Associations between capsular serotype, multilocus sequence type, and macrolide resistance in Streptococcus agalactiae isolates from Japanese infants with invasive infections.

SUMMARY Streptococcus agalactiae (group B streptococcus; GBS) isolates (n = 150) from infants with invasive infections between 2006 and 2011 were analysed for capsular serotype, multilocus sequence type, and antibiotic susceptibility. In cases with late-onset disease (n = 115), primary meningitis was predominant (62.6%), but represented only 39.1% in cases with early-onset disease (n = 23). The most common serotype was III (58.7%), followed by Ia (21.3%) and Ib (12.7%). Sequence types (STs) of serotype III strains included ST17 (50.0%), ST19 (26.1%), ST335 (18.2%), ST27 (4.5%), and ST1 (1.1%). Predominant STs of serotypes Ia and Ib were ST23 (81.3%) and ST10 (84.2%), respectively. No penicillin-resistant strains were detected, but 22·0% of strains had mef(A/E), erm(A), or erm(B) genes, which mediate macrolide resistance. A new ST335, possessing an mef(A/E) gene belonging to clonal complex 19 gradually increased in frequency. Improved prevention of invasive GBS infections in infants requires timely identification, and ultimately vaccine development.

Advantame--an overview of the toxicity data.

Advantame is an N-substituted (aspartic acid portion) derivative of aspartame that is similar in structure to neotame, another N-substituted aspartame. An extensive series of studies, were conducted on advantame to define the pharmacokinetics and metabolism in various species, subchronic and chronic toxicity in the rat and dog, carcinogenicity in the rat and mouse, genotoxicity, reproductive, and developmental toxicity, and human tolerability studies. The results of these studies, presented in overview in the present publication, and in greater detail in the accompanying publications, show that advantame is well tolerated by both animals and humans and does not possess systemic toxicity. The metabolic data demonstrate that the animal species used in the toxicity testing are relevant to the evaluation of human safety. The no-observed-adverse-effect levels (NOAELs) identified in the animal studies in which advantame was administered in the diet were generally the highest doses tested. Under the anticipated conditions of use, the predicted intakes of advantame are about 20,000- to 70,000-fold lower than the identified animal study NOAEL values. The results of the animal toxicology and human trial data support the safety of use of advantame in food.

Pharmacokinetics and metabolism of N-[N-[3-(3-hydroxy-4-methoxyphenyl) propyl]-α-aspartyl]-L-phenylalanine 1-methyl ester, monohydrate (advantame) in the rat, dog, and man.

The pharmacokinetics and metabolism of advantame were evaluated in rats, dogs, and humans. The oral pharmacokinetic studies using (14)C-advantame showed that advantame undergoes rapid but incomplete absorption, with an oral bioavailability of total radioactivity in the range of 4-23%. Data indicated that absorption was mainly as ANS9801-acid (de-esterified advantame), which was formed in the gastrointestinal tract as a result of the hydrolysis of the methyl ester group of the parent compound. In the dog, plasma ANS9801-acid was present largely in the form of an unidentified conjugate. Advantame (chiefly in the form of metabolites) was mainly excreted in the feces in rats, dogs, and humans (>80% in each species), with urinary excretion representing a minor route. The predominant metabolite of (14)C-advantame detected in the feces and the urine of rats, dogs, and humans was ANS9801-acid, with lower amounts of 3-[3-hydroxy-4-methoxyphenyl]-1-propylamine (termed HU-1) or N-(3-(3-hydroxy-4-methoxy phenyl))propyl-L-aspartic acid (termed HF-1) present, as well as other minor metabolites and areas of indistinct radioactivity. ANS9801-acid, HU-1, and HF-1 were detected and identified in the urine of rats, humans, and dogs, while ANS9801-acid and HF-1 were identified in the feces of humans and dogs. In the feces of rats, in addition to ANS9801-acid, other additional metabolites were detected, including demethylated ANS9801-acid (designated as RF-1) and another unidentified metabolite (designated as RF-2). Overall, the data show generally similar pharmacokinetics of advantame and ANS9801-acid in animals and in humans and close similarity with neotame. Metabolites of advantame that occur in humans are also found in the 2 species utilized in the toxicology studies, and the metabolism studies support the interpretation of safety data from studies conducted in rats and dogs.

