Clinical and molecular epidemiology of erythromycin-resistant beta-hemolytic lancefield group G streptococci causing bacteremia

Infections Caused by Group C and G Streptococcus (Streptococcus dysgalactiae subsp. equisimilis and Others): Epidemiological and Clinical Aspects

Streptococci carrying serogroup C and G antigens, and in particular, Streptococcus dysgalactiae subsp. equisimilis (SDSE), are emerging human pathogens that are increasingly isolated from patients with a myriad of infections that range from mundane to life-threatening. SDSE is microbiologically similar to Streptococcus pyogenes. These streptococci frequently cause infections of the throat and skin and soft tissues. Moreover, they may invade the bloodstream and disseminate widely to many deep tissue sites, including the endocardium. Life-threatening invasive infections due to SDSE, including the streptococcal toxic shock syndrome, occur most frequently in patients with severe underlying medical diseases. Treatment with penicillin is adequate under most circumstances, but treatment failure occurs. SDSE may also be resistant to other antibiotic classes including tetracyclines, macrolides, and clindamycin. Most human infections caused by groups C and G streptococci are transmitted from person to person, but infections due to Streptococcus equi subsp. zooepidemicus (and, rarely, to S. equi subsp. equi) are zoonoses. Transmission of these latter species occurs by animal contact or by contamination of food products and has been associated with the development of poststreptococcal glomerulonephritis. Members of the Streptococcus anginosus group, usually classified with the viridans group of streptococci, are associated with a variety of pyogenic infections.

Highly prevalent emmSTG840.0 and emmSTC839.0 types of erythromycin non-susceptible group G Streptococcus isolated from bacteremia in southern Taiwan

BACKGROUND/PURPOSE

Group G Streptococcus (GGS) infections in human have increased. Treatment relied on antibiotic therapy, including erythromycin. However, information regarding the dominant strains and erythromycin susceptibility in GGS bacteremia is limited.

METHODS

A total of 134 GGS were isolated from patients with bacteremia in a university hospital of southern Taiwan during 1993-2010. The erythromycin susceptibility was determined by disc diffusion and agar dilution assays. The bacterial species was determined by MALDI-TOF. The presence of erythromycin-resistant genes and emm types were determined by polymerase chain reaction and sequence. The clonal spreading was analyzed by pulsed-field gel electrophoresis with SmaI or SgrAI digestion.

RESULTS

The annual erythromycin non-susceptible rate varied, with an average of 40.3%. All erythromycin non-susceptible strains belonged to the Streptococcus dysgalactiae. No erythromycin non-susceptible strains belong to the anginosus group. The most prevalent erythromycin-resistant gene was mefA (57.4%), followed by ermB (37%), and ermA (3.7%). The N terminal hyper variable region of emm was sequenced to determine the emm type, and only S. dysgalactiae had the emm gene. The most prevalent emm types were emmSTG840.0 (17.2%), emmSTG485.0 (10.4%), and emmSTC839.0 (9.0%). 73% and 47% of the strains with only mefA and ermB belonged to emmSTG840.0 and emmSTC839.0 types, respectively. Pulsed-field gel electrophoresis showed that different clones of emmSTG840.0 and emmSTC839.0 strains were spread in this region during the 18 years of surveillance.

CONCLUSION

Our data indicate that there were dominant emm types with erythromycin non-susceptibility in S. dysgalactiae isolated from bacteremia in Taiwan, and thus constant surveillance is warranted.

[Group G streptococcal bacteremia in the post-partum period. A case report]

Bacteremia with streptococcus group G is a rare infection, particularly in the post-partum, but of which the incidence has been increasing since the end of the 20th century. The objective of our work is to report the clinical and the bacteriologic aspects, as well as the therapeutic modalities of an exceptional case of bacteremia with streptococcus group G, after a normal vaginal delivery, in a 26-year-old woman. Streptococcus group G being a part of the normal flora of the female genital tract, the endogenous contamination probably took place by passage in the blood circulation during the episiotomy.

