Emergence of invasive serotype VIII group B streptococcal infections in Denmark

Serotype VIII group B streptococcus has only rarely been described outside Japan. The Streptococcus Unit, Statens Serum Institut, performed national surveillance of invasive group B streptococcal (GBS) diseases in Denmark in 1999 to 2002 and identified seven clinical GBS isolates of serotype VIII in blood from seven patients admitted to different hospitals.     

Experimental group B streptococcal infections in mice: hematogenous virulence and mucosal colonization.

A group B streptococcus recovered from a blood specimen from a neonate with sepsis was used to evaluate the use of mice for studies characterizing the hematogenous virulence and the asymptomatic mucosal colonization of the vagina or of the respiratory tract by these bacteria. When injected intravenously, the 50% lethal dose for mice was 10(6); however, as few as 10(2) organisms produced septic deaths. In mice undergoing water diuresis, bacteriuria and pyelonephritis were not produced after direct bladder inoculation of the streptococci. Asymptomatic vaginal colonizations that persisted for 12 days were produced in both pregnant and virgin mice. Vaginal colonization before delivery did not result in transmission of infection to litters or in protection against subsequent oropharyngeal colonization in the suckling mice. In mice born of nonexposed mothers, oropharyngeal colonization was produced in both suckling and 3-week-old weaned mice. Whereas infection persisted for 14 days in all suckling mice, clearance occurred in over 50% of the weaned mice by day 14. The use of mice for studies on the virulence of the group B streptococci as well as for studies on the pathogenesis of disease by virulent strains is discussed.     

Fulminant group A streptococcal infections

Summary We describe two female patients presenting with spontaneous peritonitis and fulminant Streptococcus pyogenes (Strep. pyogenes) septicemia and shock. Both patients recovered completely upon immediate antibiotic therapy, initially with broad range combination therapy effective againstStrep. pyogenes, which was switched to penicillin G when culture results became available. The isolated strain in case 1 was M-type 28, which is the M-type most often isolated from vaginal swabs (as commensal) and from blood from patients with puerperal sepsis. Patient 1 had signs and symptoms of a toxic shock-like syndrome, including rapid onset of fever and shock, skin rash, desquamation of palms and soles, and multisystem involvement with vomiting, diarrhea, myalgia, renal failure, and severe disorientation without focal neurological deficits.Abbreviations Strep. pyogenes Streptococcus pyogenes (=group A beta-hemolytic streptococcus)     

Serotypes and clinical manifestations of group B streptococcal infections in western Sweden

Objectives   To study the serotype distributions of group B streptococci (GBS) isolated from blood and cerebrospinal fluid and from the genital tract of pregnant women and to investigate any possible relation between serotype, age and clinical manifestation.
Methods   Invasive strains were collected from 1988 to 1997 and genital strains from 1995 to 1996. Strains of GBS were serotyped with coagglutination. Clinical data were obtained from hospital notes.
Results   A total of 144 invasive strains, 78 from neonates and infants and 66 from adults, were serotyped. The most common isolates from neonates and infants were types III (62%), Ia (18%), and V (9%). The most common isolates from adults were types III (29%), Ib (23%), V (21%) and II (15%). A majority of the adults (94%) had an underlying medical condition. The most common serotypes of the 114 strains isolated from the genital tract of pregnant women were types III (32%), V (22%), Ia (13%), Ib (13%) and II (11%).
Conclusions   Serotype III was the single most frequent GBS isolate from infants and adults. Serotype V, which appeared first in 1992, was the third most frequent isolate. A vaccine containing five GBS capsular polysaccharides appears to be appropriate for the Swedish population.     

Pathogenesis of group A streptococcal infections

Group A streptococci are model extracellular gram-positive pathogens responsible for pharyngitis, impetigo, rheumatic fever, and acute glomerulonephritis. A resurgence of invasive streptococcal diseases and rheumatic fever has appeared in outbreaks over the past 10 years, with a predominant M1 serotype as well as others identified with the outbreaks. emm (M protein) gene sequencing has changed serotyping, and new virulence genes and new virulence regulatory networks have been defined. The emm gene superfamily has expanded to include antiphagocytic molecules and immunoglobulin-binding proteins with common structural features. At least nine superantigens have been characterized, all of which may contribute to toxic streptococcal syndrome. An emerging theme is the dichotomy between skin and throat strains in their epidemiology and genetic makeup. Eleven adhesins have been reported, and surface plasmin-binding proteins have been defined. The strong resistance of the group A streptococcus to phagocytosis is related to factor H and fibrinogen binding by M protein and to disarming complement component C5a by the C5a peptidase. Molecular mimicry appears to play a role in autoimmune mechanisms involved in rheumatic fever, while nephritis strain-associated proteins may lead to immune-mediated acute glomerulonephritis. Vaccine strategies have focused on recombinant M protein and C5a peptidase vaccines, and mucosal vaccine delivery systems are under investigation.     

