early step in identifying
clinical isolates.

Streptococci are facultatively anaerobic and catalase-negative. Carbohydrates are metabolised

fermentatively; lactic acid is the major metabolite.

Classification based on Lancefield antigens:

A serologic classification dividing haemolytic streptococci into groups (A to O) which bear a definite
relationship to their sources, based upon precipitation tests depending upon group-specific substances that
are carbohydrate in nature:

Group A contains strains pathogenic for man

Group B, strains from mastitis in cows and from normal milk, including a few strains from the human
throat and vagina;

Group C, strains from various lower animals, including a number from cattle;

Group D, strains from cheese

Group E, strains from certified milk;

Group F, strains mainly from the human throat, associated with tonsillitis;

Group G, strains from man, a few from monkeys and dogs; and

Groups up to 21H, K, and O, nonpathogenic strains from normal human respiratory tracts.

Another way to classify streptococci is through the presence of hemolysis on blood agar.

• α-haemolysis - partial lysis of the red blood cells surrounding a colony causing a greenish discolouration
of the medium

• β-haemolysis - complete lysis of the red blood cells surrounding a colony causing a clearing of the blood
from the medium

• non-haemolytic or γ-haemolysis - no colour change or clearing of the medium

• α-prime (α‘) or “wide zone α“ haemolysis - a small zone of intact red blood cells are seen adjacent to the
colony with a zone of complete haemolysis surrounding the zone of intact red blood cells.
Expected
Hemolysis
alpha beta gamma
Streptococcus pyogenes never always never
Streptococcus agalactiae never usually sometimes
Streptococcus bovis sometimes sometimes usually
Streptococcus pneumoniae always never never
Enterococcus faecalis sometimes sometimes usually

Tests to identify Streptococci

The bacitracin and optochin susceptibility tests are similar to the novobiocin
susceptibility test used for the identification of Staphylococcus species. Filter paper
discs impregnated with the appropriate chemical are placed on an agar surface. The
chemical diffuses through the agar. Organisms that are susceptible to the chemical will
not grow on the agar containing the chemical. The size of the zone of growth inhibition
determines the organisms susceptibility to the chemical.

Interpretation for the Bacitracin test: Any zone of inhibition of growth is considered positive (+) for this
test. If a red ring can be seen around the disc this is considered a positive test. This test
should be done only on organisms that display beta hemolysis.

Interpretation for the Optochin test: A growth inhibition zone of 15-30 mm is considered a positive (+) test.
Zone sizes of less than 15 mm are considered negative (-) for this test. This test should
be done only on organisms that display alpha hemolysis.

CAMP factor is a diffusable protein produced by certain species of

Streptococcus. This factor will react with the beta toxin produces by Staphylococcus
aureus to rapidly lyse sheep red blood cells. When a CAMP producing Streptococcus is
grown near a beta toxin producing strain of Staphylococcus aureus a definite hemolytic
pattern is produced.
Interpretation: The arrowhead hemolysis pattern is considered positive (+) for this test.
No hemolysis or indistinct hemolysis patterns are considered negative (-) for this test.
This test should be done only on organisms that display beta or gamma hemolysis.

Only a few organisms can tolerate a salt concentration of 6.5% NaCl. Those that
can will grow in high salt broth.
Interpretation: Organisms that can tolerate a high salt environment (6.5% NaCl) will
grow in this broth causing the broth to become cloudy or turbid. Turbidity is considered
positive (+) for this test. Organisms that can not tolerate the high salt environment will
not grow and the broth will remain clear. Clear broth is considered negative (-) for this
test. This test should be done on all suspected streptococci.

Bile esculin agar contains bile that inhibits the growth of many organisms. Some
organisms can hydrolyze esculin to esculetin and dextrose. Esculetin will react with
ferric citrate in the media to produce a black-brown product.
Interpretation: Blackening of the agar is considered positive (+) for this test. No change
in the color of the agar is considered negative (-) for this test. This test should be done
on all suspected streptococci.
Streptococcus pyogenes (Lancefield group A)
Streptococcus pyogenes is a Gram-positive coccus occurring in chains. After 18 - 24 h incubation at 35°C -
37°C on blood agar colonies are approximately 0.5 mm, domed, with an entire edge. Some strains may
produce mucoid colonies. Haemolysis is best observed by growing the culture under anaerobic conditions
because the haemolysins are more stable in the absence of oxygen.
Lancefield group A streptococci will not grow on media containing bile.
Low concentration bacitracin susceptibility has been used for screening purposes but is unreliable .
Resistance to benzylpenicillin has not been reported.

Streptococcus agalactiae (Lancefield group B)

Streptococcus agalactiae are Gram-positive cocci, occurring in chains. After 18 - 24 h incubation at 35°C -
37°C colonies tend to be slightly larger than other streptococci (approximately 1 mm) and have a less
distinct zone of β-haemolysis. Some strains may be non-haemolytic.
Lancefield group B streptococci will grow on media containing bile.

Enterococcus species, Streptococcus bovis group (Lancefield group D)

The genus Enterococcus and organisms of the S. bovis group possess Lancefield group D antigen.
Microscopically the organisms are Gram-positive cocci, spherical or ovoid in shape (0.6 - 2.5 μm), usually
occurring in pairs or short chains in broth culture. After 18 - 24 h incubation at 35°C - 37°C on blood agar
colonies are 1 - 2 mm and may be α, β or non-haemolytic on horse blood agar. Most species will grow on
nutrient agar at 45°C. A few will grow at 50°C, at pH 9.6 and in 6.5% NaCl. They can also survive at 60°C
for 30 minutes.