Clinical aspects of invasive infections with Streptococcus dysgalactiae ssp. equisimilis in Japan: differences with respect to Streptococcus pyogenes and Streptococcus agalactiae infections.

Streptococcus dysgalactiae ssp. equisimilis (SDSE) is increasingly being identified as a pathogen responsible for invasive and non-invasive infections. We compared the clinical features of invasive SDSE infections with those of invasive infections caused by Streptococcus pyogenes (group A streptococcus (GAS)) and Streptococcus agalactiae (group B streptococcus (GBS)). Active surveillance for invasive SDSE, GAS and GBS was maintained over 1 year at 142 medical institutions throughout Japan. Clinical information was collected together with isolates, which were characterized microbiologically. Two hundred and thirty-one invasive SDSE infections were identified, 97 other patients had infections with GAS, and 151 had infections with GBS. The median age of the SDSE patients was 75 years; 51% were male and 79% had underlying diseases. Forty-two SDSE patients (19%) presented to the emergency department. Among the 150 patients (65%) for whom follow-up was completed, 19 (13%) died and eight (5%) had post-infective sequelae (poor outcome). Insufficient white blood cell responses (<5000 cells/microL) and thrombocytopenia on admission each suggested significantly higher risk of poor outcome (ORs 3.6 and 4.5, respectively). Of 229 isolates, 55 (24%) showed an stG6792 emm type, which was significantly associated with poor outcome (OR 2.4). Clinical manifestations of invasive SDSE infections were distinct from those of invasive GBS infections. Primary-care doctors should consider invasive SDSE infections when treating elderly patients.

Spontaneous pneumomediastinum complicating pneumonia in children infected with the 2009 pandemic influenza A (H1N1) virus.

We report two occurrences of spontaneous pneumomediastinum (SPM) complicating pneumonia in Japanese children infected with the novel influenza A (H1N1) virus (IV). General practitioners especially should suspect possible SPM when examining and treating children with the novel influenza accompanied by status asthmaticus or wheezing. The presented patients illustrate the specific clinical and radiological signs associated with SPM complicating pneumonia in children infected with A(H1N1)v.

Serotype and antibiotic resistance of isolates from patients with invasive pneumococcal disease in Japan.

Invasive pneumococcal disease (IPD) is of concern in Japan, where the heptavalent pneumococcal conjugate vaccine (PCV7) is unavailable. We determined serotypes, genotypes indicating beta-lactam resistance, and antibiotic susceptibilities of 496 isolates from normally sterile sites in patients (193 children, 303 adults) from 186 institutions between August 2006 and July 2007. Disease presentations included sepsis (46.2%), pneumonia (31.5%), and meningitis (17.5%). Mortality was 1.4% in children and 22.1% in adults, many of whom had underlying diseases. In children, serotype 6B (22.5%) was followed by 19F (14.1%), and 14 (13.1%); potential coverages of PCV7 and PCV13 were 75.4% and 93.7%, respectively. In adults, serotype 12F (14.3%) was followed by 3 (11.3%), and 6B (10.3%); 23-valent polysaccharide vaccine (PPV23) coverage was 85.4%. Most serotype 12F strains were gPISP, with pbp2b gene alteration; carbapenem had an excellent MIC90. PCV7 is recommended for children and PPV23 for adults to increase prevention against IPD.

Increased macrolide resistance of Mycoplasma pneumoniae in France directly detected in clinical specimens by real-time PCR and melting curve analysis.

