Postpartum infections and antimicrobial resistance of responsible pathogens in Ukraine: results a multicenter study (2020-2022).

OBJECTIVE: Aim: To determine the current prevalence of postpartum infections and antimicrobial resistance and antimicrobial resistance of responsible pathogens in Ukraine. PATIENTS AND METHODS: Materials and Methods: Multicenter prospective cohort study was conducted from January 2020 to December 2022 in fifteen hospitals from twelve regions of Ukraine. Definitions of healthcare- associated postpartum infection were adapted from the Centers for Disease Control and Prevention's National Healthcare Safety Network. Antibiotic susceptibility was done by the disc diffusion test as recommended by EUCAST. RESULTS: Results: Among 21,968 women, 6,175 (28.1%) postpartum infections were observed. Of all postpartum infection cases, 83.1% were detected after hospital discharge. The postpartum infection rates were 17.3% after cesarean section and 10.8% after vaginal delivery. The most common postpartum infection types were endometritis (17.3%), followed by urinary tract Infection (3.5%), mastitis (3.4%), surgical site infection (excluding endometritis) (2.4%), and episiotomy site infection (1.5%). The predominant postpartum infection pathogens in Ukraine were: Escherichia coli (10.4%), Enterococcus spp. (9.6%), Staphylococcus aureus (6.7%), Pseudomonas aeruginosa (5.8%), Enterobacter spp. (5.8%). In our study pathogens of postpartum infection had differently levels of resistance to antibiotics. CONCLUSION: Conclusions: Our results indicate that postpartum infections requiring medical attention are common in Ukraine and that most postpartum infections occur after hospital discharge, so that use of routine inpatient surveillance methods alone will lead to underestimation of postpartum infection rates. Optimizing the antibiotic prophylaxis may reduce the burden of postpartum infection, but prevention is the key element.

Intrauterine bacterial growth in elective and non-elective caesarean sections.

We assessed intrauterine bacterial growth for elective and non-elective caesarean sections (CSs). Aerobic uterine cultures were obtained from the uterine cavity immediately following placental removal from 1376 patients who underwent CS in one center during one year. About 13.8% (115/832) of elective CS were positive vs. 55.9% (304/544) of non-elective CS (p < .001). Of non-elective CSs, 28.6% (56/196) of those without ruptured membranes (ROM) were positive vs. 71.3% (248/348) with ROM (p < .001). Mean birth weight and 1-minute Apgar scores were significantly lower in women with positive cultures, elective and non-elective, than negative cultures. A higher percentage of women with positive uterine cultures presented with postpartum endometritis (p < .05). Intrauterine bacteria in elective CSs demonstrate that the uterine cavity is not sterile. Non-elective CS, particularly after membrane rupture, is a significant risk factor for positive uterine culture. Positive uterine culture is associated with lower birth weight, lower one-minute Apgar score and postpartum endometritis.Impact statementWhat is already known on this subject? Postpartum endometritis is a leading cause of postpartum febrile morbidity. Caesarean sections, in particular non-elective cesareans, are an important risk factor for the development of postpartum endometritis. Controversy exists concerning the sterility of the placenta and uterus. The diagnosis of endometritis is based mainly on clinical findings and does not necessitate bacterial isolation from the uterine cavity. Positive culture at caesarean section has been associated with positive postoperative culture and yet, currently, professional organisations do not recommend the routine sampling of intrauterine cultures during caesarean section.What do the results of this study add? Since positive uterine culture rate was higher in non-elective CSs and associated with lower birth weight and 1-minute Apgar score and postoperative endometritis, obtaining uterine culture in those cases might be of clinical value.What are the implications of these findings for clinical practice and/or further research? Obtaining routine intrauterine cultures during non-elective caesarean sections might be useful for detecting significant pathogens and tailoring antibiotic treatment in postpartum endometritis. Further studies are necessary in order to determine the impact of obtaining intrauterine cultures during caesarean sections, particularly non-elective cesareans.