Lancefield group D streptococci will grow on media containing bile and may be differentiated from other
streptococci by rapid hydrolysis of aesculin in the presence of 40% bile.

Enterococci are also heat resistant (60°C/30 mins) and PYR-positive which differentiates them from S.
bovis and S. gallolyticus.

STREPTOCOCCUS PYOGENES

Streptococcus pyogenes is one of the most frequent pathogens of humans. It is estimated that between 5-
15% of normal individuals harbor the bacterium, usually in the respiratory tract, without signs of disease.
As normal flora, S. pyogenes can infect when defenses are compromised or when the organisms are able to
penetrate the constitutive defenses. When the bacteria are introduced or transmitted to vulnerable tissues, a
variety of types of suppurative infections can occur.

Acute Streptococcus pyogenes infections may present as pharyngitis (strep throat), scarlet fever (rash),
impetigo (infection of the superficial layers of the skin) or cellulitis (infection of the deep layers of the
skin). Invasive, toxigenic infections can result in necrotizing fasciitis, myositis and streptococcal toxic
shock syndrome. Patients may also develop immune-mediated post-streptococcal sequelae, such as acute
rheumatic fever and acute glomerulonephritis, following acute infections caused by Streptococcus
pyogenes.

Streptococcus pyogenes produces a wide array of virulence factors and a very large number of diseases.
Virulence factors of Group A streptococci include:

(1) M protein, fibronectin-binding protein (Protein F) and lipoteichoic acid for adherence.

The M proteins are clearly virulence factors associated with both colonization and resistance to
phagocytosis. More than 50 types of S. pyogenes M proteins have been identified on the basis of
antigenic specificity, and it is the M protein that is the major cause of antigenic shift and antigenic drift
 in the Group A streptococci. The M protein (found in fimbriae) also binds fibrinogen from serum and
blocks the binding of complement to the underlying peptidoglycan. This allows survival of the
organism by inhibiting phagocytosis.

The streptococcal M protein, as well as peptidoglycan, N-acetylglucosamine, and group-specific

carbohydrate, contain antigenic epitopes that mimic those of mammalian muscle and connective tissue. As
mentioned above, the cell surface of recently emerging strains of streptococci is distinctly mucoid
(indicating that they are highly encapsulated). These strains are also rich in surface M protein. The M
proteins of certain M-types are considered rheumatogenic since they contain antigenic epitopes related to
heart muscle, and they therefore may lead to autoimmune rheumatic carditis (rheumatic fever) following an
acute infection.

There is evidence that Streptococcus pyogenes utilizes lipoteichoic acids (LTA), M protein, and
multiple fibronectin-binding proteins in its repertoire of adhesins. LTA is anchored to proteins on the
bacterial surface, including the M protein. Both the M proteins and lipoteichoic acid are supported
externally to the cell wall on fimbriae and appear to mediate bacterial adherence to host epithelial cells.
The fibronectin-binding protein, Protein F, has also been shown to mediate streptococcal adherence to the
amino terminus of fibronectin on mucosal surfaces.

(2)hyaluronic acid capsule as an immunological disguise and to inhibit phagocytosis;

The capsule of S. pyogenes is non antigenic since it is composed of hyaluronic acid, which is
chemically similar to that of host connective tissue. This allows the bacterium to hide its own antigens
and to go unrecognized as antigenic by its host. The Hyaluronic acid capsule also prevents opsonized
phagocytosis by neutrophils or mancrophages.

(3)Invasins such as streptokinase, streptodornase (DNase B), hyaluronidase, and streptolysins; For the
most part, streptococcal invasins and protein toxins interact with mammalian blood and tissue components
in ways that kill host cells and provoke a damaging inflammatory response. The soluble extracellular
growth products and toxins of Streptococcus pyogenes , have been studied intensely. Streptolysin S is an
oxygen-stable leukocidin; Streptolysin O is an oxygen-labile leukocidin. NADase is also leukotoxic.
Hyaluronidase (the original "spreading factor") can digest host connective tissue hyaluronic acid, as well
as the organism's own capsule. Streptokinases participate in fibrin lysis. Streptodornases A-D possess
deoxyribonuclease activity; Streptodornases B and D possess ribonuclease activity as well. Protease
activity similar to that in Staphylococcus aureus has been shown in strains causing soft tissue necrosis or
toxic shock syndrome. This large repertoire of products is important in the pathogenesis of S. pyogenes
infections. Even so, antibodies to these products are relatively insignificant in protection of the host.

(4)exotoxins, such as pyrogenic (erythrogenic) toxin which causes the rash of scarlet fever and systemic
toxic shock syndrome.

Three streptococcal pyrogenic exotoxins (SPE), formerly known as Erythrogenic toxin, are recognized:
types A, B, C. These toxins act as superantigens by a mechanism similar to those described for
staphylococci. As antigens, they do not requiring processing by antigen presenting cells. Rather, they
stimulate T cells by binding class II MHC molecules directly and nonspecifically. With superantigens about
20% of T cells may be stimulated (vs 1/10,000 T cells stimulated by conventional antigens) resulting in
massive detrimental cytokine release. SPE A and SPE C are encoded by lysogenic phages; the gene for SPE
B is located on the bacterial chromosome.

