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Rampersadh K, Salie MT, Engel KC, Moodley C, Zühlke LJ, Engel ME. Presence of Group A streptococcus frequently assayed virulence genes in invasive disease: a systematic review and meta-analysis. Front Cell Infect Microbiol 2024; 14:1337861. [PMID: 39055978 PMCID: PMC11270091 DOI: 10.3389/fcimb.2024.1337861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/18/2024] [Indexed: 07/28/2024] Open
Abstract
Introduction It is currently unclear what the role of Group A streptococcus (GAS) virulence factors (VFs) is in contributing to the invasive potential of GAS. This work investigated the evidence for the association of GAS VFs with invasive disease. Methods We employed a broad search strategy for studies reporting the presence of GAS VFs in invasive and non-invasive GAS disease. Data were independently extracted by two reviewers, quality assessed, and meta-analyzed using Stata®. Results A total of 32 studies reported on 45 putative virulence factors [invasive (n = 3,236); non-invasive (n = 5,218)], characterized by polymerase chain reaction (PCR) (n = 30) and whole-genome sequencing (WGS) (n = 2). The risk of bias was rated as low and moderate, in 23 and 9 studies, respectively. Meta-,analyses of high-quality studies (n = 23) revealed a significant association of speM [OR, 1.64 (95%CI, 1.06; 2.52)] with invasive infection. Meta-analysis of WGS studies demonstrated a significant association of hasA [OR, 1.91 (95%CI, 1.36; 2.67)] and speG [OR, 2.83 (95%CI, 1.63; 4.92)] with invasive GAS (iGAS). Meta-analysis of PCR studies indicated a significant association of speA [OR, 1.59 (95%CI, 1.10; 2.30)] and speK [OR, 2.95 (95%CI, 1.81; 4.80)] with invasive infection. A significant inverse association was observed between prtf1 [OR, 0.42 (95%CI, 0.20; 0.87)] and invasive infection. Conclusion This systematic review and genomic meta-analysis provides evidence of a statistically significant association with invasive infection for the hasA gene, while smeZ, ssa, pnga3, sda1, sic, and NaDase show statistically significantly inverse associations with invasive infection. SpeA, speK, and speG are associated with GAS virulence; however, it is unclear if they are markers of invasive infection. This work could possibly aid in developing preventative strategies.
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Affiliation(s)
- Kimona Rampersadh
- AFROStrep Research Group, Department of Medicine and Cape Heart Institute, University of Cape Town, Cape Town, South Africa
| | - M. Taariq Salie
- AFROStrep Research Group, Department of Medicine and Cape Heart Institute, University of Cape Town, Cape Town, South Africa
| | - Kelin C. Engel
- AFROStrep Research Group, Department of Medicine and Cape Heart Institute, University of Cape Town, Cape Town, South Africa
| | - Clinton Moodley
- Department of Pathology, Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- The National Health Laboratory Service, Microbiology, Groote Schuur Hospital, Cape Town, South Africa
| | - Liesl J. Zühlke
- Division of Paediatric Cardiology, Department of Paediatrics, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council, Parrow Valley, Cape Town, South Africa
| | - Mark E. Engel
- AFROStrep Research Group, Department of Medicine and Cape Heart Institute, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council, Parrow Valley, Cape Town, South Africa
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2
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Smeesters PR, de Crombrugghe G, Tsoi SK, Leclercq C, Baker C, Osowicki J, Verhoeven C, Botteaux A, Steer AC. Global Streptococcus pyogenes strain diversity, disease associations, and implications for vaccine development: a systematic review. THE LANCET. MICROBE 2024; 5:e181-e193. [PMID: 38070538 DOI: 10.1016/s2666-5247(23)00318-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 02/12/2024]
Abstract
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.
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Affiliation(s)
- Pierre R Smeesters
- Department of Paediatrics, Brussels University Hospital, Academic Children Hospital Queen Fabiola, Université libre de Bruxelles, Brussels, Belgium; Molecular Bacteriology Laboratory, European Plotkin Institute for Vaccinology, Université Libre de Bruxelles, Brussels, Belgium; Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.
