COAGULASE +VE

COAGULASE -VE

1. Always Pathogenic 2. Eg: S. Aureus

1. Often contaminants in culture.

2. Can be pathogenic in situations like

Indwelling Prosthetic devices

Plastic Vascular Catheters

3. Eg: S. Epidermis, S. Hemolyticus

Tests to differentiate S. Aureus

Coagulase Production

Rapid Test : Latex Assay

Coagulase + Ve
A. Eg: S.Aureus B. CARRIER: Skin, Nasopharynx, Vagina C. INFECTIONS: SKIN DEEP: Endocarditis, Meningitis, Arthritis, Pneumonia, Sepsis, MOF TOXIN MEDIATED: Food poisoning Toxic Shock Syndrome

Scalded Skin Syndrome

Coagulase - Ve
A. Eg : S. Epidermis B. CARRIER: Skin , Ear canal,GU Tract, Mucous membranes. C. INFECTIONS Indwelling Foreign body Valves, Catheter, Pacemakers, Shunts, Grafts, IV Catheter. UTI Others : Post OP, Endocarditis D. TREATMENT: Vancomycin + Aminoglycoside Surgical Removal

Folliculitis,Furunculosis& Recurrent Furunculosis

FOLLICULITIS (Superficial Skin Infection) Staphylococcus, Pseudomonas

FURUNCULOSIS ( Inflamm.. Nodule around hair follicle)

EXTENSIVE CELLULITIS

BACTRAEMIA

Hyper Immunoglobunaemia E Syndrome

Primary immunodeficiency disease with high IgE titre. Chronic Staphylococcal infections ( Furunculosis).

Rx of Chronic Furunculosis :
- Avoid strong irritants - Role of Vitamin C ? - 2 % Mupirocin Intra nasal 5 days every month for 1 year - Oral Rifampicin + Pencillinase resistant penicillin

 1940 : Pencillin 1960 : Methicillin, Oxacillin 1961 : MRSA Identified

1970 & Later : Hospital Acquired MRSA

 1990 : VISA ( Vancomycin Intermediate S. Aureus)

Seen in Hemodialysis Patients on prolonged vancomycin Rx.

Responds to Cotrimoxazole, Linezolid, Streptogramins.

2002 : VRSA
Sensitive to same drug as VISA and Tetracycline.

What Are These ?

1. MRSA ( Methicillin Resistant S. Aureus)
- Resistant to all Beta Lactam Antibiotics (Pencillin, Cephalosporin, Carbepenem) DOC : Vancomycin DOC in deep infection : Vancomycin + Aminoglycoside, Rifampicin Cotrimoxazole

MRSA as a Nosocomial pathogen

In Tertiary Care Hospitals Rapid Detection Prompt Implementation of barrier precautions

Eradication of Nasal discharge in patients / Carriers using Intra nasal muciporin

2. MSSA (Methicillin Sensitive S. Aureus)

A. DOC : Nafcillin, Oxacillin

B. If Allergy to Pencillin :
1st Gen Cephalosporin's : Caphazolin.

C. If Allergy to all Beta Lactams :

Vancomycin / Clindamycin / Macrolides

3. GRSA (Glycopeptide Resistant S. Aureus) MIC > 32 mcg/ml of V

4. VRE (Vancomycin Resistant Enterococci)

STREPTOGRAMINS
MOA : Complex with Bacterial Ribosome's to inhibit Protein synthesis. Useful against VRE, VISA, VRSA Strep. Pneumoniae when vancomycin cant be tolerated. Eg : Quinupristin, Dalfopristin

DRUG RESISTANCE IN STAPHYLOCOCCI

Beta Lactamase Plasmid Mediated Drug inactivation.

Methicillin resistant

Chromosomal Linked
Decreased activity to penicillin binding protein

Plasmid Mediated

VIRULENCE OF MRSA & MSSA

Both are equally capable of producing life threatening infections (Endocarditis, Pneumonia, Bactraemia). Source may be carrier Mortality is up to 50% . Drugs useful : Vancomycin, Linezolid, Quinopristin, Dalfopristin, Daptomycin, Ciprofloxacin, Cotrimoxazole

STERPTOCOCCI
Gram + Ve
Catalase Ve Grow in Pairs/ Chains

CLASSIFICATION
Patterns of Hemolysis in Blood Agar (Alpha, Beta, Gamma)

B A S E D O N

Antigenic differences in Cell Wall carbohydrates (A to H J K to V) in LANCEFIELD scheme for beta hemolytic streptococci

Biochemical Reactions

Growth Characteristics

DISEASES
Group A
S. Pyogenes Pharyngitis, Tonsillitis, Scarlet fever, pneumonia, Septicemia, Necrotizing Fascitis.
Acute Rheumatic Fever Acute Glomerular nephritis

Non Suppurative

 Group B :

Serious Neonatal Infections ( Meningitis, Sepsis), Female pelvic Infection.

