The epidemiology of severe Streptococcus pyogenes associated disease in Europe

Several European countries reported outbreaks of severe disease caused by Streptococcus pyogenes in the late 1980s. This marked a departure from the previous decades, where very few such outbreaks were noted. These changes in disease occurrence formed part of a global phenomenon, the reasons for which have yet to be explained. Results of surveillance activities for invasive S. pyogenes infection within Europe over the past fifteen years identified further increases in many countries. However, variations in surveillance methods between countries preclude robust comparisons being made, illustrating the need for a unified surveillance strategy across Europe. This was finally embodied in the Strep-EURO programme, introduced in 2002.

The epidemiology of severe Streptococcus pyogenes associated disease in Europe

Several European countries reported outbreaks of severe disease caused by Streptococcus pyogenes in the late 1980s. This marked a departure from the previous decades, where very few such outbreaks were noted. These changes in disease occurrence formed part of a global phenomenon, the reasons for which have yet to be explained. Results of surveillance activities for invasive S. pyogenes infection within Europe over the past fifteen years identified further increases in many countries. However, variations in surveillance methods between countries preclude robust comparisons being made, illustrating the need for a unified surveillance strategy across Europe. This was finally embodied in the Strep-EURO programme, introduced in 2002.

Comparison of strand displacement and ligase chain amplification for detection of Chlamydia trachomatis infection in urogenital specimens

Two amplification tests for the diagnosis of Chlamydia trachomatis infection, namely the ligase chain reaction (LCx) and the strand displacement assay (ProbeTec), were compared using samples from 1183 patients at sexually transmitted disease clinics. The overall prevalence of positive results was 8.0%, with agreement between the two assays of 98.8%. For endocervical, urethral and male urine samples, agreement was 99.3%, 99.4% and 97.7%, respectively. For ten discrepant samples, alternative amplification assays suggested that the LCx and ProbeTec assays gave erroneous results in six and four cases, respectively. Inhibition of amplification was observed with three (0.25%) urine specimens.

Myocardial tissue damage in rabbits injected with group A streptococci, types M1 and M22. Role of bacterial immunoglobulin G-binding surface proteins

Acute rheumatic fever (ARF) and acute poststreptococcal glomerulonephritis (APSGN), two important sequelae of streptococcal throat or skin infections, according to current concepts may be elicited by autoimmune mechanisms due to molecular mimicry between group A streptococci (GAS) and human tissue. In the case of APSGN, however, our experimental data have indicated that GAS immunoglobulin-binding surface proteins (IgG BPs) might be of pathogenic significance by triggering anti-IgG production and immune complex formation leading to renal damage. Thus, rabbits injected with IgG-binding, as opposed to non-binding, GAS strains were found to develop renal deposition of IgG and complement factor C3 and inflammatory and degenerative glomerular changes resembling the picture seen in APSGN. In the present study, cardiac tissue material from rabbits injected with GAS was investigated. After 8 or more weeks of intravenous (i.v.) injections, minimal changes were seen in those animals receiving an IgG non-binding GAS strain, type T27, whereas those animals receiving either of two IgG-binding GAS strains, types M1 or M22, developed strong inflammatory and degenerative myocardial changes accompanied by deposition of IgG and C3. Furthermore, on injecting rabbits with defined mutants of a type M22 strain, the development of myocardial tissue damage proved to be dependent on the presence of streptococcal IgG-binding activity. Our results demonstrate that myocardial tissue changes may be induced in the rabbit by i.v. injection of whole heat-killed GAS of at least two M serotypes. Conceivably, induction of immune complexes by bacterial IgG BPs may lead to myocardial deposition of IgG, in turn triggering a series of events, involving the complement system and proinflammatory cytokines, with resulting tissue damage. Though many virulence factors may be involved in the development of ARF and APSGN, and a given GAS strain will never cause both, our results may suggest a new pathogenetic mechanism common to these two major non-suppurative complications.

New antimicrobial peptide active against Gram-positive pathogens

BACKGROUND & OBJECTIVES

Human and animal cystatins have been shown to inhibit the replication of certain viruses and bacteria, though it is not directly demonstrated that the effects are due to protease inhibitory capacity of the cystatins. We report antibacterial properties of a novel antimicrobial peptidyl derivative, (2S)-2-(N(alpha)-benzyloxycarbonyl-arginyl-leucylamido)-1-[(E)-cinnamoylamido]-3- methylbutane, structurally based upon the aminoterminal segment of the inhibitory centre of the human cysteine protease inhibitor, cystatin C.

METHODS

Clinical isolates of group A, B, C and G streptococci were collected. The antibacterial activity of Cystapep 1 derivative was tested by agar well diffusion method.

RESULTS

Cystapep 1, displayed antibacterial activity against several clinically important Gram-positive bacteria. It displayed minimal inhibitory and bactericidal concentrations of about 16 microg/ml for both Staphylococcus aureus and Streptococcus pyogenes. In radial agar diffusion assays, groups A, B, C and G streptococci as well as staphylococci were generally susceptible to the action of Cystapep 1, whereas pneumococci and enterococci were less susceptible. No activity against Gram-negative bacteria was observed.

INTERPRETATION & CONCLUSION

Cystapep 1 also showed high activity against methicillin-resistant Staph. aureus (MRSA) and multi-antibiotic resistant coagulase negative staphylococci (CNS), suggesting its mechanism of action to be different from most currently used antibiotics.

Induction of myocarditis in rabbits injected with group A streptococci

BACKGROUND & OBJECTIVES

We have earlier proposed that group A streptococcal (GAS) immunoglobulin binding surface proteins (IgGBPs) might trigger anti-IgG production and immune complex formation leading to glomerulonephritis. In the present study, cardiac tissue material from rabbits injected with heat-killed GAS was investigated.

METHODS

Rabbits were injected intravenously with 10(9) colony forming units of streptococci three times weekly for 8 wk. Cardiac tissue samples were obtained at different times and deposition of IgG, C3, TNF-alpha and IL-6 was studied.

