Chapter 8: Staphylococci

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Chapter 8 Staphylococci

• Family Micrococcaceae
• Genus Staphylococcus
• Species Staphylococcus aureus
• Staphylococcus epidermidis
• Staphylococcus saprophyticus
• Microscopic Morphological Appearance
• Gram () cocci (round)
• Arrangement irregular clusters cluster of
  grapes
• Nonspore formers
• Non-motile
• Usu. no capsule present, but some w/ notable
  capsules
• Facultatively anaerobic and fastitidious,
  requiring various AA and other growth factors.

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Staphylococci

• Virulence Factors of genus Staphylococcus
• Extracellular Products
• Blood Cell Toxins
• Hemolysin lyses RBCs by disrupting cell
  membrane
• Leukocidin lyses WBCs
• Variety of Enzymes
• Coagulase plasma clotting protein
• Coats bacteria w/ fibrin prevents phagocytosis
• Aids in adherence to tissues
• Fibrinolysin digests fibrinogen (fibrin clots)
• Hyaluronidase digest hyaluronic acid around
  host cells promotes invasion (spreading
  factor)
• Lipase degrades lipids allows bacteria to
  colonize oily skin
• Penicillinase confers drug resistance
• 90 of Staph. Infections are resistant to
  Penicillin

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Staphylococci

• Virulence Factors of genus Staphylococcus
• Extracellular Products
• Variety of enzymes
• Catalase degrades H2O2, a toxic metabolic end
  product used for genus differentiation
  Staphylocooci are Catalase (), whereas
  Streptococci are Catalase (-)
• Exfoliatin causes peeling of superficial skin
  layers
• Enterotoxin food poisoning causes acute GIT
  sxs.
• Enterotoxin a bacterial exotoxin that is
  absorbed thru the intestinal mucosa most cause
  nausea, vomiting, /or diarrhea.
• Most virulent species Staphylococcus aureus
  Coagulase ()
• All other Staph. spp Coagulase (-)

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Staphylococci

• Staphylococcus aureus
• Epidemiology
• Frequently carried by healthy individuals on skin
  or mucous membranes (ant. Nares, skin,
  nasopharynx intestine)
• Significant host compromise reqd for infection
• Break in skin (wounds/surgical infections) or
  insertion of foreign body (central venous
  catheters)
• Carriers source of infection to themselves
  others gtp-p, direct contact/contamination,
  fomites or food (food poisoning)
• Carriage rate widespread, being found on tisss
  of healthy individuals 30-50 of the time.
• Colonization of infant 90 of infants w/in 10
  days of birth

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Staphylococci

• Staphylococcus aureus
• Pathogenesis
• Structural Surface Component
• Protein A surface component linked to PG layer
  of cell wall ONLY representative of Staph.
  aureus.
• Function Decreases Ab immunity, it competitively
  interacts w/ the constant region of IgG
  molecules, pointing these Ab molecules AWAY for
  the bacterium
• Virulence Factors/Species ID
• Coagulase () most important
• Hemolysin (a-toxin) lyses RBCs
• Protein A
• Capsule therefore, cannot be phagocytized easily
• Leukocidin lyses WBCs

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Staphylococci

• Toxins of Staphylococcus aureus
• Blood Cell Toxins
• Hemolysin
• Leukocidin
• Intestinal Toxins
• Enterotoxins (acute intestinal sxs food
  poisoning)
• Contamination of food, Staph. aureus secretes
  enterotoxin ingestion causes food poisoning.
• Toxin stimulates vomiting center in brainstem by
  binding to neural receptors in upper GIT
• Epithelial Toxins
• Exfoliatin or epidermolytic toxin
• Causes peeling of superficial skin layers

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Staphylococci

• Clinical Staphylococcal Infections
• Superficial Cutaneous (skin) Infections
• Localized to a specific site on the skin
• Pyoderma Infections boils, carbuncles, furuncles
  impetigo
• Characteristic Sx pus-formation inflammatory
  exudate (Staphylococcipyogenic cocci)
• Mode of Infection invasion of skin that is
  damaged entry _at_ sebaceous gland openings, hair
  follicle, wounds and respiratory tract
• Infection site gt ABSCESS localized lesion w/ a
  cavity of necrotic tissue filled w/ pus
• Local host response inflammation swelling, pus
  accumulation, necrosis of tissue
• Fibroblasts form wall around inflamed area,
  producing pus-filled boil or abscess
• Sx extreme pain at the local site

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Staphylococci

• Clinical Staphylococcal infections
• Superficial Cutaneous (skin) Infections
• Serious consequences result in bacteria enter the
  bloodstream
• Result septicemia presence persistence of
  the bacteria and their toxins w/in the
  bloodstream may be fatal
• Bacteremia presence of viable bacteria
  circulating in the blood may result in internal
  abscesses skin lesions infections of lung,
  kidney, heart, skeletal m., or meninges.

