Review
Pathogenesis of infections due to coagulasenegative staphylococci

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Summary

As a group, the coagulase-negative staphylococci (CoNS) are among the most frequently isolated bacteria in the clinical microbiology laboratory and are becoming increasingly important, especially as causes of hospitalacquired infections. These bacteria are normal inhabitants of human skin and mucous membranes and, therefore, one of the major challenges of daily diagnostic work is to distinguish clinically significant CoNS from contaminant strains. This overview addresses current knowledge of the pathogenesis of infections due to CoNS and particularly focuses on virulence factors of the species Staphylococcus epidermidis. S epidermidis has been identified as a major cause of nosocomial infections, especially in patients with predisposing factors such as indwelling or implanted foreign polymer bodies. Most important in the pathogenesis of foreign-body-associated infections is the ability of these bacteria to colonise the polymer surface by the formation of a thick, multilayered biofilm. Biofilm formation takes place in two phases. The first phase involves the attachment of the bacteria to polymer surfaces that may be either unmodified or coated with host extracellular matrix proteins. In the second phase, the bacteria proliferate and accumulate into multilayered cell clusters that are embedded in an extracellular material. The bacterial factors involved in both phases of biofilm formation are discussed in this review. In addition, the most important aspects of the pathogenic potential of S saprophyticus, S lugdunensis, and S schleiferi are decribed, although, compared with S epidermidis, much less is known in these species concerning their virulence factors.

Section snippets

Coagulase-negative staphylococci as nosocomial pathogens

Data taken from the National Nosocomial Infections Surveillance System from January 1990 until May 1999 showed that coagulase-negative staphylococci (CoNS) are the most commonly reported pathogens (37·3%, compared with 12·6% for Staphylococcus aureus) isolated from bloodstream infections in intensive care unit patients.1 However, recognition of infection is hampered by the difficulty in distinguishing the infecting strain from the normal flora. CoNS have long been dismissed as culture

Spectrum of disease due to novobiocinsusceptible CoNS

Novobiocin-susceptible CoNS, particularly S epidermidis, have emerged as a major cause of nosocomial infections, and of nosocomial bacteraemia in particular. These microorganisms usually infect immunocompromised patients, such as premature babies and patients hospitalised for chemotherapy, other malignant diseases, or organ transplantation.7, 8, 9

In intravenous heroin users who develop right-sided endocarditis S epidermidis is the most frequently isolated causative organism. The drug injected

Pathogenesis of polymer-associated infection due to S epidermidis

The pathogenesis of foreign-body-associated infections with S epidermidis is characterised by the ability of this species to colonise the polymer surface by the formation of a thick, multilayered biofilm. Small numbers of bacteria from the patient's skin or mucous membranes, where these bacteria normally occur, probably contaminate the polymer during the surgical implantation of the device. Sometimes the bacteria are acquired from the hands of the surgical or clinical staff. Recently published

Extracellular enzymes and toxins

The establishment of an infection and the survival of the bacteria in the host depends on the ability to invade host tissues and to evade host defense systems, respectively. For this, staphylococci, in particular S aureus, have developed multiple mechanisms including production of several extracellular proteins and enzymes such as protein A, lipases, proteases, esterases, phospholipases, fatty-acid modifying enzymes (FAME), as well as production of haemolysins and toxins with superantigenic

Pathogenicity of S saprophyticus

In past years several potential virulence factors that may explain the pathogenic potential of this S saprophyticus have been identified and characterised. This species seems to have a greater capacity to adhere specifically to uroepithelial cells than many other staphylococcal species. Thus, a surface-exposed 160 kDa protein with haemagglutinin/adhesin properties that mediates binding to uroepithelial cells might explain the tropism for kidney colonisation of S saprophyticus.74, 75, 76 This

Diseases and virulence factors in S lugdunensis and S schleiferi

Following the description of S lugdunensis and S schleiferi in 1988, these CoNS have been reported as causative pathogens in a range of nosocomial infections. Infections include endocarditis, polymer-associated infections, osteomyelitis, septic arthritis, UTIs, and wound infections.83, 84, 85, 86, 87, 88, 89 Because multiple cases highlighted the aggressive nature of infections, particularly of endocarditis due to S lugdunensis, this species has been regarded as more pathogenic than most other

Search strategy and selection criteria

Data for this review were identified by searches of Medline, references from relevant articles and book chapters, and personal reference manager files. Reference articles were identified by a Medline search that cross-referenced the terms “coagulase-negative staphylococci”, “Staphylococcus epidermidis”, “Staphylococcus saprophyticus”, “Staphylococcus schleiferi”, and “Staphylococcus lugdunensis” with “pathogenesis” and “infection”. Only English language papers were included.

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