RESULTS

After 8 or more weeks of intravenous (iv) injections, minimal changes were seen in animals receiving an IgG non-binding GAS strain, type T27, whereas in those animals receiving either of two IgG binding GAS strains, types M1 or M22, strong inflammatory and degenerative myocardial changes accompanied by deposition of IgG and C3 were noted. Furthermore, on injecting rabbits with defined mutants of a type M22 strain, the development of myocardial tissue damage proved to be dependent on the presence streptococcal IgGBPs.

INTERPRETATION & CONCLUSION

The present data supported a role of streptococcal IgGBPs in the induction of myocardial tissue injury by GAS.

Unusual occurrence of M type 77, antibiotic-resistant group A streptococci in southern Sweden

For many years group A streptococci of T type 28 (T28) have been common in southern Sweden; however, since 1995 resistance to both macrolide-lincosamide-streptogramin B (MLS) antibiotics and tetracycline was observed among T28 isolates, which prompted the present studies on clonal relatedness of antibiotic-resistant T28 strains. By extended T typing, 95 of 100 examined tetracycline-resistant strains showed the combination T9-T13-T28; of these, 94 belonged to M type 77 (M77) and one belonged to M73. Three strains were T28-M28 and two were T28-M nontypeable. The serological M77 was confirmed by PCR capture enzyme-linked immunosorbent assay, emm amplicon restriction profiling, and emm sequence typing. Fifty strains were examined for superantigen genes: speA was detected in three blood isolates only, whereas all isolates harbored speB, and only two of the strains were negative for speC. Eighty-nine of the 100 strains were also macrolide resistant, of which 59 were inducibly MLS resistant (IR) and 21 were constitutively MLS resistant (CR), 6 were noninducibly resistant (NI), and 3 had novel subphenotypes recently reported by our group. Resistance genes were determined by PCR and hybridization methods. Eighty-four of the 100 strains harbored tetM. ermB was detected in all CR and IR strains, and mefA was found in all NI strains; both ermB and mefA were identified in two strains with novel subphenotypes. Pulsed-field gel electrophoresis showed that these antibiotic-resistant M77 strains belonged to at least five different clones.

Synthesis and antibacterial properties of peptidyl derivatives and cyclopeptides structurally based upon the inhibitory centre of human cystatin C. Dissociation of antiproteolytic and antibacterial effects

Cysteine protease-inhibiting proteins of the cystatin superfamily can inhibit the replication of certain viruses and bacteria. The inhibitory centre of human cystatin C, the most widely distributed human cystatin, comprises three peptide segments. The present work describes the synthesis and antibacterial activity of 27 new peptidyl derivatives or cyclopeptides based upon the aminoterminal segment Arg8-Leu9-Val10-Gly11. Fourteen of the new compounds displayed antibacterial activity against from 1 up to 9 of 17 clinically important bacterial species tested. Antiproteolytic activity of a compound was usually not required for its antibacterial capacity. Peptidyl diazomethanes generally had a very narrow antibacterial spectrum, inhibiting only Streptococcus pyogenes, whereas cyclopeptides and peptidyl derivatives of the general structure X-Arg-Leu-NH-CH(iPr)-CH2-NH-Y had a much wider spectrum. The most potent of these substances displayed approximately equal minimal inhibitory and bactericidal concentrations of about 20 microg/ml for both Staphylococcus aureus and S. pyogenes and were devoid of antiproteolytic activity. Several of the new substances could protect mice against lethal intraperitoneal challenge with S. pyogenes. Though their target remains to be disclosed, the group of substances here reported might be promising for the development of antibacterial drugs and the discovery of novel principles of action.

Intraoperative contamination of synthetic vascular grafts. Effect of glove change before graft implantation. A prospective randomised study

OBJECTIVES

to investigate the incidence of intraoperative graft contamination, bacterial species and the influence of change of surgeon's gloves on contamination.

DESIGN

a prospective randomised study.

MATERIALS AND METHODS

forty patients had implantation of synthetic vascular grafts. All patients received intraoperative cloxacillin (2.0 g) or clindamycin (0.6 g) intravenously. The procedures were randomised to two groups: Group 1 - surgeons changed the gloves before the first contact with the vascular prosthesis and Group 2 - operation without glove change. The growth of all bacterial species from graft segments and from the gloves was recorded. The susceptibility to antibiotics was tested.

RESULTS

the number of contaminated grafts was similar in the two groups. Growth of bacteria was recorded from 92.5% (37/40) of the graft segments and 33% (51/156) of glove imprints. Of the cultured species, 75% and 47%, respectively, were identified as coagulase-negative staphylococci (CNS). Twenty-eight per cent of CNS were resistant to cloxacillin, 15% to clindamycin, and 10% to cloxacillin and clindamycin. In all, 25% of the CNS strains were resistant to the prophylactic antibiotic used. In 50% of cases, the antibiogram of the CNS strain recovered from gloves agreed with that of the strain harvested from the graft.

CONCLUSIONS

a high incidence of graft contamination was found which was not reduced by changing gloves. However, changing gloves did seem to reduce the number of bacterial species.

Streptococcal opacity factor: a family of bifunctional proteins with lipoproteinase and fibronectin-binding activities

The serum opacity factor (SOF) of Streptococcus pyogenes is a type-specific lipoproteinase of unknown biological significance. We have sequenced the sof gene and characterized the corresponding SOF protein from a strain of type M63. It was found that sof63 is related to sof22 and that, similar to SOF22 [25], SOF63 binds fibronectin. Moreover, we demonstrate opacity factor activity in a Streptococcus dysgalactiae fibronectin-binding protein FnBA that is structurally related to the SOF proteins of S. pyogenes. Sequence analysis of these three SOF proteins showed a unique periodical pattern of conserved and variable regions. The enzymatically active part of SOF63 was localized to the fragment corresponding to the entire set of conserved and variable sequences, while for fibronectin-binding a single repeat in the C terminal part of the protein was sufficient. The results show that streptococcal SOF proteins form a novel family of bifunctional proteins with lipoproteinase and fibronectin-binding activities.

Epidemiologic and molecular investigation of outbreaks of hepatitis C virus infection on a pediatric oncology service

BACKGROUND

Despite screening of blood donors, hepatitis C virus (HCV) infection can occur in patients who receive multiple transfusions.

OBJECTIVE

To clarify mechanisms of nosocomial transmission of HCV.

