Bacteremia caused by group G streptococci, Taiwan.
A retrospective observational study In statistics, the goal of an observational study is to draw inferences about the possible effect of a treatment on subjects, where the assignment of subjects into a treated group versus a control group is outside the control of the investigator. in Taiwan, 19982004, identified 92 patients with group G streptococcal streptococcal /strep·to·coc·cal/ (-kok´al) pertaining to or caused by a streptococcus.
Pertaining to any of the Streptococcus bacteria. bacteremia bacteremia: see septicemia.
Presence of bacteria in the blood. Short-term bacteremia follows dental or surgical procedures, especially if local infection or very high-risk surgery releases bacteria from isolated sites. ; 86 had Streptococcus streptococcus (strĕp'təkŏk`əs), any of a group of gram-positive bacteria, genus Streptococcus, some of which cause disease. dysgalactiae subspecies subspecies, also called race, a genetically distinct geographical subunit of a species. See also classification. equisimilis. The most common diagnosis was cellulitis Cellulitis Definition
Cellulitis is a spreading bacterial infection just below the skin surface. It is most commonly caused by Streptococcus pyogenes or Staphylococcus aureus. (48 cases), followed by primary bacteremia (34 cases). Infection recurred in 9 patients. Mortality rate was low (3.3%); resistance to quinupristin-dalfopristin was high.
Group G streptococci Streptococcus (plural, streptococci)
A genus of spherical-shaped anaerobic bacteria occurring in pairs or chains. Sydenham's chorea is considered a complication of a streptococcal throat infection. (GGS GGS Geelong Grammar School (Australia)
GGS Generations and Gender Survey
GGS Global Geospace Science
GGS Good Games (Quake)
GGs Governor-General's Literary Awards (Canada) ) are part of the normal microbial microbial
pertaining to or emanating from a microbe.
the breakdown of organic material, especially feedstuffs, by microbial organisms. flora of the gastrointestinal tract gastrointestinal tract
The part of the digestive system consisting of the stomach, small intestine, and large intestine.
Gastrointestinal tract , vagina, and skin and cause a variety of infections (1). Major underlying illnesses in patients with GGS bacteremia are malignancy, cardiovascular disease Cardiovascular disease
Disease that affects the heart and blood vessels.
Mentioned in: Lipoproteins Test
cardiovascular disease , diabetes mellitus diabetes mellitus
Disorder of insufficient production of or reduced sensitivity to insulin. Insulin, synthesized in the islets of Langerhans (see Langerhans, islets of), is necessary to metabolize glucose. In diabetes, blood sugar levels increase (hyperglycemia). , bone and joint diseases, and cirrhosis cirrhosis (sərō`səs), degeneration of tissue in an organ resulting in fibrosis, with nodule and scar formation. The term is most often used in relation to the liver, because that organ is most often involved in cirrhosis. (1,2). Reported mortality rates for patients with GGS bacteremia also vary, ranging from 5% to 30% (1-3). Recent studies of [beta]-hemolytic streptococci isolates carrying Lancefield group G antigen showed that they consist of Streptococcus dysgalactiae subspecies equisimilis, S. anginosus, and S. canis (2,4-6). To supplement the limited clinical information about bacteremia caused by GGS strains identified to the species level (2-4), we conducted a retrospective observational study.
We included all patients with GGS-positive blood cultures who had been treated from April 1998 through August 2004 at National Taiwan University Hospital National Taiwan University Hospital (NTUH, 國立台灣大學醫學院附設醫院) started operations under Japanese rule in Dadaocheng on June 18, 1895, and moved to its present location in 1898. , a 2,000-bed teaching hospital in northern Taiwan. We recorded demographic parameters, underlying illness, clinical diagnosis, and outcome for each patient. Clinical diagnosis was based on the attending physician's judgment and examination results. Recurrence of bacteremia was defined as repeated positive blood culture after complete treatment (at least 14 days) of previous bacteremia.
Differentiation of GGS was based on colony size, hemolytic he·mo·lyt·ic
Destructive to red blood cells; hematolytic.