Production of bacteremia and meningitis in infant rats with group B streptococcal serotypes.

Group B streptococcal strains, representing the five major serotypes, were inoculated into infant rats by intranasal, oral, and intraperitoneal routes. Bacteremia regularly followed injection by the intraperitoneal route. Four strains (three of type III) isolated from human cerebrospinal fluid appeared more virulent for 5-day-old rats. Injection of fewer than 10 colony-forming units of one strain, a type III, led to bacteremia and death in 27% of animals. The cumulative bacteremia and mortality rate with this strain was 66% in animals given inocula of less than 10 to 10(3) colony-forming units. Bacteremia developed by 24 to 48 h with concentrations of greater than 10(5) colony-forming units per ml of blood, and death occurred soon afterward. Among bacteremic animals, positive cerebrospinal fluid cultures were found in 97%, and cerebrospinal fluid bacterial concentrations were equal to or exceeded bacterial counts in blood. The susceptibility of infant rats to infection with type Ia, Ic, or III strains was age dependent. Histopathological studies of the brain and meninges in 34 bacteremic animals with culture-positive cerebrospinal fluid revealed that 5- to 10-day-old animals had numerous bacteria distributed in a perivascular pattern but, with one exception, no leukocytic infiltration. In contrast, three of the 11- to 12-day-old and two 15-day-old animals had very thickened meninges infiltrated with polymorphonuclear leukocytes, macrophages, and bacteria.     

Outbreak of late-onset group B streptococcal infections in healthy newborn infants after discharge from a maternity hospital: a case report

During a four-week period, four healthy term newborn infants born at a regional maternity hospital in Korea developed late-onset neonatal group B Streptococcus (GBS) infections, after being discharged from the same nursery. More than 10 days after their discharge, all of the infants developed fever, lethargy, and poor feeding behavior, and were subsequently admitted to the Korea University Medical Center, Ansan Hospital. GBS was isolated from the blood cultures of three babies; furthermore, GBS was isolated from 2 cerebral spinal fluid cultures. Three babies had meningitis, and GBS was isolated from their cerebral spinal fluid cultures. This outbreak was believed to reflect delayed infection after early colonization, originating from nosocomial sources within the hospital environment. This report underlines the necessity for Korean obstetricians and pediatricians to be aware of the risk of nosocomial transmissions of GBS infection in the delivery room and/or the nursery.     

Detection of group B streptococcal antigen in early-onset and late-onset group B streptococcal disease with the Wellcogen Strep B latex agglutination test.

The Wellcogen Strep B latex agglutination test (Wellcome Diagnostics, Dartford, England) was evaluated as a method of detecting group B streptococcal antigen in urine, cerebrospinal fluid, and serum from neonates with early-onset (less than or equal to 7 days of age) and late-onset group B streptococcal disease. Urine was the best source of antigen, which was detected in 100% of six neonates with early-onset group B streptococcal disease who had urine available in the first 12 h of illness and in 88% of 17 group B streptococcus-infected neonates with urine available in the first 48 h of illness. Antigen was not detected in any samples from patients without group B streptococcal disease except in the urine of one patient with Proteus mirabilis meningitis. The Wellcogen Strep B latex test of the lot tested compares favorably with a noncommercially available latex agglutination test.     

Age-dependent susceptibility of neonatal rats to group B streptococcal type III infection: correlation of severity of infection and response of myeloid pools.

A distinct age-dependent susceptibility to group B streptococcus type III (GBS) was demonstrated, utilizing a neonatal rat model. The most dramatic changes in susceptibility occurred within the first 7 days of postnatal life. To further investigate this susceptibility, experiments were performed utilizing two age groups of rats: (i) animals within the first 24 h of life (NB) and (ii) 7-day-old animals (7d). The infective dosage used was 10(4) GBS per g of body weight, a dose lethal to 100% of NB but only to 15% of 7d. The responses of the myeloid cells in the peripheral blood, spleen, and bone marrow were evaluated at intervals during the first 24 h post-GBS infection. The susceptibility of the NB to GBS appeared to be associated with a number of events, including smaller base-line levels of myeloid elements particularly in the bone marrow, a lag of at least 2 h in their initial response to infection, and an inability to maintain the myeloid pools. The band form of neutrophils appeared to be the predominant cell type in both total number and rapidity of response to infection. Moreover, an initial depletion of this band form was seen in both groups, which returned to base-line levels with recovery in 7d but persisted until death in NB animals. Similarly, shifts in numbers of peripheral nucleated erythrocytes appeared to reflect changes in the myeloid storage pools, with numbers of nucleated erythrocytes significantly decreasing in 7d animals with recovery in contrast to persistence in NB until death. Therefore, shifts in these cells in peripheral blood during infection appear to reflect the state of myeloid storage pools which parallel disease outcome.     