The erythrogenic toxin is so-named for its association with scarlet fever which occurs when the toxin is
disseminated in the blood. Re-emergence in the late 1980's of exotoxin-producing strains of S. pyogenes
has been associated with a toxic shock-like syndrome similar in pathogenesis and manifestation to
staphylococcal toxic shock syndrome, and with other forms of invasive disease associated with severe
tissue destruction. The latter condition is termed necrotizing fasciitis. Outbreaks of sepsis, toxic shock and
necrotizing fasciitis have been reported at increasing frequency. The increase in invasive streptococcal
disease was associated with emergence of a highly virulent serotype M1 which is disseminated world-
wide. The M1 strain produces the erythrogenic toxin (Spe A), thought to be responsible for toxic shock,
and the enzyme cysteine protease which is involved in tissue destruction. Because clusters of toxic shock
were also associated with other serotypes, particularly M3 strains, it is believed that unidentified host
factors may also have played an important role in the resurgence of these dangerous infections.

Post streptococcal sequelae

Infection with Streptococcus pyogenes can give rise to serious nonsuppurative sequelae: acute rheumatic
fever and acute glomerulonephritis. These pathological events begin 1-3 weeks after an acute
streptococcal illness, a latent period consistent with an immune-mediated etiology. Whether all S. pyogenes
strains are rheumatogenic is controversial; however, clearly not all strains are nephritogenic.

Acute rheumatic fever is a sequel only of pharyngeal infections, but acute glomerulonephritis can follow
infections of the pharynx or the skin. Although there is no adequate explanation for the precise
pathogenesis of acute rheumatic fever, an abnormal or enhanced immune response seems essential. Also,
persistence of the organism on pharyngeal tissues (i.e., the tonsils) is associated with an increased
likelihood of rheumatic fever. Acute rheumatic fever can result in permanent damage to the heart valves.
Less than 1% of sporadic streptococcal pharyngitis infections result in acute rheumatic fever; however,
recurrences are common, and life-long antibiotic prophylaxis is recommended following a single case.

The occurrence of cross-reactive antigens in S. pyogenes and heart tissues possibly explains the
autoimmune responses that develop following some infections. The antibody mediated immune (AMI)
response (i.e., level of serum antibody) is higher in patients with rheumatic fever than in patients with
uncomplicated pharyngitis. In addition, cell-mediated immunity (CMI) seems to play a role in the
pathology of acute rheumatic fever.

Acute glomerulonephritis results from deposition of antigen-antibody-complement complexes on the

basement membrane of kidney glomeruli. The antigen may be streptococcal in origin or it may be a host
tissue species with antigenic determinants similar to those of streptococcal antigen (cross-reactive epitopes
for endocardium, sarcolemma, vascular smooth muscle). The incidence of acute glomerulonephritis in the
United States is variable, perhaps due to cycling of nephritogenic strains, but it appears to be decreasing.
Recurrences are uncommon, and prophylaxis following an initial attack is unnecessary.

Summary of diseases caused by Streptococcus pyogenes

Suppurative conditions (active infections associated with pus) occur in the throat, skin, and systemically.

Throat
Streptococcal pharyngitis is acquired by inhaling aerosols emitted by infected individuals. The symptoms
reflect the inflammatory events at the site of infection. A few (1-3%) people develop rheumatic fever weeks
after the infection has cleared.

Skin
Impetigo involves the infection of epidermal layers of skin. Pre-pubertal children are the most susceptible.
Cellulitis occurs when the infection spreads subcutaneous tissues. Erysipelas is the infection of the dermis.
About 5% of patients will develop more disseminated disease. Necrotizing fasciitis involves infection of
the fascia and may proceed rapidly to underlying muscle.

Systemic
Scarlet fever is caused by production of erythrogenic toxin by a few strains of the organism.
Toxic shock is caused by a few strains that produce a toxic shock-like toxin.

Non-suppurative Sequelae
Some of the antibodies produced during the above infections cross-react with certain host tissues. These
can indirectly damage host tissues, even after the organisms have beencleared, and 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.

TREATMENT

Penicillin is still uniformly effective in treatment of Group A streptococcal disease. It is important to

identify and treat Group A streptococcal infections in order to prevent sequelae. No effective vaccine has
been produced, but specific M-protein vaccines are being tested.

STREPTOCOCCUS PNEUMONIAE

S. pneumoniae is a leading cause of pneumonia in all ages (particularly the young and old), often after
"damage" to the upper respiratory tract (e.g. following viral infection). It also causes middle ear infections
(otitis media). The organism often spreads causing bacteremia and meningitis. S. pneumoniae is α
hemolytic and there is no group antigen.

Direct Gram staining or detection of capsular antigen in sputum can be diagnostic. The organism grows
well on sheep blood agar. Streptococcus pneumoniae are Gram-positive, lancet-shaped cocci (elongated
cocci with a slightly pointed outer curvature). Usually they are seen as pairs of cocci (diplococci), but they
may also occur singly and in short chains. When cultured on blood agar, they are alpha hemolytic.
Individual cells are between 0.5 and 1.25 micrometers in diameter. They do not form spores, and they are
nonmotile. Like other streptococci, they lack catalase and ferment glucose to lactic acid. Unlike other
streptococci, they do not display an M protein, they hydrolyze inulin, and their cell wall composition is
characteristic both in terms of their peptidoglycan and their teichoic acid).

