Clinical characteristics of hospitalised children with acute post-streptococcal glomerulonephritis in the Top End of Australia.

AIMS: Despite the declining incidence of acute post-streptococcal glomerulonephritis (APSGN) in Australia, there is still a significant burden of disease amongst Aboriginal and Torres Strait Islander people in the Northern Territory. Childhood APSGN has been highlighted as a predictor of chronic kidney disease in this population. We aimed to describe clinical characteristics and outcomes of hospitalised children with APSGN in the Northern Territory. METHODS: Single-centre, retrospective cohort study of children (<18 years) with APSGN admitted to a tertiary hospital in the Top End of the Northern Territory between January 2012 and December 2017. Cases were confirmed using the Centre for Disease Control case definition guidelines. Data were extracted from the case notes and electronic medical records. RESULTS: There were 96 cases of APSGN with median age of 7.1 years (interquartile range (IQR) 6.7-11.4). Majority were Aboriginal and Torres Strait Islander (90.6%) and from rural and remote areas (82.3%). Preceding skin infections were identified in 65.5% and sore throat in 27.1%. Severe complications included hypertensive emergencies (37.4%), acute kidney injury (43.8%) and nephrotic-range proteinuria (57.7%). All children improved from their acute illness with supportive medical therapy; however, only 55 out of 96 (57.3%) children were followed up within 12 months of their acute illness. CONCLUSIONS: APSGN disproportionately affects Aboriginal and Torres Strait Islander children and highlights the need for continued and improved public health response. There is room for significant improvement in the medium- and long-term follow-up of affected children.

Increasing Incidence of Invasive Group A Streptococcus Disease in First Nations Population, Alberta, Canada, 2003-2017.

The incidence of invasive group A Streptococcus (iGAS) disease in the general population in Alberta, Canada, has been steadily increasing. To determine whether rates for specific populations such as First Nations are also increasing, we investigated iGAS cases among First Nations persons in Alberta during 2003-2017. We identified cases by isolating GAS from a sterile site and performing emm typing. We collected demographic, social, behavioral, and clinical data for patients. During the study period, 669 cases of iGAS in First Nations persons were reported. Incidence increased from 10.0 cases/100,000 persons in 2003 to 52.2 cases/100,000 persons in 2017. The 2017 rate was 6 times higher for the First Nations population than for non-First Nations populations (8.7 cases/100,000 persons). The 5 most common emm types from First Nations patients were 59, 101, 82, 41, and 11. These data indicate that iGAS is severely affecting the First Nations population in Alberta, Canada.

Persistence of group B Streptococcus vaginal colonization and prevalence of hypervirulent CC-17 clone correlate with the country of birth: a prospective 3-month follow-up cohort study.

To identify factors associated with vaginal colonization and persistence by group B Streptococcus (GBS) and by the hypervirulent neonatal CC-17 clone in late pregnancy and after delivery, a multicentre prospective observational cohort with 3-month follow-up was established in two university hospitals, Paris area, France. Pregnant women were recruited when antenatal screening for GBS vaginal colonization at 34-38 weeks of gestational age was positive. Vaginal samples were analysed by conventional culture methods at antenatal screening, delivery, and 21 and 60 days following delivery. Identification of the hypervirulent neonatal GBS CC-17 was performed. Colonization was defined as persistent when all vaginal samples were positive for GBS. A total of 754 women were included. GBS vaginal colonization was persistent in 63% of the cases (95% CI 59%-67%). Persistent colonization was more likely in women born in Sub-Saharan Africa compared with women born in France (OR = 1.88, 95% CI 1.05-3.52), and GBS CC-17 was overrepresented in women born in Sub-Saharan Africa (OR = 2.09, 95% CI 1.20-3.57). Women born in Sub-Saharan Africa are at higher risk for GBS vaginal persistence than women born in France. This observation correlates with an increased prevalence of the hypervirulent GBS CC-17 in the former group, which likely reflect variations linked to ethnicity and vaginal community-state types and might account for the increased susceptibility of black neonates to GBS infections.

Calculation of the age of the first infection for skin sores and scabies in five remote communities in northern Australia.

