Essential Microbiology for Dentistry. 5th ed.

Chapter 11. Streptococci, staphylococci and enterococci

Streptococci comprise a diverse group of Gram-positive cocci, which continuously undergo taxonomic revision. They are distributed widely in humans and animals, mostly forming part of their normal flora. A few species cause significant human morbidity. The oral streptococci, which include the cariogenic mutans group, are important members of the genus. There is also an accumulating database to indicate that enterococci, particularly Enterococcus faecalis (commonly found as gut microbes) is a pathogen of significance in endodontic (root canal) infections. Another common group of cocci, the staphylococci, live on the skin but are infrequently isolated from the oral cavity and are significant agents of many pyogenic (pus-producing) human infections.


General properties


They are catalase-negative, Gram-positive spherical or oval cocci in pairs and chains; 0.7-0.9 μm in diameter. Chain formation is best seen in liquid cultures or pus. Cell division in this genus occurs along a single axis thus they grow in chains or pairs, hence the name - from Greek streptos, meaning easily bent or twisted, like a chain.


These cocci grow well on blood agar, although enrichment of media with glucose and serum may be necessary. Typical haemolytic reactions are produced on blood agar (Fig. 11.1):

 a-haemolysis: narrow zone of partial haemolysis and green (viridans) discolouration around the colony, for example, viridans streptococci

 β-haemolysis: wide, clear, translucent zone of complete haemolysis around the colony, for example, Streptococcus pyogenes

 no haemolysis (y-haemolysis), for example, non-haemolytic streptococci.


The carbohydrate antigens found on the cell walls of the organisms are related to their virulence. Hence, serogrouping, termed Lancefield grouping, is useful in the identification of the more virulent β-haemolytic species. Currently, 20 Lancefield groups are recognized (A-H and K-V) but not all are equally important as human pathogens. The following are worthy of note:

 group A includes the important human pathogen Streptococcus pyogenes

 group B contains one species, Streptococcus agalactiae, an inhabitant of the female genital tract; it causes infection in neonates

 group C mainly causes diseases in animals

 group D includes the enterococci (Enterococcus faecalis, an endodontic pathogen) and ranks next to group A in causing human disease.

Streptococcus pyogenes (group A)

Habitat and transmission

The normal habitat of this species is the human upper respiratory tract and skin; it may survive in dust for some time. Spread is by airborne droplets and by contact.


It is found as a commensal in the nasopharynx of a minority of healthy adults, but more commonly (about 10%) in children. It grows well on blood agar, with a characteristic halo of β-haemolysis. Some strains produce mucoid colonies as a result of having a hyaluronic acid capsule. This may contribute to virulence by offering resistance to phagocytosis.

Fig. 11.1 a- and β-haemolysis: p-haemolytic colonies (e.g., Streptococcus pyogenes) produce complete translucence of blood agar, whereas a-haemolytic colonies (e.g., Streptococcus pneumoniae) do not. Note also the sensitivity of Streptococcus pneumoniae to a disc impregnated with optochin.

Exotoxins and enzymes

Produces a large number of biologically active substances, such as:

 streptokinase (fibrinolysin): a proteolytic enzyme that lyses fibrin

 hyaluronidase: attacks the material that binds the connective tissue, thereby causing increase in permeability (hence called the 'spreading factor')

 DNAases (streptodornases): destroy cellular DNA

 haemolysins (streptolysins, leukocidins): phage mediated and are responsible for the characteristic erythematous rash in scarlet fever; also cause the translucency around colonies in blood agar due to breakdown of haemoglobin (Fig. 11.1)

 pyrogenic exotoxins (erythrogenic toxin): associated with streptococcal toxic shock syndrome and scarlet fever.

(Note: not all these products are produced by every strain; the combined action of enzymes and toxins contributes to the pathogenicity.)

Culture and identification

Culture on blood agar yields characteristic β-haemolytic colonies (lysis of blood due to streptolysins O and S). A Gram-stained smear may show characteristic cocci in chains (Fig. 11.2); these are more developed in liquid than in solid media. The isolate can be presumptively identified as Streptococcus pyogenes if it is sensitive to bacitracin.