S. pneumoniae is a transient member of the normal flora, colonizing the nasopharynx of 40% of healthy
adults and children with no adverse effects. Children carry this pathogen in the nasopharynx
asymptomatically for about 4-6 weeks, often several serotypes at a time. New serotypes are acquired
approximately every 2 months. Serotypes 6, 14, 18, 19, and 23 are the most prevalent accounting for 60-
80% of infections depending on the area of the world. Pneumococcal infection accounts for more deaths
than any other vaccine-preventable bacterial disease. Those most commonly at risk for pneumococcal
infection are children between 6 months and 4 years of age and adults over 60 years of age. Virtually every
child will experience pneumococcal otitis media before the age of 5 years. It is estimated that 25% of all
community-acquired pneumonia is due to pneumococcus (1,000 per 100,000 inhabitants). The Centers for
Disease Control and Prevention ( CDC) reported 60,000 cases of invasive pneumococcal disease in 1997
approximately 6,000 deaths. Recently, epidemics of disease have reappeared in settings such as chronic
care facilities, military camps and day care centers, a situation not recognized since the pre-antibiotic era.

Also of concern, is the increased emergence of antibiotic resistance, especially in the past decade. Multiple
antibiotic resistant strains of S. pneumoniae that emerged in the early 1970s in Papua New Guinea and
South Africa were thought to be a fluke, but multiple antibiotic resistance now covers the globe and has
rapidly increased since 1995. Increases in penicillin resistance have been followed by resistance to
cephalosporins and multidrug resistance. The incidence of resistance to penicillin increased from <0.02 in
1987 to 3% in 1994 to 30% in some communities in the United States and 80% in regions of some other
countries in 1998. Resistance to other antibiotics has emerged simultaneously: 26% resistant to
trimethoprim-sulfa, 9% resistant to cefotaxime, 30% resistant to macrolides, and 25% resistant to multiple
drugs. Resistant organisms remain fully virulent but seem to have arisen in less than 10 serotypes.
Serotypes 6A, 6B, 9V, 14, 19A and 23F are included in the vast majority of resistant strains.

Vaccines

Given the 90 different capsular types of pneumococci, a comprehensive vaccine based on polysaccharide
alone is not feasible. Thus, vaccines based on a subgroup of highly prevalent types have been formulated.
The number of serotypes in the vaccine has increased from four in 1945, to 14 in the 1970s, and finally to
the current 23-valent formulation (25 mg of each of serotypes 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A,
12F, 14, 15B, 17F, 18C, 19A, 19F, 20, 22F, 23F, and 33F). These serotypes represent 85-90% of those that
cause invasive disease and the vaccine efficacy is estimated at 60% . However, underutilization of the
vaccine is so extensive that the pneumococcus remains the most common infectious agent leading to
hospitalization in all age groups. This is further complicated by the fact that polysaccharides are not
immunogenic in children under the age of 2 years where a significant amount of disease occurs.

Streptococcus pneumoniae is a normal inhabitant of the human upper respiratory tract. The bacterium can
cause pneumonia, usually of the lobar type, paranasal sinusitis and otitis media, or meningitis which is
usually secondary to one of the former infections. Streptococcus pneumoniae is currently the leading cause
of invasive bacterial disease in children and the elderly.

Pneumococci spontaneously cause disease in humans, monkeys, rabbits, horses, mice and guinea pigs.
Nasopharyngeal colonization occurs in approximately 40% of the population. Pneumonia and otitis media
are the most common infections, meningitis being much more variable. The rabbit and the mouse have been
used extensively as animal models disease, leading to a reasonable understanding of many of the
pneumococcal determinants of virulence.

Colonization
Pneumococci adhere tightly to the nasopharyngeal epithelium by multiple mechanisms that, for most
individuals, appears to result in an immune response that generates type-specific immunity. For some
people, however, progression into the lungs or middle ear occurs. Passage of pneumococci up the
eustachian tube is accompanied by bacterial induced changes in the surface receptors of the epithelial cell,
particularly by neuraminidase. Inflammation in the middle ear is caused by pneumococcal cell wall
components, and pneumolysin inflicts major cytotoxicity on ciliated cells of the cochlea.

Upon reaching the lower respiratory tract by aerosol, pneumococci bypass the ciliated upper respiratory
epithelial cells unless there is damage to the epithelium. Instead, they progress to the alveolus and associate
with specific alveolar cells which produce a choline-containing surfactant.

Experimentally, in healthy tissues, it requires approximately 100,000 bacteria/ml to trigger an inflammatory

response. However, if a proinflammatory signal is supplied, inflammation ensues with as few as 10 bacteria
.This signal is a cytokine in experimental systems or an intercurrent viral infection in clinical situations.
The inflammatory response can cause considerable tissue damage.

Invasion
The bacteria invade and grow primarily due to their resistance to the host phagocytic response. The cell
wall components directly activate multiple inflammatory cascades including the alternative pathway of
complement activation, the coagulation cascade, and the cytokine cascade, inducing interleukin-1,
interleukin-6 and tumor necrosis factor from macrophages and other cells.