New genetic element carrying the erythromycin resistance determinant erm(TR) in Streptococcus pneumoniae

erm(A) subclass erm(TR), a common macrolide resistance determinant in Streptococcus pyogenes but quite rare in Streptococcus pneumoniae, was found in a clinical S. pneumoniae isolate (AP200) from Italy. In this isolate, erm(TR) was found included in a genetic element approximately 56 kb in size that did not appear to be conjugative but could be transferred by transformation. An erm(TR)-containing DNA fragment of approximately 10 kb was sequenced and 12 open reading frames (ORFs) were identified. Upstream of erm(TR), a regulatory protein of the TetR family and the two components of an efflux pump of the ABC type were found. Downstream of erm(TR), there were ORFs homologous to a spectinomycin phosphotransferase, transposases, and a relaxase. Since the genomic sequence of S. pyogenes MGAS10750 carrying erm(TR) became available, comparison between the erm(TR)-containing genetic elements in AP200 and in MGAS10750 was performed. The region flanking erm(TR) in MGAS10750 showed identity with AP200 for 10 ORFs out of 12. PCR mapping using primers designed on the sequence of MGAS10750 confirmed that AP200 carries a genetic element similar to that of MGAS10750. In AP200 the genetic element was inserted inside an ORF homologous to spr0790 of S. pneumoniae R6, coding for a type I restriction modification system. Homologies between the insertion sites in AP200 and MGAS10750 consisted of eight conserved nucleotides, of which three were duplicated, likely representing target site duplication. The structure of the erm(TR)-carrying genetic element shows characteristics of a transposon/prophage remnant chimera. In AP200 this genetic element was designated Tn1806.

Composite structure of Streptococcus pneumoniae containing the erythromycin efflux resistance gene mefI and the chloramphenicol resistance gene catQ

In recent years mef genes, encoding efflux pumps responsible for M-type macrolide resistance, have been investigated extensively for streptococci. mef(I) is a recently described mef variant detected in particular isolates of Streptococcus pneumoniae instead of the more common mef(E) and mef(A). This study shows that mef(I) is located in a new composite genetic element, whose sequence was completely analyzed and the left and right junctions determined, demonstrating a unique genetic organization. The new composite structure (30,505 bp), designated the 5216IQ complex, consists of two halves: a left one (15,316 bp) formed by parts of the known transposons Tn5252 and Tn916, and a right one (15,115 bp) formed by a new fragment, designated the IQ element. While the defective Tn916 contained a silent tet(M) gene, the IQ element, ending with identical transposase genes on both sides and containing the mef(I) gene with an adjacent new msr(D) gene variant and a catQ chloramphenicol acetyltransferase gene, was completely different from the genetic elements carrying other mef genes in pneumococci. This is the first report demonstrating catQ in S. pneumoniae and showing its linkage with a mef gene. Analysis of the chromosomal region beyond the left junction revealed an organization more similar to that of S. pneumoniae strain TIGR4 than to that of strain R6. The 5216IQ complex was apparently nonmobile, with no detectable transfer of erythromycin resistance being obtained in repeated transformation and conjugation assays.

Streptococcus canis infections in humans: Retrospective study of 54 patients

This 5-year retrospective study reports 54 patients with infection, caused by Streptococcus canis, a pyogenic Lancefield group G streptococcus initially isolated from various animal sources. During 1997-2002, Streptococcus canis accounted for 1% of all streptococci isolated. The clinical signs, outcome and bacteriological characteristics were reviewed. All except eight were symptomatic. Clinical manifestations were: soft tissue infection (n=35), bacteremia (n=5), urinary infection (n=3), bone infection (n=2) and pneumonia (n=1). The course was favorable in 52 cases while two died from sepsis. Cultures were often polymicrobial (n=42, 77.8%) apart from hemocultures. The isolates were sensitive to most antibiotics. Presence of the bacteria did not always signify infection owing to the possible occurrence of colonization. The frequency of S. canis infections is rare and likely underestimated owing to the fact that streptococci are sought only on the basis of the Lancefield classification. The search for S. canis is recommended whenever patients present with symptoms evocative of exposure to a potentially contaminated animal.

