Title

Author(s)

Group B streptococcal infection in non-pregnant adults

Yung, Chi-yui;

Citation

Issued Date

URL

Rights

2010

http://hdl.handle.net/10722/133491

Creative Commons: Attribution 3.0 Hong Kong License


GroupBStreptococcalInfectioninNonpregnantAdults

By

YungChiYui

Thisworkissubmittedto
FacultyofMedicineofTheUniversityofHongKong
Inpartialfulfillmentoftherequirementsfor
ThePostgraduateDiplomainInfectiousDiseases,PDipID(HK)

Date:24thAugust,2010

Supervisor:DrSKPLau

Declaration

I,YungChiYui,declarethatthisdissertationrepresentsmyownworkandthatithas
notbeensubmittedtothisorotherinstitutioninapplicationforadegree,diplomaor
anyotherqualifications.
I, Yung Chi Yui also declare that I have read and understand the guideline on What
is plagiarism? published by The University of Hong Kong (available at
http://www.hku.hk/plagiarism/) and that all parts of this work complies with the
guideline.

Candidate: YungChiYui

Signature:

Date:

Acknowledgement:
I would like to thank Dr Rodney Lee and Dr Allan Wu, Department of Microbiology,
Pamela Youde Nethersole Eastern Hospital, for providing the data, and Dr Susanna
Lau, Department of Microbiology, Queen Mary Hospital for the guidance on the
project.

Background
Group B streptococcus, a gram-positive coccus that frequently colonizes the human
genital and gastrointestinal tracts, and the upper respiratory tract in young infants, was
mainly concerned as an important cause of infection in pregnant and neonatal
population [1,2]. However in the past two decades, twofold to fourfold increases in the
incidence of group B streptococcal disease have been reported in nonpregnant adults
[3,4],

[5].

most of whom have underlying medical conditions or are 65 years of age or older
Despite sporadic reports of GBS infection in nonpregnant adults, it was not until

intensive population-based surveillance was performed in the 1980s and 1990s that
the emergence of this organism as an important pathogen in adults was appreciated.
Active, population-based surveillance indicates that two thirds of patients with
invasive group B streptococcal disease now are non-pregnant adults [6]. Invasive
group B streptococcal infection in non-pregnant adults is now recognized as a major
health concern. Farley and colleagues conducted a prospective surveillance of
invasive group B streptococcal disease in 1993 [4]. Men and non-pregnant women
accounted for 68 percent of all cases among adults with an annual incidence of 4.4 per
100,000. A similar surveillance conducted between 1990 to 2007 [6] showed the
incidence of adult GBS disease doubled from 3.6 cases per 100,000 persons during
1990 to 7.3 cases per 100,000 persons during 2007. In a retrospective study conducted

in Hong Kong between 1986 to 2000 [7], incidence of group B streptococcal

bacteraemia in nonpregnant adults was 8.33/100,000 admissions/year. Between 1997
and 2000, there were 13.6 cases/100,000 admissions/year among nonpregnant adults,
which is 100% more than in 1986 to 1996. They all reflect there is growing
incidence of invasive group B streptococcal in non-pregnant adult. Non-pregnant
adult now contribute 90% of the mortality in invasive group B streptococcal infection.

Method
All patients admitted to Ruttonjee Hospital, a regional hospital comprised of both
acute and convalescent service, without paediatric, obstetric and gynaecological
service, with a positive blood culture of group B streptococcal during the period of
January 2007 to December 2009 inclusive were studied retrospectively. Diagnoses
and drugs used were recovered using the Hospital Authority CMS system in the same
admission by ICD 9 coding system.

Results (Table 1)
137 blood culture isolates of non-group A streptococcal were identified during the
study period. 23 of them were positive for Streptococcus agalactiae. Repeated
positive growth in the same hospital admission was regarded as one episode. Only one
subject had consecutively positive culture, who had 3 episodes in the same day. The
age of thesubjects ranged from 26 to 94 years old, with a mean age of 73.1 years old.
There were 3 of them with polymicrobial growth on the same blood culture sample.
14 (60%) of them were female. 20 (87%) of the subjects were older than 65 years old.
Among the 23 episode, 6 (26%) were diagnosed to have cellulitis or skin abscess, 5
(21%) had pneumonia, 4 (17%) with decubitus ulcer, 2 (8%) having urinary tract
infection, 1 (4%) having infective endocarditis. For 3 (13%) of them, no identifiable
cause could be found. Among the 23 subjects, 12 (52%) of them lived in residential
home. 8 (23%) of them were diagnosed to have diabetes mellitus. 5 (21%) of them
were being labeled as bed-ridden. 3 (13%) having history of cerebocvascular disease.
9 (39%) of the subjects died in the same hospital admission. All the 3 subjects with
polymicrobial infection died during the hospital admission. The mortality in subjects
older than 65 years old was 45%. All the 9 subjects died were older than 78 years old.