The risk of urine bacterial colonisation in patients with a permanent catheter after caesarean section.

We present an observational study, conducted in Slovakia, concerning the occurrence of newly acquired urine colonisations in women with Foley catheters after a Caesarean section. A sample of urine was taken from each patient when the Foley catheter was first inserted, before the operation and was sent to the lab for culture. Later, a sample of urine was taken during the removal of the Foley catheter. Out of 176 women, the second urine sample culture result was positive in 13 women. Of those nine women had a positive pathogenic strain (5.1%). The prevalence of asymptomatic bacteriuria in our cohort was 7.7%. De novo acquired colonisation of urine was confirmed in 5.1% of cases. The only confirmed risk factor was delivery by an acute Caesarean section.Impact statementWhat is already known on this subject?: It is well known that catheterisation increases risk of colonisation of lower urinary tract by pathogens. However, the extent of this risk is not determined because there are no studies of de novo colonisation in women with sterile urine before catheterisation. According to literature approximately 8% of women have asymptomatic bacteriuria, which could be confounding factor in previous studies.What do the results of this study add?: Our study excluded women with positive bacteriuria before insertion of Foley catheter. Therefore, the study only assesses de novo colonisation, dependent on insertion of Foley catheter during caesarean section.What are the implications of these findings for clinical practice and/or further research?: De novo colonisation was observed in 5.1% of women in our cohort, with emergency caesarean section as a confirmed risk factor. Therefore, practitioners should consider avoiding catheterisation during caesarean section.

Risk factors, changes in serum inflammatory factors, and clinical prevention and control measures for puerperal infection.

BACKGROUND: To investigate the risk factors and changes in serum inflammatory factors in puerperal infection, and propose clinical prevention measures. METHODS: A total of 240 subjects with suspected puerperal infection treated in our hospital from January 2017 to December 2017 were collected, among which puerperal infection was definitely diagnosed in 40 cases, and it was excluded in 40 cases. Levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and high-sensitivity C-reactive protein (hs-CRP) were compared between the two groups, and the change trends of IL-6 and hs-CRP were recorded. RESULTS: Levels of IL-6, hs-CRP, and TNF-α in puerperal infection group were higher than those in non-infection group (P < .05). Levels of IL-6 and hs-CRP at enrollment and 1-3 days after enrollment in infection group were higher than those in non-infection group (P < .05). The body mass index >25, placenta previa, placenta accreta, postpartum hemorrhage, premature rupture of membrane, gestational diabetes mellitus, and anemia during pregnancy were relevant and independent risk factors for puerperal infection. Puerperal infection occurred in uterine cavity, vagina, pelvic peritoneum, pelvic tissue, incision, urinary system, etc, and gram-negative (G+) bacteria were dominated in pathogens. CONCLUSION: The inflammatory response of patients with puerperal infection is significantly enhanced.

Out-of-season increase of puerperal fever with group A Streptococcus infection: a case-control study, Netherlands, July to August 2018.

We observed an increase in notifications of puerperal group A Streptococcus (GAS) infections in July and August 2018 throughout the Netherlands without evidence for common sources. General practitioners reported a simultaneous increase in impetigo. We hypothesised that the outbreak of puerperal GAS infections resulted from increased exposure via impetigo in the community.We conducted a case-control study to assess peripartum exposure to possible, non-invasive GAS infections using an online questionnaire. Confirmed cases were recruited through public health services while probable cases and controls were recruited through social media. We calculated odds ratios (OR) and 95% confidence intervals (95% CI) with logistic regression analysis.We enrolled 22 confirmed and 23 probable cases, and 2,400 controls. Contact with persons with impetigo were reported by 8% of cases and 2% of controls (OR: 3.26, 95% CI: 0.98-10.88) and contact with possible GAS infections (impetigo, pharyngitis or scarlet fever) by 28% and 9%, respectively (OR: 4.12, 95% CI: 1.95-8.68). In multivariable analysis, contact with possible GAS infections remained an independent risk factor (aOR: 4.28, 95% CI: 2.02-9.09).We found an increased risk of puerperal fever after community contact with possible non-invasive GAS infections. Further study of this association is warranted.

