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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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Gergova R, Muhtarova A, Mitov I, Setchanova L, Mihova K, Kaneva R, Markovska R. Relation between emm types and virulence gene profiles among Bulgarian Streptococcus pyogenes clinical isolates. Infect Dis (Lond) 2019; 51:668-675. [DOI: 10.1080/23744235.2019.1638964] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Raina Gergova
- Department of Medical Microbiology, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Adile Muhtarova
- Department of Medical Microbiology, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Ivan Mitov
- Department of Medical Microbiology, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Lena Setchanova
- Department of Medical Microbiology, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Kalina Mihova
- Department of Medical Chemistry and Biochemistry, Molecular Medicine Center, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Radka Kaneva
- Department of Medical Chemistry and Biochemistry, Molecular Medicine Center, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Rumyana Markovska
- Department of Medical Microbiology, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
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Gherardi G, Vitali LA, Creti R. Prevalent emm Types among Invasive GAS in Europe and North America since Year 2000. Front Public Health 2018; 6:59. [PMID: 29662874 PMCID: PMC5890186 DOI: 10.3389/fpubh.2018.00059] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 02/14/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Streptococcus pyogenes or group A streptococcus (GAS) is an important human pathogen responsible for a broad range of infections, from uncomplicated to more severe and invasive diseases with high mortality and morbidity. Epidemiological surveillance has been crucial to detect changes in the geographical and temporal variation of the disease pattern; for this purpose the M protein gene (emm) gene typing is the most widely used genotyping method, with more than 200 emm types recognized. Molecular epidemiological data have been also used for the development of GAS M protein-based vaccines. METHODS The aim of this paper was to provide an updated scenario of the most prevalent GAS emm types responsible for invasive infections in developed countries as Europe and North America (US and Canada), from 1st January 2000 to 31st May 2017. The search, performed in PubMed by the combined use of the terms ("emm") and ("invasive") retrieved 264 articles, of which 38 articles (31 from Europe and 7 from North America) met the inclusion criteria and were selected for this study. Additional five papers cited in the European articles but not retrieved by the search were included. RESULTS emm1 represented the dominant type in both Europe and North America, replaced by other emm types in only few occasions. The seven major emm types identified (emm1, emm28, emm89, emm3, emm12, emm4, and emm6) accounted for approximately 50-70% of the total isolates; less common emm types accounted for the remaining 30-50% of the cases. Most of the common emm types are included in either one or both the 26-valent and 30-valent vaccines, though some well-represented emm types found in Europe are not. CONCLUSION This study provided a picture of the prevalent emm types among invasive GAS (iGAS) in Europe and North America since the year 2000 onward. Continuous surveillance on the emm-type distribution among iGAS infections is strongly encouraged also to determine the potential coverage of the developing multivalent vaccines.
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Affiliation(s)
- Giovanni Gherardi
- Microbiology Unit, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | | | - Roberta Creti
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
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Muhtarova AA, Gergova RT, Mitov IG. Distribution of macrolide resistance mechanisms in Bulgarian clinical isolates of Streptococcus pyogenes during the years of 2013-2016. J Glob Antimicrob Resist 2017; 10:238-242. [PMID: 28735056 DOI: 10.1016/j.jgar.2017.05.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/11/2017] [Accepted: 05/27/2017] [Indexed: 10/19/2022] Open
Abstract
Streptococcus pyogenes, or group A streptococcus (GAS), is the main etiological agent of bacterial tonsillopharyngitis and a common cause of a wide variety of other mild to severe infections. OBJECTIVES Objectives of the present study was to determine and evaluate the distribution of genetic mechanisms associated with certain phenotypes of macrolide resistance in Bulgarian GAS isolated during the years of 2013-2016. METHODS All GAS strains were screened for the macrolide resistance genes erm(A), erm(B) and mef(A), using multiplex polymerase chain reaction (PCR). The minimal inhibitory concentrations (MICs) of erythromycin, azithromycin, clarithromycin, clindamycin were determined by E-tests. RESULTS Almost 23% of GAS isolates obtained in 2013-2014 and near 40% of them in 2015-2016 contained various elements of resistance. The predominant gene was mef(A), which encodes an efflux pump (M-phenotype), identified in 57.84% of the macrolide-resistant strains. The next frequently prevalent mechanism was a combination of mef(A) and erm(B) in 22.55%, which determined high-level inducible or constitutive resistance to macrolides, lincosamides and streptogramins (iMLSB or cMLSB). The highest MIC value (>256mg/L) was detected in association with erm(B) (p<0.05). The MIC range was observed to be much higher in the isolates with combinations of resistance genes vs. those with mef genes alone (p<0.05). CONCLUSION The data about the distribution and prevalence of macrolide resistance mechanisms obtained in this study can help in the treatment of persistent and recurrent GAS infections and in the correct choice of empiric therapy.