Antibiotic resistances of starter and probiotic strains of lactic acid bacteria

The antibiotic resistances of 45 lactic acid bacteria strains belonging to the genera Lactobacillus, Streptococcus, Lactococcus, Pediococcus, and Leuconostoc were investigated. The objective was to determine antibiotic resistances and to verify these at the genetic level, as is currently suggested by the European "qualified presumption of safety" safety evaluation system for industrial starter strains. In addition, we sought to pinpoint possible problems in resistance determinations. Primers were used to PCR amplify genes involved in beta-lactam antibiotic, chloramphenicol, tetracycline, and erythromycin resistance. The presence of ribosomal protection protein genes and the ermB gene was also determined by using a gene probe. Generally, the incidences of erythromycin, chloramphenicol, tetracycline, or beta-lactam resistances in this study were low (<7%). In contrast, aminoglycoside (gentamicin and streptomycin) and ciprofloxacin resistances were higher than 70%, indicating that these may constitute intrinsic resistances. The genetic basis for ciprofloxacin resistance could not be verified, since no mutations typical of quinolone resistances were detected in the quinolone determining regions of the parC and gyrA genes. Some starter strains showed low-level ampicillin, penicillin, chloramphenicol, and tetracycline resistances, but no known resistance genes could be detected. Although some strains possessed the cat gene, none of these were phenotypically resistant to chloramphenicol. Using reverse transcription-PCR, these cat genes were shown to be silent under both inducing and noninducing conditions. Only Lactobacillus salivarius BFE 7441 possessed an ermB gene, which was encoded on the chromosome and which could not be transferred in filter-mating experiments. This study clearly demonstrates problems encountered with resistance testing, in that the breakpoint values are often inadequately identified, resistance genes may be present but silent, and the genetic basis and associated resistance mechanisms toward some antibiotics are still unknown.

Evolution and global dissemination of macrolide-resistant group A streptococci

Macrolide-resistant group A streptococci (MRGAS) have been recovered from many countries worldwide. However, the strain typing information that is available has been insufficient for estimating the total number of macrolide-resistant clones, their geographic distributions, and their evolutionary relationships. In this study, sequence-based strain typing was used to characterize 212 MRGAS isolates from 34 countries. Evaluation of clonal complexes, emm type, and resistance gene content [erm(A), erm(B), mef(A), and undefined] indicate that macrolide resistance was acquired by GAS organisms via > or independent genetic events. In contrast to other collections of mostly susceptible GAS, genetic diversification of MRGAS clones has occurred primarily by mutation rather than by recombination. Twenty-two MRGAS clonal complexes were recovered from more than one continent; intercontinental strains represent nearly 80% of the MRGAS isolates under study. The findings suggest that horizontal transfer of macrolide resistance genes to numerous genetic backgrounds and global dissemination of resistant clones and their descendants are both major components of the present-day macrolide resistance problem found within this species.

Cross-infection between cats and cows: origin and control of Streptococcus canis mastitis in a dairy herd

Group G streptococci in animals usually belong to the species Streptococcus canis and are most commonly found in dogs and cats. Occasionally, Strep. canis is detected in milk from dairy cows. An outbreak of Strep. canis mastitis in a dairy herd is described. Based on results from bacterial culture and ribotyping, a cat with chronic sinusitis was the most likely source of the outbreak. Subsequent cow-to-cow transmission of Strep. canis was facilitated by poor udder health management, including use of a common udder cloth and failure to use postmilking teat disinfection. Infected cows had macroscopically normal udders and milk, but significantly higher somatic cell counts than Strep. canis-negative herd mates. The outbreak was controlled through antibiotic treatment of lactating cows, early dry-off with dry cow therapy, culling of infected animals, and implementation of standard mastitis prevention measures. Cure was significantly more likely in dry-treated cows (87.5%) and cows treated during lactation (67%) than in untreated cows (9%). Whereas mastitis due to group G streptococci or Strep. canis in dairy cows is usually limited to sporadic cases of environmental (canine or feline) origin, this case study shows that crossing of the host species barrier by Strep. canis may result in an outbreak of mastitis if management conditions are conducive to contagious transmission. In such a situation, measures that are successful in control of Strep. agalactiae can also be used to control Strep. canis mastitis.