Prevalence of skin sores and scabies in remote Australian Aboriginal communities remains unacceptably high, with Group A Streptococcus (GAS) the dominant pathogen. We aim to better understand the drivers of GAS transmission using mathematical models. To estimate the force of infection, we quantified the age of first skin sores and scabies infection by pooling historical data from three studies conducted across five remote Aboriginal communities for children born between 2001 and 2005. We estimated the age of the first infection using the Kaplan-Meier estimator; parametric exponential mixture model; and Cox proportional hazards. For skin sores, the mean age of the first infection was approximately 10 months and the median was 7 months, with some heterogeneity in median observed by the community. For scabies, the mean age of the first infection was approximately 9 months and the median was 8 months, with significant heterogeneity by the community and an enhanced risk for children born between October and December. The young age of the first infection with skin sores and scabies reflects the high disease burden in these communities.

The influence of birthweight, past poststreptococcal glomerulonephritis and current body mass index on levels of albuminuria in young adults: the multideterminant model of renal disease in a remote Australian Aboriginal population with high rates of renal disease and renal failure.

BACKGROUND: Australian Aborigines in remote areas have very high rates of kidney disease, which is marked by albuminuria. We describe a 'multihit' model of albuminuria in young adults in one remote Aboriginal community. METHODS: Urinary albumin/creatinine ratios (ACRs) were measured in 655 subjects aged 15-39 years and evaluated in the context of birthweights, a history of 'remote' poststreptococcal glomerulonephritis (PSGN; ≥5 years earlier) and current body mass index (BMI). Birthweight had been <2.5 kg (low birthweight, LBW) in 25.4% of subjects and 22.8% had a remote history of PSGN. RESULTS: ACR levels rose with age. It exceeded the microalbuminuria threshold in 33.6% of subjects overall (25% of males and 45% of females). In multivariate models, birthweight (inversely), remote PSGN and current BMI were all independent predictors of ACR levels. The effects of birthweight and PSGN and their combination were expressed through amplification of ACR levels in relation to age and around the group median BMI of 20.8 kg/m(2). In people with BMI <20.8 (57.8% of all males and 40.3% of the females), LBW and PSGN alone had minimal effects on ACR, but in combination they strikingly amplified ACR in relation to age. Those with BMI ≥20.8 (which included 42.2% of the males and 59.7% of the females) had higher ACR levels, and both LBW and a PSGN history, separately and in combination, were associated with striking further amplification of ACR in the context of age. CONCLUSION: Much of the great excess of disease in this population is explained by high rates of the early life risk factors, LBW and PSGN. Their effects are expressed through amplification of ACR in the context of increasing age and are further moderated by levels of current body size. Both early life risk factors are potentially modifiable.

The microbiology of impetigo in indigenous children: associations between Streptococcus pyogenes, Staphylococcus aureus, scabies, and nasal carriage.

BACKGROUND: Impetigo is caused by both Streptococcus pyogenes and Staphylococcus aureus; the relative contributions of each have been reported to fluctuate with time and region. While S. aureus is reportedly on the increase in most industrialised settings, S. pyogenes is still thought to drive impetigo in endemic, tropical regions. However, few studies have utilised high quality microbiological culture methods to confirm this assumption. We report the prevalence and antimicrobial resistance of impetigo pathogens recovered in a randomised, controlled trial of impetigo treatment conducted in remote Indigenous communities of northern Australia. METHODS: Each child had one or two sores, and the anterior nares, swabbed. All swabs were transported in skim milk tryptone glucose glycogen broth and frozen at -70°C, until plated on horse blood agar. S. aureus and S. pyogenes were confirmed with latex agglutination. RESULTS: From 508 children, we collected 872 swabs of sores and 504 swabs from the anterior nares prior to commencement of antibiotic therapy. S. pyogenes and S. aureus were identified together in 503/872 (58%) of sores; with an additional 207/872 (24%) sores having S. pyogenes and 81/872 (9%) S. aureus, in isolation. Skin sore swabs taken during episodes with a concurrent diagnosis of scabies were more likely to culture S. pyogenes (OR 2.2, 95% CI 1.1 - 4.4, p = 0.03). Eighteen percent of children had nasal carriage of skin pathogens. There was no association between the presence of S. aureus in the nose and skin. Methicillin-resistance was detected in 15% of children who cultured S. aureus from either a sore or their nose. There was no association found between the severity of impetigo and the detection of a skin pathogen. CONCLUSIONS: S. pyogenes remains the principal pathogen in tropical impetigo; the relatively high contribution of S. aureus as a co-pathogen has also been confirmed. Children with scabies were more likely to have S. pyogenes detected. While clearance of S. pyogenes is the key determinant of treatment efficacy, co-infection with S. aureus warrants consideration of treatment options that are effective against both pathogens where impetigo is severe and prevalent. TRIAL REGISTRATION: This trial is registered; ACTRN12609000858291 .

