- Email: [email protected]
Group D streptococcal infections
EDITOR'S COLUMN
Group D streptococcal infections
D STREPTOCOCCI are recognized pathogens in urinary tract infections and bacterial endocarditis in adults. Their role in neonatal infections has not been defined. The enterococcus has been cited in several major series of sepsis neonatorum,': but the recent report in THE JOURNAL by Headings and associates' and the accompanying paper mark a new awareness of the nonenterococcal group D streptococcus in neonatal disease. First recognized as a group of "enterococci" with unusually high susceptibility to penicillin," Streptococcus bovis was not included in the group D classification until 1962.' Although Streptococcus equinus is also classified with the nonenterococcal group D streptococci, this species has rarely been isolated from human beings.' During the past five years, S. bovis has received increasing attention for its pathogenicity in bacterial endocarditis and most recently for its association with colonic carcinoma.· As a result, most clinical laboratories now routinely differentiate nonenterococcal from enterococcal species. Although the enterococcus is part of the normal intestinal microbial flora and has been cultured from the vagina," there is little epidemiologic information about S. bovis. It has been found frequently in animal feces, in only 10% of rectal cultures from adult volunteers, and in none of 27 vaginal cultures from healthy women.· In an analysis of bacteremia in women on a large obstetricgynecologic service, anaerobic bacteria were found most frequently (incidence rate of 1.5 cases per 1,000 admissions); Escherichia coli (1.4 cases) and enterococcus (0.9 cases) were the two most frequently encountered aerobes.'" Because the enterococcus was identified by precipitin testing with the Lancefield group antiserum, nonenterococcal group D streptococci would not have been identified. Additional epidemiologic studies are necessary to substantiate transmission of these organisms from the mother to the infant. In the Table we present the incidence rates (cases per 1,000live births) of selected bacterial diseases at Parkland Memorial Hospital, Dallas. Based .on 30,059 live deliveries during the four years from 1974-1977, the three major pathogens were group B streptococci (3.2 cases), group D streptococci (1.2 cases), and Escherichia coli (0.9 cases). Although the yearly rates of group D streptococcal disease GROUP
542
The Journal ofPED I A TRI C S Vol. 93, No.3, pp. 542-543
Table. Incidence of selected neonatal bacterial diseases Year/ total No livebirths 1974/ 6,502 1975/ 7,376 1976/ 7,666 1977/ 8,515
Group D streptococcus Group B streptococcus
Escherichia coli
Nonenterococcus
Entero-
coccus
Combined
21+ (3.2)t
7" (1.0)
I (0.1)
13 (2.0)
14 (2.2)
31 (4.2)
10 (104)
1(0.1)
6 (0.8)
7 (0.9)
21 (2.7)
3 (004)
0(0)
6 (0.8)
6 (0.8)
22 (2.6)
7 (0.7)
5 (0.6)
5 (0.6)
10 (1.2)
*Total num ber of cases. tNumber of cases per 1,000 live births.
varied from 0.8 to 2.211,000, enterococci were the predominant agents except in 1977, when nonenterococcal group D streptococci and enterococci each caused 0.6 cases/l,ooO live births. See related article, p. 489. In our experience, early onset « 5 days of age) septicemia with or without acute respiratory distress was the usual clinical presentation of neonatal group D streptococcal disease. The enterococcal and nonenterococcal group D streptococci each accounted for one instance of meningitis. Nonenterococcal streptococcus was isolated in pure culture of > 100,000 colonies/rnl of urine from two infants who appeared to have sepsis. Patients with infection due to these organisms were too few and heterogenous to be distinguished clinically from those with disease caused by other pathogens. Alexander and Giacoia identify the nonenterococcal group D streptococcus as an important neonatal pathogen and stress the therapeutic implications of differentiating enterococcal from nonenterococcal group D streptococci. In vitro and clinical experience has demonstrated that either a penicillin-aminoglycoside combination or ampicillin alone constitutes effective therapy for enterococcal infections, whereas penicillin alone is adequate for disease
0022-3476/78/0393-0542$00.20/0
e
1978 The C. V. Mosby Co.
Editor's column
Volume 93
543
Number 3
caused by the nonenterococcal group D streptococci. Further studies are needed to define the epidemiology and pathogenesis of neonatal group D streptococcal infections. Jane D. Siegel, M.D. George H. Mc Cracken, i-; M.D. Department of Pediatrics University of Texas Health Science Center at Dallas Dallas, TX 75235
4.
5.
6.
7.
8.
REFERENCES I,
2. 3.
McCracken GH Jr, and Shinefield HR: Changes in the pattern of neonatal septicemia and meningitis, Am J Dis Child 112:33, 1966. Gluck L, Wood HF, and Forsek MD: Septicemia of the newborn, Pediair Clin N Am 13:1131, 1966. Bultow KC, Klein SW, and Love RB: Septicemia In premature infants, Am J Dis Child 110:29, 1965.