A Mobile Genetic Element Promotes the Association Between Serotype M28 Group A Streptococcus Isolates and Cases of Puerperal Sepsis.

BACKGROUND: Bacterial infections following childbirth-so-called puerperal infections-cause morbidity in 5%-10% of all new mothers. At low frequency, the infection can spread to the blood, resulting in life-threatening sepsis known as puerperal sepsis. Pathogens causing puerperal sepsis include group A Streptococcus (GAS), and epidemiological analyses have identified isolates of a single serotype, M28, as being nonrandomly associated with cases of puerperal sepsis. The genomes of serotype M28 GAS isolates harbor a 36.3-kb mobile genetic element of apparent group B Streptococcus origin, termed region of difference 2 (RD2). METHODS: The phenotypic (determined via tissue culture and a vaginal colonization model) and regulatory (determined via RNA sequencing analysis) contributions of RD2 were assessed by comparing parental, RD2 deletion mutant, and complemented mutant serotype M28 GAS strains. RESULTS: RD2 affords serotype M28 isolates an enhanced ability to adhere to human vaginal epithelial cells and to colonize the female reproductive tract in a mouse model of infection. In addition, RD2 influences the abundance of messenger RNAs from >100 core chromosomal GAS genes. CONCLUSIONS: The data are consistent with RD2 directly, via encoded virulence factors, and indirectly, via encoded regulatory proteins, modifying the virulence potential of GAS and contributing to the decades-old association of serotype M28 isolates with cases of puerperal sepsis.

Genomic characterisation, detection of genes encoding virulence factors and evaluation of antibiotic resistance of Trueperella pyogenes isolated from cattle with clinical metritis.

Trueperella pyogenes is one of the most important microorganisms causing metritis in post-partum cattle. Co-infection with other bacterial species such as Escherichia coli or Fusobacterium necrofurom increases the severity of the disease and the persistence of bacteria in utero. The aim of this study was to investigate the frequency of T. pyogenes strains, and their virulence and antimicrobial resistant profiles in metritis cases. The study was carried out on 200 samples obtained from metritis discharges of postpartum cattle on 18 farms around Tehran, Iran. Sixty-five T. pyogenes isolates (32.5%) were identified, of which 16 isolates were detected as pure cultures and the other 49 isolates from cultures most commonly mixed with E. coli or F. necrofurom. In terms of diversity in biochemical characteristic of T. pyogenes strains, 8 different biotypes were identified among the isolates. Single or multi antimicrobial resistance was observed in 48 isolates (73.9%), which was mostly against trimethoprim sulfamethoxazole, azithromycin, erythromycin and streptomycin. The tetracycline resistance gene tetW and macrolide resistance genes ermB and ermX were detected in 30, 18 and 25 isolates, respectively. In the screening of genes encoding virulence factors, fimA and plo genes were identified in all tested isolates. Genes encoding nanP, nanH, fimC, fimG, fimE and cbpA were detected in 50, 54, 45, 40, 50 and 37 of isolates, respectively. Thirteen different genotypes were observed in these T. pyogenes isolates. A significant association between clonal types and virulence factor genes, biochemical profile, CAMP test result, severity of the disease and sampling time was detected.

Microbiology and clinical outcomes of puerperal sepsis: a prospective cohort study.