Post-streptococcal glomerulonephritis is a strong risk factor for chronic kidney disease in later life.

Although unusual in western countries and in Australia in general, post-streptococcal glomerulonephritis (PSGN) is still common in Australian Aboriginal children living in remote communities. Here, we evaluated whether episodes of acute PSGN increased the risk for chronic kidney disease in later life in 1519 residents of a remote Aboriginal community (85% of those age eligible), with high rates of renal and cardiovascular disease, who participated in a health screen over a 3-year period. Of these, 200 had had at least one episode of PSGN, with 27 having had multiple episodes, usually in childhood. High levels of albuminuria (albumin/creatinine ratio) with increasing age were confirmed. All PSGN episodes were associated with group A streptococcal skin infections, often related to scabies. In both genders, aged 10-39 years at screening, about one in five had such a history. Among them, PSGN (5 years or more earlier) was significantly associated with higher levels of albuminuria than those without. In women, aged 30-39 years, a history of PSGN was associated with a significantly higher frequency of estimated glomerular filtration rates <60 ml/min. The adjusted odds ratios for an albumin/creatinine ratio over 34 g/mol (overt albuminuria) in males and females with a history of PSGN were 4.6 and 3.1, respectively, compared with those without a history. Thus, PSGN contributes to the very serious burden of chronic kidney disease in this community. Rigorous strategies to prevent scabies and Group A streptococcal infections will reduce this burden.

Throat carriage rate and antimicrobial susceptibility pattern of group A Streptococci (GAS) in healthy Ethiopian school children.

BACKGROUND: Group A Streptococci (GAS) or Streptococcus pyogenes are the most frequent cause of pharyngitis and skin infection in children and lead to post infection complications including acute rheumatic fever and glomerulonephritis. Pharyngeal carriage rates of GAS among healthy school children vary with geographical location and seasons. There is not much information on the screening of children for carriage of GAS in Ethiopia. OBJECTIVES: The study aimed at assessing the carriage rate of Group A Streptococci and antimicrobial susceptibility of the isolates in healthy Ethiopian school children. METHODS: A total of 937 children residing in Addis Ababa (n=491), Gondar (n=265) and Dire-Dawa (n=181) were investigated during a period between November 2004 and January 2005. Throat specimens were collected and cultured using standard procedure. Beta haemolytic streptococci were serogrouped by agglutination tests using specific antisera. Antimicrobial susceptibility testing of the isolates was performed by diffusion method. RESULTS: The median and the mean ages of the study participants were 11 (range 6-14) years. Girls constituted 52% (486/937) of the study participants. A total of 167 (17.8%) beta haemolytic streptococci were recovered from 937 children investigated GAS accounted for 91/167 (54.5%) of beta hemolytic streptococcal isolates. The carrier rate for GAS was 9.7% (91/937) of the screened children followed by group G with 3.2% (30/937) and group C streptococci with 2.2% (21/937). All GAS isolates were sensitive to oxacillin, penicillin, erythromycin, clindamycin and trimethoprim-sulphamethoxazole. Lower frequency of resistance was observed against tetracycline and vanocmycin. CONCLUSION: The present study revealed that GAS was the most predominant beta-haemolytic streptococcus among healthy Ethiopian school children. Our results showed that pharyngeal carriage of GAS in school children should not be underestimated. Therefore it is recommended to conduct regular screening and GAS surveillance in schools, and maintain rational use of antibiotics to minimize GAS resistance.

Clinicopathological features and prognosis of Chinese patients with acute post-streptococcal glomerulonephritis.

AIM: To investigate clinicopathological and prognostic differences between adults and children with acute post-streptococcal glomerulonephritis (APSGN). METHODS: A retrospective case series of 112 patients with APSGN was undertaken. Patients were divided into two groups according to age: adults aged more than 17 years and children aged less than 15 years. RESULTS: The incidence of APSGN, especially in adults, has decreased in the past three decades. Children have had a higher incidence of macroscopic haematuria than adults (58.3% vs 32.7%, P < 0.05). Laboratory test showed that red blood cell count of urine sediment in children was more significant. On light microscopy, adults had more global glomerulosclerosis, tubular basement membrane thickening, tubular atrophy and interstitial fibrosis, while children had more glomerular infiltrating neutrophils and monocytes and cellular casts. Immunofluorescence microscopy showed that classical staining was seen more in children. The short-term prognoses were good in both children and adults. But the recovery rate of proteinuria in children was faster than that in adults. CONCLUSION: Adults with APSGN had similar clinical features as children except that children had more significant haematuria. On pathology, adults had more outstanding chronic changes by light microscopy and more untypical staining by immunofluorescence.

