Streptococcus agalactiae

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Streptococcus agalactiae
Scientific classification
Kingdom: Bacteria Phylum: Firmicutes Class: Bacilli Order: Lactobacillales Family: Streptococcaceae Genus: Streptococcus Species: Streptococcus agalactiae
Binomial name
Streptococcus agalactiae

Description and significance

Streptococcus Agalactiae, also known as Group B streptococci are gram-positive cocci distinguished from other streptococci by the presence of the group B antigen. These bacteria range in size from 0.6 to 1.2 υm and arrange themselves in chains, forming shorter chains in clinical specimen and longer chains in culture specimen.

S. agalactiae colonize the lower gastrointestinal tract and the genitourinary tract, in a commensal relationship that is often asymptomatic, but can cause bacterial sepsis, neonatal sepsis, pneumonia, meningitis, postpartum infection and other infections in infected hosts.

Ecology

S. agalactiae inhabit a human host, colonizing the lower gastrointestinal tract and the genitourinary tract. Colonization is frequent in pregnant women, where the bacteria colonize 15% to 45% of women . In pregnant women, colonization can be transferred "in utero" to the fetus, or transferred from the birth canal during delivery.

Cell structure and metabolism

S. agalactiae are facultative anaerobes that are mostly B-hemolytic (1%-2% are non hemolytic) (hemolysis is the breakdown of red blood cells and is used to identify certain bacterial strains on culture plates).

The bacteria are well known for the serious infections and complications it causes in pregnant women and neonates. While carriage rates for pregnant women are very high (10%-30%), infection rates are much lower. In fact, the majority of pregnant women colonized with the bacteria are asymptomatic, with only 2%-4% of patients diagnosed with a urinary tract infection, the most common infection associated with pregnant women and the bacteria. These infections occur during and after pregnancy and generally clear up quite quickly. In very few cases, more serious complications such as endocarditis, meningitis, and osteomyelitis can occur.

S. agalactiae colonization complicates childbirth, as the rate of passing along colonization to the newborn is extremely high. In fact, over half – approximately 60% - of colonized mothers pass along the bacteria to newborns. Various risk factors including heavy bacterial colonization, premature delivery, prolonged membrane rupture, and fever during labor (>100.4°F) increase the probability of passing along colonization. Colonization in the baby can occur while the baby is developing in utero, during birth or in the first few months of a baby’s life. In utero colonization can have serious effects on neonates, as fetal aspiration of the bacteria can lead to stillbirth, neonatal pneumonia or neonatal sepsis . Colonization during childbirth can also seriously infect an infant’s health. While a majority of mothers pass along colonization during childbirth, only a very small percentage of colonization results in infection (only 1%-2%) . Early onset disease, which presents within an infants’ first week, is usually caused by in utero or birth colonization. Early onset disease usually presents itself as bactermia, pneumonia or meningitis. In fact, S. agalactiae is considered the main cause of these diseases in infants . Medical advancements have led to more efficient diagnosis and care of newborns colonized with S. agalactiae and have reduced the mortality rate to less than 5%. However, while the mortality rate is low, many infected newborns do not completely recover from meningitis and develop neurologic sequelae, an immulogical condition that often includes mental retardation, blindness and deafness. S. agalactiae colonization can also occur in older infants, resulting in late-onset diseases that occur from one week after birth to 3 months of age. Such infections usually present as sepsis, pneumonia, meningitis, osteomyelitis or septic arthritis . While the mortality rate is low for infants with late onset disease, developmental complications from meningitis are common.

S. agalactiae colonization occurs in individuals throughout the population, including non-pregnant women and in men. In such individuals, colonization in conjunction with compromised immunity can result in diseases such as bacteremia, pneumonia, bone and joint infections, and skin and soft-tissue infections. Mortality is higher for these patients and falls between 15% and 32%.