If rheumatic fever is suspected, then testing the patient's antistreptolysin O (ASO) antibody titre will demonstrate previous exposure to Streptococcus pyogenes.


Streptococcus pyogenes causes a number of spreading infections with minimal local suppuration; the most notable are:

 tonsillitis and pharyngitis

 necrotizing fasciitis (streptococcal gangrene; so-called disease of 'flesh eating bacteria')

 scarlet fever

Fig. 11.2 Scanning electron micrograph of a chain of streptococci.

 mastoiditis and sinusitis

 otitis media (middle-ear infection)

 wound infections leading to cellulitis and lymphangitis

 impetigo and erysipelas (a brawny, massive skin infection).


After an episode of infection, some patients develop complications, such as rheumatic fever, glomerulonephritis and erythema nodosum, which may have long-lasting effects. Note that:

 in cellulitis, hyaluronidase (spreading factor) mediates the subcutaneous spread of infection

 erythrogenic toxin causes the rash of scarlet fever

 post-streptococcal infection, manifesting as rheumatic fever, is caused by immunological cross-reaction between bacterial antigen and human heart tissue, and acute glomerulonephritis is caused by immune complexes bound to glomeruli (see Chapter 23).

Treatment and prevention

Penicillin is the drug of choice; erythromycin and clindamycin are suitable for patients hypersensitive to penicillin. No vaccine is available.

Streptococcus agatactiae (group B)

This species is increasingly recognized as a human pathogen, especially as a cause of neonatal meningitis and sepsis.

Habitat and transmission

Found in the human vagina; sometimes anorectal carriage occurs. Babies acquire infection from the colonized mother during delivery or during nursing.


Gram-positive cocci in chains.

Culture and identification

Gram-stained smear and culture yielding β-haemolytic colonies on blood agar; colonies on blood agar are generally larger than Streptococcus pyogenes. Lancefield group is determined by antiserum against cell wall polysaccharide.


No toxins or virulence factors have been identified. This species causes neonatal meningitis and septicaemia; it is also associated with septic abortion and gynaecological sepsis.

Treatment and prevention

Penicillin is the drug of choice; erythromycin is suitable for patients hypersensitive to penicillin. Prophylactic antibiotics may be given to neonates if the mother is culture-positive.

Oral streptococci

Oral streptococci, which live principally in the oropharynx, are a mixed group of organisms with variable characteristics. New typing techniques, particularly those based on molecular biology, have revealed the complex nature of the origin and the taxonomy of this group. Hence, the nomenclature of oral streptococci is in a constant state of flux. They typically show a-haemolysis on blood agar, but this is not a constant feature as some strains are non-haemolytic and others β-haemolytic. Oral streptococci can be divided into four main species groups as follows:

1. mutans group

2. salivarius group

3. anginosus group

4. mitis group.

Each of these groups comprises a number of species (Table 11.1). See also Chapter 31 for further details of oral streptococci.

Habitat and transmission

Streptococci make up a large proportion of the resident oral microbiota. It is known that roughly one-quarter of the total cultivable flora from supragingival and gingival plaque and half of the isolates from the tongue and saliva are streptococci. They are vertically transmitted from mother to child. Infective endocarditis caused by these organisms (loosely termed viridans streptococci) in specific susceptible patient groups is generally a result of their entry into the blood stream (bacteraemia) during intraoral surgical procedures (e.g., tooth extraction), and sometimes even during tooth-brushing.

Table 11.1 Some recognized species of oral streptococci



mutans group

S. mutans, serotypes c, e, f S. sobrinus, serotypes d, g S. cricetus, serotype a S. rattus, serotype b and others

salivarius group

S. salivarius S. vestibularis

anginosus group

S. constellatus S. intermedius S. anginosus

mitis group

S. sanguinis S. gordonii S. parasanguinis S. oralis and others

Fig. 11.3 Gelatinous colonies of mutans streptococci mainly comprising extracellular polysaccharides.