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Staphylococci

• Clinical Staphylococcal Infections
• Superficial Cutaneous (skin) Infections
• M/C Staph. aureus infection small, superificial
  abscesses involving the hair follicles
  (folliculitis)
• Furuncles (boils) subcutaneous abscesses
• Carbuncles large boils deeper, multilocualted
  skin infections that can lead to bacteremia
• Require Antibiotic Tx and debridement
• Impetigo localized, superficial, spreading
  crusty skin lesion in children

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Staphylococci

• Clinical Staphylococcal Infections
• Deep, localized systemic infections
• Staph. aureus m/c cause of acute chronic
  infection of bone marrow and acute infection of
  joint space in children (septic joint)
• Osteomyelitis, pnuemonia, endocarditis,
  meningitis, pyoarthritis
• Acute bacterial endocarditis
• Assocd w/ IV drug abuse
• Pneumonia
• Nosocomial Infections
• Staph. aureus 1 of m/c hospital-acquired
  infections surgical/decubital wounds, bacteremia
  d/t catheter use

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Staphylococci

• Clinical Staphylococcal Infections
• Toxigenic Staphylococcal Disease
• Staphylococcal Scalded Skin Syndrome (SSS)
• Virulent Feature Exfoliatin or epidermolytic
  toxin separates epidermal layer from the dermis
  ? blistering peeling of the skin ? exposes red
  underlayer
• General appearance burned skin
• Appearance of superficial bullae result for
  action of exfoliative toxin, which attacks
  stratum granulosum, causing marked epithelial
  desquamation

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Staphylococci

• Clinical Staphylococcal Infections
• Toxigenic Staphylococcal Disease
• Toxic Shock Syndrome (TSS)
• Incidence of infection use of super-absorbent
  vaginal tampons (cellulose-based)
• Virulent Feature Toxic Shock Syndrome Toxin - 1
  (TSST-1)
• Mode of infection
• Ultra-absorbent tampon brands bind Mg2 ions
• Low of Mg2 triggers TSST-1 production by
  resident vaginal Staphylococci
• TSST-1 stimulates production of IL-1 by M?
• IL-1 production fever induction
• Initial Sxs High fever, vomiting, diarrhea,
  myalgia
• 10 days from onset hand soles of feet develop
  sunburn-like rash, resulting in peeling of the
  skin.
• Severe Sxs Shock d/t hypotension Death d/t
  resp. failure (2-5)

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Staphylococci

• Clinical Staphylococcal Infections
• Toxigenic Staphylococcal Disease
• Toxigenic Gastrointestinal Disease Food
  Poisoning (Food Intoxication)
• Source of contamination FOOD HANDLER
  Staphylococcal lesions of skin (hand
  nasopharyngeal carriers) ? contaminate food (usu.
  Egg/potato salad, creamy pastry) ? food
  unrefrigerated ? room temperature allows for
  growth of Staph. aureus ? production of
  Staphylococcal enterotoxin (exotoxin)
• Virulence Feature Staphylococcal Enterotoxin
• Heat-stable
• Not inactivated by digestive enzymes!
• toxin production does NOT alter food taste or
  smell
• Action of Enterotoxin Disruption of normal
  osmotic balance of GI lining intestinal villi
  (brush border) w/ decrd absorption capabilities
  thus decr. in nutrient absorption
• Sxs Projectile vomit, abdominal cramps/pain,
  diarrhea, nausea
• Recovery self-limiting (24-48hrs)

