Strep A

The genus Streptococcus  was first identified by Louis Pasteur in 1879 as the bacteria responsible for puerperal sepsis¹. Streptococcus pyogenes, also known as group A Strep, causes disease of variable severity, contributing to 20% of tonsillopharyngeal infections², and causing impetigo (pyoderma). Left untreated however, symptoms may become more severe with complications such as acute rheumatic fever, toxic shock-like syndrome and glomerulonephritis³. Rapid identification is therefore important to allow early treatment and prevent disease progression².

Streptococcus pyogenes

Streptococcus pyogenes are gram positive, facultative anaerobic bacteria. They are often referred to as β-haemolytic bacteria which relates to the ‘halo’ that surrounds the individual colonies when grown on blood agar. This occurs as the bacteria produce the toxin streptolysin S, which gives the bacteria the ability to haemolyse red blood cells and damage cell membranes.  Membrane damage can also occur in lymphocytes, neutrophils, platelets, and cellular organelles such as lysosomes and mitochondria⁴. Streptococcus pyogenes also has a number of other virulence factors; the most important of which is the M protein. The M proteins resist phagocytosis by polynuclear leucocytes and therefore allow the organism to multiply rapidly in the host. Lipoteichoic acid is also expressed on the surface of Streptococcus pyogenes and is responsible for the binding of the organism to fibronectin which is present on the surface of oral epithelial-cell membranes. Mucoid strains of Streptococcus pyogenes are surrounded by a capsule that contains hyaluronic acid, which additionally contributes to the organism’s ability to evade phagocytosis.³

As well as those virulent factors expressed on the cell surface, there are a number of extracellular substances that Streptococcus pyogenes produce which also contribute to pathogenesis such as hyaluronidase, neuraminidase, DNases, streptokinase, pyrogenic exotoxins, streptolysin O and streptolysin S as described previously. Pyrogenic exotoxins for example are responsible for the rash in scarlet fever and render the patient more susceptible to endotoxic shock. Streptolysin O, DNases and hyaluronidase induce antibody formation approximately 10 to 17 days after infection⁵.

The majority of Streptococci possess group specific antigens, which are usually carbohydrate structural components of the call wall. For Streptococcus pyogenes, the group specific antigen is a polymer of L-rhamose and N-acetyl-D-glucosamine. TestPack Strep A detects this group specific carbohydrate antigen, thus confirming the presence of Group A Streptococci.

(Reproduced by permission from Kenneth Todar:
http://textbookofbacteriology.net/streptococcus.html


Epidemiology

Group A Streptococci are a major cause of upper respiratory tract infections in humans. It is thought that 20% of all cases of tonsillopharyngitis are caused by group A Streptococci². It typically occurs in young children and infection rates are particularly high in environments such as schools, nursing homes and hospitals^{8, 9}. The incidence of infections caused by group A Streptococci is believed to have re-emerged in the last 10-20 years^{5, 9}. In the past, in an effort to reduce complications such as rheumatic fever and glomerulonephritis, antibiotics have been prescribed in patients presenting with sore throats, even in those where there is no proven evidence that the cause is group A streptococci and the cause maybe viral^{2, 10}. This approach runs the risk of Streptococci developing increased resistance to antibiotics. To ensure this does not happen, the use of rapid diagnostic tests is important.


Diagnosis

A specimen should be obtained by standard throat swab collection methods. The recovery of group A Streptococci is dependent on the quality of the specimen collected. A tongue depressor and light should be used along with a good technique that swabs all areas at the back of the throat. This has been shown to increase the recovery of organisms ten-fold.


Culture:

Traditional methods for the identification of group A Streptococci depend on the isolation and subsequent identification of the organisms. Throat swabs are cultured onto solid agar (e.g. tryptose or columbia agar) supplemented with either 5% horse or sheep blood¹¹. The agar plates are then incubated for 18-24 hours at 37^oC aerobically with the addition of 5% CO_² or anaerobically. Agar supplemented with sheep blood has the advantage that it does not support the growth of Haemophilus haemolyticus which show similar colonial morphology when grown under aerobic conditions. Group A Streptococci are typically 0.5mm in diameter and are surrounded by a zone of complete haemolysis¹³.

The haemolytic action of Streptococci on erythrocytes was first described by Brown in 1919. There are 4 recognised haemolysis patterns:

Browns method has been used to characterise Streptococcal groups from culture plates but it is limited in that other groups of Streptococci also produce β-haemolytic colonies¹³.