| | - Gabrielle de Crombrugghe
- Department of Paediatrics, Brussels University Hospital, Academic Children Hospital Queen Fabiola, Université libre de Bruxelles, Brussels, Belgium; Molecular Bacteriology Laboratory, European Plotkin Institute for Vaccinology, Université Libre de Bruxelles, Brussels, Belgium
| | - Shu Ki Tsoi
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Infectious Diseases Unit, Royal Children's Hospital Melbourne, Melbourne, VIC, Australia
| | - Céline Leclercq
- Department of Paediatrics, Brussels University Hospital, Academic Children Hospital Queen Fabiola, Université libre de Bruxelles, Brussels, Belgium
| | - Ciara Baker
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Joshua Osowicki
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Infectious Diseases Unit, Royal Children's Hospital Melbourne, Melbourne, VIC, Australia
| | - Caroline Verhoeven
- Laboratoire d'enseignement des Mathématiques, Université Libre de Bruxelles, Brussels, Belgium
| | - Anne Botteaux
- Molecular Bacteriology Laboratory, European Plotkin Institute for Vaccinology, Université Libre de Bruxelles, Brussels, Belgium
| | - Andrew C Steer
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Infectious Diseases Unit, Royal Children's Hospital Melbourne, Melbourne, VIC, Australia
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3
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Martini CL, Silva DNS, Viana AS, Planet PJ, Figueiredo AMS, Ferreira-Carvalho BT. Streptococcus pyogenes Lineage ST62/ emm87: The International Spread of This Potentially Invasive Lineage. Antibiotics (Basel) 2023; 12:1530. [PMID: 37887231 PMCID: PMC10603930 DOI: 10.3390/antibiotics12101530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 10/28/2023] Open
Abstract
Streptococcus pyogenes is known to be associated with a variety of infections, from pharyngitis to necrotizing fasciitis (flesh-eating disease). S. pyogenes of the ST62/emm87 lineage is recognized as one of the most frequently isolated lineages of invasive infections caused by this bacterium, which may be involved in hospital outbreaks and cluster infections. Despite this, comparative genomic and phylogenomic studies have not yet been carried out for this lineage. Thus, its virulence and antimicrobial susceptibility profiles are mostly unknown, as are the genetic relationships and evolutionary traits involving this lineage. Previously, a strain of S. pyogenes ST62/emm87 (37-97) was characterized in our lab for its ability to generate antibiotic-persistent cells, and therapeutic failure in severe invasive infections caused by this bacterial species is well-reported in the scientific literature. In this work, we analyzed genomic and phylogenomic characteristics and evaluated the virulence and resistance profiles of ST62/emm87 S. pyogenes from Brazil and international sources. Here we show that strains that form this lineage (ST62/emm87) are internationally spread, involved in invasive outbreaks, and share important virulence profiles with the most common emm types of S. pyogenes, such as emm1, emm3, emm12, and emm69, which are associated with most invasive infections caused by this bacterial species in the USA and Europe. Accordingly, the continued increase of ST62/emm87 in severe S. pyogenes diseases should not be underestimated.
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Affiliation(s)
- Caroline Lopes Martini
- Departamento de Microbiologia Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, RJ, Brazil; (C.L.M.); (D.N.S.S.); (A.S.V.)
| | - Deborah Nascimento Santos Silva
- Departamento de Microbiologia Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, RJ, Brazil; (C.L.M.); (D.N.S.S.); (A.S.V.)
| | - Alice Slotfeldt Viana
- Departamento de Microbiologia Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, RJ, Brazil; (C.L.M.); (D.N.S.S.); (A.S.V.)
| | - Paul Joseph Planet
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
- Children’s Hospital of Philadelphia, Philadelphia, PA 19106, USA
| | - Agnes Marie Sá Figueiredo
- Departamento de Microbiologia Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, RJ, Brazil; (C.L.M.); (D.N.S.S.); (A.S.V.)
- Programa de Pós-graduação em Patologia, Faculdade de Medicina, Universidade Federal, Fluminense, Niterói 24220-900, RJ, Brazil
| | - Bernadete Teixeira Ferreira-Carvalho
- Departamento de Microbiologia Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-902, RJ, Brazil; (C.L.M.); (D.N.S.S.); (A.S.V.)
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4
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Gouveia C, Bajanca-Lavado MP, Mamede R, Araújo Carvalho A, Rodrigues F, Melo-Cristino J, Ramirez M, Friães A. Sustained increase of paediatric invasive Streptococcus pyogenes infections dominated by M1 UK and diverse emm12 isolates, Portugal, September 2022 to May 2023. Euro Surveill 2023; 28:2300427. [PMID: 37676143 PMCID: PMC10486195 DOI: 10.2807/1560-7917.es.2023.28.36.2300427] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/07/2023] [Indexed: 09/08/2023] Open
Abstract
Since autumn 2022, observed numbers of paediatric invasive group A Streptococcus infections in Portugal (n = 89) were higher than in pre-COVID-19 seasons. Between September 2022 and May 2023, the dominant diagnoses were pneumonia (25/79), mostly with empyema (20/25), and sepsis (22/79). A number of cases required admission to intensive care (27/79) and surgery (35/79), and the case fatality rate was 5.1% (4/79). Genomic sequencing (n = 55) revealed multiple genetic lineages, dominated by the M1UK sublineage (26/55) and more diverse emm12 isolates (12/55).