OBJECTIVES: Mycoplasma pneumoniae is a common aetiological agent of community-acquired respiratory tract infections for which macrolides are the treatment of choice. In France, only two macrolide-resistant isolates were reported in 1999. In contrast, several recent data reported that macrolide-resistant M. pneumoniae isolates have been spreading since 2000 in Japan. Mutations A2058G (Escherichia coli numbering), A2058C, A2059G, A2062G, C2611A and C2611G in domain V of the 23S rRNA gene were associated in vivo or in vitro with this resistance. The aim of this study was to determine whether macrolide resistance of M. pneumoniae is emerging in France. PATIENTS AND METHODS: We developed a duplex real-time PCR for the detection of the six 23S rRNA mutations associated with macrolide resistance in M. pneumoniae and a simplex real-time PCR for the identification of the A2058G mutation, the most common one. Both methods rely on fluorescence resonance energy transfer coupled to melting curve analysis and are directly applicable to clinical samples. The duplex real-time PCR assay, first validated on 40 genetically characterized M. pneumoniae strains, was then applied directly on 248 French respiratory tract clinical samples. RESULTS: Among M. pneumoniae-positive specimens collected before 2005, no macrolide-resistant M. pneumoniae isolate was detected. In contrast, among 51 samples collected between 2005 and 2007, five (9.8%) yielded a resistant genotype, suggesting a recent increase in macrolide-resistant M. pneumoniae isolates in France. CONCLUSIONS: The epidemiological monitoring of macrolide resistance in this species has become necessary in France and Europe, and will be made easier by using these PCR assays.

Evaluation of PCR primers to screen for Streptococcus pneumoniae isolates and beta-lactam resistance, and to detect common macrolide resistance determinants.

Pneumococcal isolates (n = 148) from various countries (mostly from the USA) were tested by a primer set for PCR. Thirty-eight (86.4%) of the 44 penicillin G-susceptible isolates (MIC < or = 0.06 mg/L) had unaltered pbps, while six isolates (13.6%) had either one or two alterations in pbps. Of 47 penicillin G-resistant strains (MIC > or = 2 mg/L), 41 isolates (87.2%) had all three pbps altered, six isolates (12.8%) had altered pbp1a + 2x. Various combinations of altered pbp were seen in penicillin G-intermediate isolates. Prevalence of macrolide resistance genes mef(A) and erm(B) in isolates was clearly reflected by their MICs. All isolates were positive for lytA. The primers were useful for screening for Streptococcus pneumoniae and beta-lactam resistance, and for detection of common macrolide resistance determinants.

Macrophage-oriented cytotoxic activity of novel triterpene saponins extracted from roots of Securidaca inappendiculata.

It is recognized that macrophages in peripheral tissues often proliferate under pathological conditions such as tumors, inflammation and atherosclerosis. Because the growth state of macrophages is believed to be a factor regulating the pathological process of the diseases, substances that regulate macrophage growth or survival may be useful for disease control. In this paper, we identified the activity inhibiting macrophage growth in a hot water extract of roots of Securidaca inappendiculata. The extract markedly inhibited macrophage colony-stimulating factor (M-CSF/CSF-1)-induced growth of macrophages, whereas it exerted a less potent effect on growth of Concanavalin A (Con A)-stimulated thymocytes or M-CSF-stimulated bone marrow cells. The inhibition of macrophage growth was caused by a cytotoxic effect rather than a cytostatic effect. Cell death was due to the induction of apoptosis, as judged by staining with terminal deoxynucleotidyl transferase-mediated d-UTP nick end labelling (TUNEL). The cytotoxic activity seemed to be specific to peripheral macrophages; it showed a weak effect on the growth and survival of tumor cell lines including a macrophage-like cell line, J-774.1. Moreover, the saponin fraction induced apoptotic cell death of macrophages only when they were stimulated by M-CSF; it did not affect the viability of macrophages cultured without M-CSF or with granulocyte/macrophage-CSF. We determined the structures of the two active triterpene saponin compounds in the fraction, named securioside A and securioside B having a 3,4-dimethoxycinnamic group which is essential for the cell death-inducing activity. They are believed to be the primary compounds of new drugs for the treatment of pathological states in which macrophage proliferation occurs.

Association of amino acid substitutions in penicillin-binding protein 3 with beta-lactam resistance in beta-lactamase-negative ampicillin-resistant Haemophilus influenzae.

