Invasive group A,C and G streptococcal disease in western Norway: virulence gene profiles,clinical features and outcomes

Invasive group A streptococcal (iGAS) disease is endemic in Norway, but data on invasive group C and group G streptococcal (iGCS/GGS) disease are lacking. We investigated the characteristics of iGAS and iGCS/GGS infections in western Norway from March 2006 to February 2009. Clinical information was retrospectively obtained from medical records. GAS and GCS/GGS isolates were emm typed and screened for the presence of 11 superantigen (SAg) genes and the gene encoding streptococcal phospholipase A₂ (SlaA). GCS/GGS isolates were also subjected to PCR with primers targeting speG^dys. Sixty iGAS and 50 iGCS/GGS cases were identified, corresponding to mean annual incidence rates of 5.0 per 100 000 and 4.1 per 100 000 inhabitants, respectively. Skin and soft tissue infections were the most frequent clinical manifestations of both iGAS and iGCS/GGS disease, and 14 iGAS patients (23%) developed necrotizing fasciitis. The 30-day case fatality rates of iGAS and iGCS/GGS disease were 10% and 2%, respectively. emm1, emm3 and emm28 accounted for 53% of the GAS isolates, and these types were associated with severe clinical outcome. SAg gene and SlaA profiles were conserved within most of the GAS emm types, although five profiles were obtained within isolates of emm28. stG643 was the most prevalent GCS/GGS emm type, and speG^dys was identified in 73% of the GCS/GGS isolates. Neither GAS SAg genes nor SlaA were detected in GCS/GGS. Our findings indicate a considerable burden of both iGAS and iGCS/GGS disease and a high frequency of necrotizing fasciitis caused by GAS in our community.     

Distribution of <Emphasis Type="Italic">emm</Emphasis> types in invasive and non-invasive group A and G streptococci

Our study describes the emm type distributions of invasive and non-invasive group A streptococci (GAS) and group G streptococci (GGS) strains in one of the biggest Health Districts in Finland. A total of 571 GAS or GGS were recovered from patients with invasive or non-invasive infections during a 1-year period in 2008–2009 in Pirkanmaa Health District in Finland. We describe here the emm type distributions of GAS and GGS collected from throat (n = 246), pus (n = 217), deep tissue (n = 56) and blood (n = 52). The most common emm types among GAS were emm77, emm1, emm28, emm89 and emm12. Among GGS, the most common emm types were stG480, stG643, stG6, stC6979 and stG485. Some emm types were found to associate with certain infection focus. In GAS, emm77 associated with pus isolates, whereas emm1 and emm12 were more frequent among throat isolates. In GGS, stG480 was more commonly found from throat isolates.     

Distribution of emm types and subtypes among noninvasive group A, C and G streptococcal isolates in western Norway

Characterization of the reservoir of beta-hemolytic streptococci in a community may shed light on the pathogenesis of severe infections caused by these bacteria. We used emm sequence typing to characterize group A streptococci (GAS), group C streptococci (GCS) and group G streptococci (GGS) in community isolates associated with noninvasive disease in western Norway. A total of 165 isolates during a 13-month period were examined. Skin and throat isolates accounted for 123 and 16, respectively, and the remaining 26 isolates were from other non-sterile sites. We identified 18 previously validated emm types and one novel subtype, emm11.7, among the 101 GAS isolates. The two predominant types, emm28 and 12, were found in 40.6% of the GAS isolates. Compared to other recent studies of noninvasive GAS infections from elsewhere in the world, we found a higher frequency of emm82 (5.9%) and emm87 (12.9%) and a lower frequency of emm1 (4.0%) and emm3 (4.0%). We found a different distribution of GAS emm types compared to a previous study from western Norway. Among the 64 isolates of GCS and GGS, 15 previously described emm types and four novel subtypes, stC1400.5, stCK401.3, stG6.3 and stG652.3, were found, stG6, stG643 and stG485 were the most prevalent types and accounted for 59.4% of the GCS and GGS isolates. The high proportion of skin isolates in the present study may indicate the existence of GAS, GCS and GGS strains with predominantly skin and soft tissue tropism in our community.     