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Affiliation(s)
- Adile A Muhtarova
- Department of Medical Microbiology, Faculty of Medicine, Medical University, Sofia, Bulgaria
| | - Raina T Gergova
- Department of Medical Microbiology, Faculty of Medicine, Medical University, Sofia, Bulgaria.
| | - Ivan G Mitov
- Department of Medical Microbiology, Faculty of Medicine, Medical University, Sofia, Bulgaria
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Epidemiology of Invasive Group A Streptococcal Disease in Alaska, 2001 to 2013. J Clin Microbiol 2015; 54:134-41. [PMID: 26560536 DOI: 10.1128/jcm.02122-15] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/20/2015] [Indexed: 12/14/2022] Open
Abstract
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.
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Friães A, Lopes JP, Melo-Cristino J, Ramirez M. Changes in Streptococcus pyogenes causing invasive disease in Portugal: evidence for superantigen gene loss and acquisition. Int J Med Microbiol 2013; 303:505-13. [PMID: 23932912 DOI: 10.1016/j.ijmm.2013.07.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 03/26/2013] [Accepted: 07/10/2013] [Indexed: 01/10/2023] Open
Abstract
The emergence of highly virulent and successful Streptococcus pyogenes (group A streptococci - GAS) clones has been attributed to the exchange of virulence factors by lateral gene transfer mechanisms, which strongly contribute to genomic diversity. We characterized a collection of 191 GAS isolates recovered from normally sterile sites in Portugal during 2006-2009 and compared them to invasive isolates obtained during 2000-2005. Antimicrobial resistance rates did not change significantly between the two periods and were generally low. In 2006-2009, emm1, emm89, emm3, and emm6 represented 60% of the isolates. The chromosomally encoded superantigen (SAg) genes speG and smeZ were present in the majority (>90%) of the isolates, while speJ was found in only 45%. The phage encoded SAgs varied greatly in prevalence (2-53%). The distribution of emm types, pulsed-field gel electrophoresis profiling (PFGE) clusters, and SAg profiles changed significantly between the periods, although there were no statistically supported changes in the prevalence of individual types. While the macrolide susceptible clone emm1-T1-ST28 remained dominant (28%), there was a significant decrease in clonal diversity as indicated by both PFGE profiling and emm typing. This was accompanied by intra-clonal divergence of SAg profiles, which was statistically confirmed for isolates representing emm1, emm28, and emm44. This diversification was associated with the loss and acquisition of SAg genes, carried by phages and of chromosomal origin. These data suggest an ongoing genomic diversification of GAS invasive isolates in Portugal that may contribute to the persistence of clones with improved fitness or virulence.
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Affiliation(s)
- Ana Friães
- Instituto de Microbiologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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Differences in the epidemiology between paediatric and adult invasiveStreptococcus pyogenesinfections. Epidemiol Infect 2013; 142:512-9. [DOI: 10.1017/s0950268813001386] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
SUMMARYIn order to investigate for possible differences between paediatric and adult invasiveStreptococcus pyogenes(iGAS) infections, a total of 142 cases were identified in 17 Greek hospitals during 2003–2007, of which 96 were children and 46 adults. Bacteraemia, soft tissue infections, streptococcal toxic shock syndrome (STSS), and necrotizing fasciitis were the main clinical presentations (67·6%, 45·1%, 13·4%, and 12·0% of cases, respectively). Bacteraemia and lymphadenitis were significantly more frequent in children (P = 0·019 and 0·021, respectively), whereas STSS was more frequent in adults (P = 0·017). The main predisposing factors in children were varicella and streptococcal pharyngotonsillitis (25% and 19·8%, respectively), as opposed to malignancy, intravenous drug abuse and diabetes mellitus in adults (19·6%, 15·2% and 10·9%, respectively). Of the two dominantemm-types, 1 and 12 (28·2% and 8·5%, respectively), the proportion ofemm-type 12 remained stable during the study period, whereasemm-type 1 rates fluctuated considerably. Strains ofemm-type 1 from children were associated with erythromycin susceptibility, STSS and intensive-care-unit admission, whereasemm-type 12 isolates from adults were associated with erythromycin and clindamycin resistance. Finally, specificemm-types were detected exclusively in adults or in children. In conclusion, several clinical and epidemiological differences were detected, that could prove useful in designing age-focused strategies for prevention and treatment of iGAS infections.