The affinity of [(3)H]benzylpenicillin for penicillin-binding protein (PBP) 3A was reduced in 25 clinical isolates of beta-lactamase-negative ampicillin (AMP)-resistant (BLNAR) Haemophilus influenzae for which the AMP MIC was > or =1.0 microg/ml. The affinities of PBP 3B and PBP 4 were also reduced in some strains. The sequences of the ftsI gene encoding the transpeptidase domain of PBP 3A and/or PBP 3B and of the dacB gene encoding PBP 4 were determined for these strains and compared to those of AMP-susceptible Rd strains. The BLNAR strains were classified into three groups on the basis of deduced amino acid substitutions in the ftsI gene, which is thought to be involved in septal peptidoglycan synthesis. His-517, near the conserved Lys-Thr-Gly (KTG) motif, was substituted for Arg-517 in group I strains (n = 9), and Lys-526 was substituted for Asn-526 in group II strains (n = 12). In group III strains (n = 4), three residues (Met-377, Ser-385, and Leu-389), positioned near the conserved Ser-Ser-Asn (SSN) motif, were replaced with Ile, Thr, and Phe, respectively, in addition to the replacement with Lys-526. The MICs of cephem antibiotics with relatively high affinities for PBP 3A and PBP 3B were higher than those of AMP and meropenem for group III strains. The MICs of beta-lactams for H. influenzae transformants into which the ftsI gene from BLNAR strains was introduced were as high as those for the donors, and PBP 3A and PBP 3B showed decreased affinities for beta-lactams. There was no clear relationship between 7-bp deletions in the dacB gene and AMP susceptibility. Even though mutations in another gene(s) may be involved in beta-lactam resistance, these data indicate that mutations in the ftsI gene are the most important for development of resistance to beta-lactams in BLNAR strains.

[Beta-lactam and macrolide resistance in Streptococcus pneumoniae].

The resistance of beta-lactam antibiotics in penicillin-resistant Streptococcus pneumoniae (PRSP) is due to alterations in penicillin-binding proteins(PBPs). Recently, highly beta-lactam-resistant strains(MIC: > or = 4 micrograms/ml for penicillin, > or = 8 micrograms/ml for ampicillin, and > or = 4 micrograms/ml for cefotaxime) have been isolated. High resistance of these strains is caused by further alterations in pbp2x and pbp2b genes adjacent to conserved amino acid motifs, in addition to that detected in common PRSP. The resistant mechanisms of macrolides in S. pneumoniae is recognized as production of a 23s rRNA methylase encoded by ermB and efflux system mediated by mefA gene. We detected these genes by PCR in clinical isolates, and showed the relationship between the presence of each gene and the susceptibilities of 14-, 15-, 16-membered macrolides.

[Beta-lactamase negative ampicillin-resistant Haemophilus influenzae(BLNAR)].

The affinity of [3H]-benzylpenicillin for penicillin-binding protein(PBP) 3A/3B was reduced in clinical isolates beta-lactamase-negative ampicillin(ABPC)-resistant Haemophilus influenzae(BLNAR) with MIC of > or = 1 microgram/ml to ABPC. The sequence of ftsI gene encoding the transpeptidase domain of PBP3A/3B were determined for these strains, and compared to those of ABPC-susceptible Rd strain. Common substitutions of deduced amino acid residues were identified in transpeptidase region on the ftsI gene in BLNAR strains. Homology modeling of the three-dimensional structure of PBP3 showed that every common substitution occurred at active site pocket surrounded by three conserved motifs. The MICs of beta-lactams for H. influenzae transformants in which ftsI gene from BLNAR was introduced, were as high as those for the donors and PBP3A/3B showed a decreased affinity for beta-lactams. These data indicate that mutations in the ftsI gene are the most important for development of resistance to beta-lactams in BLNAR.

[The trend of childhood bacterial meningitis in Japan (1997.7-2000.6)].

We surveyed the epidemiology of purulent meningitis in pediatrics for 3 years between July 1997 and June 2000 in Japan and obtained the following results. The number of cases of purulent meningitis was 428, which was equivalent of 1.1-1.7 children out of 1,000 hospitalized those in pediatrics per year. The age-distribution for the infections was the highest under 1 year of age and it decreased as the age increased. Under 1 year of age, the highest distribution was observed in one month of age and under 1 month of age, the highest distribution was observed in 7 days of or younger ages. Haemophilus influenzae was the most common pathogen causing the infections, followed by Streptococcus pneumoniae, group B streptococcus, and Escherichia coli. Relationship between causing pathogens and age-distribution was as follows: group B streptococcus and E. coli were major pathogens under 4 months of age and H. influenzae and S. pneumoniae were major pathogens over 3 months of age. Susceptibility tests performed at each facility demonstrated that 25.3% of H. influenzae isolates and 38.7% of S. pneumoniae isolates were drug-resistant. Analysis of resistant genes for H. influenzae and S. pneumoniae isolates, which were stored and sent, demonstrated higher rates of resistance than those observed in susceptibility tests. These results suggest that the increase in insufficient efficacy of usual treatment with combination of ampicillin and cefotaxime is predictable against the infections. Therefore, the treatment for the infections should be reconsidered.