Streptococcus pyogenes bacteraemia, emm types and superantigen profiles

The aim of this study was to investigate the emm types and superantigen profiles of bacteraemic group A streptococcal (GAS; Streptococcus pyogenes) isolates and to detect possible associations between the molecular characteristics of isolates and the clinical presentations of disease. In this population-based study, 87 bacteraemic GAS isolates from adult patients in Pirkanmaa Health District (HD), Finland, during the period 1995–2004 were emm typed and genotyped for superantigen (SAg) profiles. The epidemiological and clinical data of the patients were analysed with the microbiological characterisation data. Among the 87 isolates, 18 different emm types were found. emm1, emm28 and emm81 were the three most common types, covering 52% of isolates. The prevalence of specific emm types showed high variability during the 10-year study period. We could not find any association between the emm type and clinical features of bacteraemic infection, such as underlying diseases, disease manifestations or case fatality. Of nine superantigen genes examined, speA and speC were identified in 20 and 30% of the strains, respectively. No association was found between disease manifestation and the presence of single superantigen genes. The 26-valent GAS vaccine would have covered only 62% of isolates causing invasive disease in Pirkanmaa HD during the study period.     

Molecular epidemiological investigation of an outbreak of invasive β-haemolytic streptococcal infection in western Norway

During a decade-long, high endemic situation with severe group A streptococcal disease in western Norway, a cluster of 16 patients with invasive streptococcal disease was hospitalized during a period of 11 weeks. A study including clinical characteristics and molecular epidemiology of the outbreak was initiated. Relevant clinical information was obtained from the medical records of the patients. Nine of the 16 patients had soft tissue infection, and seven of these had streptococcal toxic shock syndrome (STSS). Mortality, both overall and among those with STSS, was 25%. Streptococcal isolates from these patients were characterized by serogrouping and emm sequence typing. The emm amplicons were further characterized by sequence analysis and restriction fragment length polymorphism ( emm RFLP) analysis. The streptococci were identified as group A streptococcus (GAS) in 11 patients and group G streptococcus (GGS) in four patients. The patients with GGS infection were older than the patients with GAS infection, and all patients infected with GGS had predisposing comorbidities. Isolates from 13 patients were available for emm gene analysis and found to belong to nine different emm types. Similar differentiation was obtained with emm RFLP in GAS. Hence, the outbreak was polyclonal. Results suggestive of horizontal gene transfer and recombination between the emm genes of GAS, group C streptococcus and GGS were found in the isolates from seven patients. Such genetic recombination events suggest a possible role in pathogenesis.     

Lateral genetic transfers between group A and G streptococci for M-like genes are ongoing

Previously we described a long-polymerase chain reaction (PCR) method to amplify a 4–7 kb target containing most of the components of the vir regulon (mga,emm-like genes andscpA) in a number of group A streptococcus (GAS) isolates.¹In contrast to GAS, strains of human group G streptococcus (GGS) gave approximately 1.6 or 1.8 kb products. Sequence analysis of the amplified products issued from GGS templates revealed a mosaic consisting of upstream sequence frommga(the gene for positive regulator of vir regulon), an unidentified open reading frame, a short segment ofemm(the gene for M protein, an antiphagocytic molecule) and an upstream sequence ofscp(C5a-peptidase gene). A full lengthscpGis present immediately downstream from the mosaic segment in the human GGS genome. The GGS PCR fragment did not code formgaor full lengthemm. All human GGS isolates are known to code foremmbut the gene is separated fromscpGby at least 10 kb.²Our data, obtained using long-PCR and unrelated strains of GGS, confirm this. We could not detect a homologue ofmgain human GGS by hybridization analysis. The mosaic sequence suggests that enbloc transfer of the vir regulon from GAS to a GGS progenitor may have occurred, following which deletion and rearrangement events may have taken place. Partial nucleotide sequences ofemmcorresponding to the variable domain of M proteins from three local GGS isolates were determined. One sequence (emmGGS6) is 99% identical toemmfrom a geographicaly separated isolate of GGS recently described.³emmGGS6 also has significant homology withemmfrom a GAS strain (STDONALD) isolated from the same geographical area as was GGS6. The twoemmsequences (emmGGS6 andemmSTDONALD) revealed frameshift-compensatory frameshift mutations relative to each other, contributing to lower amino acid homology between the two predicted M proteins. SinceemmSTDONALD has no known relatives within the 80 or soemmsequences in the database, we speculate that it could have been laterally acquired from GGS. Horizontal transfers between GGS and GAS may be ongoing.     