Culture and identification

Gram-positive cocci in chains; a-haemolytic; catalase-negative. Growth not inhibited by bile or optochin (ethylhydrocupreine hydrochloride), in contrast to pneumococci. Commercially available kits are highly useful in laboratory identification of these organisms.


The mutans group of streptococci are the major agents of dental caries (but in the absence of predisposing factors, such as sucrose, they cannot cause caries). They have a characteristic ability to produce voluminous amounts of sticky, extracellular polysaccharides in the presence of dietary carbohydrates (Fig. 11.3); these help tenacious binding of the organisms to enamel and to each other.

They are also important agents of infective endocarditis, and some 60% of cases are due to this organism. Usually, bacteria released during dental procedures settle on damaged heart valves, causing infective endocarditis (see Chapter 24).

Treatment and prevention

In patients at risk of infective endocarditis (e.g., those with damaged or prosthetic heart valves), prophylactic antibiotic cover should always be given before dental procedures (see Chapter 24).

See Chapter 32 for caries.

Streptococcus mutans

Streptococcus mutans gained notoriety in the 1960s when it was demonstrated that caries could be experimentally induced and transmitted in animals by oral inoculation with the organism. The name 'mutans' results from its frequent transition from coccal phase to coccobacillary phase. Currently, seven distinct species of human and animal mutans streptococci and eight serotypes (a—h) are recognized, based on the antigenic specificity of cell wall carbohydrates. The term Streptococcus mutans is limited to human isolates belonging to three serotypes (c, e and f).

Other oral Gram positive cocci

A group of oral organisms previously classified as nutritionally variant streptococci (Streptococcus adjacens, Streptococcus defectivus) and isolated under appropriate environmental conditions has been assigned to a new genus called Granulicatella. Their role in oral disease is not well characterized. (See Chapter 31 for further details.)

Streptococcus pneumoniae (pneumococcus)

This organism causes a number of common diseases, such as pneumonia and meningitis in adults and otitis media and sinusitis in children.

Habitat and transmission

A normal commensal in the human upper respiratory tract; up to 4% of the population carry this bacteria in small numbers. Transmission is via respiratory droplets.


Gram-positive 'lancet-shaped' cocci in pairs (diplococci) or short chains; cells are often capsulate; a-haemolytic on blood agar; catalase-negative; facultative anaerobe (i.e., grows under both aerobic and anaerobic conditions).

Culture and identification

Forms a-haemolytic colonies. After incubation for 2 days, the colonies appear typically as 'draughtsmen' because of their central indentation (a result of spontaneous autolysis of older bacteria in the centre of the colony). The species is differentiated from other a-haemolytic streptococci by its sensitivity to optochin and solubility in bile (Fig. 11.1). Observation for the capsular swelling with type-specific antiserum (quellung reaction) confirms the identity and is the standard reference method. The latex agglutination test (see Fig. 6.7) for capsular antigen in spinal fluid can be diagnostic.


Although no exotoxins are known, this organism induces an inflammatory response. The substantive polysaccharide capsule retards phagocytosis. Vaccination with antipolysaccharide vaccine helps provide type-specific immunity. Viral respiratory infection predisposes to pneumococcal pneumonia by damaging the mucociliary lining of the upper respiratory tract (the mucociliary escalator). Other common diseases caused by pneumococci include lobar pneumonia, acute exacerbation of chronic bronchitis, otitis media, sinusitis, conjunctivitis, meningitis and, in splenectomized patients, septicaemia.

Treatment and prevention

Penicillin or erythromycin is very effective. However, resistance to penicillin is rapidly emerging as a global concern.

Gram-positive anaerobic cocci

Gram-positive anaerobic cocci (GPAC) all belonged to the genus Peptostreptococcus until recently. However, they now comprise three genera: Peptostreptococcus, Micromonas and Finegoldia. The representative species are Peptostreptococcus anaerobius, Finegoldia magnus (previously Peptostreptococcus magnus) and Micromonas micros (previously Peptostreptococcus micros).