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Staphylococci

• Clinical Staphylococcal Infections
• Review of Systemic (Deep) Infections
• Osteomyelitis Inflammation of bone
• Bacteria lodge in small vessels of boney pockets,
  then multiply w/ continual growth intense soft
  tissue damage w/ swelling and necrosis of the
  bone
• Sxs fever, chills, pain over bone, muscle
  spasms
• Risk group growing children, IV drug abusers
• Pneumonia condition in which fluid exudate
  collects in air spaces of lungs
• Bacteria inhabit nasopharynx ? aspiration into
  lungs ? abscess formation
• Sxs fever, chest pain, bloody sputum
• Risk group indiv, pre-conditioned w/ lower resp.
  tract VIRAL infection
• Endocarditis Inflammation of endocardium rapid
  destruction of heart valves d/t Staphylococcal
  seeding cardiac abnormalities
• Meningitis Inflammation of the meningeal
  membranes surrounding the brain and spinal cord
• Pyoarthritis Infection of the joints, deforming
  arthritis

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Staphylococci

• Coagulase (-) Staphylococci
• Staphylococus epidermidis
• Normal flora
• Common inhabitant - human skin, resp. tract,
  mucous membranes, intestines
• Route of Infection infections related to
  surgical procedures involving insertion of
  foreign bodies/implanted or artificial prosthetic
  devices (heart valves, catheters, prosthetic hips
  of AV shunts)
• Opportunistic infections and nosocomial
  infections
• Mode of infection attachment of bacteria to
  foreign body/inanimate surface
  multiplication/colonization
• Infections Endocarditis, UTIs and wound
  infections

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Staphylococci

• Coagulase (-) Staphylococci
• Staphylococcus saprophyticus
• Normal flora
• Common inhabitant lower intestinal tract
  vaginal tract
• Primary infection UTI, cystitis in females
• Risk group sexually active adolescent women
• General risk factor predisposing one to
  Staphylococcal infection
• Poor hygiene, tissue injury, pre-existing primary
  infection, DM (limited immune response),
  immundodeficiency state, surgical procedures,
  newborns

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Staphylococcal Lab Dx

• Growth conditions Blood Agar
• Hemolytic pattern (zone of clear hemolysis) seen
  w/ Staph. aureus ONLY
• Genus Differentiation Staphylococcus vs.
  Streptococcus
• Catalase test, colony characteristics, blood agar
  hemolysis
• Catalase Test for Genus Differentiation 2H2O2 ?
  2H2OO2
• Staphylococcus gt Catalase ()
• Steptococcus gt Catalase (-)
• Differentiate Staphylococcus aureus vs.
  Staphylococcus epidermidis
• Coagulase Test Fribrinogen?Fribrin
• Staphylococcus aureus gt Coagulase ()
• Staphylococcus epidermidis gt Coagulase (-)
• Differentiate Coagulase (-) Staphylococci Staph.
  epidermidis vs. Staph. saprophyticus
• Bacterial sensitivity or resistance to antibiotic
  Novobiocin
• Staphylococcus epidermidis gt Sensitive (growth
  inhibited)
• Staphylococcus saprophyticus gt Resistant (growth
  uninhibited)

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Chapter 9 Streptococci

• Family Micrococcaceae
• Genus Streptococcus/Enterococcus (now w/ own
  genus)
• Species Streptococcus pyogenes (ß A)
  Streptococcus agalactiae (ß B)
  Steptococcus pneumoniae (a)
  Steptococcus mutan (a)
  Streptococcus mitis (a)
  Streptococcus sanguis (a H)
  Steptococcus faecalis (ß D)
  Streptococcus faecium (a D)
  

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Streptococci

• General Genus Characteristics
• Gram () cocci arrangement in pairs chains
• Non-motile
• Facultative anaerobes
• Non-spore forming
• May be encapsulated
• Biochemical Characteristics
• Catalase (-) to distinguish Staphylococcus
• Oxidase (-) to distinguish Neisseria

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Streptococci

• Species Classification System
• Hemolytic Reactions (Growth Media Blood Agar)
• a-Hemolysis partial lysis of RBCs
• ß-Hemolysis complete lysis of RBCs
• ?-Hemolysis no lysis of RBCs
• Lancefield Classification
• Grouping system based on cell wall CHOs (Ags)
• Stimulate Ab formation for neutralization
• Serological groups A ? U
• Groups A, B and D w/ human pathogens
• Biochemical Properties
• Growth in 6.5 NaCl soln. (high salt/adverse
  conditions)
• Sensitivity to Bacitracin or Optochin
• Bile solubility some Step. bacteria can grow in
  bile