In search of a way to prevent the dangerous infections caused by S. agalactiae infection, much research has gone into how to treat S. agalactiae colonization in pregnant patients. The Center for Disease Control and Prevention (CDC) has issued guidelines for detecting and treating S. agalactiae colonization in pregnant patients. These guidelines, last updated in 2002, have been largely responsible for the lowered infant mortality rate. The CDC promotes two methods of detecting colonization. The risk-based method analyzes a particular patient’s risk of colonizing the bacteria by identifying risk factors correlated with S. agalactiae infections. The presence of these factors, which include premature delivery (before 37 weeks), having a temperature during labor and delivery (greater than 100.4 degrees Fahrenheit), or premature rupture of the amniotic fluid, indicate a high probability of S. agalactiae colonization. . The screening-based method cultures swabs taken from pregnant women between 35 and 37 weeks to test for vaginal and rectal S. agalactiae colonization. Both methods indicate that an infected patient should receive antibiotics during labor in order to reduce the risk of passing along colonization to the infant. While penicillin is generally regarded as the first choice for intrapartum antibiotic prophylaxis, ampicillin can be used for patients with penicillin allergies. .

As S. agalactiae' can cause many different infections and complications, various different medical treatments are often used to treat patients sickened by the bacterium. Current research is focusing on the development of a vaccine to create immunity against the bacteria and many in the medical community are rallying to work on ways to better diagnose and treat non-pregnant patients with colonization.

Current Research

Epidemiology S. agalactiae affects three main groups within the population: pregnant women, infants, and non-pregnant women and men. Following the 2002 release of the CDC’s treatment guidelines, a major epidemiological study (Phares, et. al) was published studying the trends of S. agalactiae disease within the population. The study, conducted from 1999-2005 and studying the population in 10 U.S. states, found that there 14,573 cases of S. agalactiae disease. 1,348, or 9.25% of these cases resulted in death. The incidence of early onset disease (which the study defined as from birth until 6 days old) decreased during the study, as from 1999-2001 the rate was 0.47 per 1000 live births and from 2003-2005 the rate decreased by 0.12 to 0.34 per 1000 live births. .This decrease occurred at the same time of the revised CDC treatment guidelines, indicating that the guidelines were effective in reducing disease. The study also measured the incidence of late onset disease and reported the ratio to be relatively stable throughout the study at 0.34 per 1000 live births. The study reported 409 S. agalactiae invasive infections in pregnant women, a ratio of 0.12 per 1000 live births. Half of these cases (203/409) were urinary, placental or amniotic sac infections that caused fetal death. A large majority of these pregnant patients, 81% (330/409) did not present with previous medical conditions (such as asthma, diabetes, obesity, or alcohol and drug abuse) . While the study only knew the pregnancy outcomes of 368 of the 409 pregnant women, data from the 368 known pregnancies are known. 61% of these pregnancies never came to term and ended in a spontaneous abortion or stillbirth, 4% had induced abortions, 5% delivered babies with infections and 30% delivered healthy babies. The study reported an incidence of 233 cases of S. agalactiae infections in children aged 90 days to 14 years, with a ratio of 0.56 per 100,000. This ratio, like the ratio of late-onset neonatal disease, was relatively stable throughout the study. The majority of these cases (61%, 143/233) were found in children younger than a year, while the remaining infections were evenly distributed amongst children aged 1 year to 14 years. The study reported the incidence of 6087 causes of S. agalactiae infections in adults (age 15 thru 64) and 5576 cases in senior citizens (age 65 and older). The 2005 ratio for the first group (aged 15 thru 64) was 5.0 per 100,000, a 48% increase from the 1999 ratio of 3.4 per 100,000. A similar increase was seen in the senior citizen group that rose 20% from a 1999 ratio of 21.5 per 100,000 to 26.00 per 100,000. While this study shows the success of the CDC regulations in decreasing incidence of early-onset disease and maintaining the rate of late onset disease, the increase in adult disease and the continual incidence of pregnancy and neonatal disease (it has not been eliminated) has highlighted the importance of researching a vaccine to help relieve infection. .

Continual Incidence A recent study conducted by Drs. Karen M. Puopolo, Lawrence C. Madoff and Eric C. Eichenwald attempted to understand the continual incidence of S. agalactiae infections despite updated CDC regulations and treatment plans to combat and eliminate the infections. The study, conducted over a six year time period from 1997 to 2003, reviewed the all cases of S. agalactiae infections at the Brigham and Women’s Hospital in Boston Massachusetts. By studying these cases of early onset S. agalactiae infections, the researchers hoped to determine if clinical, procedural or microbiological factors were responsible for the continual occurrence of infections, despite updated regulations and treatment protocol. Though the study coincided with the release of the CDC’s updated protocol in 2002, Brigham and Women’s Hospital requires pregnant women to be tested for S. agalactiae colonization by rectovaginal swabs, a protocol that follows the CDC’s 2002 guidelines. Thus, this study was examining the effectiveness of the screening based method. .