Clinical and epidemiological aspects of invasive Streptococcus pyogenes infections in Denmark during 2003 and 2004

Active surveillance of invasive group A streptococcal (GAS) infections was conducted in Denmark during 2003 and 2004 as a part of the Strep-EURO initiative. The main objective was to improve understanding of the epidemiology of invasive GAS disease in Denmark. During the 2 years, 278 cases were reported, corresponding to a mean annual incidence of 2.6 cases per 100,000 inhabitants. The vast majority of isolates, 253 (91%), were from blood, with the remaining 25 (9%) being from cerebrospinal fluid, joints, or other normally sterile sites. The mean case fatality rate (CFR) was 20%, with the rate being higher in patients more than 70 years of age (36.5%). For streptococcal toxic shock syndrome (STSS) and necrotizing fasciitis the CFRs were 53% and 25%, respectively. Out of 16 T types recorded, three predominated: T28 (23%), T1 (22%), and the cluster T3/13/B3264 (14%). Among 29 different emm types, emm28 and emm1 accounted for 51% of strains, followed by emm3 (11%), emm89 (7%), and emm12 (5.5%). Low resistance rates were detected for macrolide-lincosamide-streptogramin B (MLS_B) antibiotics (3%) and tetracycline (8%); two isolates exhibited coresistance to tetracycline and macrolides. Of nine pyrogenic exotoxin (superantigen) genes examined, speA and speC were identified in 58% and 40% of the strains, respectively; either of the genes was present in all strains causing STSS. Most strains harbored speG (99%). ssa was present in 14% of the isolates only. In Denmark, as in comparable countries, GAS invasive disease shows a sustained, high endemicity, with involvement of both established and emerging streptococcal emm and T types.     

Similar superantigen gene profiles and superantigen activity in norwegian isolates of invasive and non-invasive group a streptococci

Group A streptococcus (GAS) harbours several virulence factors, including M protein (coded by the emm gene) and superantigens (SAgs). SAgs are extracellular toxins that directly activate the immune system by cross-binding to the HLA class II molecule and T cell receptor (TCR), thereby causing activation of up to 30% of the T cells and subsequent massive secretion of cytokines. Forty-eight GAS strains isolated from patients at Norwegian hospitals between 1988 and 2004 were included in this study. Of these, 24 were invasive streptococcal toxic shock syndrome (STSS) or necrotizing fasciitis (NF) isolates and 24 were non-invasive pharyngitis isolates, matched for having the same T-type and year of isolation as the invasive isolates. The isolates were characterized by emm sequence typing, multilocus sequence typing (MLST) and SAg gene profiles. A correlation between T-type, emm type, sequence type and SAg gene profile was revealed. No difference between invasive and non-invasive isolates regarding serotype or genotype was demonstrated. Selected invasive and non-invasive isolates with identical SAg gene profiles were analysed for SAg activity in bacterial growth culture media with and without human cell culture media added. A human T cell proliferation assay was used as measurement for SAg activity and simultaneously we also measured the cytokine content in normal human peripheral blood leucocyte cell culture media. The results revealed that invasive and non-invasive isolates did not differ significantly in SAg activity as it is present in semipurified bacterial culture medium.     