These GPAC can often be isolated from dental plaque and the female genital tract. They are also found in carious dentine, subgingival plaque, dentoalveolar abscesses and in advanced periodontal disease, usually in mixed culture. Their pathogenic role is still unclear.


Staphylococci are also Gram-positive cocci, but in contrast to streptococci they divide along multiple axes and generate grape-like clusters of cells. The Staphylococcus genus contains more than 15 different species, of which the following are of medical importance: Staphylococcus aureus, Staphylococcus epidermidis and Staphylococcus saprophyticus.

Staphylococci cause a variety of both common and uncommon infections, such as abscesses of many organs, endocarditis, gastroenteritis (food poisoning) and toxic shock syndrome. They are not infrequent isolates from the oral cavity. Higher proportions of Staphylococcus aureus are found in the saliva of healthy subjects older than 70 years.

Staphylococcus aureus

Habitat and transmission

The habitat is the human skin, especially the anterior nares and the perineum. Domesticated animals also carry staphylococci. Higher carriage rates are seen in hospital patients and staff. These bacteria are disseminated through air and dust and are always present in the hospital environment. The usual transmission route is via the hands and fingertips.


Gram-positive cocci in clusters (cluster formation is due to their ability to divide in many planes); non-sporing, non-motile; some strains are capsulate.

Culture and identification

Grows aerobically as yellow or gold colonies on blood agar (Fig. 11.4); catalase-positive (this differentiates them from the catalase-negative streptococci).

Other tests used to differentiate the more virulent Staphylococcus aureus from the less pathogenic Staphylococcus epidermidis include the following.

Coagulase test

Staphylococcus aureus coagulates dilute human serum or rabbit plasma (i.e., it is coagulase-positive), whereas Staphylococcus epidermidis does not (coagulase-negative). This test could be done either in a test tube (the tube test), which requires overnight incubation (Fig. 11.5), or on a slide (the slide test), which is a rapid test.

Protein A: Latex agglutination test

Protein A, synthesized by almost all strains of Staphylococcus aureus, has a special affinity to the Fc fragment of immunoglobulin G (IgG). Hence, when latex particles coated with IgG (and fibrinogen) are mixed with an emulsified suspension of Staphylococcus aureus on a glass slide, visible agglutination of the latex particles occurs; no such reaction is seen with Staphylococcus epidermidis (Fig. 11.6).

Other tests

These include the phosphatase test, DNAase test and mannitol fermentation test (most strains of Staphylococcus aureus form acid from mannitol, whereas few Staphylococcus epidermidis do so).

Typing of Staphylococcus aureus

Typing is important to determine the source of an outbreak of infection. This was commonly done by the pattern of susceptibility to a set of more than 20 bacteriophages: phage typing and serotyping. These methods are currently supplanted by molecular typing techniques. Antibiotic-susceptibility patterns are also helpful in tracing the source of outbreaks.

Fig. 11.4 Golden-yellow colonies of Staphylococcus aureus.

Fig. 11.5 a positive tube coagulase test for Staphylococcus aureus (tube a); tube B: bacteria-free control with uncoagulated plasma.

Fig. 11.6 Identification of Staphylococcus aureus. Protein A of Staphylococcus aureus has a special affinity for immunoglobulin G (IgG); when latex particles coated with IgG are mixed with a suspension of the organism, visible agglutination of latex particles occurs.

Table 11.2 Toxins and enzymes produced by Staphylococcus aureus




Cytotoxins (а, β, у, δ)

Cell lysis


Kills leukocytes

Epidermolytic toxin

Exfoliation and splitting of epidermis

Toxic shock syndrome toxin

Shock, rash, desquamation

Enterotoxin (A-E)

Induces vomiting and diarrhoea



Clots plasma


Affects bactericidal activity of polymorphs


Connective tissue breakdown

DNAase (nuclease)

DNA hydrolysis


Breaks lipids of cell membranes


Breaks down β-lactam drugs

Protein A



A variety of enzymes and toxins are produced by Staphylococcus aureus, although no one strain produces the whole range listed in Table 11.2. The two most important are coagulase and enterotoxin. Coagulase is the best correlate of pathogenicity. Some of the diseases caused by Staphylococcus aureus are:

 superficial infections: common agent of boils, carbuncles, pustules, abscesses, conjunctivitis and wound infections; rarely causes oral infections; may cause angular cheilitis (together with the yeast Candida) at the angles of the mouth

 food poisoning (vomiting and diarrhoea) caused by enterotoxins

 toxic shock syndrome, also caused by an enterotoxin

 deep infections: osteomyelitis, endocarditis, septicaemia, pneumonia.

