Streptococcus pyogenes emm and T types within a decade, 1996–2005: implications for epidemiology and future vaccines

Global Streptococcus pyogenes strain diversity, disease associations, and implications for vaccine development: a systematic review

The high strain diversity of Streptococcus pyogenes serves as a major obstacle to vaccine development against this leading global pathogen. We did a systematic review of studies in PubMed, MEDLINE, and Embase that reported the global distribution of S pyogenes emm-types and emm-clusters from Jan 1, 1990, to Feb 23, 2023. 212 datasets were included from 55 countries, encompassing 74 468 bacterial isolates belonging to 211 emm-types. Globally, an inverse correlation was observed between strain diversity and the UNDP Human Development Index (HDI; r=-0·72; p<0·0001), which remained consistent upon subanalysis by global region and site of infection. Greater strain diversity was associated with a lower HDI, suggesting the role of social determinants in diseases caused by S pyogenes. We used a population-weighted analysis to adjust for the disproportionate number of epidemiological studies from high-income countries and identified 15 key representative isolates as vaccine targets. Strong strain type associations were observed between the site of infection (invasive, skin, and throat) and several streptococcal lineages. In conclusion, the development of a truly global vaccine to reduce the immense burden of diseases caused by S pyogenes should consider the multidimensional diversity of the pathogen, including its social and environmental context, and not merely its geographical distribution.

Invasive Multidrug-Resistant emm93.0 Streptococcus pyogenes Strain Harboring a Novel Genomic Island, Israel, 2017-2019

Invasive group A Streptococcus (iGAS) infections have increased in Israel since 2016 as successful lineages have emerged. We report the emergence and outbreak of a multidrug-resistant S. pyogenes emm93.0, sequence type 10, among iGAS infections in Israel since 2017. This type has been observed very rarely in other countries. During this period, emm93.0 was the cause of 116 infections in Israel and became the leading type during 2018. Most of the infections were from bacteremia (75%), and most patients were male (76%). We observed infections across Israel, mainly in adults. Of note, we observed multidrug resistance for clindamycin, tetracycline, and trimethoprim/sulfamethoxazole. Whole-genome sequencing confirmed clonality among geographically disseminated isolates. The local emm93.0 sequence type 10 clone contained a novel genomic island harboring the resistance genes lsa(E), lnu(B), and ant (6)-Ia aph(3')-III. Further phenotypic and genomic studies are required to determine the prevalence of this resistance element in other iGAS types.

Invasive Group A Streptococcus Infection in Children in Southern Israel Before and After the Introduction of Varicella Vaccine

The annual rates of group A Streptococcus bacteremia per 100 000 children in southern Israel declined after introduction of the varicella vaccine to the national immunization program, from 2.43 (95% confidence interval, 1.73-3.13) in 1995-2002 to 1.30 (95% confidence interval, 0.91-1.72) in 2010-2016 (P = .04). This reduction correlated with the disappearance of varicella rash as a predisposing factor.

Molecular characterization of Streptococcus pyogenes group A isolates from a tertiary hospital in Lebanon

Streptococcus pyogenes [Group A Streptococcus (GAS)] is one of the most important human pathogens, responsible for numerous diseases with diverse clinical manifestations. As the epidemiology of GAS infections evolves, a rapid and reliable characterization of the isolates remains essential for epidemiological analysis and infection control. This study investigated the epidemiological patterns and genetic characteristics of 150 GAS isolates from a tertiary hospital in Lebanon by emm typing, superantigens (SAgs) detection, PFGE and antibiotic profiling. The results revealed 41 distinct emm types, the most prevalent of which were emm89 (16 %), emm12 (10 %), emm2 (9 %) and emm1 (8 %). Testing for the presence of superantigens showed that speB (87 %), ssa (36 %) and speG (30 %) were predominant. PFGE detected 39 pulsotypes when a similarity cut-off value of 80 % was implemented. Antibiotic-susceptibility testing against seven different classes of antibiotics showed that 9 % of the isolates were resistant to clindamycin, 23 % were resistant to erythromycin and 4 % showed the macrolide-lincosamide-streptogramin B (MLSB) phenotype. The emergence of tetracycline-resistant strains (37 %) was high when compared with previous reports from Lebanon. This study provided comprehensive evidence of the epidemiology of GAS in Lebanon, highlighting the association between emm types and toxin genes, and providing valuable information about the origin and dissemination of this pathogen.