Strep. Pneumoniae Pneumonia, Otitis Media,

Sinusitis, Meningitis, Bactraemia.

 Enterococcus Faecalis

Endocarditis, UTI

Anaerobic Streptococci (pepto streptococcus)

Peritonitis, Dental infections, Liver abscess, PID

*All Streptococci cause Septicemia

Streptococcus Pyogenes
Pyogenic Exotoxins: A, B, C
A Toxic Shock Syndrome M Protein - Major Virulence Antigen
- Makes the bacterium resistant to phagocytosis

Necrotizing Fascitis
Produced by Strep. Pyogenes Flesh eating Bacteria
PAIN

NECROTIZING SKIN & SUB CUTANEOUS TISSUE

FRANK GANGRENE

SEVERE SEPSIS

DEATH

SEPTIC SHOCK, MULTI ORGAN FAILURE, DIC

TYPES
TYPE I TYPE II

Polymicrobial ( Enterobacteriacae
and Anaerobes)

Seen Commonly following surgery in DM, HIV

Pure growth of Strep. Pyogenes. Cutaneous findings do not correlate with extent of the disease Seen following Anesthesia of skin, Nerve damage, Vascular blockade

Differentials
1. Clostridia :
Anaerobic Cellulitis, Myonecrosis

2. Staph Aureus + Strepto : Progressive bacterial

synergistic gangrene.

3. Anaerobic Streptococci : Myonecrosis 4. Group A Streptococci : Myositis with out abscess

Treatment of NF
A. High dose Penicillin IV

B. Penicillin Allergy : Cephalosporin, Vancomycin,

Clindamycin

Toxic Shock Syndrome

Streptococcal TSS :
Group A Streptococcus ( pyogenic exotoxin A) - Initially influenza like illness. - 50 % has features of NF - Faint rash followed by multisystem involvement and MOF

Rx :
Fluid restriction. BenzylPencillin + Clindamycin

 Staphylococcal TSS
- F > M (9:1)
- Vaginal Colonization of Staph. Aureus - TSS Toxin 1 is responsible for systemic manifestations.

Fever + Rash (localised erythema in Flexural Areas)

Rapidly Progressive (Erythroderma Desquamatum)

Multisystem Involvement

Treatment
SPECIFIC Rx SUPPORTIVE Rx

1.Flucloxacillin, Vancomycin 2.Avoid Tampon Use

1.Haemodynamic Monitoring 2. Supportive Care

ENTEROCOCCI
INFECTIONS INDUCED COMMON UNCOMMON

UTI, Bactraemia, Endocarditis, Intra abdominal & Pelvic infections.

Soft tissue, Meningitis, Neonatal sepsis, Pneumonia

Treating Enterococcal Infections

UTI
Penicillin, Ampicillin, Vancomycin, Quinolones, Nitrofurantoin.

ENDOCARDITIS / BACTRAEMIA
Penicillin/ Ampicillin + Amino glycoside Vanomycin + Amino glycoside

INTRA ABDOMINAL/ PELVIC INFECTIONS

Ampicillin / Penicillin + Aminoglycoside

Vancomycin Resistant Enterococus

Action:
Inhibits cell wall synthesis by binding to cell wall precursors.

Resistance to Vancomycin
By producing Cell Wall precursors with less affinity to Vancomycin. E. Faecium VRE It is also resistant to Tobramycin Bactericidal of Choice : Gentamicin

 RESISTANCE TO GENTAMYCIN
By altering the molecule (G) by phosphorylation and Acetylating.

INFECTIONS
Hospitalized patients, Device related.

LESSONS
1. Infection Control Measures 2. Avoid Excessive antibiotic use especially Vancomycin

Treatment of VRE
Device Removal Surgical Debridgment of Source UTI : Nitrofurantoin, Amoxicillin, Fluroquinolone, Linezolid, Daptomycin, Otrivancin, Daflopristin.

LINEZOLID
Acts on VRE, MRSA, GRSA, Penicillin Resistant Strep. Pneumoniae. S/E : Thrombocytopenia (25%), Reversible Bone marrow Toxicity