The objectives of this study were to determine the identity and antibacterial susceptibility profiles of bacteria colonising the female genital tract and blood stream and their association with clinical outcomes in women with puerperal sepsis. A prospective descriptive cohort study was conducted at two tertiary hospitals in Zimbabwe. Endocervical swabs and blood were collected for culture and susceptibility testing from 151 consecutive women who met the World Health Organisation criteria for puerperal sepsis. Medical records were reviewed for assessment of clinical outcomes. The commonest bacterial isolates were Escherichia coli (30.6%) and Klebsiella pneumoniae (15.3%). Multidrug-resistant organisms (MDRO) accounted for 10.9% of all isolates. MDRO were associated with prolonged hospital stay, 23.0 days compared to 10.5 days in women without MDRO (p = .009). Puerperal sepsis case fatality rate was 7.3%. Clinical culture surveillance to monitor epidemiologic trends, identify MDRO, robust infection control strategies and emphasis on rational drug use are recommended. Impact statement What is already known? Puerperal sepsis is often a polymicrobial infection. Escherichia coli has been reported as a common cause of severe maternal sepsis originating from the genital tract. Other bacteria include Group A Streptococcus, S. aureus, Streptococcus spp. Klebsiellae spp, Pseudomonas spp. and anaerobes. What does this study add? This study confirms Escherichia coli as the commonest cause of sepsis in Harare. There is high level resistance to first-line antibiotic regimens on most Gram-negative isolates from the endocervix among women with puerperal sepsis. Emerging resistance to carbapenems is demonstrated. MDRO significantly increased length of hospital stay, and there was a clinically important trend towards higher rates of pelvic abscess, septic shock, death, need for laparotomy and ICU admission specific to puerperal sepsis. What are the implications for clinical practice and further research? Clinical culture surveillance to monitor epidemiologic trends in conjunction with robust infection control strategies and rational drug use may assist in prevention of community acquired and nosocomial multidrug-resistant infections.

Puerperal sepsis, the leading cause of maternal deaths at a Tertiary University Teaching Hospital in Uganda.

BACKGROUND: Maternal mortality is highest in sub-Saharan Africa. In Uganda, the WHO- MDG 5 (aimed at reducing maternal mortality by 75 % between 1990 and 2015) has not been attained. The current maternal mortality ratio (MMR) in Uganda is 438 per 100,000 live births coming from 550 per 100,000 in 1990. This study sets out to find causes and predictors of maternal deaths in a tertiary University teaching Hospital in Uganda. METHODS: The study was a retrospective unmatched case control study which was carried out at the maternity unit of Mbarara Regional Referral Hospital (MRRH). The sample included pregnant women aged 15-49 years admitted to the Maternity unit between January 2011 and November 2014. Data from patient charts of 139 maternal deaths (cases) and 417 controls was collected using a standard audit/data extraction form. Multivariable logistic regression analysis was used to assess for the factors associated with maternal mortality. RESULTS: Direct causes of mortality accounted for 77.7 % while indirect causes contributed 22.3 %. The most frequent cause of maternal mortality was puerperal sepsis (30.9 %), followed by obstetric hemorrhage (21.6 %), hypertensive disorders in pregnancy (14.4 %), abortion complications (10.8 %). Malaria was the commonest indirect cause of mortality accounting for 8.92 %. On multivariable logistic regression analysis, the factors associated with maternal mortality were: primary or no education (OR 1.9; 95 % CI, 1.0-3.3); HIV positive sero-status (OR, 3.6; 95 % CI, 1.9-7.0); no antenatal care attendance (OR 3.6; 95 % CI, 1.8-7.0); rural dwellers (OR, 4.5; 95 % CI, 2.5-8.3); having been referred from another health facility (OR 5.0; 95 % CI, 2.9-10.0); delay to seek health care (delay-1) (OR 36.9; 95 % CI, 16.2-84.4). CONCLUSIONS: Most maternal deaths occur among mothers from rural areas, uneducated, HIV positive, unbooked mothers (lack of antenatal care), referred mothers in critical conditions and mothers delaying to seek health care. Puerperal sepsis is the leading cause of maternal deaths at Mbarara Regional Referral Hospital. Therefore more research into puerperal sepsis to describe the microbiology and epidemiology of sepsis is recommended.

Diagnostic methods to determine microbiology of postpartum endometritis in South Asia: laboratory methods protocol used in the Postpartum Sepsis Study: a prospective cohort study.