Molecular characteristics of pharyngeal and invasive emm3 Streptococcus pyogenes strains from Norway, 1988–2003

A major virulence factor of group A streptococci (GAS) is the M protein. Strains with the M3 type are more often associated with necrotizing fasciitis (NF) and streptococcal toxic shock syndrome, and have a higher case fatality rate than strains of other M types. To better understand the epidemiology of M3 GAS strains in Norway, we analyzed 59 invasive and 69 pharyngeal isolates with respect to prophage content, allelic variation in emm3, mtsR encoding the metal transporter of Streptococcus repressor (mtsR), and sclB coding for streptococcal collagen-like protein B. The Norwegian emm3 strains were very homogeneous, mainly harboring the emm allele 3.1 and prophage profile ΦG3.01. Other prophage profiles were transient. The mutation in mtsR known to truncate the protein and result in decreased capacity to cause NF was not found in our isolates. The sclB gene usually harbored five or eight contiguous repeats of a CAAAA pentanucleotide sequence and a highly modular and variable collagen structural motif (CSM) region with 9 and 12 amino acid M3-specific conserved motif repeats distributed across the entire CSM region. Strains with 5 CAAAA repeats emerged in 1993 and these strains were associated with the increase in invasive M3 cases in the period 1993–2003.     

Molecular characterisation of invasive <Emphasis Type="Italic">Streptococcus pyogenes</Emphasis> isolates from Hungary obtained in 2004 and 2005

Our aim was to characterise by molecular techniques group A streptococci isolated from invasive infections in Hungary in 2004–2005. Twenty-six nonduplicate invasive GAS isolates were selected and examined. The mortality rate proved high (52.3%) for those cases (n = 21) where data were available. Predominant emm types were emm1 (n = 13, 50%) and emm80 (n = 5, 19.2%), but other M types (emm4, emm28, emm66, emm81.1, emm82, emm84) were also identified. Eight different PFGE types were distinguished, and each emm type showed an individual PFGE pattern. Our results show that—similarly to results obtained in several other countries—emm type 1 strains predominate among invasive GAS isolates, and that emm 1 type strains recovered from severe streptococcal infections were associated with the presence of the speA gene. The rate for macrolide resistance proved low: only two isolates showed elevated MICs for erythromycin.     

emm and C-Repeat Region Molecular Typing of Beta-Hemolytic Streptococci in a Tropical Country: Implications for Vaccine Development