Guanine-plus-cytosine composition of five group B streptococcal serotypes.

The percent guanine-plus-cytosine content of deoxyribonucleic acid of each of the five serotypes of group B streptococci was determined by thermal denaturation. The range of guanine-plus-cytosine content was 35.1 to 36.9%, with a mean value of 35.9%. These values suggest a genetic homogeneity to the serotypes of the group B streptococci.     

The hemolytic and cytolytic activity of group B streptococcal hemolysin and its possible role in early onset group B streptococcal disease.

The in vitro and cytolytic properties of the hemolysin of group B streptococcus (GBS) were investigated using sheep erythrocytes and McCoy cells adapted for growth in a serum-deficient medium. The relationship between the hemolysin, various carrier molecules and phospholipids was examined. Starch-based carriers interfered with the inhibitory activity of phospholipids and solvents for the phospholipids reduced the activity of the hemolysin. These technical problems were resolved by use of an albumin-based carrier, a strain producing large amounts of hemolysin and sonication of the phospholipid. The hemolysin was cytolytic for McCoy cells and this activity and its hemolytic action on sheep erythrocytes were inhibited by a number of phospholipid components of surfactant. It is possible that GBS hemolysin has a direct or indirect role in the pathogenesis of the pneumonitis of early onset GBS infection.     

Diagnosis of group A streptococcal infections directly from throat secretions.

The diagnosis of group A streptococcal disease still relies on isolation of group A streptococcal strains on sheep blood agar followed by presumptive identification based on bacitracin sensitivity or the results of the more precise serogrouping methods such as the Lancefield precipitin test. A technique that would permit rapid identification of streptococcal infections directly from throat secretions would allow immediate appropriate antimicrobial therapy for the management of streptococcal infections to be started. We have been able to identify soluble group A antigen directly from throat secretions by using a latex agglutination test. In a clinical trial in which latex (Streptex group A) and conventional culturing techniques were used, 53 throat secretion cultures were tested: 26 were positive by both procedures, 5 were positive by culture only, 3 were positive by the latex agglutination test only, and 19 were negative by both tests.     

Prevention of perinatal group B streptococcal infections: A review with an Indian perspective

Group B Streptococcus (GBS) is an important cause of maternal and neonatal morbidity and mortality in many parts of the world. Asymptomatic colonisation of the vagina and rectum with Group B streptococci is common in pregnancy. Maternal colonisation of GBS can vary depending on ethnicity and geographical distribution. Vertical transmission of this organism from mother to foetus may lead to neonatal GBS disease. Intra-partum use of antibiotics in these women has led to a decrease in the rate of early onset but not late onset GBS disease. Identification of women with GBS is the key factor in the prevention of perinatal GBS disease. There are different screening strategies available to identify women at risk of perinatal GBS disease. Clinicians continue to face the challenge of choosing between preventive strategies to reduce the impact of perinatal GBS disease. Controversy exists regarding the ideal preventive strategy. In India, the mortality and morbidity associated with the GBS disease remains largely a under-recognised problem. This comprehensive review summarises the salient features of GBS disease and discusses the epidemiology, risk factors, screening strategies, intra-partum antibiotic prophylaxis with an Indian perspective and how it compares with the Western nations.     

Enzyme-linked immunosorbent assay for group B streptococcal antibodies.

We report here on the development of enzyme-linked immunosorbent assays (ELISAs) for antibodies to types II and III group B streptococci. Streptococcal antigens were prepared by trichloroacetic acid extraction and fractional alcohol precipitation. Microtiter wells were coated with antigen in 0.1 M carbonate buffer at pH 9.6. Lyophilization was found to be an essential step for efficient binding of the streptococcal antigens. After incubation with antibody-containing rabbit serum, bound antibody was detected with peroxidase-labeled goat anti-rabbit immunoglobulin G. Optimal antigen concentrations were 200 micrograms/ml for type II and 100 micrograms/ml for type III. An ELISA is also described that uses intact bacteria as antigen. Hyperimmune rabbit serum reacted at a titer in excess of 512 against trichloroacetic acid-soluble antigen and 4,096 against whole bacteria. Sera from human subjects were also tested. Most human sera contained antibody which bound to intact bacteria but not to trichloroacetic acid-solubilized streptococcal antigens. Antibody titers in human sera against intact bacteria correlated very well with opsonic antibody activity measured in a chemiluminescence assay.     