In addition, as pneumococci begin to lyse in response to host defensins and antimicrobial agents, they
release cell wall components, pneumolysin and other substances that lead to greater inflammation and
cytotoxic effects. Pneumolysin and hydrogen peroxide kill cells and induce production of nitric oxide
which may play a key role in septic shock.

During invasion, the interaction between the bacterial cell wall choline and the host PAF receptor G-protein
contributes to a state of altered vascular permeability. In the lung, this leads to arrival of an inflammatory
exudate. At first, a serous exudate forms. This is followed by the arrival of leukocytes, thereby making the
switch from a serous to a purulent exudate. Sites of pneumococcal infection are particularly noted for the
intensity of the purulent response.

Pneumococci occasionally are able to directly invade endothelial cells. The ligands by which pneumococci
bind to activated human cells include choline located on the cell wall teichoic acid that can serve as a direct
ligand to the PAF receptor, and the choline-binding protein, CbpA, which binds to a specific carbohydrate
on the alveolar cell surface. When bound to the PAF receptor, the pneumococcus enters a vacuole in a
receptor-mediated endocytic process and the vacuole moves across the cell expelling the bacteria on the
ablumenal surface. In vitro, pneumococci will adhere to and traverse an endothelial barrier over
approximately 4 hours.

If bacteremia occurs, the risk of meningitis increases. Pneumococci can adhere specifically to cerebral
capillaries using the same pairings of choline to PAF receptor and CbpA to carbohydrate receptor. Thus, the
bacteria subvert the endocytosis/recycling pathway of the PAF receptor for cellular transmigration. Once in
the cerebrospinal fluid, a variety of pneumococcal components, particularly cell wall components, incite
the inflammatory response.

Bacterial Determinants of Virulence

Capsule
The bacterial capsule interferes with phagocytosis by leukocytes, a property dependent on its chemical
composition. Apparently, resistance to phagocytosis is brought about by interference with binding of
complement C3b to the cell surface.

During invasion of the mucosal surface, encapsulated strains are 100,000 times more virulent than
unencapsulated strains. The polysaccharide is nontoxic and noninflammatory, and the capsule does not
appear to engage any host defenses except for the induction of antibody-mediated immunity. The
pneumococcal capsule is not an antigenic disguise, and it does not impede the activities of underlying
components, such as the cell wall and surface proteins, to engage the host defense systems. However, C-
reactive protein or antibodies to teichoic acid, both of which bind to the cell wall under the capsule, fail to
opsonize encapsulated strains.
This is highly prominent in virulent strains and its carbohydrate antigens vary greatly in structure among
strains. The capsule is anti-phagocytic and immunization is primarily against the capsule. Capsular
vaccines are available for susceptible individuals; immunity is serotype-specific.

The quellung reaction (swelling reaction) forms the basis of serotyping and relies on the swelling of the
capsule upon binding of homologous antibody The test consists of mixing a loopful of colony with equal
quantity of specific antiserum and then examining microscopically at 1000X for capsular swelling.
Although generally highly specific, cross-reactivity has been observed between capsular types 2 and 5, 3
and 8, 7 and 18, 13 and 30, and with E. coli, Klebsiella, H. influenzaeType b, and certain viridans
streptococci.
Cell Wall Components
The pneumococcal cell wall is a collection of potent inflammatory stimuli. Challenge with cell wall
components alone can recreate many of the symptoms of pneumonia, otitis media and meningitis in
experimental models. The phosphorylcholine decorating the teichoic acid and the lipoteichoic acid is a key
molecule enabling invasion, and acts both as an adhesin and as a docking site for the choline-binding
proteins (CBPs). Other respiratory pathogens such as Haemophilus, Pseudomonas, Neisseria and
Mycoplasma also have phosphorylcholine on lipopolysaccharide, proteins or fimbriae, suggesting a shared
mechanism for invasion of the respiratory tract. Two host-derived elements that recognize choline are
platelet activating factor (PAF) receptor and the C-reactive protein. Since respiratory pathogens may be
recognized and cleared by the C-reactive protein response as part of the constitutive defenses, respiratory
pathogens may share this invasive mechanism to subvert the signaling cascade of endogenous PAF.

The peptidoglycan/teichoic acid complex of the pneumococcus is highly inflammatory. Smaller

components of peptidoglycan progressively lose specific inflammatory activity. The cell wall directly
activates the alternative pathway of the complement cascade, generating chemotaxins for leukocytes, and
the coagulation cascade, which promotes a "procoagulant state" favoring thrombosis. In addition,
peptidoglycan binds to CD14, a cell surface receptor known to initiate the inflammatory response for
endotoxin. This induces a cytokine cascade resulting in production of interleukin-1, interleukin 6 and tumor
necrosis factor from human cells.

Choline Binding Proteins

The CBP family includes such important determinants as PspA (protective antigen), LytA, B, and C (three
autolysins), and CbpA (an adhesin).

The protective antigen (PspA) is a 65 kD protein with 10 choline-binding repeats. PspA appears to inhibit
complement-mediated opsonization of pneumococci, and mutants lacking PspA have reduced virulence.
Antibodies against PspA confer passive protection in mice.

Autolysin LytA is responsible for pneumococcal lysis in stationary phase as well as in the presence of
antibiotics. The protein has two functional domains: a C-terminal domain with six choline-binding repeats
that anchor the protein on the cell wall, and an N-terminal domain that provides amidase activity.
Autolysin LytB is a glucosaminidase involved in cell separation, and LytC exhibits lysozyme-like activity.