We designed a study to investigate the molecular epidemiology of group A streptococcal (GAS) and group C and G streptococcal (GCS and GGS) disease in Fiji, a country which is known to have a high burden of streptococcal disease. Molecular typing of the N-terminal portion (emm typing) of the M protein was performed with 817 isolates (535 GAS and 282 GCS/GGS). We also performed genotyping of the C-repeat region in 769 of these isolates to identify J14 sequence types. The profile of emm types for Fiji was very different from that found for the United States and Europe. There were no dominant emm types and a large number of overlapping types among clinical disease states. Commonly found GAS emm types in industrialized countries, including emm1, emm12, and emm28, were not found among GAS isolates from Fiji. Over 93% of GAS isolates and over 99% of GCS/GGS isolates that underwent J14 sequence typing contained either J14.0 or J14.1. Our data have implications for GAS vaccine development in developing countries and suggest that a vaccine based upon the conserved region of the M protein may be a feasible option for Fiji and potentially for other tropical developing countries.The group A streptococcus (GAS) is an important cause of morbidity and mortality globally, with variation in disease burden between populations (9). A greater burden of GAS disease occurs in developing countries, particularly those located in the tropics, than in industrialized nations (9). The spectrums of GAS disease also differ between developed and developing countries. In many developing countries, GAS impetigo is often endemic, with resultant high rates of acute poststreptococcal glomerulonephritis, acute rheumatic fever, and rheumatic heart disease leading to at least 200,000 deaths annually, and the burden of invasive disease has probably been underestimated (9, 43). In industrialized countries, a massive number of cases of GAS pharyngitis leads to significant economic impact (27) and invasive disease leads to a significant number of deaths (25, 26).The molecular epidemiologies of GAS disease appear to differ between industrialized and developing nations, although there is a paucity of data from developing nations (5, 9). There are a number of different methods used to characterize GAS, with sequence typing of the 5′ N-terminal end of the M protein gene (emm) the most widely used (3, 17, 18). There have been recent large epidemiologic studies that have used emm sequence typing to investigate the molecular epidemiology of GAS pharyngitis and invasive GAS disease in industrialized nations, most notably in the United States, Canada, and Europe (16, 26, 37) (R. R. Tanz, S. T. Shulman, W. Kabat, E. Kabat, E. Cederlund, D. Patel, Z. Li, V. Sakota, J. B. Dale, and B. Beall, presented at the XVIth Lancefield International Symposium on Streptococci and Streptococcal Diseases, Palm Cove, Queensland, Australia, 2005). Far fewer studies have been conducted in developing nations. The limited available data suggest that numerous new emm types and subtypes have been discovered that have not previously been observed in industrialized countries (40, 45), that the diversity of emm types in developing countries is greater than that in industrialized countries (23, 32-34, 40, 45), and that the majority of isolates are of emm types traditionally associated with impetigo, irrespective of the clinical site of recovery of the isolates (5, 6, 23, 33, 40).Molecular epidemiologic data have implications for vaccine design. Although a number of antigens have shown promise as potential vaccine candidates, only one vaccine, a 26-valent M-protein-based vaccine, has reached clinical trials in recent times (15, 24). Serotypes for this vaccine were chosen if they were known to be common causes of invasive GAS disease or uncomplicated pharyngitis in the United States or if they were associated with rheumatic fever in classical studies from the United States in the mid-20th century (14). While this vaccine is likely to be efficacious in the United States, concerns have been raised about the transferability of this vaccine to developing-country settings (8).Alternative approaches to a multivalent vaccine strategy include the development of a conserved-epitope vaccine. A number of conserved epitopes have been identified and are under investigation, including some within the portion of the M protein closest to the cell wall (the C-repeat region) which appear to be relatively conserved (2, 11, 31, 36). An example is the J8 peptide, a B-cell epitope, contained within the larger sequence J14 (named J14.0 in this article for clarity) (28, 29). Following the discovery of J14.0, a number of J14 sequence types have been identified (47). To date, across all C-repeat regions, there have been 55 different J14 sequence types described, which have been named in the order that they have been discovered (J14.0 to J14.54) (47). Typing of the C-repeat region by the J14 sequence type of GAS has been employed previously (47). J14 sequence type is relevant to J8 because antibodies raised against J8 in mice provide cross-protective immunity against GAS isolates containing J14.0 and J14.1 (Michael Batzloff, Queensland Institute of Medical Research, unpublished data). Antibodies raised against the J14.0 peptide in mice have been shown to opsonize GAS strains belonging to a variety of emm subtypes that contain J14 sequences other than the J14.0 sequence type, including J14.2 (47).Group C streptococci (GCS) and group G streptococci (GGS) are emerging infectious agents, particularly as a cause of invasive disease and of epidemic pharyngitis (19, 35, 48). We have observed higher than expected rates of invasive GCS/GGS in Fiji, as well as high pharyngeal carriage among school children (43). There is also some evidence to suggest that these organisms may play a role in the pathogenesis of acute rheumatic fever and poststreptococcal glomerulonephritis (13, 30). There are very few data regarding emm sequence typing of GCS/GGS and no available data regarding sequence typing of the C-repeat region of these organisms (22).We designed a study to investigate the molecular epidemiology of GAS and GCS/GGS disease in a tropical setting known to have a high burden of invasive, pharyngeal, and impetiginous streptococcal disease (42-44). Because of the implications for vaccine development, we included molecular typing of both the 5′ end of the M protein (emm sequence typing) and the C-repeat region of the M protein (J14 sequence typing).     