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Affiliation(s)
- Catarina Gouveia
- Infectious Diseases Unit, Pediatric Department, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Maria Paula Bajanca-Lavado
- Laboratório Nacional de Referência a Infeções Respiratórias a Agentes Bacterianos, Departamento de Doenças Infeciosas, Instituto Nacional de Saúde Dr. Ricardo Jorge, Lisbon, Portugal
| | - Rafael Mamede
- Instituto de Microbiologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Ana Araújo Carvalho
- Infectious Diseases Unit, Pediatric Department, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Fernanda Rodrigues
- Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - José Melo-Cristino
- Instituto de Microbiologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Mario Ramirez
- Instituto de Microbiologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Ana Friães
- Instituto de Microbiologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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5
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Brouwer S, Rivera-Hernandez T, Curren BF, Harbison-Price N, De Oliveira DMP, Jespersen MG, Davies MR, Walker MJ. Pathogenesis, epidemiology and control of Group A Streptococcus infection. Nat Rev Microbiol 2023; 21:431-447. [PMID: 36894668 PMCID: PMC9998027 DOI: 10.1038/s41579-023-00865-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 03/11/2023]
Abstract
Streptococcus pyogenes (Group A Streptococcus; GAS) is exquisitely adapted to the human host, resulting in asymptomatic infection, pharyngitis, pyoderma, scarlet fever or invasive diseases, with potential for triggering post-infection immune sequelae. GAS deploys a range of virulence determinants to allow colonization, dissemination within the host and transmission, disrupting both innate and adaptive immune responses to infection. Fluctuating global GAS epidemiology is characterized by the emergence of new GAS clones, often associated with the acquisition of new virulence or antimicrobial determinants that are better adapted to the infection niche or averting host immunity. The recent identification of clinical GAS isolates with reduced penicillin sensitivity and increasing macrolide resistance threatens both frontline and penicillin-adjunctive antibiotic treatment. The World Health Organization (WHO) has developed a GAS research and technology road map and has outlined preferred vaccine characteristics, stimulating renewed interest in the development of safe and effective GAS vaccines.
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Affiliation(s)
- Stephan Brouwer
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia
| | | | - Bodie F Curren
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Nichaela Harbison-Price
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia
| | - David M P De Oliveira
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
- Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, Queensland, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia
| | - Magnus G Jespersen
- Department of Microbiology and Immunology, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Mark R Davies
- Department of Microbiology and Immunology, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Mark J Walker
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia.
- Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, Queensland, Australia.
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia.
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6
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Hirose Y, Kolesinski P, Hiraoka M, Uchiyama S, Zurich RH, Kumaraswamy M, Bjanes E, Ghosh P, Kawabata S, Nizet V. Contribution of Streptococcus pyogenes M87 protein to innate immune resistance and virulence. Microb Pathog 2022; 169:105636. [PMID: 35724830 PMCID: PMC9878354 DOI: 10.1016/j.micpath.2022.105636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 05/16/2022] [Accepted: 06/10/2022] [Indexed: 01/29/2023]
Abstract
Streptococcus pyogenes is a pre-eminent human pathogen, and classified by the hypervariable sequence of the emm gene encoding the cell surface M protein. Among a diversity of M/emm types, the prevalence of the M/emm87 strain has been steadily increasing in invasive S. pyogenes infections. Although M protein is the major virulence factor for globally disseminated M/emm1 strain, it is unclear if or how the corresponding M protein of M/emm87 strain (M87 protein) functions as a virulence factor. Here, we use targeted mutagenesis to show that the M87 protein contributes to bacterial resistance to neutrophil and whole blood killing and promotes the release of mature IL-1β from macrophages. While deletion of emm87 did not influence epithelial cell adherence and nasal colonization, it significantly reduced S. pyogenes-induced mortality and bacterial loads in a murine systemic infection model. Our data suggest that emm87 is involved in pathogenesis by modulating the interaction between S. pyogenes and innate immune cells.