BACKGROUND: The South Asian region has the second highest risk of maternal death in the world. To prevent maternal deaths due to sepsis and to decrease the maternal mortality ratio as per the World Health Organization Millenium Development Goals, a better understanding of the etiology of endometritis and related sepsis is required. We describe microbiological laboratory methods used in the maternal Postpartum Sepsis Study, which was conducted in Bangladesh and Pakistan, two populous countries in South Asia. METHODS/DESIGN: Postpartum maternal fever in the community was evaluated by a physician and blood and urine were collected for routine analysis and culture. If endometritis was suspected, an endometrial brush sample was collected in the hospital for aerobic and anaerobic culture and molecular detection of bacterial etiologic agents (previously identified and/or plausible). DISCUSSION: The results emanating from this study will provide microbiologic evidence of the etiology and susceptibility pattern of agents recovered from patients with postpartum fever in South Asia, data critical for the development of evidence-based algorithms for management of postpartum fever in the region.

The development and evaluation of a community-based clinical diagnosis tool and treatment regimen for postpartum sepsis in Bangladesh and Pakistan.

BACKGROUND: Postpartum sepsis accounts for most maternal deaths between three and seven days postpartum, when most mothers, even those who deliver in facilities, are at home. Case fatality rates for untreated women are very high. Newborns of ill women have substantially higher infection risk. METHODS/DESIGN: The objectives of this study are to: (1) create, field-test and validate a tool for community health workers to improve diagnostic accuracy of suspected puerperal sepsis; (2) measure incidence and identify associated risk factors and; (3) describe etiologic agents responsible and antibacterial susceptibility patterns. This prospective cohort study builds on the Aetiology of Neonatal Infection in South Asia study in three sites: Sylhet, Bangladesh and Karachi and Matiari, Pakistan. Formative research determined local knowledge of symptoms and signs of postpartum sepsis, and a systematic literature review was conducted to design a diagnostic tool for community health workers to use during ten postpartum home visits. Suspected postpartum sepsis cases were referred to study physicians for independent assessment, which permitted validation of the tool. Clinical specimens, including urine, blood, and endometrial material, were collected for etiologic assessment and antibiotic sensitivity. All women with puerperal sepsis were given appropriate antibiotics. DISCUSSION: This is the first large population-based study to expand community-based surveillance for diagnoses, referral and treatment of newborn sepsis to include maternal postpartum sepsis. Study activities will lead to development and validation of a diagnostic tool for use by community health workers in resource-poor countries. Understanding the epidemiology and microbiology of postpartum sepsis will inform prevention and treatment strategies and improve understanding of linkages between maternal and neonatal infections.

Leukotriene B4 enhances innate immune defense against the puerperal sepsis agent Streptococcus pyogenes.

Puerperal sepsis is a leading cause of maternal mortality worldwide. Streptococcus pyogenes [group A Streptococcus; (GAS)] is a major etiologic agent of severe postpartum sepsis, yet little is known regarding the pathogenesis of these infections. Tissue macrophages provide innate defense against GAS, and their actions are highly regulated. The intracellular second messenger cAMP can negatively regulate macrophage actions against GAS. Because leukotriene (LT) B(4) has been shown to suppress intracellular cAMP in macrophages, we hypothesized that it could enhance innate defenses against GAS. We assessed the capacity of LTB(4) to modulate antistreptococcal actions of human macrophages, including placental and decidual macrophages and used a novel intrauterine infection model of GAS in mice lacking the 5-lipoxygenase enzyme to determine the role of endogenous LTs in host defense against this pathogen. Animals lacking 5-lipoxygenase were significantly more vulnerable to intrauterine GAS infection than were wild-type mice and showed enhanced dissemination of bacteria out of the uterus and a more robust inflammatory response than did wild-type mice. In addition, LTB(4) reduced intracellular cAMP levels via the BLT1 receptor and was a potent stimulant of macrophage phagocytosis and NADPH oxidase-dependent intracellular killing of GAS. Importantly, interference was observed between the macrophage immunomodulatory actions of LTB(4) and the cAMP-inducing lipid PGE(2), suggesting that interplay between pro- and anti-inflammatory compounds may be important in vivo. This work underscores the potential for pharmacological targeting of lipid mediator signaling cascades in the treatment of invasive GAS infections.