During the study, 67,260 babies were born in the hospital, of which 25 were infected with S. agalactiae colonization. 17 of these babies were term infants and 8 were preterm. As some mothers were preterm, only 21 of the 25 mothers had been screened for colonization, and 16 (64%) were found negative. Of the 17 term babies, 12 were asymptomatic or mildly ill, while 5 had more invasive infections, and one of these 5 died. The 8 preterm babies were all more critically ill, and 3 died. . The study observed that while 19 (76%) of the mothers presented with identifiable risk factors of S. agalactiae colonization (including positive signs of S. agalactiae colonization, delivering earlier than 37 weeks, intrapartum fever greater than 100.4°C, or clinical chorioamnionitis) only 4 received intrapartum antibiotic prophylaxis. . In fact, two term mothers who tested for colonization did not receive antibiotics. While one of these cases were the result of hospital error (and the other was due to a quick and unexpected delivery) the study concluded that hospital error was not responsible for most of the infection cases, as only 3 cases in total were caused by such errors. Additionally, the study observed that antibiotic resistance was not responsible for infection, as this only occurred in 1 of the 25 cases. Rather, the study references the high incidence of S. agalactiae infections in patients with negative cultures and suggests that in the presence of a negative culture, many other risk factors are ignored. This results in “a false sense of reassurance” which prevents these factors from being recognized, the proper steps being taken and increases the infection rate. The study identified a 4% false-negative colonization rate, a percentage that can have serious implications when this is the only screening method used and other risk factors are ignored. This study therefore highlights the need for a risk based method to accompany the screening method in order to help decrease S. agalactiae infections. .

Vaccine While CDC regulations have helped to decrease the amount of S. agalactiae invasive diseases in mothers and neonates, the continual incidence of disease, as well as the increase in adult infections, have led to increased research concerning an S. agalactiae vaccine. A recent (2006) study, conducted by Scilla Buccato, et al, researched such a vaccine that would provide patient immunity to S. agalactiae infections. The study focused on the bacterial pili that extend outside of the S. agalactiae cell, acting as adhesive factors that help with host colonization and virulence. Research has shown that there are 3 types of pili present in S. agalactiae, and genome sequencing of 8 S. agalactiae serotypes have shown that at least 1 pili is present in each strain of the bacteria. These pili are coded by genomic islands, a once mobile part of the genome that can be removed and transferred to a new genome. As a pathogenic factor found in all strains of S. agalactiae, the pili present as a possible vaccine component. A vaccine was made when a S. agalactiae pilus 1 operon was inserted into the Lactociccus lactis species. In order to test the vaccine’s ability to provide immunity and pass along antibodies to neonates, mice were immunized with the recombinant microorganism (the vaccine) and their offspring were later exposed to S. agalactiae. The vaccine proved to pass along immunity to the offspring, as after parental immunization with 107 cfu of the recombinant bacteria, more than 70% of the offspring survived exposure to S. agalactiae that was meant to kill 90% off the offspring. . Mucosal immunization was also tested, as the vaccine was also given intranasaly. The intranasal mucosal immunization, like the subcutaneous injected vaccine, was found to successfully pass along immunity to the offspring, as a “statistically significant protection” with P>.0002 was found. .

While the experiment successfully immunized mice against S. agalactiae infection, the mice were not totally immune to all infections, as different serotypes of S. agalactiae have different pili. The researchers attempted to make a hybrid vaccine, made up of genes for two or more of the bacterial pili. Such a sequence, made up of genes that encode for pili on island 1 and island 2, was made and inserted into L. lactis. This vaccine was tested in a similar way as the pili 1 vaccine and the offspring of immunized mice were found to be immune to infections from each of the individual pili that the hybrid vaccine was made of. Thus, the L. lactis pili vaccine was found to not only confer immunity upon mice and their offspring, but also serves as a way to recombine different pili in order to provide protection against infection. By creating such a hybrid, the experiment exposed groundbreaking research on the path to making a vaccine to combat "S. agalactiae" infections. .