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Affiliation(s)
- Yujiro Hirose
- Department of Oral and Molecular Microbiology, Osaka University Graduate School of Dentistry, Suita, Osaka 5650871, Japan,Department of Pediatrics, University of California at San Diego, La Jolla, California 92093, USA
| | - Piotr Kolesinski
- Department of Chemistry and Biochemistry, University of California at San Diego, La Jolla, California 92093, USA
| | - Masanobu Hiraoka
- Department of Pediatrics, University of California at San Diego, La Jolla, California 92093, USA,Department of Otorhinolaryngology-Head and Neck Surgery, Wakayama Medical University, Wakayama, Wakayama 6418509, Japan
| | - Satoshi Uchiyama
- Department of Pediatrics, University of California at San Diego, La Jolla, California 92093, USA
| | - Raymond H. Zurich
- Department of Pediatrics, University of California at San Diego, La Jolla, California 92093, USA
| | - Monika Kumaraswamy
- Department of Medicine, University of California at San Diego, La Jolla, California 92093, USA,Infectious Diseases Section, VA San Diego Healthcare System, San Diego, CA 92161, USA
| | - Elisabet Bjanes
- Department of Pediatrics, University of California at San Diego, La Jolla, California 92093, USA
| | - Partho Ghosh
- Department of Chemistry and Biochemistry, University of California at San Diego, La Jolla, California 92093, USA
| | - Shigetada Kawabata
- Department of Oral and Molecular Microbiology, Osaka University Graduate School of Dentistry, Suita, Osaka 5650871, Japan,Correspondence: Victor Nizet, , TEL: +18585347408, Shigetada Kawabata, , TEL: +81668792896
| | - Victor Nizet
- Department of Pediatrics, University of California at San Diego, La Jolla, California 92093, USA,Skaggs School of Pharmaceutical Sciences, University of California at San Diego, La Jolla, California 92093, USA,Correspondence: Victor Nizet, , TEL: +18585347408, Shigetada Kawabata, , TEL: +81668792896
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7
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Rafei R, Al Iaali R, Osman M, Dabboussi F, Hamze M. A global snapshot on the prevalent macrolide-resistant emm types of Group A Streptococcus worldwide, their phenotypes and their resistance marker genotypes during the last two decades: A systematic review. INFECTION, GENETICS AND EVOLUTION : JOURNAL OF MOLECULAR EPIDEMIOLOGY AND EVOLUTIONARY GENETICS IN INFECTIOUS DISEASES 2022; 99:105258. [PMID: 35219865 DOI: 10.1016/j.meegid.2022.105258] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 12/29/2021] [Accepted: 02/22/2022] [Indexed: 06/14/2023]
Abstract
Watchful epidemiological surveillance of macrolide-resistant Group A Streptococcus (MRGAS) clones is important owing to the evolutionary and epidemiological dynamic of GAS. Meanwhile, data on the global distribution of MRGAS emm types according to macrolide resistance phenotypes and genotypes are scant and need to be updated. For this, the present systematic review analyses a global set of extensively characterized MRGAS isolates from patients of diverse ages and clinical presentations over approximately two decades (2000 to 2020) and recaps the peculiar epidemiological features of the dominant MRGAS clones. Based on the inclusion and exclusion criteria, 53 articles (3593 macrolide-resistant and 15,951 susceptible isolates) distributed over 23 countries were dissected with a predominance of high-income countries over low-income ones. Although macrolide resistance in GAS is highly variable in different countries, its within-GAS distribution seems not to be random. emm pattern E, 13 major emm types (emm12, 4, 28, 77, 75, 11, 22, 92, 58, 60, 94, 63, 114) and 4 emm clusters (A-C4, E1, E6, and E2) were significantly associated with macrolide resistance. emm patterns A-C and D, 14 major emm types (emm89, 3, 6, 2, 44, 82, 87, 118, 5, 49, 81, 59, 227, 78) and 3 well-defined emm clusters (A-C5, E3, and D4) were significantly associated with macrolide susceptibility. Scrutinizing the tendency of each MRGAS emm type to be significantly associated with specific macrolide resistance phenotype or genotype, interesting vignettes are also unveiled. The 30-valent vaccine covers ~95% of MRGAS isolates. The presented data urge the importance of comprehensive nationwide sustained surveillance of MRGAS circulating clones particularly in Low and Middle income countries where sampling bias is high and GAS epidemiology is obfuscated and needs to be demystified.
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Affiliation(s)
- Rayane Rafei
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon.
| | - Rayane Al Iaali
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - Marwan Osman
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon; Department of Public and Ecosystem Health, College of Veterinary Medicine, Cornell University, Ithaca, NY 14850, USA
| | - Fouad Dabboussi
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
| | - Monzer Hamze
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School of Sciences and Technology, Faculty of Public Health, Lebanese University, Tripoli, Lebanon
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8
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Gouveia C, Branco J, Norte S, Arcangelo J, Alves P, Pinto M, Tavares D. Acute haematogenous osteomyelitis in Lisbon: an unexpectedly high association with myositis and arthritis. An Pediatr (Barc) 2022; 96:106-114. [DOI: 10.1016/j.anpede.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/11/2020] [Indexed: 11/16/2022] Open
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9
