Emergence of further serotypes of multiple drug-resistant Streptococcus pneumoniae in Queensland

We describe 27 cases of multiple drug-resistant pneumococcal infection in Queensland children (7 cases) and adults (20 cases), between February 1995 and October 1996. Seven patients had invasive disease. Serotypes were those commonly associated with paediatric infections and included types 19F (15 strains), 14 (6), 23F (4), 6A (1) and 19A (1). No rifampicin or vancomycin resistance was encountered. However, pneumococci fully resistant to cotrimoxazole, erythromycin and tetracycline were isolated from 25 of 27 cases (93%). Strains with high level resistance to penicillin and chloramphenicol were also recovered from 16 (59%) and 19 (70%) patients respectively. Twelve of 16 penicillin-resistant isolates showed intermediate resistance to ceftriaxone and two strains were fully resistant to this antibiotic. Clones of types 19F and 14 pneumococci, each with two distinctive resistance patterns, appear to be established in south-east Queensland.     

Detection of Streptococcus pneumoniae in clinical specimens, its antimicrobial susceptibility and serotypes

The purpose of our investigation was the detection of S. pneumoniae and the isolation frequency of PRSP/PISP from the patients of the area. 457 strains of S. pneumoniae were isolated from the clinical specimens which had been requested for cultivation from the individual general practitioners in the city. Screening of the PRSP/PISP in 457 strains was carried out with the oxacillin (MPIPC) disk method. The MIC (benezylpenicillin: PCG) was measured at the same time in 73 strains, and compared with the disk method. The results were as follows: 1) Regarding the detection rate of S. pneumoniae, nose discharge was the highest (11.4%) in all the specimens. 2) There was a greater number of isolation of S. pneumoniae in one year from November to March. Then it was scarce in August and September. This change in seasons was noted. 3) There were many 9-year olds and over-60 year olds in the age group of the patients in whom the S. pneumoniae was isolated. 4) All 30 strains where a 6 mm diameter was found when a MIC was compared with the MPIPC disk method were resistant (PRSP/PISP). All 20 strains with a > or = 20 mm diameter were sensitive (PSSP). But in the 23 strains which had a 7 mm -19 mm, 7 strains (30%) were PSSP, and 16 strains (70%) in the intermediate (PISP). 5) A diameter of 6 mm was found in 194 strains (42.5%) with the MPIPC disk method, among the 457 strains isolated from the clinical specimens. 141 strains (30.9%) were found with a diameter of 7 mm -19 mm and 122 strains (26.7%) with a diameter of > or = 20 mm. 6) More than 70% in PRSP/PISP were multiple antimicrobiotics resistant strains to PCG, EM and MINO. 7) The distribution of the serotype in PRSP/PISP was in the order of 19 type (41.3%), 23 type (21.7%), 6 type (13.0%). Moreover, it was in the order of 3 type (18.5%), 6 type (11.1%), 19 type (11.1%), and there were few 23 type (3.7%) for PSSP. The distribution of the serotype was different for PRSP/PISP and PSSP.     

A live recombinant avirulent oral Salmonella vaccine expressing pneumococcal surface protein A induces protective responses against Streptococcus pneumoniae

A live oral recombinant Salmonella vaccine strain expressing pneumococcal surface protein A (PspA) was developed. The strain was attenuated with Deltacya Deltacrp mutations. Stable expression of PspA was achieved by the use of the balanced-lethal vector-host system, which employs an asd deletion in the host chromosome to impose an obligate requirement for diaminopimelic acid. The chromosomal Deltaasd mutation was complemented by a plasmid vector possessing the asd+ gene. A portion of the pspA gene from Streptococcus pneumoniae Rx1 was cloned onto a multicopy Asd+ vector. After oral immunization, the recombinant Salmonella-PspA vaccine strain colonized the Peyer's patches, spleens, and livers of BALB/cByJ and CBA/N mice and stimulated humoral and mucosal antibody responses. Oral immunization of outbred New Zealand White rabbits with the recombinant Salmonella strain induced significant anti-PspA immunoglobulin G titers in serum and vaginal secretions. Polyclonal sera from orally immunized mice detected PspA on the S. pneumoniae cell surface as revealed by immunofluorescence. Oral immunization of BALB/cJ mice with the PspA-producing Salmonella strain elicited antibody to PspA and resistance to challenge by the mouse-virulent human clinical isolate S. pneumoniae WU2. Immune sera from orally immunized mice conferred passive protection against otherwise lethal intraperitoneal or intravascular challenge with strain WU2.     