Molecular epidemiology of macrolide resistance in beta-haemolytic streptococci of Lancefield groups A, B, C and G and evidence for a new mef element in group G streptococci that carries allelic variants of mef and msr(D)

OBJECTIVES

To study the molecular mechanisms of erythromycin resistance in beta-haemolytic streptococci of Lancefield groups A, B, C and G.

METHODS

Erythromycin-resistant clinical isolates from North East Scotland were collected over 2 years. Resistance phenotypes were determined by disc diffusion and MICs by Etest. Resistance genes mef, msr(D), erm(B) and erm(TR) were identified by PCR and mef and msr(D) were sequenced.

RESULTS

Erythromycin resistance prevalence was 1.9% in group A streptococci (31 of 1625), 4.3% in group B (53 of 1233), 3.8% in group C (18 of 479) and 6.2% in group G (64 of 1034). The numbers of resistant isolates available were 26, 42, 9 and 52 in each group respectively. The majority of resistant isolates in groups A (57.7%, 15 of 26), B (88.1%, 37 of 42) and G (90.4%, 47 of 52) were MLS(B). The contribution of M phenotype was significant in groups C (77.8%, 7 of 9) and A (42.3%, 11 of 26). Group A isolates carried mef(A) and group B carried mef(E) exclusively. A mef sequence distinct from mef(A) and mef(E) was identified in group G and was associated with a new msr(D) sequence. These sequence variants appear to be part of a new genetic element that is inserted in the comEC gene. A bimodal distribution of erythromycin MICs was noted in erm(TR) isolates.

CONCLUSIONS

The results demonstrate significant differences in the mechanisms of macrolide resistance amongst different Lancefield groups in the same geographical area. New sequences show that resistance mechanisms are still evolving.

Life-threatening invasive Helcococcus kunzii infections in intravenous-drug users and ermA-mediated erythromycin resistance

We report the first two cases of life-threatening invasive Helcococcus kunzii infection, with primary bacteremia and empyema thoracis, respectively. Gram smears of both H. kunzii isolates showed a mixture of gram-positive and gram-negative cocci. The isolate from the first patient, resistant to erythromycin and clindamycin, possessed an ermA gene.

Macrolide and lincosamide resistance genes of environmental streptococci from bovine milk

Environmental streptococcus isolates from bovine milk were identified to the species and strain level and screened for resistance to macrolide and lincosamide antibiotics by phenotypic and genotypic methods. Isolates were tested for resistance to erythromycin and pirlimycin by broth microdilution assays. Presence of ribosomal methylase genes (ermA, ermB, ermC) and efflux pump genes (mefA/E, msrA/C) was detected by polymerase chain reaction (PCR). Resistance to pirlimycin (minimum inhibitory concentration (MIC) = 8microg/ml) was detected in 6 of 13 Enterococcus isolates that were identified as E. faecium by API20Strep typing. msrC was detected in 10 enterococcal isolates but the detection of msrC was not associated with phenotypic resistance. msrC negative isolates were reclassified as Enterococcus mundtii based on sequencing of housekeeping genes. Resistance to erythromycin and pirlimycin (MIC > 16microg/ml) was detected in 4 of 4 Streptococcus dysgalactiae and 12 of 20 Streptococcus uberis isolates and was encoded by ermB. All Streptococcus isolates tested negative for ermA, ermC, mefA/E and msrA/C. Among ermB positive streptococci, three alleles were identified based on a 527 bp gene fragment. Each allele was detected in at least two herds. The same alleles have also been detected in other bacterial species from bovine and non-bovine hosts and farm soil, suggesting a theoretical potential for horizontal transfer of macrolide resistance genes on dairy farms.

mef(A), mef(E) and a new mef allele in macrolide-resistant Streptococcus spp. isolates from Norway

OBJECTIVES

To type mef genes in a nationwide collection of clinical isolates of Streptococcus pneumoniae and Streptococcus pyogenes as well as pharyngeal carrier strains of viridans streptococci in Norway.