Disease manifestations and pathogenic mechanisms of Group A Streptococcus

Streptococcus pyogenes, also known as group A Streptococcus (GAS), causes mild human infections such as pharyngitis and impetigo and serious infections such as necrotizing fasciitis and streptococcal toxic shock syndrome. Furthermore, repeated GAS infections may trigger autoimmune diseases, including acute poststreptococcal glomerulonephritis, acute rheumatic fever, and rheumatic heart disease. Combined, these diseases account for over half a million deaths per year globally. Genomic and molecular analyses have now characterized a large number of GAS virulence determinants, many of which exhibit overlap and redundancy in the processes of adhesion and colonization, innate immune resistance, and the capacity to facilitate tissue barrier degradation and spread within the human host. This improved understanding of the contribution of individual virulence determinants to the disease process has led to the formulation of models of GAS disease progression, which may lead to better treatment and intervention strategies. While GAS remains sensitive to all penicillins and cephalosporins, rising resistance to other antibiotics used in disease treatment is an increasing worldwide concern. Several GAS vaccine formulations that elicit protective immunity in animal models have shown promise in nonhuman primate and early-stage human trials. The development of a safe and efficacious commercial human vaccine for the prophylaxis of GAS disease remains a high priority.

Disease manifestations and pathogenic mechanisms of Group A Streptococcus

Streptococcus pyogenes, also known as group A Streptococcus (GAS), causes mild human infections such as pharyngitis and impetigo and serious infections such as necrotizing fasciitis and streptococcal toxic shock syndrome. Furthermore, repeated GAS infections may trigger autoimmune diseases, including acute poststreptococcal glomerulonephritis, acute rheumatic fever, and rheumatic heart disease. Combined, these diseases account for over half a million deaths per year globally. Genomic and molecular analyses have now characterized a large number of GAS virulence determinants, many of which exhibit overlap and redundancy in the processes of adhesion and colonization, innate immune resistance, and the capacity to facilitate tissue barrier degradation and spread within the human host. This improved understanding of the contribution of individual virulence determinants to the disease process has led to the formulation of models of GAS disease progression, which may lead to better treatment and intervention strategies. While GAS remains sensitive to all penicillins and cephalosporins, rising resistance to other antibiotics used in disease treatment is an increasing worldwide concern. Several GAS vaccine formulations that elicit protective immunity in animal models have shown promise in nonhuman primate and early-stage human trials. The development of a safe and efficacious commercial human vaccine for the prophylaxis of GAS disease remains a high priority.

Group A streptococci clones associated with invasive infections and pharyngitis in Portugal present differences in emm types, superantigen gene content and antimicrobial resistance

Background

A few lineages of Group A streptococci (GAS) have been associated with a reemergence of severe invasive streptococcal disease in developed countries. However, the majority of the comparisons between invasive and non-invasive GAS isolates have been performed for collections of reduced genetic diversity or relied on limited typing information to distinguish clones. We characterized by several typing methods and compared a collection of 160 isolates recovered from normally sterile sites with 320 isolates associated with pharyngitis and recovered in the same time period in Portugal.

Results

Although most of the isolates belonged to clones that were equally prevalent in invasive infections and pharyngitis, we identified markers of invasiveness, namely the emm types 1 and 64, and the presence of the speA and speJ genes. In contrast, emm4, emm75, and the ssa and speL/M genes were significantly associated with pharyngitis. There was a strong agreement between the emm type, the superantigen (SAg) genes and the clusters defined by pulsed-field gel electrophoresis (PFGE) profiling. Therefore, combinations of particular emm types and SAg genes frequently co-occurred in the same PFGE cluster, but there was no synergistic or antagonistic interaction between them in determining invasiveness. Only macrolide-susceptible PFGE clones were significantly associated with invasive infections or pharyngitis, while the clones of resistant isolates sharing all other molecular properties analyzed were equally prevalent in the two groups of isolates.

Conclusions

This study confirmed the importance of the widely disseminated emm1-T1-ST28 clone in invasive infections but also identified other clones linked to either invasive infections (emm64-ST164) or pharyngitis (emm4-T4-ST39), which may be more limited in their temporal and geographical spread. Clonal properties like some emm types or SAg genes were associated with disease presentation, highlighting the importance of bacterial genetic factors to the outcome of GAS infections, although other, yet unidentified factors may also play an important role.

