Evaluation of methodology for serotyping invasive and nasopharyngeal isolates of Haemophilus influenzae in the ongoing surveillance in Brazil

Meningitis due to Haemophilus influenzae type f

With the decline in the rate of infections caused by Haemophilus influenzae serotype b since the widespread vaccination, non-b serotypes should be considered as potential pathogenic agents in children with invasive disease younger than 5 years old. We report the case of an immunocompetent 1-year-old boy with Haemophilus influenzae type f meningitis. The agent was identified in cerebrospinal fluid and blood cultures. Serotyping was performed by tests using polyclonal sera and confirmed by polymerase chain reaction. All Haemophilus influenzae isolates associated with invasive disease should be serotyped and notified as a way to evaluate the changes and trends in serotype distribution of this disease.

Identification of Haemophilus influenzae and Haemophilus haemolyticus by matrix-assisted laser desorption ionization-time of flight mass spectrometry

Generally accepted laboratory methods that have been used for decades do not reliably distinguish between H. influenzae and H. haemolyticus isolates. H. haemolyticus strains are often incorrectly identified as nontypeable Haemophilus influenzae (NTHi). To distinguish H. influenzae from H. haemolyticus we have created a new database on the matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) bio-typer 2 and compared the results with routine determination of Haemophilus (growth requirement for X and V factor), and multilocus sequence typing (MLST). In total we have tested 277 isolates, 244 H. influenzae and 33 H. haemolyticus. Using MLST as the gold standard, the agreement of MALDI-TOF MS was 99.6 %. MALDI-TOF MS allows reliable and rapid discrimination between H. influenzae and H. haemolyticus.

International circumpolar surveillance interlaboratory quality control program for serotyping Haemophilus influenzae and serogrouping Neisseria meningitidis, 2005 to 2009

The International Circumpolar Surveillance (ICS) program was initiated in 1999 to conduct population-based surveillance for invasive pneumococcal disease in select regions of the Arctic. The program was expanded to include the surveillance of invasive diseases caused by Neisseria meningitidis and Haemophilus influenzae. An interlaboratory quality control (QC) program to monitor laboratory proficiencies in the serogrouping of N. meningitidis and serotyping of H. influenzae strains was codeveloped by the Arctic Investigations Program (Anchorage, AK) and the Public Health Agency of Canada National Microbiology Laboratory (Winnipeg, Manitoba, Canada) and introduced into the ICS program in 2005. Other participating laboratories included the Provincial Laboratory for Public Health (Edmonton, Alberta, Canada), Laboratoire Santé Publique du Québec (Sainte-Anne-de-Bellevue, Québec, Canada), and Statens Serum Institut (Copenhagen, Denmark). From 2005 through 2009, 50 isolates (24 N. meningitidis and 26 H. influenzae isolates) were distributed among the five participating laboratories. The overall serogroup concordance for N. meningitidis strains was 92.3% (96/104), without including three isolates that were found to express both serogroup Y and W135 specificities. Concordant results were obtained for serogroups A, B, C, and Y among all laboratories. Discrepancies were observed most frequently for serogroups W135, X, Z, and 29E. The overall serotype concordance for H. influenzae was 98% (125/127 attempts). The two discrepant results involved a serotype c strain and a serotype e strain, and in both cases, the serotypeable H. influenzae isolates were misidentified as being nontypeable. These data demonstrate a high degree of concordance for serogroup and serotype determinations of N. meningitidis and H. influenzae isolates, respectively, among the five laboratories participating in this quality control program.

Increasing incidence of invasive Haemophilus influenzae disease in adults, Utah, USA

TOC Summary: The infection disproportionately affected patients >65 years of age.