METHODS

Erythromycin-resistant mef-positive multilocus sequence-typed (MLST) clinical isolates of S. pneumoniae (n = 36) and S. pyogenes (n = 12) from the National Surveillance Program for Antimicrobial Resistance (NORM) as well as viridans streptococci (n = 20) from healthy adults were included. PCR-amplified mef genes were initially discriminated by BamHI digestion. Selected mef genes from representatives of different sequence types (STs) of S. pneumoniae (n = 11) and S. pyogenes (n = 4), and viridans group streptococcal species (n = 8) were typed by sequencing and their strains examined for co-resistances. Hydropathy plots of different mef-encoded proteins were performed.

RESULTS

A predominance of mef(A) was detected in S. pneumoniae (23/36) and S. pyogenes (9/12) due to the clonal spread of ST9 and ST39, respectively. mef(E) was the most widely distributed mef determinant occurring in nine different STs of S. pneumoniae and in four different viridans species. A new mef allele was identified in two STs of S. pyogenes.

CONCLUSIONS

mef(E) is the most widely distributed mef determinant in Norwegian clinical strains of S. pneumoniae and pharyngeal carrier strains of various viridans streptococci. However, mef(A) is more prevalent in S. pneumoniae and S. pyogenes due to clonal spread. A new mef allele was found in two different STs of S. pyogenes.

Rapid and reliable real-time PCR assay for detection of the macrolide efflux gene and subsequent discrimination between its distinct subclasses mef(A) and mef(E)

A real-time PCR assay is described for detection of the macrolide efflux gene, mef. Following amplification, unambiguous discrimination between the two mef subclasses, mef(A) and mef(E), is easily established using a melting curve analysis. The results of this novel assay were 100% concordant with a conventional PCR-RFLP approach but requires far less hands-on time. Furthermore, the real-time format offers semiquantitative results allowing identification of contaminated cultures and/or DNA preparations.

Continuous ambulatory peritoneal dialysis-related peritonitis associated with Lancefield group G beta-hemolytic streptococcus: report of two cases requiring Tenckhoff catheter removal

We describe the first two cases of continuous ambulatory peritoneal dialysis-related peritonitis associated with Lancefield group G beta-hemolytic streptococci in the literature. Both patients presented with abdominal pain and turbid dialysis effluent with or without fever. Both had concomitant gastrointestinal tract disturbance. Both did not respond to intraperitoneal cefazolin and tobramycin and required removal of the Tenckhoff catheters.

Resistance phenotypes and genotypes of erythromycin-resistant Streptococcus pneumoniae isolates in Beijing and Shenyang, China

Of a total of 192 Streptococcus pneumoniae isolates, 149 (77.6%) were not susceptible to erythromycin. Of these 149 isolates, 117 (79.1%) contained the erm(B) gene, 16 (10.8%) contained the mef(A) gene, and 15 (10.1%) harbored both the erm(B) and mef(A) genes.

Lack of evidence that DNA in antibiotic preparations is a source of antibiotic resistance genes in bacteria from animal or human sources

Although DNA encoding antibiotic resistance has been discovered in antibiotic preparations, its significance for the development of antibiotic resistance in bacteria is unknown. No phylogenetic evidence was obtained for recent horizontal transfer of antibiotic resistance genes from antibiotic-producing organisms to bacteria from human or animal sources.

Phenotypic and molecular characterization of erythromycin resistance in four isolates of Streptococcus-like gram-positive cocci causing bacteremia

Among nine patients with bacteremia caused by Granulicatella or Gemella in a 6-year period (July 1995 to June 2001), three had bacteremia caused by erythromycin-resistant Granulicatella adiacens and one had bacteremia caused by erythromycin-resistant Gemella haemolysans. All four isolates possessed mef genes, whereas none possessed ermT, ermTR, or ermB genes.