DESIGN

Epidemiologic and molecular analyses of hepatitis C outbreaks.

SETTING

Pediatric oncology ward.

PATIENTS

Children with cancer.

MEASUREMENTS

Epidemiologic analysis, HCV RNA detection, genotyping, and hypervariable region 1 (HVR1) sequencing.

RESULTS

Ten cases of infection with acute HCV genotype 3a occurred between 1990 and 1993. Sequencing of HVR1 revealed three related strains. Despite an overhaul of hygiene procedures, a patient infected with genotype 1b generated nine subsequent infected patients in 1994. Several patients had high virus titers and strongly delayed anti-HCV antibody responses. All had permanent intravenous catheters. Multidose vials used for flushing or treatment had probably been contaminated during periods of overlapping treatment.

CONCLUSIONS

Contamination of multidose vials was the most likely mode of HCV transmission; therefore, use of such vials should be restricted. Rigorous adherence to hygiene routines remains essential to preventing transmission of bloodborne infections.

Survey of macrolide resistance phenotypes in Swedish clinical isolates of Streptococcus pyogenes

Two hundred selected Swedish clinical strains of Streptococcus pyogenes, identified as erythromycin-resistant and isolated between 1980 and 1988, and 37 consecutive, resistant strains from 1989-90 were examined for resistance phenotype by disc diffusion. Strains constitutively resistant to macrolides, lincosamides and streptogramin B were absent in 1980-85 but accounted for 10% in 1986-88. The majority of the isolates belonged to a recently reported, non-inducible phenotype, described as having low-level resistance to erythromycin and sensitivity to clindamycin (82% in 1980-85, 50% in 1986-88). A significant proportion of the isolates did not agree with any known phenotype and therefore were considered as having one of three novel resistance subphenotypes. Most of the 37 strains from 1989-90 belonged to a novel subphenotype.

Binding of complement subcomponent C1q to Streptococcus pyogenes: evidence for interactions with the M5 and FcRA76 proteins

Binding of C1q, the first component of the complement system, to some human pathogens has been earlier reported. In the present study, direct binding of C1q to group A streptococci (GAS) of various serotypes as well as some other Gram-positive and Gram-negative species was demonstrated. The interaction between C1q and GAS was investigated more in detail. In hot neutral extracts of a number of GAS strains two components of 64 and 52 kDa, respectively, bound C1q; alkaline and SDS extracts yielded the 52 kDa component as the main C1q-binding substance. Trypsin treatment of the SDS extracts of two GAS strains suggested the C1q-binding component(s) to be of protein nature. C1q-binding material purified from the SDS extract of an avirulent strain, type T27, was separated in 12% SDS-PAGE and probed in Western blot with human C1q and fibrinogen, conjugated to horse radish peroxidase (HRP) as well as rabbit IgG antibodies complexed to HRP (PAP system). The 52 kDa component was non-reactive with fibrinogen or rabbit IgG. However, C1q-binding components purified from the alkaline extracts of two M-positive strains revealed strong binding of either fibrinogen (type M5) or both fibrinogen and rabbit IgG (type M76); the molecular mass of these components. 55 kDa and 43-40 kDa, respectively, was in agreement with the reported molecular mass of the M5 and FcRA76 proteins. Our findings suggest that C1q may interact with GAS through certain M-family proteins as well as by a so far unidentified surface factor of protein nature occurring in most GAS strains. The involvement of M-family proteins, regarded as virulence factors of these organisms, may suggest the interaction of GAS with C1q as biologically important.

Influence of heparin coating on in vitro bacterial adherence to poly(vinyl chloride) segments

End-point attached, covalently bound heparin has been shown to be effective in preventing activation of the coagulation cascade by biomaterials. Data concerning its possible influence on bacterial attachment and resistance to biomaterial-associated infection are, so far, lacking. In the present work, the in vitro adherence of Staphylococcus aureus, Staphylococcus epidermidis and Escherichia coli, one isolate of each species, to plain poly(vinyl chloride) (plain PVC) and heparin coated poly(vinyl chloride) (EPA-PVC) segments was compared. Also, the influence of precoating the segments with human normal plasma for 2 h was studied. 35S-Methionine was used to radiolabel bacteria. The segments were exposed to bacterial suspensions of approximately 10(7) colony forming units (CFU) per milliliter at 37 degrees C for 0.5-6 h. Following repeated washing in phosphate buffered saline (PBS), radioactivity associated with the segments was measured. Plain PVC as compared to EPA-PVC bound significantly more cells of all three tested species. Plasma precoating significantly decreased adherence of the tested species to plain PVC but did not affect the binding to EPA-PVC. However, after precoating with human plasma, EPA-PVC compared to plain PVC showed a higher binding of S. aureus which might possibly be due to bridging effects of fibronectin or other plasma proteins, interacting with S. aureus.

Clindamycin in recurrent group A streptococcal pharyngotonsillitis--an alternative to tonsillectomy?

Fifty-three patients with bacterial treatment failure after a 10-day course of treatment with phenoxymethyl penicillin (pcV) for group A streptococcal (GAS) pharyngotonsillitis were randomly assigned to continued treatment with pcV, or to treatment with clindamycin instead. The patients were then followed for 1 year with throat cultures and clinical examination every third month and in the event of symptoms of sore throat. In the first 3-month period, 15/22 patients in the pcV group yielded one or more positive cultures for GAS, all of the same T-type as in the original throat culture, as compared to 3/26 in the clindamycin group (p < 0.001). All three cases in the clindamycin group were due to a new T-type and thus were re-infections. In the pcV group, owing to repeated treatment failure, 12/22 patients were switched to treatment with clindamycin within the 3-month period following the second treatment. During the remainder of the 1-year follow-up period, sporadic cases of GAS-positive throat cultures occurred in both groups, but there was no significant difference in frequency between the two groups. It is concluded that, in patients with GAS pharyngotonsillitis and failure after pcV treatment, a 10-day course of clindamycin can protect the patient from recurrence for at least 3 months and might be an alternative to tonsillectomy.