CbpA is a major pneumococcal adhesin. It has eight choline-binding repeats. The adhesin interacts with
carbohydrates on the pulmonary epithelial surface carbohydrates. CbpA-deficient mutants are defective in
colonization of the nasopharynx and fail to bind to various human cells in vitro. CbpA also has been
reported to bind secretory IgA and complement component C3.

Hemolysins
In addition to surface-associated virulence determinants, pneumococci secrete exotoxins. Two hemolysins
have been described, the most potent of which is pneumolysin. Pneumolysin is stored intracellularly and is
released upon lysis of pneumococci by autolysin. Pneumolysin binds to cholesterol and thus can
indiscriminately bind to all cells without restriction to a receptor. This protein assembles into oligomers to
form transmembrane pores which ultimately lead to cell lysis. Pneumolysin can also stimulate the
production of inflammatory cytokines, inhibit beating of the epithelial cell cilia, inhibit lymphocyte
proliferation, decrease the bactericidal activity of neutrophils, and activate complement. A second
hemolysin activity has been described but has not been identified. In addition, pneumococci also produce
hydrogen peroxide in amounts greater than human leukocytes produce. This small molecule is also a potent
hemolysin.

Capsule

The organism also produces pneumolysin that degrades red blood cells under anaerobic conditions
(observed as α hemolysis).
Complement activation by teichoic acid may explain the attraction of large numbers of inflammatory cells
to the focal site of infection.

Most strains of S. pneumoniae are susceptible to penicillin. However, resistance is quite common.

Genetics

S. pneumoniae has a natural transformation system as a mechanism for genetic exchange. This process is
of medical significance because it clearly underlies the explosion of antibiotic resistance in the bacterium
over the past 20 years. For example, penicillin resistance is due to altered penicillin-binding proteins
(PBPs) which exhibit a low affinity for beta lactam antibiotics. Comparison of the nucleotide sequences
encoding the PBPs in S. pneumoniae and S. mitis demonstrates that horizontal gene transfer has occurred
between these two bacteria. In the laborotory, S. pneumoniae can also be transformed with genes from
related and unrelated bacteria. As well, in the upper respiratory tract of the host, horizontal exchanges of
genetic information could take place between strains of pneumococci that co-habitate or compete for
dominance as normal flora.

Streptococcus pneumoniae can also develop antibiotic resistance by the timeless process of mutation and
selection. The bacterium has a relatively fast growth rate and achieves large cell densities in an infectious
setting, These conditions not only favor the occurrence natural transformation, but also the emergence of
spontaneous mutants resistant to the antibiotic.

PRESENTATION OF STREPTOCOCCAL PNEUMONIA

o Apprehension, high fever (no or low-grade fever in older individuals) or hypothermia,

and tachycardia

o Hypoxia and respiratory distress, including tachypnea and splinting

o Signs of pulmonary consolidation (ie, dullness to percussion, tubular breath sounds, and
egophony)

o Crackling sounds

o Signs of pleural empyema/effusion, occasionally present (eg, flatness to percussion,

decreased breath sounds)

o Diaphragmatic motion (may be undetectable)

LAB EXAMS

• Gram stain and culture

• Sputum, endotracheal secretions, and bronchoalveolar lavage

o Always attempt to obtain a sputum sample from patients with CAP.

o When a patient cannot provide an expectorated specimen, a trial of hypertonic saline mist
may be helpful. If clinically indicated, another option is a bronchoalveolar lavage through
flexible bronchoscopy.
 o Good-quality sputum (microscopic demonstration of large amount of polymorphonuclear
neutrophils and few epithelial cell) showing slightly elongated gram-positive cocci in
pairs is good evidence for pneumococcal pneumonia.
o For sputum culture, the specimen is plated on blood containing agar and incubated under
5-10% carbon dioxide atmosphere.
o Gray colonies with alpha-hemolysis are visible after 24 hours of incubation.

o Sensitivity to the Optochin disk (P disk) or bile solubility confirms that the colonies are S
pneumoniae and not viridans streptococci.

o An absence of pathogens occasionally is reported in this setting because S pneumoniae

can be overgrown by mouth flora or may be due to rapid autolysis.

• Chest radiograph

o This study is always indicated because the portal of entry of pneumococci is the
respiratory tract, and any infection can be associated with pneumonia.

o Very early in the disease, a patient with acute pneumonia may have a normal radiograph.

o Findings can include lobar or multilobar consolidation, segmental infiltration, patchy

infiltrates representing bronchopneumonia, and pleural effusion, uncommonly.

• Cavitation is not a feature of pneumococcal pneumonia.

• Sinus radiograph may show radiological signs of sinusitis, the most convincing being an air-fluid
level in at least 1 of the sinuses.

• CT scanning or magnetic resonance imaging occasionally is useful for additional lung detail.