Epidemiological markers of Streptococcus pyogenes strains in Tunisia

To further understand the epidemiology of Streptococcus pyogenes or group A streptococcus (GAS) infections in Tunisia, phenotypic and genomic markers of GAS isolates, including antibiotic susceptibility, biotypes, T and emm types and toxin gene profiles, have been characterized. A total of 103 isolates, collected between 2000 and 2006, were investigated; 47 were recovered from invasive infections, and 56 from non-invasive infections. Rates of tesistance to tetracycline, erythromycin, clindamycin and rifampin were 70.8%, 4.8%, 4.8% and 0.9%, respectively. High levels of resistance to streptomycin and kanamycin were observed in 1.9% and 4.8% of isolates, respectively. Biotype 3 was most common. Twenty different T patterns were observed, with a predominance of T3/13/B3264, and 38 different emm types. In both invasive and non-invasive isolates, emm118 (9.7%), emm42 (8.7%), emm1 (7.8%), st432 (6.8%), emm28 (5.8%) and emm76 (5.8%) were the most prevalent types; emm1, emm76 and emm18 were mainly observed among invasive infections, whereas emm118 (12.5%), emm42 (10.7%) and emm28 (8.9%) were predominant among non-invasive infections. The speB gene was detected in all isolates, but there were variable frequencies of speA, speC and ssa (20.3%, 32% and 25.2% respectively). Significant associations of emm1, emm18 and emm3 with speA and of emm4 and st432 with ssa were found. This first report from Tunisia revealed a unique emm distribution of GAS that differs from those of other regions. This information on the distribution of such emm types will be useful for the development of an appropriate vaccine in a country where the incidence of rheumatic fever remains high.     

Survey of emm gene sequences and T-antigen types from systemic Streptococcus pyogenes infection isolates collected in San Francisco, California; Atlanta, Georgia; and Connecticut in 1994 and 1995.

The variable 5' emm (M-protein gene) sequences and T-antigen types were determined from 340 systemic group A streptococcal (GAS) isolates taken from hospitalized patients in San Francisco, Calif.; Atlanta, Ga.; and Connecticut in 1994 and 1995. Eighty percent of these isolates had emm sequences and T-antigen types in agreement with previously recorded M- and T-antigen associations. Most of the remaining strains either were T nontypeable (11%) or contained emm genes encoding M proteins for which T-antigen associations have not been made (6%). One newly encountered emm gene, designated ST2974, from each of 13 isolates had the T type 8/25/Imp19. Another new emm gene, ST2967, from 8 of 11 isolates was T nontypeable. Six other unique emm gene sequences from seven isolates were encountered. Sequencing of the variable region of the emm gene of GAS isolates (emm typing) is effective for surveying the sequence variability of the M virulence protein, and combined with T typing, emm typing is useful for monitoring GAS strain diversity.     

Group A streptococcal infection caused by <Emphasis Type="Italic">emm</Emphasis>1 strains among children in southern Taiwan

The aim of this study was to characterize the molecular epidemiology of invasive and non-invasive group A streptococcus (GAS) infections in children from 1997 through 2004 in southern Taiwan. A collection of 32 invasive and 150 non-invasive isolates were recruited for analysis. emm1 (34.4%) and emm12 (40.0%) predominated in the invasive and non-invasive isolates, respectively. The peak incidence of invasive GAS infection (IGASI) occurred between 2002 and 2003. emm4 and emm12 were the major types among clinical isolates before 2001, and was replaced by emm1 during 2002–2003. All emm1 isolates were clonal relatedness. The declined prevalence of erythromycin resistance occurred in the major shift of the endemic isolates to emm1 strains during 2002–2003 in the community. Financial support: the National Health Research Institute, Taiwan (NHRI-EX90∼EX92-9027SP), and the National Science Council, Taiwan (NSC93-2314-B-006-059).     