Since the introduction of the Haemophilus influenzae type b vaccine, the incidence of invasive H. influenzae type b disease among children has fallen dramatically, but the effect on invasive H. influenzae disease among adults may be more complex. In this population-based study we examined the epidemiology and outcomes of invasive disease caused by typeable and nontypeable H. influenzae among Utah adults during 1998–2008. The overall incidence increased over the study period from 0.14/100,000 person-years in 1998 to 1.61/100,000 person-years in 2008. The average incidence in persons >65 years old was 2.74/100,000 person-years, accounting for 51% of cases and 67% of deaths. The incidence was highest for nontypeable H. influenzae (0.23/100,000 person-years), followed by H. influenzae type f (0.14/100,000 person-years). The case-fatality rate was 22%. The incidence of invasive H. influenzae in Utah adults appears to be increasing. Invasive H. influenzae infection disproportionately affected the elderly and was associated with a high mortality rate.

Changes in serotype distribution of Haemophilus influenzae meningitis isolates identified through laboratory-based surveillance following routine childhood vaccination against H. influenzae type b in Brazil

Following routine childhood vaccination against Haemophilus influenzae type b (Hib) disease in Brazil in 1999, passive laboratory surveillance reported increasing numbers of non-b serotypes and nontypeable H. influenzae (NTHi) from meningitis cases. To characterize this increase, we analyzed data on 3910 H. influenzae isolated from cerebrospinal fluid or blood from meningitis cases that were sent to the national reference laboratory for serotyping from 1990 to 2008. Hib accounted for 98% of H. influenzae meningitis isolates received during 1990-1999 versus 59% during 2000-2008, while non-b serotypes increased from 1% to 19% and NTHi increased from 2% to 22% of H. influenzae isolates received during the two periods. Higher proportions of non-b serotypes and NTHi than Hib were isolated from blood rather than cerebrospinal fluid. Estimated incidence rates for H. influenzae meningitis for Sao Paulo state remained below 1 case per million population during 2000-2008, although annual incidence of NTHi meningitis (mean, 0.03 cases per 100,000 population) increased in several age groups. Changes in surveillance for H. influenzae following introduction of Hib conjugate vaccine likely contributed to increased numbers of non-b and nontypeable H. influenzae meningitis isolates received at the national reference laboratory.

Determination of capsulation status in Haemophilus influenzae by multiplex polymerase chain reaction

Since the introduction of Haemophilus influenzae type b conjugate vaccines, there have been concerns regarding the emergence of invasive non-type b strains. Serotyping of H. influenzae with commercially available reagents is subjective. Definitive characterization of the capsulation status can be performed by polymerase chain reaction (PCR) amplification of capsular genes. However, PCR amplification of the conserved export locus in the 2 known phylogenic lines of type b strains and detection of serotype conferring genes in each of the 6 serotypes require multiple assays. To rapidly screen multiple isolates, we devised a multiplex method using 15 primers, which produced a serotype-specific, distinct pattern of amplicons with reference-encapsulated H. influenzae. We applied this technique to a panel of 35 clinical isolates that had been serotyped as type a, c, d, e, or f by slide agglutination; 15 strains lacked capsular genes. Conversely, of 69 invasive isolates that were not serotypeable, all but 11 contained capsule genes. We conclude that this technique will be useful in screening recently isolated H. influenzae for capsulation status.

Stronger in vitro phagocytosis by monocytes-macrophages is indicative of greater pathogen clearance and antibody levels in vivo