Discussion
Group B streptococcus has emerged as an important cause of invasive infection in
nonpregnant adults. We tried to compare our result to a major population-based
surveillance in USA by Skoff [6] and a local retrospective series by Wong [7].
Age was being identified as a major risk factor for invasive group B streptococcal
infection in various published series [4-6]. The reported annual incidence of GBS
infection in nonpregnant adults in the general population is between 4 and 7 per
100,000 [1-4, 6, 8]. However, the risk is as high as 26 per 100,000 in patients older than
65 years of age. Compared the subjects age, the average age was 63 in Skoffs series
and 59.3, which is significantly smaller than in current series (73.1), which may
reflects different patient composition in the institutions being studied. 20 of the total
23 subjects (87%) were elderly more than 65 years old. There were no major
prevenlace over male or female sex in the three series.
There was a definitely higher mortality rate (39%) in this series compared with
Wongs (10.6%) and Skoffs (7.5%). Table 2 showed the details of the 9
mortalites.The case fatality in elderly population is around 15% in various case series
[5],

where the mortality rate is 45% (9/20) in our series. And all the 9 mortality

occurred in subjects older than 78 years old. 3 (33%) died of bedsore and 3 (33%)
died of pneumonia. 4 (44%) of the subjects were nursing home residents.

There were 3 subjects (13%) with polymicrobial infection in our series and all of the
them died in the admission episode. Among causes of bacteremia, there was a
significantly lower rate of primary bacteremia in our series (13%) when compared to
Skoff (39.3%) and Wongs (23.4). The average rate of primary bacteremia in various
reports ranges from 20 to 50% [4,9], which usual carry a high mortality rate to around
60%. There was 1 mortality in the 3 subjects with primary bacteremia. Recurrence of
infection is commonly noted in previous case report, whereas there was no
documented recurrence noted in our series.
Whereas skin and soft tissue infection and pneumonia consistently comprised the
major causes of group B streptococcal septicemia in three case series. The high rate of
decubitus ulcer in this series maybe related to the high average age of subject. There
was only one (4%) patient diagnosed to have infective endocarditis in this series,
which was less than that of Wongs series (12.8%) but comparable to Skoffs series
(3%), which was less than traditionally thought [4,9].
Among various identifiable risk factor, old age home residency was the major risk
factor associated with the infection in our series (52%), which was only present in
10.9% in Skoffs series and not being studied in Wongs series. A previous
surveillance study on rectal carriage rate of group B streptococcus in nursing home
staff and residents in 1983 [10] was about 12-15%, which was comparable to usual

population [11]. This might implies the increase incidence of invasive group B
streptococcal infection reflects the older age and poorer general condition of the
subjects, rather than environmental factors. Diabetes mellitus was both identified also
as a major risk factor in our series (21.2%) and Skoffs series (44.4%), but
surprisingly only comprised of 4.3% of patient in Wongs series. Neurological
disorders, for example dementia and cerebrovascular accident comprised a major risk
factor similarly across the three series. 100% of the patient in our series, 88% in
Skoffs series and 76.6% in Wongs series had at least one identifiable risk factors for
the infection.
There were several limitations to our study. First, because there was no control group,
risk factors for disease could not be evaluated directly. The diagnosis identified most
of the time did not support by positive culture results, rather than attending physcians
clinical impression and by voluntary coding system in the CMS. No temporal
comparison could be made as only a short period of time was studied. Prevalence of
invasive group B streptococcal infection of non-pregnant adults among the population
also could not be well assessed as no pregnant and neonatal subjects being included in
this series.

10

Conclusion
In conclusion, the result of our series is comparable to previous major series, which
showed age, nursing home residency and diabetes were the major risks factors for
invasive group B streptococcal infection. The higher mortality noted in our series
might reflects the different patient composition of the studied institute, as reflected by
the older average age of the subjects. Skin and soft tissue infections, decubitus ulcer
and pneumonia remained the major causes of the infection as in other series.