Directional Gene Movement from Human-Pathogenic to Commensal-Like Streptococci

Group A streptococci (GAS) are highly pathogenic for humans, and their closest genetic relatives, group C and G streptococci (GCS and GGS, respectively), are generally regarded as commensals, although they can be found in association with human disease. As part of an effort to better understand the evolution of virulence, the phylogenetic relationships between GAS, GCS, and GGS were examined. The nucleotide sequence was determined for an internal portion of seven housekeeping (neutral) loci among >200 isolates of GAS and 34 isolates of GCS or GGS obtained from human subjects. Genotypic analysis failed to show support for the separation of GCS and GGS into two distinct populations. Unlike GAS, there was poor concordance between emm type and genetic relatedness among GCS and GGS. All housekeeping genes within GAS displayed relatively low levels of sequence diversity. In contrast, individual GCS and GGS strains had mosaic genomes, containing alleles at some loci that were similar or identical to GAS alleles, whereas the alleles at other loci were about 10 to 30% diverged. The data provide evidence for a history of recent interspecies transfer of neutral genes that exhibits a strong net directionality from GAS donors to GCS and GGS recipients. A model for the evolution of GAS and of GCS and GGS is described.     

Clonal relationships between invasive and noninvasive Lancefield group C and G streptococci and emm-specific differences in invasiveness

Lancefield group G and group C streptococci (GGS and GCS, respectively) are pathogens responsible for a number of life-threatening infections. A collection of 116 recent (1998 to 2004) invasive (n = 28) and noninvasive (n = 88) GGS and GCS clinical isolates from Portugal were characterized. All isolates were identified as Streptococcus dysgalactiae subsp. equisimilis and characterized by emm typing and DNA macrorestriction profiling using pulsed-field gel electrophoresis (PFGE). emm typing revealed the presence of 22 distinct types, including 3 novel types. PFGE identified 14 clones with more than two isolates, but over half of the isolates were concentrated in 3 large clones. Individual clones and emm types showed a low level of association, since the majority of the clones included more than one emm type and the same emm type was found among diverse genetic backgrounds. Two emm types, stg2078 and stg10, were significantly more frequent among invasive isolates, and another two, stg6792 and stg166b, were present only in noninvasive isolates, suggesting a correlation between emm type and invasive disease potential.     

Epidemiology of Invasive Group A Streptococcal Disease in Alaska, 2001 to 2013

The Arctic Investigations Program (AIP) began surveillance for invasive group A streptococcal (GAS) infections in Alaska in 2000 as part of the invasive bacterial diseases population-based laboratory surveillance program. Between 2001 and 2013, there were 516 cases of GAS infection reported, for an overall annual incidence of 5.8 cases per 100,000 persons with 56 deaths (case fatality rate, 10.7%). Of the 516 confirmed cases of invasive GAS infection, 422 (82%) had isolates available for laboratory analysis. All isolates were susceptible to penicillin, cefotaxime, and levofloxacin. Resistance to tetracycline, erythromycin, and clindamycin was seen in 11% (n = 8), 5.8% (n = 20), and 1.2% (n = 4) of the isolates, respectively. A total of 51 emm types were identified, of which emm1 (11.1%) was the most prevalent, followed by emm82 (8.8%), emm49 (7.8%), emm12 and emm3 (6.6% each), emm89 (6.2%), emm108 (5.5%), emm28 (4.7%), emm92 (4%), and emm41 (3.8%). The five most common emm types accounted for 41% of isolates. The emm types in the proposed 26-valent and 30-valent vaccines accounted for 56% and 78% of all cases, respectively. GAS remains an important cause of invasive bacterial disease in Alaska. Continued surveillance of GAS infections will help improve understanding of the epidemiology of invasive disease, with an impact on disease control, notification of outbreaks, and vaccine development.     

Molecular characterization and antibiotic resistance of group G streptococci in Israel: comparison of invasive,non-invasive and carriage isolates