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Berbel D, Càmara J, González-Díaz A, Cubero M, López de Egea G, Martí S, Tubau F, Domínguez MA, Ardanuy C. Deciphering mobile genetic elements disseminating macrolide resistance in Streptococcus pyogenes over a 21 year period in Barcelona, Spain. J Antimicrob Chemother 2021; 76:1991-2003. [PMID: 34015100 DOI: 10.1093/jac/dkab130] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 03/23/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To phenotypically and genetically characterize the antibiotic resistance determinants and associated mobile genetic elements (MGEs) among macrolide-resistant (MR) Streptococcus pyogenes [Group A streptococci (GAS)] clinical isolates collected in Barcelona, Spain. METHODS Antibiotic susceptibility testing was performed by microdilution. Isolates were emm and MLST typed and 55 were whole-genome sequenced to determine the nature of the macrolide resistance (MR) determinants and their larger MGE and chromosomal context. RESULTS Between 1998 and 2018, 142 of 1028 GAS (13.8%) were MR. Among 108 isolates available for molecular characterization, 41.7% had cMLSB, 30.5% iMLSB and 27.8% M phenotype. Eight erm(B)-containing strains were notable in having an MDR phenotype conferred by an MGE encoding several antibiotic resistance genes. MR isolates were comprised of several distinct genetic lineages as defined by the combination of emm and ST. Although most lineages were only transiently present, the emm11/ST403 clone persisted throughout the period. Two lineages, emm9/ST75 with erm(B) and emm77/ST63 with erm(TR), emerged in 2016-18. The erm(B) was predominantly encoded on the Tn916 family of transposons (21/31) with different genetic contexts, and in other MGEs (Tn6263, ICESpHKU372 and one harbouring an MDR cluster called ICESp1070HUB). The erm(TR) was found in ICESp2905 (8/17), ICESp1108-like (4/17), ICESpHKU165 (3/17) and two structures described in this study (IMESp316HUB and ICESp3729HUB). The M phenotype [mef(A)-msr(D)] was linked to phage φ1207.3. Eight integrative conjugative element/integrative mobilizable element (ICE/IME) cluster groups were classified on the basis of gene content within conjugation modules. These groups were found among MGEs, which corresponded with the MR-containing element or the site of integration. CONCLUSIONS We detected several different MGEs harbouring erm(B) or erm(TR). This is the first known description of Tn6263 in GAS and three MGEs [IMESp316HUB, ICESp3729HUB and ICESp1070HUB] associated with MR. Periods of high MR rates in our area were mainly associated with the expansion of certain predominant lineages, while in low MR periods different sporadic and low prevalence lineages were more frequent.
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Affiliation(s)
- Dàmaris Berbel
- Microbiology Department, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.,CIBER de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Jordi Càmara
- Microbiology Department, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.,CIBER de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Aida González-Díaz
- Microbiology Department, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.,CIBER de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Meritxell Cubero
- Microbiology Department, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.,CIBER de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Guillem López de Egea
- Microbiology Department, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sara Martí
- Microbiology Department, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.,CIBER de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Fe Tubau
- Microbiology Department, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.,CIBER de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - M Angeles Domínguez
- Microbiology Department, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.,Departament of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain
| | - Carmen Ardanuy
- Microbiology Department, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.,CIBER de Enfermedades Respiratorias, ISCIII, Madrid, Spain.,Departament of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain
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10
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Ikebe T, Okuno R, Kanda Y, Sasaki M, Yamaguchi T, Otsuka H, Kazawa Y, Suzuki M, Ohya H, Uchida K, Ohnishi M. Molecular characterization and antimicrobial resistance of group A streptococcus isolates in streptococcal toxic shock syndrome cases in Japan from 2013 to 2018. Int J Med Microbiol 2021; 311:151496. [PMID: 33756191 DOI: 10.1016/j.ijmm.2021.151496] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/08/2021] [Accepted: 03/14/2021] [Indexed: 12/01/2022] Open
Abstract
Streptococcal toxic shock syndrome (STSS) is a severe invasive infection characterized by the sudden onset of shock, multi-organ failure, and puerperal sepsis and shows high mortality. Its primary cause is group A streptococcus (GAS, Streptococcus pyogenes). In this study, we genotyped the cell-surface M virulence protein gene (emm) from 621 GAS isolates obtained from patients with STSS in Japan in 2013-2018 and performed antimicrobial susceptibility testing using the broth microdilution method. The predominant emm type was found to be 1, followed by 89, 12, and 3, which were identified in more than 70 % of STSS isolates. The proportions of emm3 and emm89 increased from 2.4 % and 12.0 %, respectively, during 2010-2012 to 5.6 % and 23.3 % during 2013-2018. In contrast, the proportion of emm1 decreased from 60.6 % to 39.3 % during the same two periods. Some emm types showed increasing proportions and were not isolated from patients with STSS in 2010-2012. Among these, an emm76 type increased in prevalence and was not included in the 30-valent M protein-based vaccine. Continual investigation of changes in the epidemiology of GAS which causes STSS can provide useful monitoring information such as future vaccination strategies and the emergence status of antimicrobial-resistant bacteria.