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Streptococci

• Streptococcus pyogenes Group A ß-Hemolytic
• 90 of human disease caused by Strep. pyogenes
• Can invade intact skin or mucous membranes,
  causing rapidly progressive infections
• Nasopharyngeal carriage common in winter
• Most serious streptococcal pathogen of humans
• Growth on Blood Agar ß Hemolysis
• () Bacitracin sensitivity growth is inhibited
• Strict parasite opportunistic pathogen
• Virulence associated w/ surface Ags. toxins and
  enzymes

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Streptococci

• Virulence Factors
• Cell Surface Ags
• Hyaluronic Acid Capsule
• Antiphagocytic factor
• Not immunogenic b/c hyaluronic acid is normal
  component of human CT
• M Protein (Fig 9.3 p.80)
• Component of fimbriae
• Antiphagocytic
• Attachment factor
• C-CHOs (Cell Wall CHOs)
• Protection protects bacterium from being
  dissolved by lysozyme defense of host
• Lipoteichoic Acid cell surface molecule
• Adherence factor attachment to epithelial cells
  of skin pharynx

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Streptococci

• Virulence Factors
• Extracellular Toxins
• Hemolysins Streptolysins (ß Hemolysis)
• Steptolysin O (SLO)
• ß Hemolysis (anaerobic conditions only)
• Injurious to cell membranes
• Steptolysin S (SLS)
• ß Hemolysis (aerobic conditions only)
• Multiple cytotoxic effects on leukocytes, liver,
  heart muscle
• General action of SLO SLS
• Both Lyse RBCs destroy phagocytic WBCs
• Erythrogenic Toxin (pyrogenic toxin)
• Toxin production induced by lysogeny w/ temperate
  bacteriophage
• Toxin induces a fever w/ alteration of
  temperature regular system
• Toxin responsible for bright red rash typical of
  scarlet fever

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Streptococci

• Virulence Factors
• Extracellular Enzymes or Spreading/Invasive
  Factors
• Spreading/Invasive factor promotes bacterial
  spread in tissues
• Streptokinase dissolves fibrin clots in the
  inflammatory response
• Hyaluronidase breaks down hyaluronic acid (the
  intracellular glue of CT)
• Streptodornase (DNAase) liquefies purulent
  discharges (break-down WBCs)
• Purulent discharge contain dead/injured WBCs
• DNAase hydrolyzes WBC nuclear exudate releasing
  purines pyrimidines, which serve as nutritional
  value to streptococci
• Epidemiology
• Transmission p-p, direct contact via respiratory
  droplets (crowded areas classrooms, child play
  areas)
• Only known reservoir human skin mucous
  membranes

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Streptococci

• Site of infection
• Localized patch of skin
• Mucous membranes of pharynx (throat)
• Uterus
• Factors contributing to Infection type of
  Infection
• Lowered host resistance
• Incidence type of infection altered by climate,
  season and living conditions
• Skin infections increased incidence in
  summer/autumn
• Pharyngeal infection increased incidence in
  winter

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Streptococci

• Steptococcal Disease
• Suppurative or Primary Infection
  Nonsuppurative or infections
• (Pus is formed)
  - caused by complications
• following primary infection
• Pyogenic infections
• Invasion of skin impetigo (localized),
  erysipelas (localized), necrotizing fasciitis
  (multi-system disease)
• Invasion of the Throat pharyngitis or
  tonsilitis (Step throat)
• Invasion of the Uterus peurperal fever
  (puerperalsepsis) child bed fever traumatized
  uterine tissue after childbirth/abortion
  bacteria can spread for uterus to blood ?
  multi-system disease

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Streptococci

• Human skin Infections
• Streptococcal Impetigo (pyoderma)
• Localized purulent dermatitis superficial least
  harmful will be resolved
• Bacteria enters thru small wound or incision on
  face or extremities
• Infection site papules or blisters rupture
  when scratched ? release of fluid ? dries to
  contagious yellow crust
• Erysipelas
• Acute febrile disease of skin, more invasive
  (subcutaneous infection)
• Bacteria enters thru small wound or incision on
  face/extremities ? spread to dermis and then
  subcutaneous tiss.
• Edema and redness at portal of entry, fever and
  chills
• Later sxs lesion is red hot, vesicular ridged
  and can rupture
• Necrotizing Fasciitis
• Muti-system disease, flesh eating bacteria
  disease
• Spread of infection along fascial planes of
  muscle and fat extensive destruction
• Only way to tx cut it out rid the body of the
  bacteria
• Bacteria introduced by break in skin
• Bacteremia leads to organ involvement