Septic arthritis caused by Streptococcus pneumoniae

BACKGROUND: Streptococcus pneumoniae is an uncommon agent of infective arthritis. In this report three cases of pneumococcal arthritis are described. METHODS: Retrospective review of synovial fluids processed in our laboratory yielding bacteria. The study period was from January 1991 to December 1995. The clinical records of patients with the clinical and microbiological diagnosis of septic arthritis were reviewed. RESULTS: Twenty-eight out of a total of 43 clinical records had the clinical and microbiological diagnosis of septic arthritis and three (11%) were caused by Streptococcus pneumoniae. The infective source in two of these three cases was probably the respiratory tract, and the most common location was the knee. CONCLUSIONS: In our cases immunosuppression seemed to be the major risk factor involved in the development of pneumococcal arthritis.     

Primary peritonitis caused by Streptococcus pneumoniae

OBJECTIVES: To examine the dilemmas for children, family, and mental health professionals posed by the presence of a delusional parent in a family, including someone with induced psychotic disorder (IPD); to identify frequently unrecognized problems; and to propose practical suggestions for professionals. METHOD: The pertinent literature on the effects of delusional parents on children, families, and professionals is reviewed. By way of 3 case vignettes, the dilemmas are identified and discussed. RESULTS: Delusional disorders are underdiagnosed, resulting in poor anticipation of their implications. Unanticipated family factors, such as "pursuit of isolation" and the related heightened risk of violence, contribute to the failure of professional interventions, which has been described as "therapeutic systems paralysis." CONCLUSIONS: These cases are complex, often requiring multisystemic involvement to reduce the risks of flight. violence, psychosis, posttraumatic stress disorder, and other psychiatric sequelae to children and other family members. The critical features of the innovative collaboration ("therapeutic consensus") required between professionals for successful therapeutic interventions with these families are described.     

Occurrences of penicillin-binding protein 2B gene in clinically isolated penicillin-resistant Streptococcus pneumoniae

We analyzed 88 strains of Streptococcus pneumoniae (S. pneumoniae) isolated in Showa University Hospital from June 1995 to July 1996. The ratios of antibiotic resistance were 39% to penicillin G, 50% to erythromycin, and 2% to imipenem. No resistant to cefotaxime and ofloxacin was observed. Thirty-four strains (39%) were considered to be penicillin-resistant S. pneumoniae (PRSP) strains (MIC of penicillin G > or = 0.5 microgram/ml), according to the breakpoint determined by the Japanese Working Group for Penicillin-Resistant Streptococcus pneumoniae. The ratio of PRSP was higher in S. pneumoniae isolated from inpatients (25/47) when compared to that from outpatients. By PCR analysis, DNA regions of autolysin were amplified in all the 88 strains, confirming that the isolates were S. pneumoniae. Penicillin-binding protein 2B (PBP2B) class B region was positive in 32 strains, and PBP2B class A was in 2 strains. Twenty eight of 34 strains of PRSP contained the PBP2B class B gene. In the remaining six PRSP strains, neither the PBP2B class A nor B region was amplified. The PBP2B class B region was detected as a 180-kb fragment of SmaI digestion of S. pneumoniae DNA by Southern blot analysis, confirming that the detection of PBP2B class B gene by PCR is reliable. We concluded that the PBP2B class B gene is considered to be a major gene responsible for phenotypic resistance of PRSP. We performed genotyping by SmaI digestion pattern using pulsed field gel electrophoresis. No identical pattern was observed in isolates from inpatients, suggesting that apparent nosocomial infection of S. pneumoniae was negligible.     

Acute bilateral amaurosis in sphenoid empyema caused by Streptococcus pneumoniae

PATIENT: A 14-year-old boy suffered from an acute bilateral blindness which occurred in 24-h time, accompanied by headache and raised temperature, with inconspicuous optic nerve head and fundus. After diagnosis of empyema with magnet resonance tomography (MRT) the sphenoid sinus was fenestrated and streptococcus pneumoniae isolated. Liquor and serology being inconspicuous, there was no evidence of leucaemic or autoimmune disease, intoxication or intracranial tumor. CLINICAL COURSE: The condition of the patient improved under systemic antibiotic therapy. The bilateral amaurosis remained and opticus atrophy developed. CONCLUSION: A bilateral amaurosis with descending opticus atrophy as a consequence of a sphenoiditis and spreading inflammation to the meninges and the optic nerve in the area of the chiasm is a rare event. The imaging technique of the MRT offers new opportunities for an early and more pointed diagnosis and therapy.     