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Liang Y, Liu X, Chang H, Ji L, Huang G, Fu Z, Zheng Y, Wang L, Li C, Shen Y, Yu S, Yao K, Ma L, Shen X, Yang Y. Epidemiological and molecular characteristics of clinical isolates of Streptococcus pyogenes collected between 2005 and 2008 from Chinese children. J Med Microbiol 2012; 61:975-983. [PMID: 22442290 DOI: 10.1099/jmm.0.042309-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Yunmei Liang
- Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, PR China
- Beijing Children’s Hospital Affiliated to Capital Medical University, Beijing 100045, PR China
| | - Xiaorong Liu
- Beijing Children’s Hospital Affiliated to Capital Medical University, Beijing 100045, PR China
| | - Hesheng Chang
- Beijing Chaoyang Hospital Affiliated to Capital Medical University, Beijing 100020, PR China
- Beijing Children’s Hospital Affiliated to Capital Medical University, Beijing 100045, PR China
| | - Lili Ji
- Beijing Children’s Hospital Affiliated to Capital Medical University, Beijing 100045, PR China
| | - Guoying Huang
- Children’s Hospital of Fudan University, Shanghai 200040, PR China
| | - Zhou Fu
- Chongqing Children’s Hospital Affiliated to Chongqing Medical University, Chongqing 400015, PR China
| | - Yuejie Zheng
- Shenzhen Children’s Hospital, Shenzhen 518035, PR China
| | - Libo Wang
- Children’s Hospital of Fudan University, Shanghai 200040, PR China
| | - Chengrong Li
- Shenzhen Children’s Hospital, Shenzhen 518035, PR China
| | - Ying Shen
- Beijing Children’s Hospital Affiliated to Capital Medical University, Beijing 100045, PR China
| | - Sangjie Yu
- Beijing Children’s Hospital Affiliated to Capital Medical University, Beijing 100045, PR China
| | - Kaihu Yao
- Beijing Children’s Hospital Affiliated to Capital Medical University, Beijing 100045, PR China
| | - Lin Ma
- Beijing Children’s Hospital Affiliated to Capital Medical University, Beijing 100045, PR China
| | - Xuzhuang Shen
- Beijing Children’s Hospital Affiliated to Capital Medical University, Beijing 100045, PR China
| | - Yonghong Yang
- Beijing Children’s Hospital Affiliated to Capital Medical University, Beijing 100045, PR China
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Dundar D, Sayan M, Tamer GS. Macrolide and tetracycline resistance and emm type distribution of Streptococcus pyogenes isolates recovered from Turkish patients. Microb Drug Resist 2010; 16:279-84. [PMID: 20624096 DOI: 10.1089/mdr.2010.0021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The aims of this study were to determine the susceptibilities to macrolide and tetracycline antibiotics and emm type distribution of Streptococcus pyogenes strains isolated in the Kocaeli University Hospital, Turkey. A total of 127 S. pyogenes clinical isolates were tested. Eleven (9%) isolates were resistant to erythromycin, and 23 (18%) isolates were resistant to tetracycline. Ten of the erythromycin-resistant isolates were also resistant to tetracycline. By the triple-disk test, all erythromycin-resistant isolates showed the inducible macrolide-lincosamide-streptogramin-C phenotype and harbored erm(TR) gene. tet(O) was the most common tetracycline resistance gene. Among erythromycin-tetracycline coresistant isolates, seven harbored the tet(O) gene. emm 4, emm 1, emm 2,114, and emm 89 were the most common emm types. These isolates were more susceptible to erythromycin. There was considerable emm type heterogeneity in macrolide or tetracycline resistant isolates. According to our knowledge, this is the first study in which emm type distribution is investigated in Turkey. More comprehensive studies are needed to obtain true information about the epidemiology of macrolide and tetracycline resistance and emm type distribution in Turkey.
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Affiliation(s)
- Devrim Dundar
- Department of Microbioloy and Clinical Microbiology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey.
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Macrolide resistance in Streptococcus pyogenes: prevalence, resistance determinants, and emm types. Diagn Microbiol Infect Dis 2009; 64:295-9. [DOI: 10.1016/j.diagmicrobio.2009.03.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Revised: 02/25/2009] [Accepted: 03/05/2009] [Indexed: 11/21/2022]
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