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Streptococci

• Human Throat Infection Streptococcal Pharyngitis
• M/C Group A Streptococcal infection
• Causative agent Strep. pyogenes
• Mode of Infection bacteria colonize mucous
  membranes of pharynx and tonsils
• Sxs redness, edema, enlargement and tenderness
  of throat (severe sore throat) painful and
  difficult swallowing purulent exudate over the
  tonsils DX
• Risk group children 5 15 yoa
• Tx penicillin or erythromycin

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Streptococci

• Human Throat Infection Streptococcal Pharyngitis
• Untreated streptococcal may progress to
• Scarlet Fever (Scarlitina)
• Bright red diffuse rash over face, trunk, inner
  arms, legs and tongue (strawberry tongue)
• Rash resolves in 10 days
• Rheumatic Fever
• Delayed inflammatory condition of joints, heart
  and subcutaneous tissue
• Autoimmune disease step-induced Abs attack
  heart proteins (esp. MYOSIN) ? decrease in heart
  function d/t damaged heart valves
• Clinical Carditis (inflammation of heart
  tissue), painful arthritis
• Self-resolves 3-6 weeks w/ no lasting damage,
  UNLESS there is severe heart involvement
  (carditis)
• Acute Glomerulonephritis (usu. clears
  spontaneously)
• Inflammation of the kidneys, long-term ? kidney
  failure
• Autoimmune disease AgAb x-rxn Ags from
  bacterial cytoplasmisc membrane cross-react w/
  basement membrane of kidney glomerulus
• ICs deposited cause injury in epithelial tiss of
  glomerulus and hence damage the filtering
  apparatus ? poor blood filtration
• Sxs swelling of hands feet, low urine output,
  increased BP

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Streptococci

• Diagnosis of Group A Streptococci
• Microscopy gram stain (gram () cocci)
• Culture enriched media (blood plate w/ ß
  hemolysis)
• Antigen detection
• Immunological assays for group specific CHO in
  Bacterial cell wall (Ag CHO ())
• Antibody detection anti-SLO (ASO) test
• Presence of Abs to strepolysin-O confirms
• Rheumatic fever
• Acute Glomerulonephritis
• Treatment
• Penicillin, erythromycin, cephalosporin

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Streptococci

• Group B Streptococci ß Hemolytic
• Streptococcus agalactiae normal flora of oral
  cavity, intestinal tract and female vagina)
• Infections associated w/ newborns
  immunocompromised adults
• Newborn (Neonatal) infection m/frequent
  m/serious
• Compromised Adult infections
• Birth (vertical transmission mother to child in
  utero or thru vagina _at_ birth)
• Hospital Tx highest transmission contact w/
  contaminated hands of hospital personnel
• Compromised Adult infections
• Contributing risk factors chemotherapy,
  diabetes, pregnancy
• Infections urinary tract, ear, postpartum
  infections (meningitis, pneumonia
• Tx Antibiotic therapy

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Streptococci

• Streptococcus pneunomiae (Pneumococcus)
• Causative agent of Typical Pneumoniae
• 80 of all bacterial pneumonias, thus m/c
• Normal flora of URT
• General Characteristics
• Gram () cocci occur singly or paired
  (diplococci)
• Culture blood agar or chocolate agar
• a Hemolysis (partial hemolysis displayed green
  color results)
• Facultative anaerobe grows best at elevated CO2

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Streptococci

• Streptococcus pneunomiae (Pneumococcus)
• Virulence Factors
• Capsule resists phagocytosis
• Pneumolysin forms pores in host cell membrane
  by combining w/ cholesterol (in phospholipid
  bilayer causes lysis once it is released by
  autolysin
• Autolysin PG hydrolase present in the cell
  wall when triggered, causes cell lysis
• Responsible for release of intracellular
  Pneumolysin
• Predisposing factors contributing to pneumonia
• Elderly (weakened IS), underlying illness, winter
  season, institutional living (crowded, community
  acquired), alcoholics