A competence regulon in Streptococcus pneumoniae revealed by genomic analysis

Transformation in bacteria is the uptake and incorporation of exogenous DNA into a cell's genome. Several species transform naturally during a regulated state defined as competence. Genetic elements in Streptococcus pneumoniae induced during transformation were identified by combining a genetic screen with genomic analysis. Six loci were discovered that composed a competence-induced regulon. These loci shared a consensus promoter sequence and encoded proteins, some of which were similar to proteins involved in DNA processing during transformation in other bacteria. Each locus was induced during competence and essential for genetic transformation.     

Multiple antibiotic resistance in Streptococcus pneumoniae

A 40-year-old Libyan male was admitted to the intensive therapy unit of Zliten Central Hospital, Libya after a road traffic accident in which he had been the driver. On physical examination he was irritable, dyspnoeic, cyanotic, had contusions and abrasions on his chest and abdomen (mainly on the left side), a lacerated wound on the forehead, a large haematoma over the left thigh and tenderness over the left side of the chest and abdomen.     

Oligoclonality of serum immunoglobulin G antibody responses to Streptococcus pneumoniae capsular polysaccharide serotypes 6B, 14, and 23F

Serum antibodies (Abs) specific for the capsular polysaccharides of Streptococcus pneumoniae provide protection against invasive pneumococcal disease. Previous studies indicate that Abs to pneumococcal polysaccharide (PPS) serotypes 1 and 6B have limited clonal diversity. To determine if restricted diversity was a feature common to other PPS specificities, we examined the light (L)-chain expression and isoelectric heterogeneity of type 6B, 14, and 23F Abs elicited in 15 adults following PPS vaccination. At the population level, both PPS-6B and PPS-14 Abs expressed kappa and lambda chains, although 6B Abs more frequently expressed lambda chains lambda and 14 Abs more frequently expressed kappa chains. In individual sera, Abs were generally skewed towards either kappa or lambda expression. 23F-specific Abs had predominantly kappa chains. Isoelectric focusing analyses showed that sera contained one or at most a few immunoglobulin G Ab spectrotypes to all three respective capsular serotypes, a result indicative of oligoclonality. A sequence analysis of a purified PPS-14-specific Ab having a single spectrotype gave uniform amino-terminal sequences for both the heavy chain (V(H)III subgroup) and the L chain (kappaIII-A27 V region). From these results we conclude that within individual adults, serum Ab responses to PPS serotypes 6B, 14, and 23F derive from a small number of dominant B-cell clones, and consequently variable-region expression is probably individually limited as well. Oligoclonality appears to be a general characteristic of human PPS-specific Ab repertoires, and we suggest that this property could lead to individual differences in Ab fine specificity and/or functional activity against encapsulated pneumococci.     

Vancomycin in meningitis caused by penicillin G resistant Streptococcus pneumoniae

We report two cases of penicillin G-resistant pneumococcal meningitis in adults, with clinical and bacteriological failure of amoxicillin and negative or incomplete response to third generation cephalosporins. Meningitis occurred in a man treated for myeloma and in an elderly woman under prolonged intermittent amoxicillin therapy for chronic otitis. Such situations are known as exposing to pneumococcal meningitis and to resistance of the strain involved to penicillin G. Both patients were cured by vancomycin in continuous infusion associated with rifampicin or fosfomycin. Contrary to third generation cephalosporins, which have higher minimal inhibitory concentrations, vancomycin and rifampicin are still fully active against penicillin G-resistant pneumococcal strains. Thus, vancomycin administered in continuous infusion and associated with rifampicin and fosfomycin deserves to be tried as first-line treatment of pneumococcal meningitis in patients at risk of resistance to penicillin G.     