• CBC count
o Leukocytosis (>12,000/mL)
o WBC count (occasionally within reference range early in disease)
o Leukopenia (<6000/mL) - Associated with overwhelming infection and a poor prognosis

• Blood cultures - 2 sets

o Positive for gram-positive cocci in pairs, with later identification as S pneumoniae

PROGNOSIS

Prognostic factors: Reviewing data from 14,199 patients with CAP, Fine et al classified patients in 5 risk
classes with respect to risk of death within 30 days. Points were assigned according to the patient's
characteristics as follows:

 Age - Points given for each year of age, with a substraction of 10 points for
women; patients older than 50 years (excluded from class I)
 Coexisting conditions - Neoplastic disease (+30 points), liver disease (+20),
congestive heart failure (+10), cerebrovascular diseases (+10), renal disease
(+10)
 Physical examination - Altered mental status (+20), pulse 125 beats per minute
or more (+20), respiratory rate of 30 breaths per minute or more (+20), systolic
 blood pressure of less than 90 mm Hg (+20), temperature less than 35°C or
greater than 40&%176;C (+15)
 Laboratory and radiographic findings - Arterial pH less than 7.35 (+30), BUN of
30 mg/dL (11 mmol/L) or more (+20), sodium less than 130 mmol/L (+20),
glucose of 250 mg/dL (14 mmol/L) or more (+10), hematocrit less than 30%
(+10), partial pressure of oxygen (PO2) less than 60 mm Hg (+10), and pleural
effusion (+10)
 Classes I and II are 70 points or less; class III is 71-90 points; class IV is 91-130
points; and class V is greater than 130 points.
 Mortality rates - Classes I, II, and III are less than 1%; class IV is 9.3%; and
class V is 27%.
 Mortality was similar in the first 3 classes, regardless of whether patients were
treated as inpatients or outpatients.
 Although subsequent hospital admission may be required, patients in class I
(admission rate of 5.1%), class II (admission rate of 8.2%), and possibly class III
(admission rate of 16.7%) can be treated as outpatients if follow-up can be
arranged.

TREATMENT

First-generation cephalosporins are equally effective against infections caused by penicillin-susceptible S

pneumoniae. All first-generation cephalosporins are equally effective against pneumococci; therefore, only
cefazolin and cephalexin are detailed below. Third-generation cephalosporins include ceftriaxone and
cefotaxime. These are active against non–penicillin-susceptible S pneumoniae, even though the MIC is
higher than the MIC for penicillin-susceptible S pneumoniae. For empiric treatment of meningitis, third-
generation cephalosporins may be administered in conjunction with vancomycin or rifampin. Other
cephalosporins (eg, cefaclor, cefuroxime, and cefixime) have the same efficacy as cephalexin and cefazolin.

Azithromycin has activity against penicillin-susceptible strains of S pneumoniae.

Vancomycin is the only glycopeptide class that is useful in the treatment of severe pneumococcal
infections. Clindamycin also may be used to treat nonmeningeal penicillin-resistant S pneumoniae.
Imipenem also is useful to treat penicillin-resistant S pneumoniae.

SCARLET FEVER

• Peak incidence of scarlet fever occurs in children aged 4-8 years.

• By the time children are 10-years-old, 80% have developed lifelong protective antibodies against
streptococcal pyrogenic exotoxins.
• Scarlet fever is rare in children younger than 2 years because of the presence of maternal
antiexotoxin antibodies and lack of prior sensitization.

PRESENTATION OF SCARLET FEVER

• Scarlet fever generally has a 1- to 4-day incubation period.

• Emergence of the illness tends to be abrupt, usually heralded by sudden onset of fever associated
with sore throat, headache, nausea, vomiting, abdominal pain, myalgias, and malaise.
• The characteristic rash appears 12-48 hours after onset of fever.
• In the untreated patient, fever peaks by the second day (temperature as high as 103-104°F) and
gradually returns to normal in 5-7 days.
• Fever abates within 12-24 hours after initiation of antibiotic therapy.
 • Exudative tonsillitis preceding scarlet fever often is accompanied by erythematous oral mucous
membranes, along with petechiae and punctate red macules on the hard and soft palate and uvula
(ie, Forchheimer spots).
• On day 1 or 2, a white coating covers the dorsum of the tongue with reddened papillae projecting
through, giving rise to the white strawberry tongue.
• By day 4 or 5, the white coating disappears, revealing the representative raspberry tongue.
• Generally, the rash develops 12-48 hours after the onset of fever, first appearing as erythematous
patches below the ears, chest, and axilla.
•
• Dissemination to the trunk and extremities occurs over 24 hours.
• Typically, the rash consists of scarlet macules over generalized erythema (boiled lobster
appearance).
• As the skin lesions evolve and become more diffuse, they turn punctate and resemble a
sunburn with goose pimples.
• Numerous punctate lesions the size of pinheads give the skin a rough sandpaperlike
texture.
• Lesions tend to be accentuated in the skin folds, particularly in the region of the neck,
axilla, antecubital fossae, and inguinal and popliteal creases.
• Rupture of fragile capillaries at these sites displays linear arrays of petechiae (ie, Pastia
lines) that may persist for 1-2 days after resolution of the generalized rash.
• Another distinctive facial finding is circumoral pallor.
• In severe disease, small vesicular lesions termed miliary sudamina may appear on the abdomen,
hands, and feet.
• Mitigation of the exanthem occurs in approximately 1 week.

• Desquamation, one of the most distinctive features of scarlet fever, begins 7-10 days after
resolution of the rash and may continue up to 6 weeks.
• Peeling of the skin is most prominent in the axilla, groin, and tips of the fingers and toes.
• Extent and duration of desquamation is directly proportional to initial intensity of the
rash.