Selective media can also be used for the isolation of group A Streptococci e.g. SXT blood agar (blood agar containing sulfamethoxazole and trimethoprim). This media has limitations in that despite being a selective agar for group A Streptococci, other Streptococci may also grow in small numbers. Also a few strains of group A Streptococci are susceptible to SXT and generally a second day of incubation is required for optimal recovery of group A Streptococci¹⁴.

Following culture, all β-haemolytic organisms are confirmed with a streptococcal grouping kit.


Serological Testing:

Streptococci are identified according to their cell wall antigen, which is specific for each Streptococcus group. This classification system was first described by Rebecca Lancefield in 1933¹⁴. There are many commercially available Streptococcal kits including latex agglutination tests. The Streptococcal group antigens are extracted from the cells (β-haemolytic colonies of Streptococci) and their presence demonstrated with latex particles previously coated with group-specific antibodies. The latex particles will agglutinate in the presence of the homologous antigen. The Streptococcal grouping kits allow the identification of Streptococcal groups, A, B, C, D, F and G.


References

1. Efstratiou A. (2000) Group A streptococci in the 1990s. Journal of Antimicrobial Chemotherapy. 45,Topic T1, 3-12.

2. Adam D. (2000) Group A beta-haemolytic streptococcal (GABHS) tonsillopharyngitis is still a common problem. Journal of Antimicrobial Chemotherapy. 45, Topic T1, 1-2.

3. Bisno A. L. (1991) Group A Streptococcal Infections and Acute Rheumatic Fever. The New England Journal of Medcine. 325(11), 783-793.

4. Nizet V., Beall B., Bast D.J., Datta V., Kilburn L., Low D.E. & De Azevedo J.C.S. (2000) Genetic Locus for Streptolysin S Production by Group A Streptococcus. Infection and Immunity. 68(7), 4245-4254.

5. Kiselica D. (1994) Group A Beta-Haemolytic Streptococcal Pharyngitis: Current Clinical Concepts. American Family Physician. 49(5), 1147-1154.

6. Heath A., DiRita V.J., Barg N.L. & Engleberg N.C. (1999) A Two-Component Regulatory System, CsrR-CsrS, Represses Expression of three Streptococcus Pyogenes Virulence factors, Hyaluronic acid capsule, Streptolysin S, and Pyogenic Exotoxin B. Infection and Immunity. 67(10), 5298-5305.

7. Woods W.A., Carter C.T. & Schlager T.A. (1999) Detection of group A streptococci in children under 3 years of age with pharyngitis: Paediatric Emergency care. 15(5), 338-340.

8. Schwartz B., Elliot J.A., Butler J.C., Simon P.A., Jameson B.L., Welch G.E. & Facklam R.R. (1992) Clusters of Invasive Group A Streptococcal Infections in family, hospital and nurse home settings: Clinical infectious Diseases. 15, 277-84.

9. O’Brien K.L., Beall B., Barrett N.L., Cieslak P.R., Reingold A., Farley AM.M., Danila R., Zell E.R., Facklam R., Scwartz B. & Schuchat A. (2002) Epidemiology of Invasive Group A Streptococcus Disease in the United States, 1995-1999. Clinical Infectious Diseases. 35, 268-276.

10. Little P.S., Williamson I. (1994) Are antibiotics appropriate for sore throats? Costs outweigh the benefits. British Medical Journal. 309, 1010-1011.

11. Kaufhold A. & Ferrieri P. (1993) The Microbiological Aspects, Including Diagnosis, of β-Hemolytic Streptococcal and Enterococcal Infections. Laboratory Diagnosis of Infectious Diseases. 7(2), 235-256.

12. Ross P.W. (1971) Throat Swabs and Swabbing Technique. The Practitioner. 207, 791-796.

13. Facklam R.R. & Washington J.A. II (1991) Streptococcus and related catalase negative gram positive cocci: In: Balows A., Hausler W.J. Jr, Herrmann K.L., et al (eds): Manual of Clinical Microbiology, ed 5. Washington, DC, American Society for Microbiology: 238-257.

14. Lancefield R.C. (1933) A Serological Differentiation of Human and Other Groups of Hemolytic Streptococci. J.Exp.Med. 57, 571-593.