Predisposing factors for infection are minor and major breaks in the skin, foreign bodies such as sutures, low neutrophil levels and injecting drug abuse.

Treatment and prevention

The vast majority (>80%) of strains are resistant to β-lactam drugs, and some to a number of antibiotics. The latter phenomenon (multiresistance) is common, particularly in strains isolated from hospitals; these cause hospital (nosocomial) infection. Penicillin resistance is due to the production of β-lactamase encoded by plasmids. The enzyme destroys the efficacy of antibiotics with a β-lactam ring (i.e., the penicillin-group drugs).

Antibiotics active against Staphylococcus aureus include penicillin for sensitive isolates, flucloxacillin (stable against β-lactamase), erythromycin, fusidic acid (useful for skin infections), cephalosporins and vancomycin.

Cleanliness, hand-washing and aseptic management of lesions reduce the spread of staphylococci.

Antibiotic resistance in staphylococci

This is a global problem of much concern and falls into several classes:

 resistance to β-lactam drugs (see earlier discussion)

 resistance to methicillin (and to nafcillin and oxacillin) independent of β-lactamase. The spread of methicillin-resistant Staphylococcus aureus (MRSA) worldwide is posing problems in many community and hospital settings

 resistance to vancomycin, one of the last-line defences against staphylococci and the emergence of vancomycin-resistant Staphylococcus aureus (VRSA). The mechanism of resistance here is due to alterations in the cell wall

 'tolerance', where the organism is inhibited but not killed by the antibiotic (i.e., there is a large difference between minimum inhibitory concentration and minimum bactericidal concentration), leading to prolonged course of infections (e.g., staphylococcal infective endocarditis).

Staphylococcus epidermidis

Habitat and transmission

This species is found on the skin surface and is spread by contact.

Culture and identification

Grows as white colonies on blood agar, hence the earlier name Staphylococcus albus; catalase-positive; coagulase-negative; biochemically characterized by commercially available kits (e.g., API STAPH).


Being a normal commensal of the skin, this bacterium causes infection only when an opportunity arises (it is an opportunist pathogen). Common examples are catheter-related sepsis, infection of artificial joints and urinary tract infections.


Staphylococcus epidermidis exhibits resistance to a number of drugs (multiresistance), including penicillin and methicillin. It is sensitive to vancomycin.

Staphylococcus saprophyticus

This organism causes urinary tract infections in women, an infection especially associated with intercourse. It has the ability to colonize the periurethral skin and the mucosa. The organism can be differentiated from Staphylococcus epidermidis (both grow as white colonies on blood agar) by the mannitol fermentation reaction and other biochemical tests.


Habitat and transmission

Normal constituents of the gut microbiota; Enterococcus faecalis is the most virulent species.

Commonly isolated form endodontic infections, and difficult to eradicate due to persistence within dentinal tubules where access to antibiotics or antiseptics is limited. Why enterococci preferentially colonizes dentine and how these organism are transmitted to infected pulp is yet unknown.

Culture and identification

Grows well on blood agar even with 6.5% NaCl; usually non-haemolytic but are occasionally а-haemolytic. Enterococci are pyridoxine positive and grow in the presence of bile, and hydrolyze esculin (bile esculin positive).


In general, enterococci are among the most frequent causes of nosocomial infections, particularly in intensive care units,

where they are selected due to constant antibiotic exposure. E faecalis is common in pulpal infection and is commonly associated with treatment failure in endodontic infections (see Chapter 34).