Molecular analysis of clinical group B streptococcal strains by use of alpha and beta gene probes

Group B streptococci (GBS) are a leading cause of neonatal sepsis and meningitis. Besides the type-specific capsule, which is considered to be a major virulence factor of the species, some proteins are believed also to be virulence determinants and have been found to elicit protective immunity. In the present work, the genes for two surface proteins, the alpha and beta antigens, were detected in hybridization tests with chromosomal DNA of clinical GBS isolates. Using as a probe a PCR-generated 1.5 kb part of the beta gene, hybridization was found for 4/19 type Ia, 8/11 type Ib, 5/6 type II but for 0/8 type III strains. Positive outcome of hybridization coincided with an ability of the strains to bind IgA. A 200 bp alpha gene probe hybridized with all tested strains of serotypes Ia, Ib or II but only with 4/17 type III strains. By Southern blot, it was found that the size of the EcoRI chromosomal gene fragments hybridizing with the alpha gene probe correlated with the genomic presence or absence of the beta gene, possibly reflecting evolutionary relationship between the two genes. This assumption was further supported by pulsed field gel hybridization analysis which, however, showed the chromosomal positions of these two genes not to be adjacent.

Moraxella catarrhalis in acute laryngitis: infection or colonization?

The complement phenotypes of Moraxella catarrhalis isolates obtained from adult patients with acute laryngitis were investigated using a microliter serum bactericidal assay and compared with those of other donor groups. Laryngitis isolates had a higher proportion (57%) of complement-resistant strains than did carrier strains from healthy 8- to 13-year-old schoolchildren (16%). The difference between these groups was statistically significant (chi2 [3 x 2 table] = 21.55; P < .001). The relatively frequent occurrence of the complement-resistant (virulence-associated) phenotype in adults with acute laryngitis supports the theory of an active role of M. catarrhalis in the pathogenesis of acute laryngitis.

Treatment failure in streptococcal pharyngotonsillitis. An attempt to identify penicillin tolerant Streptococcus pyogenes

Penicillin tolerance in group A streptococci has been suggested to cause treatment failures in pharyngotonsillitis. In the present study, group A streptococci from patients with pharyngotonsillitis, who healed (n = 33) or failed (n = 25) on phenoxymethylpenicillin therapy for 10 days, as well as isolates obtained following the first (n = 25) and second (n = 7) failure were tested for penicillin tolerance by a plate-screening method. For most strains, the survival rate after a 6-h exposure of log-phase bacteria (10(4) CFU) to a phenoxymethylpenicillin concentration of 4 times the minimum inhibitory concentration (MIC) was below 0.1%. Five strains from cases of failure, exhibiting survival rates of 0.2-0.5%, were subjected to time killing kinetic tests with phenoxymethylpenicillin at 12 times the MIC. At 6 h each of the strains from failures showed survival rates below 0.03%. One single group A strain, previously selected in our laboratory, showed a survival rate of 0.4-1.2%, which was close to tolerance as defined. Four streptococcal strains, earlier reported as tolerant, showed survival rates of > 1% but were found to be group G. Penicillin tolerance does not significantly contribute to failures in penicillin therapy of group A streptococcal pharyngotonsillitis, but seems to be a common property of group C and G streptococci.

Characterization of an erythromycin resistance (erm) plasmid in Streptococcus pyogenes

Three erythromyxin-resistant Swedish isolates of Streptococcus pyogenes, representing different T-types, were studied. Two of the strains showed constitutive high-level (MIC > 200 micrograms/ml) and one showed moderate (MIC 6.4 micrograms/ml) resistance; the latter strain was sensitive to lincosamide and clindamycin, and resistance was not induced by erythromycin. In each of the strains, a plasmid with an estimated Mw of 17.6 +/- 0.9 x 10(6) was isolated in addition to smaller cryptic plasmids. The three plasmids pSE701, pSE702, and pSE703 had very similar restriction enzyme cleavage patterns. Novobiocin curing of the high-level resistance strain ER559 showed the resistance to be linked to its 17.6 x 10(6) plasmid, pSE703. Furthermore, by electroporation this rather large plasmid was reintroduced into an erythromycin-sensitive cured derivative, acquiring resistance, and the plasmid was again recovered from the transconjugant. One of the plasmids, pSE702, was shown by filter mating to be conjugative within S. pyogenes. DNA-DNA hybridization showed that the resistance determinant of the present three isolates was related to the erm gene on plasmid pAM beta 1 of Enterococcus faecalis but not to that of plasmid pE194 of Staphylococcus aureus. The copy numbers of pSE702 and pSE703, derived from the two high-level resistant strains, were 11 +/- 3 and 17 +/- 5 compared to 2 +/- 1 for pSE701, derived from the moderately resistant strain, possibly accounting for the phenotypic variation observed. The plasmids pSE702 and pAM beta 1 showed about 80% homology in DNA-DNA hybridization tests and high similarity in their restriction maps.

Additive effect of clarithromycin combined with 14-hydroxy clarithromycin, erythromycin, amoxycillin, metronidazole or omeprazole against Helicobacter pylori

The in-vitro activities of clarithromycin, 14-OH clarithromycin, erythromycin, amoxycillin, metronidazole and omeprazole against Helicobacter pylori were determined at pH 7.2 and 5.5. At pH 5.5 the activities of clarithromycin and erythromycin decreased approximately 16 times while 14-OH clarithromycin was less influenced. Chequerboard titration indicated that the combined activity of clarithromycin and the other compounds was additive.

Sequencing of genes within the vir regulon of Streptococcus pyogenes type M15--an opacity factor-positive serotype with low opacity factor expression

Major virulence determinants of group A streptococci, such as M-protein, immunoglobulin Fc-receptors (FcRA, EmmL) and C5a peptidase, appear to be genetically co-regulated, their genes being located within a vir regulon. We studied the organization of these genes in a group A, type M15 strain of Streptococcus pyogenes, previously defined as OF-, by hybridization analysis of chromosomal DNA and of an S. pyogenes gene library in Escherichia coli, and by gene sequencing. Within the vir regulon, in addition to the virR and scpA genes, three so-called emm-related genes were found: fcrA, emmL and enn. Whereas IgG Fc-binding proteins were encoded by fcrA and emmL, the product of enn was not identified. The presence of three emm-related genes in this region is reminescent of vir regulon organization in OF+ rather than OF- strains as earlier defined by others. Furthermore, analysis of the deduced product of the emmL gene showed deletions and amino acid substitutions within the PGTS-rich domain and membrane anchor, which thus resembles corresponding products of OF+ rather than OF- strains. In view of these findings, the opacity factor (OF) activity of the strain was tested using growth supernatant, with negative outcome. However, a concentrated SDS cell extract revealed definite OF activity. One of two other type M15 reference strains also showed definite OF activity in SDS extracts. We therefore propose that type M15 strains belong to the OF+ category but often show low levels of expression of OF.