Monocytes-macrophages are crucial players in specific and nonspecific immune responses to protect organisms from invasion of bacteria or viruses. In this study, monocytes in circulation from 2 lines of Silky and Starbro chickens with different disease resistance were separated and cultured in vitro. After identification with acridine orange (AO), Giemsa staining, and CD14 immunostaining, monocytes-macrophages were used for adherence and phagocytosis test. The overall percentages of adherence of Silky monocytes was 1.5 times greater than that of Starbro (P < 0.01), which were 26.85% +/- 8.24% and 18.34% +/- 8.15%, respectively (mean +/- SD). The monocytes-macrophages phagocytic index, phagocytic product, and percentage of phagocytosis in Silkies were greater than in Star-bros, respectively. The difference of phagocytic index was significant (P < 0.05), that is, 3.70 +/- 1.75 and 1.97 +/- 0.31, respectively (mean +/- SD). Then, 20 Silkies were divided into 2 groups according to phagocytic index: high phagocytic index (HPI) group and low phagocytic index (LPI) group, to study the relationship between phagocytic activity in vitro and pathogen clearance. After being challenged against Salmonella Pullorum C79-13, the Silky birds with HPI produced a 3-fold greater level of specific antibodies compared with those with LPI (P < 0.01), 50.21 +/- 6.67 and 16.85 +/- 4.52, respectively (mean +/- SD). In contrast to LPI birds, HPI birds shed less Salmonella Pullorum bacteria (P < 0.05), that is, 168.98 x 10(8) +/- 294.74 x 10(8) compared to 385.40 x 10(8) +/- 399.94 x 10(8) (mean +/- SD), and the shedding peak of Salmonella Pullorum in the test span appeared 4 d earlier. These results indicated that phagocytosis of monocytes-macrophages had strong effects on antibody titer and bacteria shedding postchallenge, which could be used to predict the disease resistance in animals.

Invasive infections caused by haemophilus influenzae serotypes in twelve Canadian IMPACT centers, 1996-2001

BACKGROUND

Haemophilus influenzae type b (Hib) immunization has changed the epidemiology of pediatric bacterial invasive disease. We describe the epidemiology of H. influenzae invasive infections in 12 Canadian pediatric tertiary care [Immunization Monitoring Program, ACTive (IMPACT)] centers during the era of universal immunization against this pathogen.

METHODS

Children with positive cultures for H. influenzae serotypes a to f (Hia to Hif) and nontypable H. influenzae from sterile sites were identified from the laboratory records at 12 IMPACT centers from January 1, 1996 to December 31, 2001. Hospital records were retrospectively reviewed for demographic and clinical information.

RESULTS

Of 166 H. influenzae cases, 58 (35%) were caused by Hib, 89 (54%) by non-b serotypes, and 19 (11%) were not serotyped. The non-b serotypes included: 25 Hia (28%), 4 Hid (4%), 2 Hie (2%), 11 Hif (12%), and 47 were nontypable isolates (53%). For patients with Hib and Hia infection, meningitis was the most common presentation, accounting for 40% and 52% respectively, whereas the most common presentation for nontypable serotypes was pneumonia, seen in 43% of cases. Epiglottitis was associated mainly with Hib. Aboriginal ethnicity was an important risk factor for Hia cases, accounting for 76% of patients with infections caused by this serotype. Mean duration of hospitalization, need for admission to a pediatric intensive care unit, and case fatality rates were similar for the cases because of Hib, Hia, Hif, and nontypable serotypes.

CONCLUSIONS

In 1996-2001, two-thirds of H. influenzae invasive disease in the 12 IMPACT centers was caused by non-b serotypes, which were associated with significant morbidity and mortality.

Capsule gene analysis of invasive Haemophilus influenzae: accuracy of serotyping and prevalence of IS1016 among nontypeable isolates

We evaluated the accuracy of serologic capsule typing by analyzing capsule genes and related markers among invasive Haemophilus influenzae isolates before and after the introduction of H. influenzae serotype b (Hib) conjugate vaccines. Three hundred and sixty invasive H. influenzae isolates were collected as part of Active Bacterial Core surveillance within the Georgia Emerging Infections Program between 1 January 1989 and 31 July 1998. All isolates were biotyped, serotyped by slide agglutination serotyping (SAST), and evaluated using PCR capsule typing. Nontypeable H. influenzae (NTHi) isolates were probed with Hib cap-gene-containing plasmid pUO38 and with IS1016; a subset was examined with phosphoglucose isomerase (pgi) genotyping and pulsed-field gel electrophoresis (PFGE). Discrepancies between SAST and PCR capsule typing were found for 64/360 (17.5%) of the isolates; 48 encapsulated by SAST were NTHi by PCR, 8 NTHi by SAST were encapsulated by PCR, 6 encapsulated by SAST were a different capsule type by PCR, and 2 encapsulated by SAST were capsule-deficient Hib variants (Hib-minus). None of the PCR-confirmed NTHi isolates demonstrated homology with residual capsule gene sequences; 19/201 (9.5%) had evidence of IS1016, an insertion element associated with division I H. influenzae capsule serotypes. The majority of IS1016-positive NTHi were biotypes I and V and showed some genetic relatedness by PFGE. In conclusion, PCR capsule typing was more accurate than SAST and Hib-minus variants were rare. IS1016 was present in 9.5% of NTHi isolates, suggesting that this subset may be more closely related to encapsulated organisms. A better understanding of NTHi may contribute to vaccine development.