Referring to the destruction of the cell membranes of red blood cells, resulting in the release of hemoglobin from the damaged cell. reaction, Voges-Proskauer reaction, and [beta]-glucuronidase activity. All [beta]-hemolytic streptococci, whether large or small colonies, were tested for Lancefield group by using an agglutination agglutination, in biochemistry
agglutination, in biochemistry: see immunity.
agglutination, in linguistics
agglutination, in linguistics: see inflection. kit (Streptex; Murex mu·rex
n. pl. mu·ri·ces or mu·rex·es
Any of various marine gastropods of the genus Murex common in tropical seas and having rough spiny shells, especially M. trunculus, the source of Tyrian purple. Bio tech Ltd., Dartford, UK). PCR PCR polymerase chain reaction.
polymerase chain reaction
Polymerase chain reaction (PCR) to differentiate between S. anginosus and S. dysgalactiae subsp, equisimilis was performed for all GGS isolates as described (7). For identification of S. canis, a probable isolate was identified by a negative [beta]-glucuronidase result and further confirmed with the 16sRNA method as described (8). Susceptibilities of these isolates were tested by using the broth microdilution method as defined by the Clinical and Laboratory Standards Institute (formerly National Committee for Clinical Laboratory Standards) (9).
To determine the similarity of isolates in cases of recurrence, we used pulsed-field gel electrophoresis gel electrophoresis
Electrophoresis performed in a gel composed of agarose, polyacrylamide, or starch. (PFGE PFGE Pulsed-Field Gel Electrophoresis ) as described (10). The emm typing of isolates in cases of recurrence were also determined as described (11). The first 160 bases sequenced by emmseq2 that had [greater than or equal to] 95% identity were defined as having the same genotype genotype (jēn`ətīp'): see genetics.
Genetic makeup of an organism. The genotype determines the hereditary potentials and limitations of an individual. (11).
During the study period, 106 episodes of GGS bacteremia in 92 patients had been recorded; 56 episodes occurred during the first half of the study period (before June 2001) and 50 episodes during the second half. The causative caus·a·tive
1. Functioning as an agent or cause.
2. Expressing causation. Used of a verb or verbal affix.
caus agent was X dysgalactiae subsp, equisimilis for 99 episodes, S. anginosus for 5, and S. canis for 2. Bacteremia recurred for 9 patients (1 had 4 episodes, and 3 had 3 episodes); bacteremia was nosocomial nosocomial /noso·co·mi·al/ (nos?o-ko´me-il) pertaining to or originating in a hospital.
1. Of or relating to a hospital.
2. for 7 patients and polymicrobial for 5. The clinical characteristics of the patients are summarized in Table 1. All 3 patients who died had a diagnosis of the primary bacteremia caused by S. dysgalactiae subsp, equisimilis.
Among the 9 patients with recurrent bacteremia, the causative agent was S. dysgalactiae subsp, equisimilis for 8 and S. canis for 1. PFGE performed with all 13 available isolates from recurrent cases showed that 10 were identical to that of the initial episode, including 1 in a patient with recurrence of S. canis bacteremia. Sequence typing showed emm type stG485 for 4 patients. The clinical characteristics of the patients and emm typing results are shown in Table 2; PFGE results are shown in the Figure. The underlying diseases of patients with recurrent episodes included genital cancer (4 [44.4%] patients) and history of cellulitis (6 [66.7%]), each of which was significantly correlated with the likelihood of recurrence (p<0.01 for each). Further analysis showed that a previous history of cellulitis was significantly correlated with female sex (p = 0.01), genital cancer (p<0.01), tissue edema edema (ĭdē`mə), abnormal accumulation of fluid in the body tissues or in the body cavities causing swelling or distention of the affected parts. (p = 0.02), heart disease (p = 0.04), and post-coronary artery bypass graft bypass graft Surgery A surrogate blood vessel used to reroute blood; BGs may be synthetic–Dacron, or autologous–vein from the Pt's own leg, to substitute for diseased vessel (p = 0.03).
Bacteremia caused by [beta]-hemolytic S. anginosus with group G antigen was identified for 5 patients, none of whom had cellulitis, compared with 48 (55.8%) of the 86 patients with S. dysgalactiae subsp, equisimilis who did have cellulitis (p = 0.03). Polymicrobial bacteremia and nosocomial bacteremia were found in a higher percentage of patients with S. anginosus (60% and 40.0%, respectively) than of patients with S. dysgalactiae subsp, equisimilis bacteremia (4.7% and 5.8%, respectively); p<0.01 and p = 0.02, respectively. The 1 patient with S. canis bacteremia was a 33-year-old man with no history of dog bite dog bite Public health The clamping of skin and subjacent soft tissues between the upper and lower mandible of a canine, which may cause infections, acting as a disease vector or even death. See Dog. . He had alcoholassociated liver cirrhosis liver cirrhosis
n a degenerative disease of the liver in which hepatic tissue is replaced with connective tissue, commonly a result of chronic alcoholism. See jaundice. of Child C (severe) classification and leg edema. He had 2 episodes of S. canis bacteremia 1 month apart. Echocardiogram ech·o·car·di·o·gram
A visual record produced by echocardiography.