[Drug-resistant bacteria of current topics and their resistance mechanisms--PRSP and BLNAR].

The prevalence of resistant isolates for beta-lactam antibiotics have been rapidly increasing in Streptococcus pneumoniae and Haemophilus influenzae. These strains having resistant elements are called penicillin-resistant S. pneumoniae(PRSP) and beta-lactamase-negative ampicillin-resistant H. influenzae(BLNAR). The mechanism of resistance was identified as the reduction of penicillin-binding proteins(PBPs) affinities as the target of beta-lactams. In PRSP, pbp1a, pbp2x, and pbp2b encoding PBP1A, -2X, and -2B enzymes, respectively, were altered. In contrast, mutations in the ftsI gene encoding PBP3A were only clarified in BLNAR. Characteristics of the resistance caused by PBPs alterations are a low-level resistance that decrease bactericidal action.

[Identification of bacterial strain at each episode of recurrent acute otitis media].

This study was undertaken to investigate whether each episode of recurrent acute otitis media (rAOM) is caused by the same strain of bacteria or different strains at each episode. Seventy infants less than 3-years of age, having experienced rAOM for a period shorter than 8 weeks, were selected and included in the present study. The total number of AOM episodes experienced by this group was 282. At each subsequent episode of AOM, otorrhea and nasopharyngeal swabs were taken for bacterial culture and determination of the MIC for antibiotics. When S. pneumoniae was identified, its serotype, and its pbp, ermAM, and mefE genes were also investigated to determine the bacterial species and strains. S. pneumoniae was the most frequently cultured bacteria with 26 penicillin-sensitive S. pneumoniae (PSSP), 65 penicillin-insensitive S. pneumoniae (PISP), and 50 penicillin-resistant S. pneumoniae (PRSP). H. influenzae was the next most frequently cultured bacteria of which 65 were sensitive to penicillin, 27 were found to be beta-bactamase-negative-ampicillin-resistant (BLNAR) and 17 were found to be beta-bactamase positive. Bacteria cultured from each pair of two successive episodes of AOM were compared as to the identity of the bacteria during the two episodes. In 150 out of 202 pairs (74%), the cultured pathogen was different. In 22 cases in which either PISP or PRSP was the pathogen detected in two consecutive AOM episodes, 15 cases (68%) were found in which the involved strain differed between the two episodes. This study indicates that the pathogen involved in rAOM is likely to differ at each episode of AOM, not only in cases caused by PSSP, but also in those caused by PRSP.

[Susceptibilities of Enterococcus faecium, PRSP and MRSA to RP59500 and their correlations with those to other drugs].

Investigations on emergence of vancomycin-resistant Enterococcus faecium (VREF) which has recently been attracting attention, especially in the Western countries, have been conducted in Japan. A total of 1,239 isolates of E. faecium were collected from 19 institutions during the period of April 1995 and June 1996, in the purpose of evaluating susceptibilities to variety of antimicrobial agents, including RP59500 and vancomycin (VCM), and detecting vancomycin-resistant genes (van genes). Susceptibilities of penicillin-resistant Streptococcus pneumoniae (PRSP) and methicillin-resistant Staphylococcus aureus (MRSA) were also studied. As a result, 2 isolates of E. faecium were found to be moderately resistant to VCM showing MIC of 8 micrograms/ml though the final identification in species level and the detection of van genes by PCR method have not been completed. On the other hand there detected no MRSA nor PRSP showing moderately resistant or resistant to VCM. It was concluded that RP59500 and VCM possessed favorable activity against clinically isolated E. faecium, PRSP and MRSA. Among other species of enterococci, moderately resistant strains to VCM showing MIC of 8 micrograms/ml were detected; 10 isolates of E. gallinarum, 4 of E. casseliflavus and 2 of E. flavescens. In those isolates, vanC1 and vanC2 were detected by PCR, and vanB was also detected in a isolates of E. gallinarum simultaneously.