Beta-hemolytic group G streptococci (GGS) are increasingly recognized as a source of substantial morbidity, causing mild to severe sporadic infections as well as outbreaks. The purpose of this study was to determine the genetic diversity and antibiotic resistance of GGS in Israel in order to aid in prevention and control. A total of 325 GGS isolates were collected in Israel between 2007 and 2011 from three determined settings: (1) carriage (n?=?60), an observational longitudinal carriage study in the IF, (2) non-invasive (n?=?166), clinical sporadic and epidemic non-invasive cases in the IDF, and (3) invasive (n?=?99) cases of bacteremia collected during this period in Israel from a similar age group, at the national Streptococcal Reference Center. All isolates were characterized genetically and by their antibiotic-resistance profile. emm typing revealed 35 distinct types and subtypes among 228?S. dysgalactiae subsp. equisimilis (SDSE) isolates, with high genetic diversity. An additional 97 GGS were identified as Streptococcus anginosus (SAG). The proportion of SDSE was higher in the invasive (100 %) and non-invasive (63.8 %) isolates compared to the carriage ones (38.3 %). Clindamycin, erythromycin, azithromycin and tetracycline resistance was detected in 6.6 %, 8.6 %, 9.7 % and 37.6 % of isolates, respectively. Overall, the most resistant isolates were in the invasive group and the fewest were in the SAG group. Considerable genetic diversity and common antibiotic resistance were revealed among GGS strains which differed according to the epidemiologic settings. Further clinical, epidemiological and basic research of GGS as a pathogen is warranted.     

Molecular characterisation of group A streptococci from invasive and non-invasive disease episodes in Belgium during 1993-1994

Five hundred clinical group A streptococcal (GAS) isolates were collected in Belgium during the period 1 Nov. 1993 to 31 Oct. 1994. Clinical and laboratory data were recorded and isolates were characterised. The presence of the genes encoding streptococcal pyrogenic exotoxin types A (speA), B (speB), C (speC), F (speF) and streptococcal superantigen (ssa) were determined by PCR to target specific sequences. These isolates were also emm-typed and analysed by pulsed-field gel electrophoresis (PFGE) of genomic macrorestriction fragments with the enzyme SmaI. In total, 136 unrelated GAS PFGE types were identified and genetic diversity was clearly demonstrated. Two GAS PFGE types predominated; a first PFGE type comprised 66 (13.2%) emm1 isolates characterised by speA-, speB+, speC-, speF+ and ssa-; the second PFGE type comprised 44 (8.8%) emm12 isolates characterised by speA-, speB+, speC+ (or speC-), speF+ and ssa-. Indistinguishable PFGE types were observed among both invasive and non-invasive isolates. Ten different PFGE types were found among 11 streptococcal toxic shock syndrome (STSS) isolates, and five of these lacked speA. Twenty-five (34.7%) of 72 invasive isolates gave negative results for speA, speC and ssa. This retrospective study confirmed the observation that the dissemination of one specific clone cannot be associated with invasive GAS disease and posed a question regarding the role of SPE A as a major virulence factor. Other streptococcal virulence factors in conjunction with host factors may determine the outcome of invasive GAS infection.     

Epidemiologic analysis of invasive and noninvasive group a streptococcal isolates in Hong Kong

Since the mid-1980s, there has been a resurgence of severe forms of invasive group A streptococcal (GAS) disease in many Western countries. In Hong Kong, a similar increase has also been observed in recent years. One hundred seven GAS isolates collected from 1995 to 1998 from individuals with necrotizing fasciitis, toxic shock syndrome, meningitis, or other type of bacteremic sepsis (invasive group, n = 24) as well as from individuals with minor skin and throat infections (noninvasive group, n = 83) were characterized through serologic and/or emm sequence typing. Thirty-two M protein gene sequence types were identified. Types M1, M4, and M12 were the most prevalent in both the invasive group and the noninvasive group; together they accounted for 70.8 and 37.3% of the isolates, respectively. No clear pattern of skin and throat infection M types was observed. Type M1 was overrepresented in the invasive and pharyngeal isolates. The same pulsed-field gel electrophoresis pattern was shared by most invasive and all pharyngeal M1 isolates. Overall, resistance to erythromycin (32%) and tetracycline (53%) was high, but M1 isolates were significantly less likely to have resistance to either antimicrobial agent than non-M1 isolates. One novel emm sequence type, stHK, was identified in an isolate from a patient with necrotizing fasciitis. Minor emm gene sequence alterations were noted for 31 isolates, and for 13 of these isolates, deletion, insertion, or point mutations were seen in the hypervariable 50 N-terminal residues.