Microarray for serotyping of Bartonella species

Background

Bacteria of the genus Bartonella are responsible for a large variety of human and animal diseases. Serological typing of Bartonella is a method that can be used for differentiation and identification of Bartonella subspecies.

Results

We have developed a novel multiple antigenic microarray to serotype Bartonella strains and to select poly and monoclonal antibodies. It was validated using mouse polyclonal antibodies against 29 Bartonella strains. We then tested the microarray for serotyping of Bartonella strains and defining the profile of monoclonal antibodies.

Bartonella strains gave a strong positive signal and all were correctly identified. Screening of monoclonal antibodies towards the Gro EL protein of B. clarridgeiae identified 3 groups of antibodies, which were observed with variable affinities against Bartonella strains.

Conclusion

We demonstrated that microarray of spotted bacteria can be a practical tool for serotyping of unidentified strains or species (and also for affinity determination) by polyclonal and monoclonal antibodies. This could be used in research and for identification of bacterial strains.

Real-time PCR for determining capsular serotypes of Haemophilus influenzae

A two-step real-time PCR assay targeting all six capsulation loci of Haemophilus influenzae (i.e., serotypes a to f) was developed and compared with a previously published qualitative PCR assay by using 131 H. influenzae clinical isolates. There was a 98.5% concordance between the two tests. The sensitivity of detection of capsular type-specific reference strains of H. influenzae a to c (10(1) CFU/PCR) was higher than that for type e (10(3) CFU/PCR) and types d and f (10(4) CFU/PCR), and a broader dynamic range was obtained (5 to 8 log(10) units). No cross-reaction was observed with bacteria commonly isolated from the respiratory tract. We showed that both PCR assays are more reliable than slide agglutination serotyping. The real-time PCR-based assay seems to be an alternative of choice for the epidemiological follow-up of H. influenzae invasive infections.

[Molecular characterization of invasive Haemophilus influenzae strains isolated in Tunisia]

We reported a molecular characterization of 25 Haemophilus influenzae strains derived from cases of meningitis and sepsis in children aged less than five years hospitalized in pediatric wards from three hospitals in the Sahel area (Tunisia) during the period 1997-2002. These strains were biotyped and subjected to a capsular typing by Slide agglutination serotyping and Polymerase Chain Reaction (PCR). The genetic polymorphism of these strains was also studied in Arbitrarily Primed Polymerase Chain Reaction (AP-PCR) with two sets of primers: RAP IV and 217 delta(2) as in Pulsed Field Gel Electrophoresis after digestion of the total DNA with the restriction enzyme SmaI (PFGE SmaI). Nineteen strains among 25 (76%) were of biotype I. The bexA gene was highlighted in 13 strains (52%) and in all the cases it was of the type b. Twelve strains (48%) were shown to be unencapsulated by PCR. AP-PCR RAP IV (23 genotypes/25 with a discrimination index ID=0.993) had shown nearly the same discriminatory power than PFGE (20 genotypes/21 strains with a discrimination index ID=0.995). We thus note, how capsular typing by PCR is more sensitive than slide agglutination serotyping. We also note the genetic diversity of the invasive strains isolated with a remarkable presence of non typable strains. AP PCR seems to be an alternative of choice for the epidemiologic follow-up of the Haemophilus influenzae invasive infections.