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Affiliation(s)
- Tadayoshi Ikebe
- Department of Bacteriology I, National Institute of Infectious Diseases, 1-23-1 Toyama, Shinjuku-ku, Tokyo 162-8640, Japan.
| | - Rumi Okuno
- Department of Microbiology, Tokyo Metropolitan Institute of Public Health, 3-24-1 Hyakunin-cho, Shinjuku-ku, Tokyo 169-0073, Japan
| | - Yoshiko Kanda
- Laboratory of Microbiology, Oita Prefectural Institute of Health and Environment, 2-8 Takae-Nishi, Oita 870-1117, Japan
| | - Mari Sasaki
- Laboratory of Microbiology, Oita Prefectural Institute of Health and Environment, 2-8 Takae-Nishi, Oita 870-1117, Japan
| | - Takahiro Yamaguchi
- Division of Microbiology, Osaka Institute of Public Health, 1-3-69 Nakamichi, Higashinari-ku, Osaka 537-0025, Japan
| | - Hitoshi Otsuka
- Department of Public Health Sciences, Yamaguchi Prefectural Institute of Public Health and Environment, 2-5-67 Aoi, Yamaguchi 753-0821, Japan
| | - Yu Kazawa
- Division of Microbiology, Fukushima Prefectural Institute of Public Health, 16-6 Mitouchi, Hokida, Fukushima 960-8560, Japan
| | - Miyuki Suzuki
- Division of Microbiology, Kanagawa Prefectural Institute of Public Health, 1-3-1 Shimomachiya, Chigasaki, Kanagawa 253-0087, Japan
| | - Hitomi Ohya
- Division of Microbiology, Kanagawa Prefectural Institute of Public Health, 1-3-1 Shimomachiya, Chigasaki, Kanagawa 253-0087, Japan
| | - Kaoru Uchida
- Department of Bacteriology, Toyama Institute of Health, 17-1 Naka-Taikouyama, Imizu, Toyama 939-0363, Japan
| | - Makoto Ohnishi
- Department of Bacteriology I, National Institute of Infectious Diseases, 1-23-1 Toyama, Shinjuku-ku, Tokyo 162-8640, Japan
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11
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Gouveia C, Branco J, Norte S, Arcangelo J, Alves P, Pinto M, Tavares D. [Acute haematogenous osteomyelitis in Lisbon: An unexpectedly high association with myositis and arthritis]. An Pediatr (Barc) 2021; 96:S1695-4033(21)00001-1. [PMID: 33674248 DOI: 10.1016/j.anpedi.2020.11.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/31/2020] [Accepted: 11/11/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Despite the current trend towards less aggressive therapeutic approaches, acute haematogenous osteomyelitis (AHO) continues to be a challenge and is associated with significant morbidity worldwide. Our aim was to determine if 80% compliance with current protocol was achieved, identify complications and associated risk factors and analyse trends in aetiology and management of AHO in children. METHODS We conducted a longitudinal, observational, single-centre study in patients with AHO aged less than 18 years admitted to a paediatric hospital, between 2008 and 2018, divided into 2 cohorts (before and after 2014). Demographic, clinical data and disease progression were analysed. RESULTS The study included 71 children with AHO, 56% male, with a median age of 3 years (interquartile range, 1-11). We found a 1.8-fold increase of cases in the last 5 years. The causative agent was identified in 37% of cases: MSSA (54%), MRSA (4%), Streptococcus pyogenes (19%), Kingella kingae (12%), Streptococcus pneumoniae (8%), and Neisseria meningitidis (4%). Complications were identified in 45% of patients and sequelae in 3.6%. In recent years, there was an increase in myositis (30% vs. 7%; p=0.02), septic arthritis (68% vs. 37.2%; p=0.012) and in the proportion of patients treated for less than 4 weeks (37% vs. 3.5%; p=0.012), with a similar sequelae rates. The risk factors for complications were age 3 or more years, CRP levels of 20mg/l or higher, time elapsed between onset and admission of 5 or more days and positive culture, although on multivariate analysis only positive culture was significant. The presence of complications was a risk factor for sequelae at 6 months. CONCLUSIONS Our study confirms that AHO can be aggressive. The identification of risk factors for complications may be fundamental for management.
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Affiliation(s)
- Catarina Gouveia
- Unidad de Enfermedades Infecciosas, Hospital de Dona Estefânia, CHULC - EPE, Lisboa, Portugal; Nova Medical School, Faculdade de Ciências Médicas, Lisboa, Portugal.
