The emergence of group B streptococci in infections of the newborn infant.
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Biomedical subjects
Publications and source records attributed to B F Anthony.
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The opsonization and phagocytosis of group B streptococci of types Ia, Ib, and Ic were studied in vitro by measuring the uptake of radioactivity by coverslip cultures of rabbit alevolar macrophages during incubation with radiolabeled, nonviable bacteria which had been exposed to rabbit serum. The uptake of counts per minute was quantitative, reproducible, and reversibly inhibited by cold, indicating that it was largely a measurement of phagocytic ingestion rather than of attachment of bacteria-immunoglobulin complexes to macrophage membranes. Moreover, suspended macrophages killed approximately 90% of viable streptococci in the presence of specific antiserum. The opsonic activity of immune serum was heat stable, and phagocytosis of streptococci was insignificant after incubation with normal serum and antiserum to some heterologous group B streptococci. By absorption studies, it was possible to identify the effect of antibodies to specific bacterial antigens. Phagocytosis of streptococci containing the corresponding antigens was maximal after opsonization with homologous or heterologous sera containing antibody to IaCHO, IbCHO, or Ibc protein. Phagocytosis of all three serotypes was intermediate when opsonization could be attributed to anti-IabcCHO. The opsonization of a specific group B streptococcus is complex and may involve two or more antigen-antibody systems.
Three patients with meningitis due to the Lancefield group D enterococci are described and the pertinent literature is reviewed. Anatomic central nervous system (CNS) defects, prior neurologic or neurosurgical interventions, group D enterococcal endocarditis, and urinary tract infection appear to be important predisposing factors. Of note is the frequent lack of cellular response in the spinal fluid to enterococci. The mortality of this infection is high (33%) and is probably dictated as much by the underlying disorder as the infection itself. The therapeutic importance of careful separation of group D streptococcal isolates into enterococci and nonenterococci, especially in instances of CNS infections, is emphasized. We discuss the appropriate antimicrobial therapy for enterococcal meningitis.
Serious infections in adults due to group B streptococci have been infrequently reported. We describe 24 such patients. Bacteremic pyelonephritis, pneumonitis and endometritis were the most common clinical syndromes observed. Group B streptococci infections tended to occur in patients with underlying illnesses, particularly genitourinary disorders and diabetes mellitus. Mortality was surprisingly low (8 per cent). Type III was the serotype most commonly isolated, and there was no significant correlation of different serotypes with specific organ-system involvement. Group B streptococcal isolates from these patients were uniformly sensitive to penicillin, ampicillin, cephalothin, chloramphenicol, erythromycin and clindamycin; all were highly resistant to kanamycin. Eighty-seven per cent were resistant to tetracycline. Although consistently sensitive to penicillin, the minimal inhibitory concentrations were significantly higher for group B than group A streptococci (p less than 0.0005).
The peripheral leukocytes of newborn infants and of adult volunteers were studied after separation of polymorphonuclear and mononuclear cells. Monocytes were identified and quantitated with the aid of histochemical staining. The in vitro killing capacity of PMN and of monocytes was assayed against Staphylococcus aureus and Escherichia coli. The monocytes of both infants and adults were significantly less active than were their PMN, but the bactericidal capacity did not differ appreciably between newborn and adult cells of either type.
Serial observations including cultures of the upper respiratory tract and of infected skin lesions and streptococcal antibody determinations were made over a two-year period in a semi-closed population of children between 10 months and 15 years of age. There was a high prevalence of group A streptococci in nose and throat cultures and of skin lesions containing these organisms. Almost 90% of the study population developed streptococcal impetigo during the study period. A slightly higher proportion of males than females developed skin infection but there was no relationship to age. Impetigo was observed throughout the calendar year, exceeding 12% of child-visits in one winter month, but was generally more common in the summer and fall. Conversely, group A streptococci were more often isolated from nose and throat cultures in the winter months. The increase in recovery of streptococci from nose and throat cultures lagged behind the increase in streptococcal impetigo and continued into the winter months, when the prevalence of impetigo had declined. Calculation of ratios for individual streptococcal serotypes isolated from different body sites revealed a clear cut distinction between "respiratory" and "impetigo" serotypes, with respect to both prevalence and acquisition rates. Respiratory serotypes were more commonly isolated in the winter and impetigo serotypes in the summer and fall. Significant antibody responses to extracellular antigens of the streptococcus were documented for pharyngeal acquisitions of both impetigo and respiratory serotypes and for skin lesions associated with impetigo serotypes. Group A streptococcal serotypes may be divided into three categories on the basis of their human pathogenicity for body sites: some with the potential for respiratory infection, others with the potential for skin infection and a few unusual serotypes with the potential for infecting both sites.
The antibody response of 40 institutionalized children involved in an epidemic associated with asymptomatic pharyngeal acquisition of a group A, M-11, T-11 typeable Streptococcus was studied. Titers of antibody to streptolysin O and to deoxyribonuclease B determined in sera collected from patients within two weeks of positive throat cultures were significantly higher than those in sera of controls (P smaller than 0.001). However, there was no rise in antibody titers in sera obtained from these patients after an interval of three weeks. Type-specific antibody to the group A Streptococcus (type M-11) was assayed in the sera of 24 patients. No detectable antibody activity was found either in the initial sera or in sera collected eight months after the epidemic. Thus, the asymptomatic nature of this epidemic could not be attributed to the presence of detectable type-specific antibody in this population at the time of the epidemic. These observations suggest that asymptomatic pharyngeal acquisition of group A Streptococcus may occur in epidemic fashion in certain populations and may not be associated with evidence of an antibody response to the streptococcal organism.
Eighty-six percent of 707 beta-hemolytic streptococci isolated in a general hospital and excluded by presumptive tests from groups A and D were identified serologically as group B. More than 70% of the group B isolates were from urine cultures, the female genital gract, or newborn infants. Types III and II were the most common group B serotypes from most sources. However, types Ia, Ib, and Ic were more commonly isolated from the respiratory tract than from other sites, and type III was responsible for most serious neonatal infections. All group B streptococci were sensitive in vitro to comparable levels of penicillin G, ampicillin, and cephalothin and were highly resistant to kanamycin. Seventy-two percent were resistant to tetracycline but only 1%-2% to erythromycin, clindamycin, and chloramphenicol. Despite consistent sensitivity to penicillin G, the minimal inhibitory concentrations were significantly higher for group B than for group A streptococci.
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The immune response after streptococcal infection of the skin and of the upper respiratory tract (URT) was studied prospectively in a group of normal children, ages 3-6 yr. The children were examined and cultures for group A streptococci were obtained weekly from the throat, nose, and skin lesions (when present). Paired sera were collected at the beginning and end of the study, and the changes in antibody titers were measured for three different streptococcal antigens: streptolysin O, deoxyribonuclease B (DNAse B), and nicotinamide adenine dinucleotidase (NADase). The findings suggest that in contrast to infection of the URT antibody response to streptolysin O is relatively feeble after streptococcal infection which is limited to the skin. The response to NADase is also poor after cutaneous infection. Antibody responses to DNAse B are generally good regardless of the site of the infection. These and other studies indicate that anti-DNAse B is the antibody of choice in studying streptococcal infection of the skin and its complications.
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