9.
10.
Wientzen RL, and McCracken GH: Pathogenesis and management of neonatal sepsis and meningitis, CUfT Prob Pediatr 8:I, 1977. Headings DL, Herera A, Mozzi E, and Bergman M: Fulminant neonatal septicemia caused by Streptococcus bovis, J PEDJATR 92:292, 1978. Hoppes WL, and Lerner PI: Nonenterococcal group D streptococcal endocarditis caused by Streptococcus bovis, Ann Intern Med 81:588, 1974. Facklam R: Recognition of group D streptococcal species of human origin by biochemical and physiological tests, Appl Microbiol23:113l, 1972. Klein RS, Recco RA, Catalano MT, Edberg SC, Casey n, and Steigbigel WH: Association of Streptococcus bovis with carcinoma of the colon, N Engl J Med 297:800, 1977. Fowler JE Jr, et al: Studies of an introital colonization in women with recurrent urinary infections. VIII. The role of bacterial interference, J Urol ])8:296, 1977. Ledger WJ, Norman M, Gee C, and Lewis W: Bacteremia on an obstetric-gynecologic service, Am J Obstet Gynecol 12t:205, 1975.
On auto-plagiarism During the past year, the editors of THEJOURNAL have been chagrined to learn that some examples of what has been termed auto-plagiarism ' have crept into the pages of THE JOURNAL. Auto-plagiarism may be defined as the duplicate reporting of very similar or identical material in more than one journal.' Frequently, this is effected by altering the sequence of the authors, with or without some minor modification of the title and the emphasis of the article. For a number of reasons, we cannot condone this practice. Ethical issues notwithstanding, the printing of an article under these circumstances serves to exclude the work of another author. When criticized on this point, we have little defense. However, it is obvious that we. as editors, cannot always control this practice, since there is no way for us to know whether articles under consideration have been submitted elsewhere. have been accepted, may be in press, or may be in print. When this has happened, we have always communicated our concern to the appropriate authors and editors. This does not solve the problem, however. and we take this opportunity to insist that authors avoid this practice. If this should happen again, we will take the liberty of printing the facts briefly in a subsequent issue of THE JOURNAL, and will suggest that a similar notice be published in the other journal or journals concerned. We plan to do this so that all of our readers will be fully informed.
R.E.M.
REFERENCES 1. Vaisrub S: Auto-plagiarism (editorial), JAMA 239:437, 1978. 2. Reiman AS: Publish or perish-or both, N Engl J Med 297:724, 1977.
Group D streptococcal infections
D STREPTOCOCCI are recognized pathogens in urinary tract infections and bacterial endocarditis in adults. Their role in neonatal infections has not been defined. The enterococcus has been cited in several major series of sepsis neonatorum,': but the recent report in THE JOURNAL by Headings and associates' and the accompanying paper mark a new awareness of the nonenterococcal group D streptococcus in neonatal disease. First recognized as a group of "enterococci" with unusually high susceptibility to penicillin," Streptococcus bovis was not included in the group D classification until 1962.' Although Streptococcus equinus is also classified with the nonenterococcal group D streptococci, this species has rarely been isolated from human beings.' During the past five years, S. bovis has received increasing attention for its pathogenicity in bacterial endocarditis and most recently for its association with colonic carcinoma.· As a result, most clinical laboratories now routinely differentiate nonenterococcal from enterococcal species. Although the enterococcus is part of the normal intestinal microbial flora and has been cultured from the vagina," there is little epidemiologic information about S. bovis. It has been found frequently in animal feces, in only 10% of rectal cultures from adult volunteers, and in none of 27 vaginal cultures from healthy women.· In an analysis of bacteremia in women on a large obstetricgynecologic service, anaerobic bacteria were found most frequently (incidence rate of 1.5 cases per 1,000 admissions); Escherichia coli (1.4 cases) and enterococcus (0.9 cases) were the two most frequently encountered aerobes.'" Because the enterococcus was identified by precipitin testing with the Lancefield group antiserum, nonenterococcal group D streptococci would not have been identified. Additional epidemiologic studies are necessary to substantiate transmission of these organisms from the mother to the infant. In the Table we present the incidence rates (cases per 1,000live births) of selected bacterial diseases at Parkland Memorial Hospital, Dallas. Based .on 30,059 live deliveries during the four years from 1974-1977, the three major pathogens were group B streptococci (3.2 cases), group D streptococci (1.2 cases), and Escherichia coli (0.9 cases). Although the yearly rates of group D streptococcal disease GROUP
542
The Journal ofPED I A TRI C S Vol. 93, No.3, pp. 542-543
Table. Incidence of selected neonatal bacterial diseases Year/ total No livebirths 1974/ 6,502 1975/ 7,376 1976/ 7,666 1977/ 8,515
Group D streptococcus Group B streptococcus
Escherichia coli
Nonenterococcus
Entero-
coccus
Combined
21+ (3.2)t
7" (1.0)
I (0.1)
13 (2.0)
14 (2.2)
31 (4.2)
10 (104)
1(0.1)
6 (0.8)
7 (0.9)
21 (2.7)
3 (004)
0(0)
6 (0.8)
6 (0.8)
22 (2.6)
7 (0.7)
5 (0.6)
5 (0.6)
10 (1.2)
*Total num ber of cases. tNumber of cases per 1,000 live births.