Enterococci can be very resistant to antibiotics and antiseptics. For instance, they are more resistant to penicillin G than the streptococci, and rarely в-lactamase positive; many are vancomycin resistant.


Micrococci are catalase-positive organisms similar to staphylococci. They are coagulase-negative and usually grow as white colonies on blood agar, although some species are brightly pigmented: pink, orange or yellow.

Stomatococcus mucilaginous, formerly classified in the genus Micrococcus, is found in abundance on the lingual surface. This species has the ability to produce an extracellular slime, which correlates with its predilection for the lingual surface. Its role in disease, if any, is unknown.

Key facts

 Streptococci are Gram-positive and appear as spherical or oval cocci in chains and pairs.

 Streptococci can be classified according to (1) the degree of haemolysis on blood agar (а, mild; β, complete; у no haemolysis) and (2) the cell wall carbohydrate antigens into Lancefield groups (20).

 Lancefield group A contains the important human pathogen Streptococcus pyogenes; the latter infection leads to rheumatic fever and rheumatic carditis, which makes the endocardium susceptible to future episodes of infection.

 Oral streptococci are a mixed group of organisms and typically show а-haemolysis on blood agar.

 Oral streptococci can be divided into four main ‘species groups’ and, of these, the mutans group bacteria are the major agents of dental caries.

Staphylococci resemble streptococci in appearance but are arranged in grape-like clusters and are all catalase-positive (all streptococci are catalase-negative).

Staphylococcus aureus is a common pathogen causing localized skin infections and serious systemic infections; it produces numerous toxins and enzymes as virulence factors. Antibiotic resistance in staphylococci, a problem of worldwide concern, has led to the emergence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Staphylococcus aureus (VRSA) and antibiotic-‘tolerant’ isolates.

Enterococci are normal constituents of the gut microbiota, and Enterococcus faecalis is the most virulent species. Enterococcus faecalis, a common isolate form pulpal infection, is associated with endodontic treatment failure.

Review questions (answers on p. 364)

Please indicate which answers are true, and which are false.

11.1 Which of the following statements on streptococci are true?

A. some are Gram-positive and anaerobic

B. can be primarily differentiated by their haemolytic reactions on blood agar

C. can cause caries in the absence of sucrose

D. mutans group streptococci cause caries

E. oral streptococci typically show в-haemolysis on blood agar

11.2 Staphylococcus aureus can be differentiated from Staphylococcus epidermidis by:

A. the coagulase test

B. protein A latex agglutination test

C. mannitol fermentation test

D. Gram stain

E. oxidase test

11.3 An 18-year-old male patient has a facial abscess from which a в-lactamase-positive Staphylococcus aureus strain was cultured. This organism:

A. is resistant to penicillin

B. is coagulase-positive

C. is в-haemolytic

D. may possess the ability to cause diarrhoea

E. may cause rheumatic carditis

11.4 Common staphylococcal infections include:

A. suppurative skin infections

B. food poisoning

C. toxic shock syndrome

D. osteomyelitis

E. pharyngitis

Further reading

Beighton, D., Hardie, J., & Whiley, R. A. (1991). A scheme for the identification of viridans streptococci. Journal of Medical Microbiology, 35, 367-372.

Brooks, J. F., Carroll, K. C., Butel, J.S., et al. (Eds.), (2013). The

Staphylococci (Chapter 13) Jawetz, Melnick and Adelebergs's Medical Microbiology (26th ed.). Lange McGraw Hill (ebook; free access), 199-206.

Brooks, J. F., Carroll, K. C., Butel, J.S., et al. (Eds.), (2013). The Streptococci, Enterococci and Related Genera (Chapter 14) Jawetz, Melnick and Adelebergs's Medical Microbiology (26th ed.). Lange McGraw Hill (ebook; free access), 209-225.

Jone, D., Board, R. G., & Sussman, M. (1990). Staphylococci. Society for Applied Microbiology Symposium Series No. 19. Oxford: Blackwell Scientific.

Murdoch, D. A. (1993). Gram-positive anaerobic cocci. Clinical Microbiology Reviews, 11, 81-120.

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