Streptococcus pneumoniae and beta-lactam antibiotic agents

Pneumococcus has been known for over 100 years. Despite an intensive research, the problem of pneumococcal diseases has not yet been solved. During the last few decades, the incidence of pneumococcal pneumonia has declined, but the S. pneumoniae is today the main, or one of the most frequent, causative agents of meningitis, sinusitis, otitis media and conjunctivitis. Besides, cases of pneumococcal appendicitis, tubo-ovarian abscess, haemolytico-uremic syndrome, cellulitis and urinary infections have been described. Therefore, it is very important from medical point of view to follow-up its sensitivity to antibacterial drugs. Unfortunately, during the latest decades, an increase in percentage of resistant clinical isolates has been registered. It is obvious that the investigation of the sensitivity of pneumococci, that is, of their resistance to beta-lactam antibiotics is essential. The examination of the interaction between pneumococci and penicillin has resulted in significant discoveries concerning the mechanism of the effect of penicillin as well as the impact of penicillin-binding proteins, lipoteichoic acid and choline-residues in the cell wall. A particular contribution as regards the effect of penicillin has been achieved by linking murein hydrolases (autolythic enzymes) with the expression of bactericidal effect of penicillin. Besides, the model of pneumococcal resistance to penicillin together with the model of meticillin resistance of staphylococci enabled the perception of the new mechanism of bacteria resistance to beta-lactam antibiotics. Given the pathogenic potential of pneumococci and the increase of clinical isolates resistant to antibiotics, it can be concluded that immunoprophylaxis is of great importance. Although several polyvalent vaccines are being used, there are still unsolved problems whose solution will improve the safety of their application, contribute to a better efficiency and enable a widespread application of antipneumococcal vaccines.     

Primary targets of fluoroquinolones in Streptococcus pneumoniae

Mutants of wild-type Streptococcus pneumoniae IID553 with mutations in parC were obtained by selection with trovafloxacin, levofloxacin, norfloxacin, and ciprofloxacin. All of the parC mutants were cross-resistant to the selecting agents but were not resistant to gatifloxacin and sparfloxacin. On the other hand, gyrA mutants were isolated by selection with gatifloxacin and sparfloxacin. The gyrA mutants were cross-resistant to gatifloxacin and sparfloxacin but were not resistant to the other fluoroquinolones tested. These results suggest that in wild-type S. pneumoniae the primary target of trovafloxacin, levofloxacin, norfloxacin, and ciprofloxacin is topoisomerase IV, whereas the primary target of gatifloxacin and sparfloxacin is DNA gyrase.     

Streptococcus pneumoniae blood culture isolates from patients with and without human immunodeficiency virus infection: alterations in penicillin susceptibilities and in serogroups or serotypes

We performed a 3-year retrospective study of Streptococcus pneumoniae blood culture isolates recovered at Baragwanath Hospital, Soweto, South Africa, from 1993 to 1995. The study group comprised 457 patients, including 98 children, of known human immunodeficiency virus (HIV) serostatus. Of these patients, 70 (30 [8.4%] of 359 adults and 40 [40.8%] of the 98 children) were infected with penicillin-resistant S. pneumoniae strains (minimal inhibitory concentration, > or = 0.12 microg/mL); 56 of these strains were intermediately resistant to penicillin. HIV-positive patients had significantly more penicillin-resistant isolates than did HIV-negative patients (43 [29.7%] of 145 HIV-positive patients vs. 27 [8.6%] of 312 HIV-negative patients; P < .001); this difference was found for both adults (19% vs. 4.3%; P < .001) and children (53.3% vs. 30.2%; P < .0343). Multiple resistance occurred more frequently in HIV-positive children (P = .02). HIV-positive adults had a statistically significant increase in the percentage of serogroups and serotype usually found in children and commonly associated with antimicrobial resistance, i.e., serotype 14 and serogroups 6, 19, and 23 (48% vs. 28.6%; P < .001). The increased prevalence of serogroups or serotypes usually found in children was also found among penicillin-susceptible strains. These data suggest that HIV-infected adults may again become susceptible to the serogroups or serotypes found in children.     

Serotyping of Streptococcus pneumoniae by coagglutination with 12 pooled antisera

We report on the performance of a recently introduced commercial chessboard method using 12 antisera, in comparison with that of the 55-antiserum panel used in determining the serogroups and types (SGTs) of Streptococcus pneumoniae, both of which were carried out by a coagglutination technique. Of a total of 150 strains of S. pneumoniae studied, 135 (90%) belonged to the SGTs represented in the 23-valent pneumococcal vaccine; of these, 130 (96.3%) were identified as the same SGTs by both typing methods. The remaining five strains showed cross-reactivity with more than two pools by the chessboard method, but could be assigned to a single SGT by the Quellung test. The 96.3% concordance of the chessboard method suggests it can be adopted for determination of the SGTs of S. pneumoniae in laboratories.