Haemolytic and phospholipase C (PLC) activities of Rhodococcus equi

Rhodococcus equi, an intracellular organism causing pneumonia and lung abscesses in foals, is generally thought to be non-haemolytic. In the present study, however, 13 of 14 representative isolates were found to be haemolytic when tested on agar media containing washed red blood cells rather than whole blood. Red cells of rabbits, dogs, horses and man were more sensitive to lysis than were those of ruminants. Two new enzymatic activities of the species were defined: a lecithinase and a phosphatidylinositol-specific phospholipase C (PI-PLC). As judged from tests for trypsin, temperature and ethanol sensitivity, the haemolytic activity was primarily dependent on PI-PLC though the participation of lecithinase seemed probable. The haemolytic activity of growing strains, but not of cell-free preparations, was partially inhibited by lecithin but enhanced by cholesterol; however, cholesterol oxidase (CO) activity, known to mediate cooperative lysis of RBC sensitized with sphingomyelin-specific phospholipases C or D of some other species, did not contribute to the direct haemolysis caused by R. equi as demonstrated here.

M-like, immunoglobulin-binding protein of Streptococcus pyogenes type M15

An M-like protein from Streptococcus pyogenes type M15 strain EF1949 (EMML15) was cloned in Escherichia coli and sequenced. Recombinant EMML15 protein revealed a unique binding pattern for human IgG subclasses not described previously. Comparative analysis of the EMML15 amino acid sequence with those of other M-like proteins of opacity factor positive (OF+) serotypes and protein H, and IgG receptor from OF- serotype M1, showed that IgG-binding proteins with common binding of IgG3 were closely related and distinct from streptococcal IgG receptors not binding IgG3. Thus, the Ig-binding proteins from S. pyogenes were subdivided into two main categories according to binding pattern, protein structure, and gene location.

Reduced susceptibility of polytetrafluoroethylene vascular prostheses to colonization by Staphylococcus aureus following in situ endothelialization

The impact of endothelialization of polytetrafluoroethylene (PTFE) grafts on susceptibility to experimental colonization by Staphylococcus aureus was studied in a rat model. One hundred and eight grafts (2 mm inner diameter, 5 mm length) were implanted into the infrarenal aorta (54 rats) or the infrarenal caval vein (54 rats). The progress of endothelialization following graft implantation was evaluated by SEM at 1, 3, 7, and 14 days on 6 grafts from each group. We found that the endothelialization was more rapid in caval vein than in aorta: The caval vein grafts were completely endothelialized 2 weeks following implantation compared with endothelialization of approximately 0.5 mm of aorta grafts, measured from each anastomosis. During this time, the resistance to standardized intravenous challenge with 10(8) colony-forming units of S. aureus increased gradually in both groups, and all caval vein grafts tested at 2 weeks were sterile. However, all aorta grafts challenged at 2 weeks were colonized, although to a somewhat lower degree than at earlier challenge. Resistance of PTFE grafts to colonization with S. aureus thus correlated to the degree of endothelialization.

Clindamycin in persisting streptococcal pharyngotonsillitis after penicillin treatment

239 patients with streptococcal pharyngotonsillitis completed treatment with phenoxymethyl penicillin 12.5 mg per kg body weight b.i.d. for 10 days. At examination after completing therapy, throat specimens from 53 patients (22%) yielded growth of group A streptococci of the same. T-type as the initial culture (bacterial treatment failure). 20 of these 53 (38%) had symptoms and signs of tonsillitis (clinical and bacterial treatment failure). 48 of the patients with bacterial failure were randomly allocated to phenoxymethyl penicillin or clindamycin in an open design; 22 of them received a second course of phenoxymethyl penicillin for 10 days and 26 were given clindamycin, 6.5 mg per kg body weight b.i.d. (children) or 300 mg t.i.d. (adults) for 10 days. After completing their treatment, 14 of 22 patients (64%) given phenoxymethyl penicillin harboured the same T-type as in the previous two cultures, while group A streptococci were not recovered from any of the 26 patients receiving clindamycin. In patients with clinical failure after phenoxymethyl penicillin treatment, a new course with this drug is not motivated. In that situation clindamycin seems to be an efficient choice.

Influence of some plasma proteins on in vitro bacterial adherence to PTFE and Dacron vascular prostheses

The in vitro adherence of Staphylococcus aureus, Staphylococcus epidermidis and Escherichia coli (one strain of each species) to commercially available, microporous polytetrafluoroethylene (PTFE) and woven Dacron vascular grafts before and after coating with human plasma was compared. Standard size segments of the materials were incubated with 35S-labeled bacteria for 0.5-18 h and, following washes, the radioactivity associated with the segment was measured. The binding of each of the tested species to native Dacron was higher than to PTFE. After coating with human plasma, however, the binding of all three species to PTFE was significantly enhanced, whereas the binding to Dacron was reduced. In addition, the influence of coating with serum albumin (HSA), immunoglobulin G (IgG), fibrinogen (Fg) or fibronectin (Fn) rather than whole plasma was tested. We found that coating with HSA reduced the binding of all three species to Dacron and of staphylococci to PTFE. IgG decreased the binding of S. epidermidis and E. coli to Dacron and of S. epidermidis to PTFE. In contrast, Fg enhanced the binding of S. aureus both to Dacron and PTFE, and that of E. coli to PTFE, but decreased the binding of S. epidermidis and E. coli to Dacron. Fn enhanced the binding of S. aureus to Dacron, and of E. coli to PTFE, but decreased the binding of S. aureus to PTFE and of S. epidermidis both to PTFE and Dacron. Thus, both whole plasma and some isolated plasma proteins were found to modulate bacterial adherence to two tested graft materials. From a clinical point of view, bacterial binding to plasma-coated rather than native materials may more adequately determine the likelihood of in vivo colonization of the various materials. Furthermore, precoating of materials with selected proteins may be of value in the prevention of graft colonization.