Differences between macrolide-resistant and -susceptible Streptococcus pyogenes: importance of clonal properties in addition to antibiotic consumption

A steady decline in macrolide resistance among Streptococcus pyogenes (group A streptococci [GAS]) in Portugal was reported during 1999 to 2006. This was accompanied by alterations in the prevalence of macrolide resistance phenotypes and in the clonal composition of the population. In order to test whether changes in the macrolide-resistant population reflected the same changing patterns of the overall population, we characterized both macrolide-susceptible and -resistant GAS associated with a diagnosis of tonsillo-pharyngitis recovered in the period from 2000 to 2005 in Portugal. Pulsed-field gel electrophoresis (PFGE) profiling was the best predictor of emm type and the only typing method that could discriminate clones associated with macrolide resistance and susceptibility within each emm type. Six PFGE clusters were significantly associated with macrolide susceptibility: T3-emm3-ST406, T4-emm4-ST39, T1-emm1-ST28, T6-emm6-ST382, B3264-emm89-ST101/ST408, and T2-emm2-ST55. Four PFGE clusters were associated with macrolide resistance: T4-emm4-ST39, T28-emm28-ST52, T12-emm22-ST46, and T1-emm1-ST28. We found no evidence for frequent ongoing horizontal transfer of macrolide resistance determinants. The diversity of the macrolide-resistant population was lower than that of susceptible isolates. The differences found between the two populations suggest that the macrolide-resistant population of GAS has its own dynamics, independent of the behavior of the susceptible population.

Group a streptococcal vaccine candidates: potential for the development of a human vaccine

Currently there is no commercial Group A Streptococcus (GAS; S. pyogenes) vaccine available. The development of safe GAS vaccines is challenging, researchers are confronted with obstacles such as the occurrence of many unique serotypes (there are greater than 150 M types), antigenic variation within the same serotype, large variations in the geographical distribution of serotypes, and the production of antibodies cross-reactive with human tissue which can lead to host auto-immune disease. Cell wall anchored, cell membrane associated, secreted and anchorless proteins have all been targeted as GAS vaccine candidates. As GAS is an exclusively human pathogen, the quest for an efficacious vaccine is further complicated by the lack of an animal model which mimics human disease and can be consistently and reproducibly colonized by multiple GAS strains.

emm typing, antibiotic resistance and PFGE analysis of Streptococcus pyogenes in Lebanon

One hundred and three Streptococcus pyogenes isolates recovered mainly from streptococcal throat infections in Lebanon were characterized by emm and PFGE typing. Thirty-three emm types and subtypes were detected among the isolates. PFGE was more discriminatory as a typing method. The prevalent emm types were emm1 (12.6 %), emm22 (8.7 %), emm28 (7.7 %), emm88 (7.7 %) and emm4 (6.8 %) and all isolates were susceptible to vancomycin and penicillin G. Ten per cent of the isolates were resistant to erythromycin and 3 % were resistant to erythromycin and clindamycin, showing the macrolide-lincosamide-streptogramin B phenotype. The emm sequences and PFGE pattern database that were generated in this study will serve as a basis for information for long-term evolutionary and epidemiological studies of local S. pyogenes recovered not only in Lebanon, but also in neighbouring countries.

Invasive infection caused by Streptococcus dysgalactiae subsp. equisimilis: characteristics of strains and clinical features

Among clinically isolated β-hemolytic streptococci, Streptococcus pyogenes and S. agalactiae were considered the main pathogens in humans until recently. In 1996, S. dysgalactiae subsp. equisimilis (SDSE) was proposed as a novel taxon among human-derived streptococcal isolates. SDSE has Lancefield group C or G antigens, exhibits strong β-hemolysis, and exerts streptokinase activity upon human plasminogen and proteolytic activity upon human fibrin. Similarly to group A streptococci, SDSE possesses virulence factors including M protein, streptolysin O, streptolysin S, streptokinase, hyaluronidase, C5a peptidase, and others. SDSE may exist among the normal flora of the skin, oropharynx, and gastrointestinal and genitourinary tracts. In the twenty-first century, invasive SDSE infection (i.e., cellulitis, urosepsis, and pneumonia) leading to various disseminated diseases is being diagnosed increasingly in Japan, elsewhere in Asia, in Europe, and in America. Particularly, among elderly patients, these invasive diseases are encountered increasingly in Japanese hospital emergency departments. Analysis of the part of the emm gene encoding the amino acid sequence at the N-terminal end of the M protein is used to determine the molecular epidemiology of SDSE. The distribution of emm types from patients with invasive or noninvasive infections differs between surveillance results from different countries. In this review, we summarize the characteristics of phenotypes and virulence factors in SDSE strains; the review also focuses on emerging SDSE infectious disease and future vaccination research.