Antimicrobial susceptibility of Haemophilus influenzae isolates collected from 4 centers in Brazil (1990–2003)

Antimicrobial susceptibility was determined for 174 Haemophilus influenzae strains collected from patients with infection before and after vaccination against Hib (1990-1999 and 2000-2003, respectively) from 4 public health -laboratories in 3 Brazilian states. All strains were characterized for serotype and beta-lactamase production and in vitro activity of the following antimicrobial agents: -ampicillin, amoxicillin/clavulanate, ceftriaxone, rifampin, chloramphenicol, and trimethoprim/sulfamethoxazole (TMP-SMX). Minimum inhibitory concentrations were determined according to the guidelines of the National Committee for Clinical Laboratory Standards. Overall, ampicillin resistance was observed in 29 strains (17%), all beta-lactamase producers. All isolates were susceptible to amoxicillin/clavulanate and ceftriaxone. The prevalence of TMP-SMX-resistant isolates increased from 32.6% in the period 1990-1999 to 65.8% during the period 2000-2003. Among these isolates, 10.0% and 12.5% were resistant to ampicillin and chloramphenicol, respectively. Resistance to rifampin was detected in 8.2% and 9.7% of the strains, in 2 periods, respectively. Continued surveillance is necessary to monitor trends with the H. influenzae disease in Brazil.

[Impact of Haemophilus influenzae b (Hib) vaccination on meningitis in Central Brazil]

OBJECTIVE

To assess the impact of the Haemophilus influenzae b (Hib) conjugate vaccine in reducing the incidence of meningitis among children under five years old.

METHODS

A 'before-after' design was used to compare Hib meningitis incidence rates in the pre-vaccine (July 1995 - June 1999) and post-vaccine (July 1999 - June 2001) periods in the state of Goias, central Brazil. Bacterial meningitis case definition was based on World Health Organization criteria. Incidence rates of S. pneumoniae and N. meningitidis were used for comparison purposes. Chi-squared and Student's t tests were used for statistical analysis. P-values below 0.05 were considered as statistically significant.

RESULTS

979 children with acute bacterial meningitis were detected throughout the entire period. The incidence rate of Hib meningitis decreased from 10.8 (x10(5)) in the pre-vaccine period to 2.3 (x10(5)) in the 2nd year post vaccination, leading to a risk reduction of 78%, targeted to the 7-23 months age group (p<0.05). A total of 65 cases of Hib meningitis were prevented. An increase in S. pneumoniae meningitis was observed. Vaccine failure was detected in one child.

CONCLUSIONS

This study showed that mass immunization with Hib conjugate vaccine brought about an expressive decline in childhood Hib meningitis in Goias soon after the first year. Notwithstanding, an enhancement of surveillance using high-accuracy tools is essential to: (i) detect a possible reemergence of Hib; (ii) identify vaccine failure, and (iii) monitor changes in the H. influenzae serotype profile over time.

PCR-based capsular serotype determination of Haemophilus influenzae strains recovered from Japanese paediatric patients with invasive infection

The serotypes of 53 isolates of Haemophilus influenzae from children with invasive infections were determined by a conventional slide agglutination test (SAT) and a recently proposed PCR-based method for serotyping H. influenzae. The PCR assay identified 47 (88.7%) type b isolates, one (1.9%) type e isolate and five (9.4%) non-typeable isolates. The only discrepancy between the methods was an isolate that was non-typeable by SAT, but was identified as serotype e by PCR. Of 41 isolates from patients with meningitis, 39 (95.1%) were type b. Of the five non-typeable isolates, three (60%) were from the blood of patients with septicaemic pneumonia and two (40%) were from the cerebrospinal fluid of patients with meningitis. None of the non-typeable isolates appeared to be a capsule-deficient mutant of an encapsulated H. influenzae strain. Overall, the study confirmed the usefulness of this PCR method for the serotyping of invasive H. influenzae isolates.