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Streptococci

• Streptococcus pneunomiae (Pneumococcus)
• Normal High Resistance to acquiring pneumonia
• Barriers preventing establishment of infection in
  lungs and bronchioles
• Ciliated epithelium 1st line of defense
• Cough reflex 1st line of defense
• Mucous stops transfer of bacteria
• Phagocytic action of M?s lining alveoli in lungs
• Mode of Infection
• Inhalation
• Aspiration of bacteria from pharynx into lungs
• Colonization multiplication w/in bronchioles
  and lungs
• Fluid accumulation in alveoli results in lobar
  pneumonia (lung consolidation) from
  inflammatory rxn.
• Solidification of fluid mix (exudates, bacteria,
  RBCs, WBCs)

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Streptococci

• Streptococcus pneunomiae (Pneumococcus)
• Initial Sxs chills, shaking rapid breath
  fever
• Later Sxs
• Cyanosis w/ severe pain in chest
• Purulent and rusty-colored (bloody) sputum
  alveolar exudate
• Systemic infections (if there is high bacterial
  load or high colonization)
• Pleuritis
• Endocarditis
• Meningitis
• Otitis media (middle ear infection)
• Bacteremia/sepsis especially w/ splenectomized
  pts.

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Streptococci

• Streptococcus pneunomiae (Pneumococcus)
• Primary risk group for secondary infection
  Children
• URT infection ? meninges ? meningitis (M/C cause
  Step. pneumoinae)
• URT infection ? eustachian tube ? otitis media
• Laboratory Dx Specimen sputum, pleural fluid,
  CSF
• Gram Stain gram () cocci and diplococci
• Quelling reaction or capsular swelling reaction
  ppt. of Abs on surface of capsule yields a
  swollen appearance
• Optochin susceptibility inhibition of
  pneumococci growth
• Bile Solubility Test bile soluble (cells
  lysed) pneumococci dissolved when added to bile
  salt soln (activation of bacterial hydrolytic
  enzymes when in presence of bile)
• Tx antibiotic therapy penicillin, erythromycin,
  cephalosporin

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Streptococci

• Viridans Group of Streptococci (a Hemolytic
  Streptococci)
• Streptococcus sanguis
• Streptococcus mutans
• Streptococcus mitis
• Normal Flora oral cavity, nasopharynx, genital
  tract and skin thought to be causative agent for
  dental plaque/tooth decay
• Mode of Infection
• Displacement form oral cavity d/t dental or
  surgical manipulation, chewing hard candy, or
  brushing teeth
• Entry into blood stream (bacteremia)
• Variety of infections SBE, bacteremia,
  meningitis, abdominal infection, sinusitis and
  wound infection

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Streptococci

• Viridans Group of Streptococci (a Hemolytic
  Streptococci)
• Subacute Bacterial Endocarditis (SBE)
• Causative agent Strep. sanguis
• Mode of Infection
• Blood-borne bacteria settle on areas of the heart
  lining or valves previously injured by rheumatic
  fever of valve surgery
• Colonization produces tissue deformities
  (vegetations)
• Vegetations increase in and size, and
  constantly release bacteria into the general
  blood circulation
• Sxs fever, heart murmur, wt. loss and anemia
• High risk group pre-existing heart condition,
  i.e., rheumatic fever, congenital heart disease.
• Control/Prevention prophylactic antibiotics
  before after dental surgery in high risk pts.
• Tx penicillin

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Streptococci

• Viridans Group of Streptococci (a Hemolytic
  Streptococci)
• Dental caries (dental plaque)
• Causative agents Strep. mutans Strep. mitis
• Plaque formation
• Strep. mutans Strep. mitis in the presence of
  sugar produce a slime layer that adheres tightly
  to the tooth surface. This sticky polymer (slime
  layer) is the basis for dental plaque.
• Note glucose is broken down to lactic acid,
  which lowers the pH (homolactic fermentation)

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Streptococci

• Group D Streptococci/Enterococci
• Enterococcus faecalis pertaining to feces / ß
  Hemolytic
• Enterococcus faecium of feces / a - Hemolytic
• Normal flora of human intestine part of normal
  fecal flora
• Growth in 6.5 NaCl
• Growth _at_ 45C
• Tolerate 40 Bile Salts growth in presence of
  bile salts
• Esculin hydrolysis Esculin ? Esculitin Fe2 gt
  Black colonies (Black ppt formed)
• Primary risk group elderly pts undergoing
  surgery
• Causative agent of Opportunistic infection or
  Nosocomial Infections
• Infections endocarditis, UTIs, post-operative
  wound infections and intra-abdominal infections
• Tx antibiotic therapy