Prevalence of IgA receptors in clinical isolates of Streptococcus pyogenes and Streptococcus agalactiae: serologic distinction between the receptors by blocking antibodies

Group A and B streptococci (Streptococcus pyogenes and Streptococcus agalactiae) are the only known bacterial pathogens expressing IgA Fc-receptors. However, the IgA binding proteins of the two species have been found genetically unrelated. In the present investigation the binding of human IgA among clinical isolates of group A and group B streptococci was studied and the respective IgA-binding epitopes were compared serologically. Surface binding of radiolabelled, monoclonal human IgA1 occurred in 38% of 115 unselected group A streptococcal isolates. Comparing four predominant T-types, IgA-binding was found in 77% and 85%, respectively, of types T4 and T28 strains but only in 5% and 25%, respectively, of T1 and T12 strains. In group B streptococci, 70% of 58 type Ib strains but only 2% of 399 strains of other serotypes bound IgA. Using rabbit immune sera raised to the two streptococcal species it was found that strains exhibiting IgA Fc-receptors often induced antibodies blocking the binding of IgA to bacteria. Furthermore, the blocking shown by an individual serum was restricted to the streptococcal group used for immunization showing that also the IgA-binding eptiopes in group A and B streptococci are conformationally distinct. Though infections with serotypes often binding IgA, compared to other types, are not known to differ, it is assumed that the non-immune binding of IgA might favour mucosal colonization of the organisms.

Antigenic diversity of IgA receptors in Streptococcus pyogenes

In a previous study, group A and group B streptococcal IgA receptors were shown to differ serologically, in agreement with their known structural unrelatedness. The present study was undertaken to serologically compare the IgA binding epitopes of group A streptococcal strains representing various serotypes by the use of antisera to this species. It was found that blocking antibodies occurred in antisera to IgA binding but not to non-binding strains and that binding of IgA to a streptococcal strain was generally blocked by antiserum to the homologous type. However, cross-testing of a panel of 11 IgA binding strains, representing various M and T serotypes, with 10 different antisera to group A streptococci, demonstrated that IgA receptors were inhibited to a highly variable degree and that inhibition patterns were unique for each type. Comparing solubilized IgA receptors of various strains in immunoblot experiments, a variation in the molecular mass, between approximately 35 and 45 kDa, emerged. The IgA binding epitopes, analogous to protective sites of streptococcal M-protein, thus exhibited hypervariability which may suggest that IgA binding also plays a key role for evading host immune defence mechanisms.

Bacterial adherence to synthetic vascular prostheses and influence of human plasma. An in vitro study

The in vitro adherence of Staphylococcus aureus, Staphylococcus epidermidis and Escherichia coli to five commercially available prosthetic vascular graft materials was compared. The influence of precoating the segments with human plasma for 2 h was also studied. S35-methionine was used to radiolabel bacteria. The segments were exposed to bacterial suspensions of approximately 10(7) CFU/ml at 37 degrees C for 0.5-18h. Following repeated washing in phosphate buffered saline (PBS), radioactivity associated with the segments was measured. The adherence of the three clinically relevant bacterial species was higher to untreated Dacron than to gelatin or collagen impregnated/coated Dacron or to PTFE. Furthermore, precoating of grafts with human plasma reduced bacterial adherence to woven Dacron, had a little effect on gelatin coated Dacron, but increased the adherence to collagen treated Dacron and, in particular, to PTFE.

Erythromycin in acute laryngitis in adults

Moraxella catarrhalis and Hemophilus influenzae are isolated from the nasopharynx in 50% to 55% and 8% to 15%, respectively, of cases of acute laryngitis in adults. This finding indicates that these organisms, M catarrhalis in particular, are in some way involved in the pathogenesis of the disorder. In the present double-blind, placebo-controlled trial, the effect of erythromycin ethylsuccinate (0.5 g twice a day for 5 days) on the elimination of nasopharyngeal pathogens and reduction of clinical signs of upper respiratory tract infection, as well as on subjective complaints, was evaluated in 106 adults with acute laryngitis. The bacterial isolation rates at presentation were M catarrhalis 50%, H influenzae 18%, and Streptococcus pneumoniae 4%. In the 99 patients who completed the study, the elimination of M catarrhalis after 1 week was better in the erythromycin group (25 of 30 cases) than in the placebo group (6 of 19 cases; p < or = .00038). The elimination of H influenzae was unaffected by erythromycin. Otolaryngologic examination did not reveal any significant group differences regarding laryngitis, pharyngitis, or rhinitis. Voice quality was improved after 1 week, irrespective of treatment. However, as compared to the placebo group, the erythromycin group reported fewer voice complaints after 1 week and fewer coughing complaints after 2 weeks. As acute laryngitis in adults is self-limiting, and subjective symptoms are spontaneously reduced after 1 week in most cases, antibiotic treatment does not seem warranted as a general policy. However, erythromycin may be justified in patients who are professionally dependent on voice function.

A one-year study of streptococcal infections and their complications among Ethiopian children

Post-streptococcal complications are known to be common among Ethiopian children. Little is known, however, about the epidemiology of beta-haemolytic streptococci in Ethiopia. A total of 816 children were studied during a one-year period: 24 cases of acute rheumatic fever (ARF), 44 chronic rheumatic heart disease (CRHD), 44 acute post streptococcal glomerulonephritis (APSGN), 143 tonsillitis, 55 impetigo, and 506 were apparently healthy children. Both ARF and APSGN occurred throughout the year with two peaks during the rainy and cold seasons. The female:male ratio among ARF patients was 1.4:1 and 1:1.9 among APSGN. The monthly carrier rate of beta-haemolytic streptococci group A varied from 7.5-39%, average being 17%. T type 2 was the most frequent serotype. Marked seasonal fluctuations were noted in the distribution of serogroups among apparently healthy children. Beta-haemolytic streptococci group A dominated during the hot and humid months of February-May. Strains were susceptible to commonly used antibiotics, except for tetracycline.