LAB EXAMS

• Throat culture remains the criterion standard for confirmation of group A streptococcal upper
respiratory infection.
•
o American Heart Association guidelines for prevention and treatment of rheumatic fever
state that group A streptococci virtually always is found on throat culture during acute
infection.1
o Throat cultures are approximately 90% sensitive for the presence of group A beta-
hemolytic streptococci in the pharynx. However, because a 10-15% carriage rate exists
among healthy individuals, the presence of group A beta-hemolytic streptococci is not
proof of disease.
o To maximize sensitivity, proper obtaining of specimens is crucial.
o Vigorously swab the posterior pharynx, tonsils, and any exudate with a cotton or Dacron
swab under strong illumination, avoiding the lips, tongue, and buccal mucosa.
• Direct antigen detection kits (ie, rapid antigen tests [RATs], strep screens) have been proposed to
allow immediate diagnosis and prompt administration of antibiotics.
• Streptococcal antibody tests are used to confirm previous group A streptococcal infection.
•
o The most commonly available streptococcal antibody test is the antistreptolysin O test.
o Currently, streptococcal antibody tests are not indicated during acute illness.
 •
• Complete blood count
•
o White blood cell (WBC) count in scarlet fever may increase to 12,000-16,000 per mm3,
with a differential of up to 95% polymorphonuclear lymphocytes.
o During the second week, eosinophilia, as high as 20%, can develop.

Imaging Studies

In most cases, no imaging studies are indicated.

TREATMENT

The goals when treating scarlet fever are to

(1) prevent acute rheumatic fever,

(2) reduce the spread of infection,

(3) prevent suppurative complications, and

(4) shorten the course of illness.

Penicillin remains the drug of choice (documented cases of penicillin-resistant group A streptococci
infections still do not exist). A first-generation cephalosporin may be an effective alternative, as long as the
patient does not have any documented anaphylactic reactions to penicillin. If this is the case, erythromycin
can be considered as an alternative.

Streptococcal pharyngitis or streptococcal sore throat is a form of group A streptococcal infection that
affects the pharynx and possibly the larynx and tonsils.

PRESENTATION OF STREP PHARYNGITIS

• Sudden and severe sore throat

• Abdominal pain
• Yellow and white patches in the throat.
• Difficulty swallowing
• Tender cervical lymphadenopathy
• Red and enlarged tonsils
• Halitosis
• Fever of 38°C (101F) or greater.
• Rash [1]
• Frequent cold chills
• Absence of cough or (dry cough may be present)
• White spots on tonsils
• Peeling skin on fingertips a few weeks after treatment
OTHER STREPTOCOCCI:There are six species included in the S. bovis group10: S. bovis, S. equinus,
S.gallolyticus (formerly S. bovis biotype I), S. infantarius (formerly S. bovis biotype II/1), S. pasteurianus
(formerly S. bovis biotype II/2) and S. lutetensis. Microscopically these species are Gram-positive cocci,
occurring in chains after 18 - 24 h incubation at 35°C - 37°C in CO2 or anaerobically. Colonies are usually
non-haemolytic on blood agar and 1 - 2 mm in diameter. Members of the S. bovis group may be
misidentified as enterococci because many strains share the group D antigen. It is important to identify S.
bovis group organisms from clinical material especially in cases of bacteraemia, because S. gallolyticus and
S. pasteurianus are associated with chronic bowel disease, particularly adenocarcinoma of the colon12. The
S. bovis group may be differentiated from enterococci by a negative reaction in both PYR and arginine
tests, whereas enterococci are usually positive for both.
Enterococci are facultative anaerobes. Two species within the genus, Enterococcus cassiflavus and
Enterococcus gallinarum, are motile. Enterococci are oxidase-negative and ferment carbohydrates. Most
species are catalase-negative, but some strains produce a pseudocatalase.
Most enterococci possess the group D antigen although some strains can cross react with Lancefield group
G antiserum13.

E. faecalis are very rarely resistant to ampicillin 14. However vancomycin or glycopeptide resistant
enterococci (V/GRE) are becoming increasingly common and this spread of resistance is thought to be due
to transposons and plasmids moving between bacterial species15.

Streptococcus anginosus group: Streptococcus anginosus, Streptococcus constellatus subspecies

constellatus, Streptococcus constellatus subspecies pharyngis, Streptococcus intermedius (formerly the
“Streptococcus milleri” group)
Microscopically these species are Gram-positive cocci, occurring in chains. Colonies on blood agar are
small (≤0.5 mm) and may exhibit α, β or no haemolysis after 16 - 24 h at 35°C - 37°C. Incubation
conditions may be of some value for the presumptive identification of the S. anginosus group as growth is
enhanced by a low oxygen tension and raised CO2 levels16.
Organisms of this group may possess the Lancefield group A, C, F or G antigen16 or be ungroupable. S.
intermedius possesses no group antigen. S. constellatus may express group C, or F and S. anginosus may
express group A, C, F or G antigens. Human isolates of streptococci which express the group F antigen are
highly likely to be members of the anginosus group. Streptococci in this group will grow on media
containing bile although they are not salt tolerant.
Resistance to sulphonamides and bacitracin may be used as screening tests for organisms of the S.
anginosus group14.
Identification of an isolate from a clinical specimen as being a member of this group is potentially clinically
significant, due to the propensity of this group to be associated with invasive pyogenic infections.