varied from 0.8 to 2.211,000, enterococci were the predominant agents except in 1977, when nonenterococcal group D streptococci and enterococci each caused 0.6 cases/l,ooO live births. See related article, p. 489. In our experience, early onset « 5 days of age) septicemia with or without acute respiratory distress was the usual clinical presentation of neonatal group D streptococcal disease. The enterococcal and nonenterococcal group D streptococci each accounted for one instance of meningitis. Nonenterococcal streptococcus was isolated in pure culture of > 100,000 colonies/rnl of urine from two infants who appeared to have sepsis. Patients with infection due to these organisms were too few and heterogenous to be distinguished clinically from those with disease caused by other pathogens. Alexander and Giacoia identify the nonenterococcal group D streptococcus as an important neonatal pathogen and stress the therapeutic implications of differentiating enterococcal from nonenterococcal group D streptococci. In vitro and clinical experience has demonstrated that either a penicillin-aminoglycoside combination or ampicillin alone constitutes effective therapy for enterococcal infections, whereas penicillin alone is adequate for disease
0022-3476/78/0393-0542$00.20/0
e
1978 The C. V. Mosby Co.
Editor's column
Volume 93
543
Number 3
caused by the nonenterococcal group D streptococci. Further studies are needed to define the epidemiology and pathogenesis of neonatal group D streptococcal infections. Jane D. Siegel, M.D. George H. Mc Cracken, i-; M.D. Department of Pediatrics University of Texas Health Science Center at Dallas Dallas, TX 75235
4.
5.
6.
7.
8.
REFERENCES I,
2. 3.
McCracken GH Jr, and Shinefield HR: Changes in the pattern of neonatal septicemia and meningitis, Am J Dis Child 112:33, 1966. Gluck L, Wood HF, and Forsek MD: Septicemia of the newborn, Pediair Clin N Am 13:1131, 1966. Bultow KC, Klein SW, and Love RB: Septicemia In premature infants, Am J Dis Child 110:29, 1965.
9.
10.
Wientzen RL, and McCracken GH: Pathogenesis and management of neonatal sepsis and meningitis, CUfT Prob Pediatr 8:I, 1977. Headings DL, Herera A, Mozzi E, and Bergman M: Fulminant neonatal septicemia caused by Streptococcus bovis, J PEDJATR 92:292, 1978. Hoppes WL, and Lerner PI: Nonenterococcal group D streptococcal endocarditis caused by Streptococcus bovis, Ann Intern Med 81:588, 1974. Facklam R: Recognition of group D streptococcal species of human origin by biochemical and physiological tests, Appl Microbiol23:113l, 1972. Klein RS, Recco RA, Catalano MT, Edberg SC, Casey n, and Steigbigel WH: Association of Streptococcus bovis with carcinoma of the colon, N Engl J Med 297:800, 1977. Fowler JE Jr, et al: Studies of an introital colonization in women with recurrent urinary infections. VIII. The role of bacterial interference, J Urol ])8:296, 1977. Ledger WJ, Norman M, Gee C, and Lewis W: Bacteremia on an obstetric-gynecologic service, Am J Obstet Gynecol 12t:205, 1975.
On auto-plagiarism During the past year, the editors of THEJOURNAL have been chagrined to learn that some examples of what has been termed auto-plagiarism ' have crept into the pages of THE JOURNAL. Auto-plagiarism may be defined as the duplicate reporting of very similar or identical material in more than one journal.' Frequently, this is effected by altering the sequence of the authors, with or without some minor modification of the title and the emphasis of the article. For a number of reasons, we cannot condone this practice. Ethical issues notwithstanding, the printing of an article under these circumstances serves to exclude the work of another author. When criticized on this point, we have little defense. However, it is obvious that we. as editors, cannot always control this practice, since there is no way for us to know whether articles under consideration have been submitted elsewhere. have been accepted, may be in press, or may be in print. When this has happened, we have always communicated our concern to the appropriate authors and editors. This does not solve the problem, however. and we take this opportunity to insist that authors avoid this practice. If this should happen again, we will take the liberty of printing the facts briefly in a subsequent issue of THE JOURNAL, and will suggest that a similar notice be published in the other journal or journals concerned. We plan to do this so that all of our readers will be fully informed.
R.E.M.
REFERENCES 1. Vaisrub S: Auto-plagiarism (editorial), JAMA 239:437, 1978. 2. Reiman AS: Publish or perish-or both, N Engl J Med 297:724, 1977.