Chlamydia trachomatis antigen detection by Chlamydiazyme combined with Chlamydia Blocking Reagent verification

Several options exist for the detection of chlamydial infection in a routine laboratory setting. Enzyme immuno assay (EIA) technology offers rapid turn around of results and is less technically demanding than chlamydial cell culture. In addition, recently introduced EIA confirmatory reagents have the potential to improve the accuracy of EIA detection. We have evaluated one such confirmatory reagent (Chlamydia Blocking Reagent, Abbott Laboratories) to determine the accuracy of the Chlamydiazyme EIA with special regard to interpretation of low absorbance values. An initial series of 192 male urethral specimens showed that use of a lowered cut off level (absorbance value 0.05) compared with that recommended by the manufacturer increased sensitivity of the EIA from 0.73 to 0.83, thus motivating studies on this interpretative modification. Of 1101 EIA reactive specimens, 65% were determined to be chlamydia positive by the Chlamydia Blocking Reagent. The proportion of female cervical specimens that did not confirm positive was elevated compared with male urethral specimens, 43% vs. 5.7% respectively. In samples yielding absorbance from the recommended cut off level to 0.05 (approximately 50% below), the corresponding figures were 78% and 14% respectively. In 85 selected EIA reactive samples, examination by a direct immunofluorescence staining assay (DFA) (MicroTrak, Syva Inc.) revealed elementary bodies in 85% of 67 blocking test positive and in 24% of 18 blocking test negative samples. The possibility that Gram-negative bacteria were responsible for unconfirmed EIA reactive specimens was investigated using bacterial suspensions. While EIA reactivity was noted with several strains for Gram-negative bacteria, both the blocking reagent and DFA correctly verified the absence of chlamydial antigen.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of streptococcal IgG Fc receptor in tissue deposition of IgG in rabbits immunized with Streptococcus pyogenes

Induction of anti-IgG during hyperimmunization of rabbit with Streptococcus pyogenes (group A streptococci; GAS) was previously shown to require the presence of IgG Fc receptors (FcR) in the vaccine strain. In the present work, we examined whether streptococcal FcR activity might also be of importance for heart and kidney deposition of IgG, known to occur in poststreptococcal sequelae as well as during experimental immunization of animals. Each of three IgG-binding (GAS types M1, M12 and M22) and two non-binding (GAS type T27 and S. agalactiae (GBS) type Ia) streptococcal strains were used for intravenous immunization of rabbits during two periods of eight and six weeks, respectively, separated by an interval of one month. Before use, vaccine strains were treated with KSCN and carefully washed in order to remove any surface-bound immunoglobulins. No deaths occurred among injected rabbits. No tissue deposition was elicited by the GAS type T27 or the GBS strain. In contrast, the strains of types M1, M12 and M22 all induced deposits of IgG in kidney and heart tissue, beginning during the first immunization period. In two tested animals, receiving GAS of types M1 or M22, circulating immune complexes containing anti-IgG antibodies were also detected. Finally, serum autoantibodies reacting with preparations of heart and kidney, but not lung or liver, were demonstrated in each of six animals receiving M1 or M22, reaching maximum levels during reimmunization; such antibodies were not evoked by the two strains not binding IgG. Our results suggest that, in GAS with capacity for non-immune binding of IgG, triggering of anti-IgG acted to enhance tissue deposition of IgG or immune complexes in immunized rabbits. Furthermore tissue-specific antibodies were elicited only by the IgG-binding strains and occurred comparatively late during immunization, suggesting that those antibodies might have been triggered due to the exposition of hidden kidney and heart determinants.

Helicobacter pylori and atrophic gastritis

Sixty-four consecutive patients which on upper gastrointestinal endoscopy had endoscopic signs of atrophic body gastritis were investigated with standard histology examinations of gastric biopsies, serology and/or culture for Helicobacter pylori and with standard blood chemistry profile. A histologic diagnosis of atrophy could be made in only 27 of the 64 patients (42%). Of these 27 patients, 5 had the pernicious anaemia (PA) type (19%), 22 had not (81%). Past and/or present H. pylori infection was found in 16/22 non-PA patients (73%) but in none of the PA patients (p = 0.00572). The present study thus confirms earlier findings that non-PA type atrophic body gastritis is more common than the PA type and suggests that, as opposed to PA-type atrophy, it is related to H. pylori infection.

Production of betalactamase by respiratory tract bacteria in children: relationship to antibiotic use

Sales of antibiotics have increased in Sweden during the past decade. This has been paralleled by an increase in the frequency of beta-lactamase-producing respiratory tract bacteria. To investigate the effects of regional differences in use of antibiotics on beta-lactamase production in respiratory tract bacteria, we collected nasopharyngeal specimens and information about antibiotic use from 1133 children attending day-care centres in four rural municipalities with low use, and one urban municipality with high use of antibiotics, use being assessed from pharmacy sales. The frequency of beta-lactamase production among isolates of Branhamella catarrhalis and Moraxella nonliquefaciens was significantly higher in the urban municipality. This appeared to be a long-term ecological effect of differences in the level of use of antibiotics between the urban and rural populations, rather than an effect of recent antibiotic treatment of individual patients.

Acute laryngitis in adults: results of erythromycin treatment

Previous studies of acute laryngitis in adults have shown high nasopharyngeal isolation rates of B. catarrhalis and H. influenzae. Phenoxymethylpenicillin had no effect on the clinical course. In the present study, 106 patients with acute laryngitis were treated with erythromycin 0.5 g x 2 V or placebo. During the first week the isolation rate of B. catarrhalis was reduced from 60 to 10% in the erythromycin group compared to 34 to 27% in the placebo group (p less than 0.01). The elimination of H. influenzae, isolated in 19% at the acute visit, did not differ between the two groups. As compared to controls, erythromycin treated patients reported significantly lower scores of subjective voice disturbance after 1 week and cough after 2 weeks. Laryngological examination and voice evaluation failed to reveal any differences between the groups.