11

Table 1

Age

73.1 (26-94)

Older than 65 years old

20 (87%)

Sex M:F(%)

9:14 (40:60%)

Mortality

9 (39%)

Polymicrobial

infection

3 (13%)

Clinical diagnosis
Cellulitis

6 (26%)

Pneumonia

5 (21%)

Decubitus ulcer

4 (17%)

Primary bacteremia

3 (13%)

UTI

2 (8%)

Endocarditis

1 (4%)

Risks
Nursing home residence

13 (52%)

Diabetes mellitus

8 (34%)

Bedridden status

5 (21%)

Cerebrovascular disease

3 (13%)

12

Table 2:
Age

Organism

Diangosis

OAH

Comorbidity

83

GBS, Klebsiella

IO

Yes

Schizophrenia

80

GBS

Primary

No

Terminal malignancy

92

GBS

Pneumonia

No

AF, IHD, PPM

78

GBS

Bedsore

Yes

TB, DM

93

GBS

Bedsore

Yes

Parkisons, CKD

91

GBS

Bedsore

No

CVA, dementia, bedbound

91

GBS, CNS

Pneumonia

No

HT, COPD, bronchiectasis

77

GBS

Cholangitis

No

DM, HT

82

GBS, MRSA

Pneumonia

Yes

Bedbound, CVA, LT Foley

13

Reference
1. Group B streptococcal disease in the era of intrapartum antibiotic prophylaxis.
Schrag SJ; Zywicki S; Farley MM; Reingold AL; Harrison LH; Lefkowitz LB;
Hadler JL; Danila R; Cieslak PR; Schuchat A
N Engl J Med 2000 Jan 6;342(1):15-20
2. Group B streptococcal disease in the United States, 1990: report from a multistate
active surveillance system.
Zangwill KM; Schuchat A; Wenger JD
MMWR CDC Surveill Summ 1992 Nov 20;41(6):25-32
3.

Eidemiology of invasive group B streptococcal disease in the United States,

1999-2005.
Phares CR; Lynfield R; Farley MM; Mohle-Boetani J; Harrison LH; Petit S; Craig
AS; Schaffner W; Zansky SM; Gershman K; Stefonek KR; Albanese BA; Zell ER
Schuchat A; Schrag SJ
JAMA. 2008 May 7;299(17):2056-65

.
4. Population-based assessment of invasive disease due to group B Streptococcus in
nonpregnant adultsFarley MM; Harvey RC; Stull T; Smith JD; Schuchat A;
Wenger JD; Stephens DS
N Engl J Med 1993 Jun 24;328(25):1807-11.
5.

Group B streptococcal infections in elderly adults.

14

Edwards MS; Baker CJ

Clin Infect Dis 2005 Sep 15;41(6):839-47
6.

Increasing burden of invasive group B streptococcal disease in nonpregnant

adults, 1990-2007.
Skoff TH; Farley MM; Petit S; Craig AS; Schaffner W; Gershman K; Harrison
LH; Lynfield R; Mohle-Boetani J; Zansky S; Albanese BA; Stefonek K; Zell ER;
Jackson D; Thompson T; Schrag SJ
Clin Infect Dis. 2009 Jul 1;49(1):85-92

7. Streptococcus agalactiae (Lancefield Group B) Bacteraemia

in Nonpregnant Adults
T.K.F. Wang A.M.Y. Fung P.C.Y. Woo K.Y. Yuen S.S.Y. Wong
Eur J Clin Microbiol Infect Dis (2002) 21:140142
8. Invasive group B streptococcal disease: the emergence of serotype V.
Blumberg HM; Stephens DS; Modansky M; Erwin M; Elliot J; Facklam
RR;Schuchat A; Baughman W; Farley MM
J Infect Dis 1996 Feb;173(2):365-73
9.

Invasive group B streptococcal disease in adults. A population-based study in

metropolitan Atlanta.
Schwartz B; Schuchat A; Oxtoby MJ; Cochi SL; Hightower A; Broome CV

15

JAMA 1991 Aug 28;266(8):1112-4.

10

Kaplan, EL, Johnson, DR, Kuritsky, JN. Rectal colonization by group B

beta-hemolytic streptococci in a geriatric population.
J Infect Dis 1983; 148:1120

11. Prevalence of group B streptococcus colonization and potential for transmission

by casual contact in healthy young men and women.
Manning SD; Neighbors K; Tallman PA; Gillespie B; Marrs CF; Borchardt SM;
Baker CJ; Pearlman MD; Foxman B
Clin Infect Dis 2004 Aug 1;39(3):380-8

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