| | - Joana Branco
- Unidad de Enfermedades Infecciosas, Hospital de Dona Estefânia, CHULC - EPE, Lisboa, Portugal
| | - Susana Norte
- Unidad de Ortopedia Pediátrica, Hospital de Dona Estefânia, CHULC - EPE, Lisboa, Portugal
| | - Joana Arcangelo
- Unidad de Ortopedia Pediátrica, Hospital de Dona Estefânia, CHULC - EPE, Lisboa, Portugal
| | - Pedro Alves
- Diagnóstico Radiológico, Centro Tecnológico e Biomédico, Hospital de Dona Estefânia, CHULC - EPE, Lisboa, Portugal
| | - Margarida Pinto
- Patología Clínica, Hospital de Dona Estefânia, CHULC - EPE, Lisboa, Portugal
| | - Delfin Tavares
- Unidad de Ortopedia Pediátrica, Hospital de Dona Estefânia, CHULC - EPE, Lisboa, Portugal
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Rafei R, Hawli M, Osman M, Khelissa S, Salloum T, Dabboussi F, Tokajian S, Hamze M. Molecular epidemiology of nonpharyngeal group A streptococci isolates in northern Lebanon. Future Microbiol 2020; 15:1555-1569. [PMID: 33236928 DOI: 10.2217/fmb-2020-0072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Aim: To characterize the epidemiology of group A Streptococcus (GAS) involved in nonpharyngeal infections sparingly addressed in Lebanon. Materials & methods: A collection of 63 nonpharyngeal GAS isolates recovered between 2010 and 2019 from northern Lebanon were analyzed through emm typing, virulence gene profiling, FCT typing and antibiotic susceptibility analysis. Results & conclusion: A total of 29 emm subtypes was detected, with emm1 being the most dominant. A great intraclonal divergence driven by the loss and gain of superantigens or by the structural variability within the FCT regions was unraveled. The resistance rates for erythromycin and tetracycline were 8 and 20.6%, respectively. The 30-valent vaccine coverage was 76%. This study evidences the complexity of the neglected GAS pathogen in Lebanon.
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Affiliation(s)
- Rayane Rafei
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School for Science & Technology, Faculty of Public Health, Lebanese University, Tripoli, 1300, Lebanon
| | - Malaik Hawli
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School for Science & Technology, Faculty of Public Health, Lebanese University, Tripoli, 1300, Lebanon
| | - Marwan Osman
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School for Science & Technology, Faculty of Public Health, Lebanese University, Tripoli, 1300, Lebanon
| | - Simon Khelissa
- Université de Lille, Centre National de la Recherche Scientifique, Institut National de Recherche pour l'Agriculture, l'Alimentation et l'Environnement, Centrale Lille, Unité Mixte de Recherche 8207 - Unité Matériaux et Transformations, Lille, 59000, France
| | - Tamara Salloum
- Department of Natural Sciences, School of Arts & Sciences, Lebanese American University, Byblos campus, Postal Box 36, Byblos, 1401, Lebanon
| | - Fouad Dabboussi
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School for Science & Technology, Faculty of Public Health, Lebanese University, Tripoli, 1300, Lebanon
| | - Sima Tokajian
- Department of Natural Sciences, School of Arts & Sciences, Lebanese American University, Byblos campus, Postal Box 36, Byblos, 1401, Lebanon
| | - Monzer Hamze
- Laboratoire Microbiologie Santé et Environnement (LMSE), Doctoral School for Science & Technology, Faculty of Public Health, Lebanese University, Tripoli, 1300, Lebanon
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13
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Epidemiological analysis of Group A Streptococcus infections in a hospital in Beijing, China. Eur J Clin Microbiol Infect Dis 2020; 39:2361-2371. [PMID: 32676802 DOI: 10.1007/s10096-020-03987-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/06/2020] [Indexed: 02/07/2023]
Abstract
Our study aimed to investigate the epidemiological and molecular characteristics of isolates collected from Group A Streptococcus (GAS) infections in children in Beijing China during the year 2019. Emm typing, superantigens, and erythromycin resistance genotypes were determined by PCR. Antimicrobial susceptibility testing was performed as recommended by Clinical Laboratory Standards Institute (CLSI). A total of 271 GAS isolates were collected. Thirteen different emm types, including 31 subtypes, were identified. The most prevalent emm types were emm12 (52.77%), emm1 (36.9%), emm3.1 (2.95%), and emm75.0 (2.95%). Two variant subtypes, STC36.0 and STG840.2, were identified. There was no difference in the portion of emm12 and emm1 isolates in scarlet fever, impetigo, and psoriasis. The majority of superantigens detected were smeZ (94.46%), speC (91.14%), and ssa (74.91%), followed by speH (56.46%), speI (45.76%), speJ (36.9%), and speA (34.32%). More scarlet fever isolates harbored speA (35.6%) and speJ (38.4%), more psoriasis isolates harbored speI (57.9%), and more impetigo isolates harbored ssa (89.7%). Isolates were universally susceptible to penicillin and resistant to erythromycin (94.83%). Moreover, 89.67% erythromycin resistance isolates harbored the ermB gene. The erythromycin resistance rate of the isolates from the three diseases was different. Scarlet fever is the common streptococcal infectious disease in dermatology. Emm12 and emm1 were the most prevalent emm types. The most prevalent superantigens detected were smeZ, spec, and ssa. There is association between diversity of superantigens and disease manifestation. Hence, continuous surveillance of GAS molecular epidemiological characterizations in different diseases is needed.