Penicillin tolerance in group A streptococci and treatment failure in streptococcal tonsillitis

Penicillin tolerance in Streptococcus pyogenes has been suggested as a possible cause of therapeutic failure in streptococcal phryngitis treated with penicillin. In 144 patients with acute group A streptococcal tonsillitis treated with phenoxymethyl penicillin 12.5 mg per kg body weight b.i.d. for 10 days the same T-type was recovered after treatment in 21%. The recovery rate was higher for non-tolerant strains, 23%, than for tolerant strains, 10% (p greater than 0.05). Of patients with a non-tolerant strain 17% had both clinical and bacterial treatment failure in comparison with 5% infected with a tolerant strain (p greater than 0.05). Reinfection with a new serotype occurred in altogether 3%. The present data did not indicate that penicillin tolerance in group A streptococci is of significance in acute tonsillitis treated with phenoxymethylpenicillin for 10 days.

High recovery of Haemophilus influenzae and group A streptococci in recurrent tonsillar infection or hypertrophy as compared with normal tonsils

One hundred and twenty-six patients who underwent tonsillectomy because of recurrent acute tonsillitis, tonsillar hypertrophy or sleep apnoea were evaluated by tonsillar core culturing. The sleep apnoea patients served as controls, since none of them had tonsillar hypertrophy at ENT examination or any history of recurrent acute tonsillitis, and thus their tonsillar core flora could be regarded as normal. The isolation rate of H. influenzae was much lower among sleep apnoea controls (2.7 per cent) than among either the patients with recurrent acute tonsillitis (20.3 per cent) or those with tonsillar hypertrophy (36.7 per cent) (p less than 0.05), as was that of group A streptococci, 5.4 per cent versus 16.9 and 20 per cent, respectively (though the latter differences were not statistically significant). The isolation frequencies of B. catarrhalis, pneumococci, group C and G streptococci did not differ between the three groups. The high tonsillar core recovery rates of H. influenzae and group A streptococci both in patients with recurrent acute tonsillitis and in those with tonsillar hypertrophy, as compared with normal controls, suggests the possible involvement of these bacteria in both conditions.

Effect of bile on growth, peritoneal absorption, and blood clearance of Escherichia coli in E coli peritonitis

The effect of intraperitoneal bile on growth, peritoneal absorption, and clearance of Escherichia coli was determined in E coli peritonitis in the rat. In E coli peritonitis, intraperitoneal bacterial counts gradually decreased, whereas they increased (after 2 hours) with subsequent development of bacteremia in E coli plus bile peritonitis. After an intraperitoneal injection of labeled bacteria, blood radioactivity was only initially lower in E coli plus bile peritonitis compared with E coli peritonitis. Clearance from blood was lower in E coli plus bile peritonitis than in E coli peritonitis. Organ localization was similar in E coli peritonitis and E coli plus bile peritonitis with decreased splenic, increased pulmonary, and unchanged hepatic uptakes compared with controls. Impaired peritoneal absorption of bacteria, together with impaired local host defense, is likely to enhance the noxious effect of bile in E coli peritonitis.

Bile increases lipopolysaccharide release in experimental E. coli peritonitis

Previous studies in rats showed increased mortality when bile was added to intraperitoneally injected Escherichia coli. In the present study bacterial counts and levels of lipo-polysaccharide (LPS) were determined in the peritoneal cavity and in blood 0.5, 1, 4 and 10 hours after induction of peritonitis with E. coli alone or together with bile. LPS was measured with gas chromatographic analysis of beta-hydroxymyristic acid, a characteristic component of E. coli-LPS. Bacterial counts and LPS levels in peritoneal fluid and blood rose higher in E. coli + bile peritonitis than in E. coli peritonitis. The intergroup difference in LPS levels was evident at 0.5 and 1 hour, whereas the bacterial counts began to differ at 2 hours. Presence of intraperitoneal bile in E. coli peritonitis thus produced rapid rise in LPS levels that could not be caused by bacterial numbers alone. This early load of LPS may help to explain the noxious effect of bile in E. coli peritonitis.

Experimental recurrent pneumococcal otitis media. Protection and serum antibodies

To elucidate immune mechanisms in otitis media, middle ear infection was induced in 12 rats by intratympanic inoculation of Streptococcus pneumoniae type 3, either the ipsilateral or the contralateral middle ear being re-challenged 4 weeks later. Otomicroscopy inspection confirmed the presence of acute otitis media (AOM) in all rats after the first challenge. After re-challenge, protection against AOM was noted both in the ipsilateral and contralateral ears. Serum antibody concentrations increased after the initial challenge, reaching a maximum at 4-7 days, but had decreased to pre-immune levels at re-challenge, after which no new increase was noted. Serum IgG-antibodies to pneumococcal type 3-polysaccharide were triggered following the initial induction of unilateral pneumococcal AOM, but mucosal immune mechanisms are argued to be a more probable explanation of the ipsilateral protection seen after re-challenge.

Septicaemia caused by unusual Campylobacter species (C. laridis and C. mucosalis)

Two cases of campylobacter septicaemia are described. The first, caused by Campylobacter laridis was associated with gastroenteritis and occurred in a healthy individual. In the second case, a catalase negative species, C. mucosalis was isolated from blood in an immunocompromised patient with symptoms of pneumonia. Both campylobacter strains grew faintly under the routine culture conditions used. Improved diagnostic procedures for Campylobacter species may thus be warranted.

Helicobacter pylori, smoking and gastroduodenitis

There is epidemiological evidence of an association between cigarette smoking and gastritis. To find out whether the reason for this might be related to the presence of Helicobacter pylori, biopsies were taken from the gastric corpus and antrum and from the duodenal bulb in 106 consecutive patients referred for oesophagogastroduodenoscopy because of epigastric pain. Patients with ulcer disease or cancer were excluded. The biopsy specimens were cultured for H. pylori and examined histologically for the presence and grade of gastritis and duodenitis. Thirty-five percent of the patients were H. pylori-positive and 57% had histological gastritis; 37% were cigarette smokers and among these, H. pylori was found significantly less frequently than in non-smokers (18 and 45%, respectively; 2p = 0.0083). Among patients colonized with H. pylori, gastritis was found in 89% compared to 39% in non-colonized patients (2p less than 0.0001). In spite of this, 51% of the smokers and 60% of the non-smokers (2p = 0.85) had histological gastritic mucosa. No differences in the severity of the gastritis or the duodenitis in patients with histologically positive findings could be seen when comparing smokers to non-smokers and H. pylori-positive to H. pylori-negative patients.