Prevention and treatment strategy in pregnant women with group B streptococcal infection.

Group B streptococcus (GBS; Streptococcus agalactiae) are encapsulated gram-positive cocci belonging to Lancefield group B, that frequently colonizes the human genital and gastrointestinal tracts. It is an important cause of illness in three categories of population: infants, pregnant women, and adults with underlying medical conditions. In pregnant women and postpartum women, GBS is a frequent cause of asymptomatic bacteriuria, urinary tract infection, upper genital tract infection (i.e. intraamniotic infection or chorioamnionitis), postpartum endometritis (8%), pneumonia (2%), puerperal sepsis (2%), and bacteremia without a focal site (31%). It also can cause focal infections such as pneumonia, meningitis, and endocarditis, albeit rarely. Invasive maternal infection with GBS is associated with pregnancy loss and preterm delivery. Prior to the widespread use of maternal intrapartum chemoprophylaxis, maternal colonization with GBS conferred an increased risk of chorioamnionitis, and early postpartum infection. The serotype distribution of invasive GBS infection in pregnant women is similar to that of early-onset neonatal disease. The most common GBS serotypes causing invasive disease in adults and neonates are Ia, Ib, III, and V. Vaccination of adolescent women is considered an ideal solution. However, recent reports (April 2015) have shown that serotype IV GBS is emerging in pregnant carriers and causing infections in neonates and adults. This emergence is of concern because GBS conjugate vaccines that are being developed to prevent invasive disease may protect only against serotypes Ia, Ib, II, III, and V, or combinations thereof. Though research for the development of such a vaccine is underway, a good candidate vaccine has yet to surface.

Does Coxiella burnetii affect reproduction in cattle? A clinical update.

Q fever is a zoonosis produced by Coxiella burnetii, a bacterium that is widely distributed worldwide. Domestic ruminants are the most important source of C. burnetii for human infection. In sheep and goats, abortion is the main clinical consequence of infection, yet the symptoms described in cattle have so far been inconsistent. Q fever has been also scarcely reported in cattle, most likely because of its difficult diagnosis at the farm level and because of the many existing responsible C. burnetii strains. In this report, the effects of C. burnetii infection or Q fever disease on the reproductive behaviour of dairy cattle are reviewed, with special emphasis placed on the scarcity of data available and possible control actions discussed.

Burden of Antimicrobial Resistance Among Women with Post-Partum Infections in Low-Middle Income Countries: A Systematic Review.

BACKGROUND: Due to the rising incidence of multidrug-resistant (MDR) pathogens, especially in Low-Middle-Income Countries (LMIC), post-partum infections represent a significant treatment challenge. METHODS: We performed a systematic review of the literature from January 2005 to February 2023 to quantify the frequency of maternal post-partum infections due to MDR pathogens in LMICs, focusing on methicillin-resistant Staphylococcus aureus (MRSA) and/or extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales. SECONDARY OBJECTIVES: description of antimicrobials' prescriptions. FINDINGS: We included 22 studies with 14,804 total bacterial isolates from 12 countries, mostly from WHO African-Region. Twelve papers described wound- and 10 puerperal-infections. Seven were high-quality articles. Seventeen studies reported data on MRSA, and 18 on ESBL-producing Enterobacterales. Among high-quality studies, MRSA ranged from 9.8% in Ghana to 91.2% in Uganda; ESBL-producing Enterobacterales ranged from 22.8% in Ukraine to 95.2% in Uganda. Nine articles, mostly on C-sections, described different protocols for antibiotic prophylaxis and/or post-partum treatment. INTERPRETATION: We described a high burden of post-partum infections caused by MRSA and/or ESBL-producing Enterobacterales in LMICs, but only a few studies met quality standards. There is an urgent need for high-quality studies to better describe the real burden of antimicrobial resistance in low-resource settings and inform policies to contain the spread of multidrug-resistant organisms.