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Li H, Zhou L, Zhao Y, Ma L, Liu X, Hu J. Molecular epidemiology and antimicrobial resistance of group a streptococcus recovered from patients in Beijing, China. BMC Infect Dis 2020; 20:507. [PMID: 32660436 PMCID: PMC7359455 DOI: 10.1186/s12879-020-05241-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 07/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Group A streptococcus (GAS) is an important human pathogen responsible for a broad range of infections. Epidemiological surveillance has been crucial to detect changes in the geographical and temporal variation of the disease pattern. The objective of this study was to investigate the molecular epidemiological characteristics and antimicrobial resistance of GAS isolates from patients in Children's Hospital in Beijing. METHODS From 2016 to 2017, pharyngeal swab samples were collected from the outpatients in Children's Hospital, Capital Institute of Pediatrics, who were diagnosed with scarlet fever. Antimicrobial susceptibility test was performed according to the distribution of conventional antibiotics and Clinical and Laboratory Standards Institute (CLSI) recommendations. The distribution of the macrolide-resistance genes (ermB, ermA, mefA), emm (M protein-coding gene) typing, and superantigens (SAg) gene profiling were examined by polymerase chain reaction (PCR). RESULTS A total of 297 GAS isolates were collected. The susceptibility of the isolates to penicillin, ceftriaxone, and levofloxacin was 100%. The resistance rate to erythromycin and clindamycin was 98.3 and 96.6%, respectively. The dominant emm types were emm12 (65.32%), emm1 (27.61%), emm75 (2.69%), and emm89 (1.35%). Of the 297 isolates, 290 (97.64%) carried the ermB gene, and 5 (1.68%) carried the mefA gene, while none carried the ermA gene. The most common superantigen genes identified from GAS isolates were smeZ (96.97%), speC (92.59%), speG (91.58%), ssa (85.52%), speI (54.55%), speH (52.19%), and speA (34.34%). Isolates with the genotype emm1 possessed speA, speC, speG, speJ, speM, ssa, and smeZ, while emm12 possessed speC, speG, speH, speI, speM, ssa, and smeZ superantigens. CONCLUSIONS The prevalent strain of GAS isolates in Beijing has a high resistance rate to macrolides; however, penicillin can still be the preferred antibiotic for treatment. Erythromycin resistance was predominantly mediated by ermB. The common emm types were emm12 and emm1. There was a correlation between emm and the superantigen gene. Thus, long-term monitoring and investigation of the emm types and superantigen genes of GAS prevalence are imperative.
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Affiliation(s)
- Hongxin Li
- Department of Dermatology, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, 100020, China.
| | - Lin Zhou
- Department of Clinical Laboratory, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, 100020, China
| | - Yong Zhao
- The Sixth Medical Centre of PLA, General Hospital, Beijing, 100048, China
| | - Lijuan Ma
- Department of Clinical Laboratory, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, 100020, China
| | - Xiaoyan Liu
- Department of Dermatology, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, 100020, China
| | - Jin Hu
- Department of Dermatology, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, 100020, China.
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Oppegaard O, Skrede S, Mylvaganam H, Kittang BR. Emerging Threat of Antimicrobial Resistance in β-Hemolytic Streptococci. Front Microbiol 2020; 11:797. [PMID: 32477287 PMCID: PMC7242567 DOI: 10.3389/fmicb.2020.00797] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/03/2020] [Indexed: 11/13/2022] Open
Abstract
Highly variable resistance rates to erythromycin and clindamycin have been reported in the β-hemolytic streptococcal species Streptococcus pyogenes, Streptococcus agalactiae, and Streptococcus dysgalactiae, depending on geographic and temporal context. In the present study we aimed to examine the longitudinal trends of antimicrobial resistance in these three species in a northern European setting. Furthermore, we used whole genome sequencing to identify resistance determinants and the mobile genetic elements involved in their dissemination, as well as elucidate phylogenetic relationships. All cases of invasive β-hemolytic streptococcal diseases in Health Region Bergen, western Norway, in the period 2004 to 2018 were retrospectively identified, comprising 271, 358, and 280 cases of S. pyogenes, S. agalactiae, and S. dysgalactiae, respectively. Antimicrobial susceptibility testing revealed a gradual but significant increase in erythromycin and clindamycin resistance for S. agalactiae and S. dysgalactiae during the study period. Whole genome sequencing of the erythromycin and clindamycin resistant bacterial population revealed a substantial phylogenetic diversity in S. agalactiae and S. dysgalactiae. However, the mobile genetic elements harboring the resistance determinants showed remarkable intra- and interspecies similarities, suggesting a dissemination of antimicrobial resistance predominantly through conjugative transfer rather than clonal expansion of resistant strains in these two species. Conversely, antimicrobial resistance in S. pyogenes remained low, apart from a transient outbreak of a clindamycin and erythromycin resistant emm11/ST403-clone in 2010-2012. Increased epidemiological attentiveness is warranted to monitor the emerging threat of antimicrobial resistance in β-hemolytic streptococci, particularly in S. agalactiae and S. dysgalactiae.
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Affiliation(s)
- Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Steinar Skrede
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Haima Mylvaganam
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
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