A non-invasive ultrasound test that shows an image of the inside of the heart. results showed no evidence of valvular valvular /val·vu·lar/ (val´vu-ler) pertaining to, affecting, or of the nature of a valve.
Relating to, having, or operating by means of valves or valvelike parts. vegetation. For the first episode, the patient received a 14-day course of cefotaxime.
Antimicrobial antimicrobial /an·ti·mi·cro·bi·al/ (-mi-kro´be-al)
1. killing microorganisms or suppressing their multiplication or growth.
2. an agent with such effects. drug-susceptibility testing showed decreased susceptibility to only macrolides (susceptibity rates: azithromycin 67.4%, clarithromycin 73.9%), clindamycin (87.0%), and quinupristin-dalfopristin (33.7%) (online Appendix Table, available from www.cdc.gov/EID/content/14/5/837-appT.htm). No clinical factor correlated with macrolide resistance. All isolates of recurrent bacteremia were susceptible to macrolides.
We documented 5 cases of primary bacteremia caused by [beta]-hemolytic group G S. anginosus and unintentionally documented recurrence of S. canis bacteremia. S. canis bacteremia in humans was first clearly described in 1997 (12).
Our finding of 5 [beta]-hemolytic S. anginosus isolates and 1 S. canis isolate in patients with GGS bacteremia in this study differs from findings of previous studies (2,3). Factors that may have contributed to this discrepancy include serotype serotype /se·ro·type/ (ser´o-tip) the type of a microorganism determined by its constituent antigens; a taxonomic subdivision based thereon.
v. determination and PCR method. Serotype determination was performed for all [beta]-hemolytic streptococci isolated in our hospital, whether colonies were large or small, which might have led to the detection of more streptococcal isolates with G antigen. The PCR method developed in our hospital and used in this study could effectively differentiate S. anginosus from S. dysgalactiae subsp, equisimilis (7).
Information about clinical infection with S. milleri with group G antigen is limited (4). In a previous study of GGS bacteremia, Cohen-Poradosu et al. reported that 6 of 84 patients had recurrence of bacteremia (3). We found recurrence in 9 of the 92 patients. Risk factors were similar to those previously reported for non--group A streptococcal cellulitis (13). PFGE of these isolates showed that a high percentage of recurrence was caused by identical strains. Although Cohen-Poradosu et al. reported that emm type stG840 was the most common strain (3), we found emm type stG485 to be most common.
For years in Taiwan, macrolide resistance of streptococci has been a major health problem (14,15). A previous study found erythromycin erythromycin (ĭrĭth'rōmī`sĭn), any of several related antibiotic drugs produced by bacteria of the genus Streptomyces (see antibiotic). resistance in 23.5% of GGS strains (14). Although we did not test for erythromycin resistance, we found some resistance even to new macrolides. Since restriction of macrolide use in Taiwan, a linear relationship has been noted between the decline in erythromycin use and the decline in erythromycin resistance in S. pyogenes (15). Our study, however, found no decline in macrolide resistance from first half of the study period (27.1%) to the second half (37.0%).
In summary, in our study, infection with S. dysgalactiae subsp, equisimilis was the most common cause of GGS bacteremia. Infection recurred for [approximately equal to] 10%. The mortality rate for patients with GGS bacteremia was relatively low (< 10%), but resistance to quinupristin-dalfopristin was extremely high.
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Of or relating to taxonomy: a taxonomic designation.
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Chun-Hsing Liao, * Liang-Chun Liu, ([dagger]) Yu-Tsung Huang, ([dagger]) Lee-Jeng Teng, ([dagger]) and Po-Ren Hsueh ([dagger])
* Far-Eastern Memorial Hospital, Taipei, Taiwan; and ([dagger]) National Taiwan University National Taiwan University (Traditional Chinese: 國立臺灣大學; Simplified Chinese: 国立台湾大学 College of Medicine, Taipei, Taiwan
Address for correspondence: Po-Ren Hsueh, National Taiwan University, No. 7, Chung-Shan South Road, 100 Taipei, Taiwan; email: email@example.com
Dr Liao is an infectious diseases infectious diseases: see communicable diseases. specialist in the Department of Internal Medicine, Far-Eastern Memorial Hospital. His major research interests are clinical and epidemiologic studies and pathogenesis of gram-positive bacterial infections, particularly streptococcal and methicillin-resistant Staphylococcus aureus methicillin-resistant Staphylococcus aureus Methicillin-aminoglycoside resistant Staphylococcus aureus, MRSA An organism with multiple antibiotic resistances–eg, aminoglycosides, chloramphenicol, clindamycin, erythromycin, rifampin, tetracycline, infections.