Pregnancy-related group a streptococcal infections: temporal relationships between bacterial acquisition, infection onset, clinical findings, and outcome.

Puerperal sepsis caused by group A Streptococcus (GAS) remains an important cause of maternal and infant mortality worldwide, including countries with modern antibiotic regimens, intensive care measures and infection control practices. To provide insights into the genesis of modern GAS puerperal sepsis, we reviewed the published cases and case series from 1974 to 2009, specifically seeking relationships between the likely source of pathogen acquisition, clinical signs, and symptoms at infection onset and patient outcomes that could provide clues for early diagnosis. Results suggest that the pathogenesis of pregnancy-related GAS infections in modern times is complex and not simply the result of exposure to GAS in the hospital setting. Additional research is needed to further explore the source of GAS, the specific M types involved, and the pathogenesis of these pregnancy-related infections to generate novel preventative and therapeutic strategies.

Human CEACAM1 is targeted by a Streptococcus pyogenes adhesin implicated in puerperal sepsis pathogenesis.

Life-threatening bacterial infections in women after childbirth, known as puerperal sepsis, resulted in classical epidemics and remain a global health problem. While outbreaks of puerperal sepsis have been ascribed to Streptococcus pyogenes, little is known about disease mechanisms. Here, we show that the bacterial R28 protein, which is epidemiologically associated with outbreaks of puerperal sepsis, specifically targets the human receptor CEACAM1. This interaction triggers events that would favor the development of puerperal sepsis, including adhesion to cervical cells, suppression of epithelial wound repair and subversion of innate immune responses. High-resolution structural analysis showed that an R28 domain with IgI3-like fold binds to the N-terminal domain of CEACAM1. Together, these findings demonstrate that a single adhesin-receptor interaction can drive the pathogenesis of bacterial sepsis and provide molecular insights into the pathogenesis of one of the most important infectious diseases in medical history.

Analysis of a Streptococcus pyogenes puerperal sepsis cluster by use of whole-genome sequencing.

Between June and November 2010, a concerning rise in the number of cases of puerperal sepsis, a postpartum pelvic bacterial infection contracted by women after childbirth, was observed in the New South Wales, Australia, hospital system. Group A streptococcus (GAS; Streptococcus pyogenes) isolates PS001 to PS011 were recovered from nine patients. Pulsed-field gel electrophoresis and emm sequence typing revealed that GAS of emm1.40, emm75.0, emm77.0, emm89.0, and emm89.9 were each recovered from a single patient, ruling out a single source of infection. However, emm28.8 GAS were recovered from four different patients. To investigate the relatedness of these emm28 isolates, whole-genome sequencing was undertaken and the genome sequences were compared to the genome sequence of the emm28.4 reference strain, MGAS6180. A total of 186 single nucleotide polymorphisms were identified, for which the phylogenetic reconstruction indicated an outbreak of a polyclonal nature. While two isolates collected from different hospitals were not closely related, isolates from two puerperal sepsis patients from the same hospital were indistinguishable, suggesting patient-to-patient transmission or infection from a common source. The results of this study indicate that traditional typing protocols, such as pulsed-field gel electrophoresis, may not be sensitive enough to allow fine epidemiological discrimination of closely related bacterial isolates. Whole-genome sequencing presents a valid alternative that allows accurate fine-scale epidemiological investigation of bacterial infectious disease.

Group A streptococcal infections in obstetrics and gynecology.

Group A streptococcal (GAS) infections continue to be an infrequent, but potentially lethal infections in women despite the victory over childbed fever in the 1800s. Invasive group A streptococcal infection still causes 40% of septic deaths among patients with postpartum endometritis, necrotizing fasciitis, and toxic shock syndrome. Many times symptoms and signs of this infection are nonspecific, but laboratory evaluation can suggest serious infection. The prudent combination of antibiotic and surgical therapy can be lifesaving.