Streptococcus agalactiae in childbearing age immigrant women in Comunitat Valenciana (Spain).

Streptococcus agalactiae (GBS) remains the leading cause of meningitis and neonatal sepsis in the world, and causes disease in pregnant and puerperal women. This is a retrospective study of GBS infections on women of childbearing age living in Comunitat Valenciana, Spain (years 2009-2014) and GBS colonization rate on pregnant women attending Hospital La Fe (years 2013-2015) according to their origin. An aggregated total of 6,641,960 women exposed during the study period had an average GBS isolation rate of 5.19‰ (5.14-5.25‰), geographical group rates being: Western Europe (2.2‰), North America (2.1‰), Australia (3.7‰), Spain (4.6‰), Latin America II (4.5‰), Eastern Europe (5.3‰), Asia (6.7‰), Latin America I (7.7‰), Middle East (7.9‰), Indian Subcontinent (17.2‰), North Africa (17.8‰), Sub-Saharan Africa (22.7‰). The 4532 pregnant women studied had an average GBS colonization rate of 12.47% (11.51-13.43) and geographical group rates varied similar to geographical isolation rates. Low GDP and high temperatures of the birth country were associated with higher colonization rates. Thus, differences in GBS colonization depend on the country of origin; Africa and the Indian subcontinent presented the highest, while Western Europe and North America had the lowest. This variability portrays a geographical pattern influenced by temperature and GDP.

Trends in perinatal group B streptococcal disease - United States, 2000-2006.

Group B Streptococcus (GBS) is a leading infectious cause of neonatal morbidity and mortality in the United States. The bacterium, a common colonizer of the maternal genital tract, can infect the fetus during gestation, causing fetal death. GBS also can be acquired by the fetus during passage through the birth canal or after delivery. Infection commonly manifests as meningitis, pneumonia, or sepsis. In 2002, CDC, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics issued revised guidelines for prevention of early-onset GBS disease (i.e., in infants aged <7 days). These guidelines recommended universal screening of all pregnant women for rectovaginal GBS colonization at 35-37 weeks' gestation and administration of intrapartum antibiotic prophylaxis (IAP) to carriers. A report published in 2007 indicated that, during 2003-2005, the overall rate of early-onset GBS disease increased, whereas incidence of late-onset GBS disease (i.e., in infants aged 7-89 days) remained stable. This report updates the 2007 report by incorporating 2006 data from the Active Bacterial Core surveillance (ABCs) system. The updated analysis revealed an increase in the overall rate of early-onset GBS disease from 2003 to 2006, driven by an increasing incidence among black term infants. Late-onset GBS disease incidence among black infants, which had increased during 2003-2005, declined in 2006. Continued monitoring is needed to follow trends in early-onset GBS disease among black infants to determine whether additional interventions are warranted.

Outcome of severe acute post-streptococcal glomerulonephritis in New Zealand children.

Post-streptococcal glomerulonephritis (PSGN) is the commonest cause of severe acute glomerulonephritis in New Zealand children, with the majority (85%) of the patients being of either Pacific Island or Maori ethnicity. We have performed a retrospective study on 27 pediatric patients with acute PSGN. Of these patients, those with crescentic glomerulonephritis (n = 11) had a greater tendency (72.7%) for needing acute dialysis and were left with persistent urinary sediment abnormalities after a mean follow-up of 3.2 years (95% confidence interval 2.1-4.3). The efficacy of immunosuppression in the group with crescentic disease was uncertain. The severity of renal histopathological abnormalities as judged by the total biopsy score did not correlate with either presentation or eventual outcome. Severe childhood acute post-streptococcal glomerulonephritis, although uncommon, results in significant long-term renal morbidity, particularly among Maori and Pacific Island children.

Streptococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 287 cases.