Table 1. Clinical characteristic of 92 patients with group G streptococcal bacteremia, April 1998-August 2004, Taiwan Characteristic No. (%) patients Age, y <10 1 (1.1) 10-50 12 (13.0) 51-75 68 (73.9) >75 11 (12.0) Median (range) 72 (10-93) Sex Male 58 (63.0) Female 34 (37.0) Underlying diseases Malignancy 35 (38.0) Genital 10 (10.9) Head and neck 8 (8.7) Gastrointestinal 6 (6.5) Hematologic 3 (3.3) Tissue edema 25 (27.2) Heart disease 20 (21.7) Post-coronary artery bypass graft 6 (6.5) Diabetes mellitus 16 (17.4) Central nervous system disease 15 (16.3) Liver cirrhosis 9 (9.8) Chronic renal disease 8 (8.7) Chronic lung disease 6 (6.5) Bone disease 5 (5.4) Deep venous thrombosis 2 (2.2) Type of infection Cellulitis 48 (52.1) * Primary bacteremia 34 (36.9) Deep-seated abscess 4 (4.2) ([dagger]) Neutropenia and fever 3 (3.3) Septic arthritis 2 (2.2) Urinary tract infection 1 (1.1) Infective endocarditis 1 (1.1) Pneumonia 1 (1.1) Initial findings Fever 86 (93.5) Leukocytosis (>10,000 cells/[micro]L) 34 (37.0) Septic shock 4 (5.4) Outcome Death 3 (3.3) Recurrence of bacteremia 9 (9.8) * Includes 2 patients who also had septic arthritis. ([dagger]) Includes 2 patients with psoas muscle abscess, 1 with epidural abscess, and 1 with deep neck infection. Table 2. Summary of characteristics of patients with recurrence of group G streptococcus bacteremia, April 1998-August 2004, Taiwan * Patient Age, y/ Date of no. sex Isolate isolation Underlying disease 1 67/F A1 2001 May 28 Coronary heart disease, A2 2002 Jul 18 post-coronary artery A3 2003 Oct 14 bypass graft 2 33/M B1 ([dagger]) 2002 Nov 13 Alcoholic liver B2 ([dagger]) 2002 Oct 15 cirrhosis, child C 3 47/F C1 1998 May 15 Vulvar cancer after C2 2002 Jan 18 surgery and radiotherapy C3 2002 Dec 19 4 49/M D1 2000 May 24 Nasopharyngeal carcinoma D2 2000 Aug 9 after chemotherapy and radiotherapy 5 28/M E1 1998 Dec 26 von Willebrand disease, E2 1999 Aug 28 type I 6 72/F F1 1998 Aug 24 Cervical cancer after F2 1998 Oct 23 surgery and F3 1999 Dec 3 radiotherapy, diabetes mellitus 7 55/F G1 1999 Oct 9 Cervical cancer after G2 2000 Apr 18 surgery and radiotherapy G3 2001 Sep 24 NA 2000 Jul 19 8 46/M H1 2001 Aug 21 Acute myeloid H2 2001 Sep 6 leukemia (M4) 9 80/F I1 2003 May 5 Cervical cancer with I2 2003 Nov 17 lung metastasis and obstructive uropathy Patient Date of PFGE no. isolation Clinical diagnosis emm type pattern 1 2001 May 28 Cellulitis stG166b -- 2002 Jul 18 Cellulitis stG166b Identical 2003 Oct 14 Cellulitis stG166b Identical 2 2002 Nov 13 Primary bacteremia STL1929.1 -- 2002 Oct 15 Primary bacteremia STL1929.1 Identical 3 1998 May 15 Cellulitis stG166b -- 2002 Jan 18 Cellulitis stG6.1 Related 2002 Dec 19 Cellulitis stG6.1 Identical 4 2000 May 24 Cellulitis stG485 -- 2000 Aug 9 Cellulitis stG485 Identical 5 1998 Dec 26 Cellulitis stG485 -- 1999 Aug 28 Cellulitis stG840 Different 6 1998 Aug 24 Cellulitis stG485 -- 1998 Oct 23 Cellulitis stG485 Identical 1999 Dec 3 Cellulitis stG840 Different 7 1999 Oct 9 Cellulitis stG485 -- 2000 Apr 18 Cellulitis stG485 Identical 2001 Sep 24 Cellulitis stG485 Identical 2000 Jul 19 Cellulitis NA NA 8 2001 Aug 21 Primary bacteremia stGLP 1.0 -- 2001 Sep 6 Primary bacteremia stGLP 1.0 Identical 9 2003 May 5 Primary bacteremia stG245.0 2003 Nov 17 Primary bacteremia stG245.0 Identical * PFGE, pulsed-field gel electrophoresis; NA, not available. ([dagger]) Streptoccus canis.