Role of C5a-ase in group B streptococcal resistance to opsonophagocytic killing.

Type III group B streptococci (GBS) can be subdivided into three subtypes, RDP III-1, III-2, and III-3, on the basis of numerical analysis of HindIII restriction endonuclease digestion patterns (HindIII RDP) with their chromosomal DNAs. In the present study, the effect of C5a on opsonophagocytic killing of a representative strain from each RDP type was investigated by using a novel optical method for determining opsonophagocytic killing, and the effect of C5a-ase treatment of C5a on opsonophagocytic killing was also investigated. Pre-stimulation of polymorphonuclear leukocytes (PMNs) with C5a significantly increased opsonophagocytic killing of all three strains. The increase in killing was abolished by pretreating the C5a with GBS that express C5a-ase, a treatment that also destroyed the chemoattractant activity of the C5a. The kinetics of killing of the RDP III-2 strain differed from those of the other two strains. The survival of the RDP III-2 bacteria continued to decline over the entire 60-min incubation of the opsonophagocytic assay when PMNs were prestimulated with C5a or with C5a that had been inactivated with GBS C5a-ase (dC5a). In contrast, killing of the RDP III-1 and III-3 strains almost ceased after 20 or 60 min when PMNs were prestimulated with dC5a or C5a, respectively. A difference in bacterial killing between the III-2 strain and the III-1 and III-3 strains therefore became increasingly apparent with prolonged incubation time. The percentage of bacteria surviving in the extracellular fluid was approximately the same as the percentages of bacteria surviving in both intracellular and extracellular locations when PMNs were prestimulated with either C5a or dC5a. These data imply that the majority of bacterial killing occurred following phagocytosis and suggest that the enhanced killing of GBS following prestimulation of PMNs with C5a resulted from increased ingestion of the bacteria.     

Variable susceptibility of mice to group B coxsackievirus infections.

Laboratory strains of group B coxsackievirus serotypes 1 to 6 were inoculated intraperitoneally into newborn mice of differing genetic backgrouns. Of the four genetic strains investigated, C3H mice appeared to be resistant to all six serotypes, whereas BALB/c mice were most susceptible. Swiss mice and a random-bred Swiss strain (COH) were intermediate in susceptibility. The findings underscore the fact that clinical isolation attempts and experimental studies involving group B coxsackieviruses must take into account both the virus strain used and the genetic background of the host. For clinical isolation of these viruses, the BALB/c mouse may be the most suitable of th strains tested.     

Heterogeneity of group A streptococcal pyrogenic exotoxin type B.

Streptococcal pyrogenic exotoxin type B purified from culture filtrates of either the NY-5 or T-19 strain of group A streptococcus was found to be heterogeneous in charge. Three protein fractions with isoelectric points of 8.0, 8.4, and 9.0 were isolated by differential solubility in ethanol and acetate-buffered saline followed by isoelectric focusing and shown to be antigenically identical to streptococcal pyrogenic exotoxin type B. The molecular weights of all three fractions were approximately 17,500, as determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, with aggregates forming in the presence of hyaluronic acid. Only the pI 8.4 fraction showed the characteristic activities of streptococcal pyrogenic exotoxin in rabbits: pyrogenicity and ability to enhance susceptibility to lethal endotoxin shock. The pI 8.0 and pI 9.0 fractions were not pyrogenic, but could be used to immunize against pyrogenicity. These two fractions failed either to enhance lethal endotoxin shock or to immunize against enhancement activity. When the isolated fractions were electrofocused again they appeared heterogeneous, suggesting an instability of the B toxin molecular forms.     

Characterization of PepB, a group B streptococcal oligopeptidase.

Group B streptococci were recently reported to possess a cell-associated collagenase. Although the enzyme hydrolyzed the synthetic collagen-like substrate N-(3-[2-furyl]acryloyl)-Leu-Gly-Pro-Ala, we found that neither the highly purified enzyme nor crude group B streptococcal cell lysate solubilized a film of reconstituted rat tail collagen, an activity regarded as obligatory for a true collagenase. We cloned and sequenced the gene for the enzyme (pepB). The deduced amino acid sequence showed 66.4% identity to the PepF oligopeptidase from Lactococcus lactis, a member of the M3 or thimet family of zinc metallopeptidases. The group B streptococcal enzyme also showed oligopeptidase activity and degraded a variety of small bioactive peptides, including bradykinin, neurotensin, and peptide fragments of substance P and adrenocorticotropin.