BACKGROUND: There has not been a comprehensive, multi-centre study of streptococcal peritonitis in patients on peritoneal dialysis (PD) to date. METHODS: The predictors, treatment and clinical outcomes of streptococcal peritonitis were examined by binary logistic regression and multilevel, multivariate poisson regression in all Australian PD patients involving 66 centres between 2003 and 2006. RESULTS: Two hundred and eighty-seven episodes of streptococcal peritonitis (4.6% of all peritonitis episodes) occurred in 256 individuals. Its occurrence was independently predicted by Aboriginal or Torres Strait Islander racial origin. Compared with other organisms, streptococcal peritonitis was associated with significantly lower risks of relapse (3% vs 15%), catheter removal (10% vs 23%) and permanent haemodialysis transfer (9% vs 18%), as well as a shorter duration of hospitalisation (5 vs 6 days). Overall, 249 (87%) patients were successfully treated with antibiotics without experiencing relapse, catheter removal or death. The majority of streptococcal peritonitis episodes were treated with either intraperitoneal vancomycin (most common) or first-generation cephalosporins for a median period of 13 days (interquartile range 8-18 days). Initial empiric antibiotic choice did not influence outcomes. CONCLUSION: Streptococcal peritonitis is a not infrequent complication of PD, which is more common in indigenous patients. When treated with either first-generation cephalosporins or vancomycin for a period of 2 weeks, streptococcal peritonitis is associated with lower risks of relapse, catheter removal and permanent haemodialysis transfer than other forms of PD-associated peritonitis.

Racial disparities in intrapartum group B Streptococcus colonization: a higher incidence of conversion in African American women.

OBJECTIVE: To compare the incidence of group B Streptococcus (GBS) conversion from a negative antepartum to a positive intrapartum culture among women who self-identify as non-Hispanic black, Hispanic, or non-Hispanic white. STUDY DESIGN: This was a prospective cohort study of women with a negative rectovaginal GBS culture obtained within 35 days of enrollment. An intrapartum rectovaginal swab was collected and cultured for GBS. Data were compared with chi-square, Fisher's exact, or Wilcoxon rank-sum test. Modified Poisson regression was used. RESULTS: We enrolled 737 women; 75.4% were non-Hispanic white, 17.6% were non-Hispanic black, and 6.9% were Hispanic. Non-Hispanic black women were more likely to convert to GBS positive than non-Hispanic white women, 9.2% as compared to 5.3% (RR: 2.0; 95% CI: 1.02-3.8). CONCLUSION: The increased incidence of positive intrapartum GBS cultures among non-Hispanic black women suggests that non-Hispanic black race is a risk factor for GBS conversion in the late third trimester.

Early and late endophthalmitis following trabeculectomy in a Chinese population.

PURPOSE: To investigate the rate of bleb-related endophthalmitis over 5 years in a Chinese population. METHODS.:Retrospective chart review. RESULTS: Of 988 trabeculectomies performed over 5 years, one case (0.1%) developed early endophthalmitis caused by Morganella morganii, which was rarely reported in the literature. Six cases (0.6%) developed late-onset endophthalmitis. Mitomycin C significantly increased the risk of late-onset endophthalmitis (p=0.0002). CONCLUSIONS: Physicians should weigh the benefits against the risks of mitomycin C application in performing trabeculectomies.

A repeat audit of primary care management of group A streptococcal pharyngitis in Northland, New Zealand 2016.

INTRODUCTION One of the New Zealand Government's Better Public Services targets was to reduce the rate of acute rheumatic fever (ARF) nationally by two-thirds by 2017. Maori children and young people are disproportionately affected by ARF in the Northland District Health Board region. General practice contributes to ARF prevention in detecting and appropriately treating group A streptococcal (GAS) pharyngitis. An audit in 2012 suggested improvements in adherence to national guidelines were needed. AIM The aim was to reassess general practice adherence to national guidelines for the management of GAS pharyngitis in Northland, New Zealand, following implementation of the national Rheumatic Fever Prevention Programme. METHODS Throat swab and dispensing data were obtained and analysed for children and young people aged 3-20 years who attended general practice in Northland between 1 April and 31 July 2016 and had laboratory-proven GAS pharyngitis. RESULTS Between 2012 and 2016, the number of throat swabs carried out in general practice more than doubled, and amoxicillin was more commonly prescribed. The proportion of GAS pharyngitis patients in general practice not receiving recommended antibiotics, or receiving an inadequate length of treatment or no prescription, has not reduced. There are significant differences in the management of care for Maori and non-Maori patients, with much higher risk of ARF for Maori. Discussion The management of GAS pharyngitis by general practice in Northland remains substandard. Implicit bias may contribute to inequity. Focused engagement with identified subgroups of general practices and practitioners who disproportionately contribute to non-guideline prescribing should be further investigated.

Prevalence and Capsular Types of Group B Streptococci Colonizing Indian Women Living in the United States.

Group B streptococcal rectovaginal colonization prevalence in women of Indian descent living in the United States was 24.7% comparable with US rates but higher than rates reported from India. The capsular polysaccharide types were distinct in that type V was most common and 33% of group B streptococcal strains were nontypeable.