Latex agglutination techniques, phenotypic reactions and antibiograms

chronic, recurrent or persistent sore throat, which is believed to respond poorly to penicillin in vivo.

quite a rare condition and modern-day clinicians of various medical disciplines are frequently unaware of this organism and the severity of symptoms that it can cause

leukotoxin, endotoxin, haemolysin, haemagglutinin and adhesin

Gram-negative, non-spore-forming anaerobe, is a normal inhabitant of the alimentary tract of animals and humans

unilateral neck swelling due to suppurative thrombophlebitis of the internal jugular vein and may lead to sepsis, pulmonary abscess, and death

Vancomycin is effective against most Gram-positive cocci and bacilli

Growth Requirements of N. Gonorrhoeae

Pharyngeal infectionMay be sole site of infection if oral-genital contact is the only exposureMost often asymptomatic,but symptoms, if present, may include pharyngitis, tonsillitis, fever,and cervical adenitis. Exudative pharyngitis is rare.

Microbiologyand PathologyoEtiologic agent is Neisseria gonorrhoeae.oGram-negative intracellular diplococcus, oxidase-positive, utilizes glucose, but not sucrose, maltose, or lactose. Infects mucus-secreting epithelial cells.oDivides by binary fission every 20-30 minutes.oN. gonorrhoeaeattachesto different types of mucus-secreting epithelial cells via a number of structures located on the surface of gonococci.oN. gonorrhoeaehas ability to alter these surface structures, which helps the organism evade an effective host response.oN. gonorrhoeaeemploys several mechanisms to disarm the complement system, which may result in a survival advantage in the humanhost.

Gram-negative intracellular diplococcus, oxidase-positive, utilizes glucose, but not sucrose, maltose, or lactose. In

Pharyngeal gonorrheais readily acquired by fellatio but less efficientlyacquired bycunnilingus.

Oral cephalosporins are up to 90 percent effective, compared with 99 percent for intramuscular ceftriaxone (Rocephin

oropharyngeal erythema or exudates

persistent or recurrent tonsillitis

Group B streptococcus (strep) is a common bacterium often carried in your intestines or lower genital tract. Group B strep is usually harmless in adults. In newborns, however, it can cause a serious illness known as group B strep disease.

penicillin

Disease

250 to 500 mg orally 3 times a day for 7 to 10 days; alternatively, 500 to 875 mg orally twice a day may be administered

SURVIVAL OUTSIDE HOST: The bacterium can survive on a dry surface for 3 days to 6.5 months (22). It has been found to survive in ice cream (18 days), raw and pasteurized milk at 15-37 ºC (96 hrs), room temperature butter (48 hrs), and neutralized butter (12-17 days) (17). GAS has been found to last several days in cold salads at room temperature (18).

This is another picture of a blood agar plate with growth and hemolytic activity of group B streptococci (GBS) (on the left) and group A streptococci (GAS) (on the right). Note that the colonies of both bacteria appear about the same color and size, but the degree of hemolytic activity is very different. The group A Streptococcus has more hemolytic activity than the group B Streptococcus. Experienced microbiologist use these traits to identify the two types of bacteria.

am positive cocci in pairs and short

Viridans streptococci gram-positive cocci usually in chains, but not always. Notice that these cannot be differentiated from Streptococcus pyogenes by the Gram stain.

nucleic acid amplification tests (NAATs)

Gonococcal specimens should be subcultured from the selective primary medium to a noninhibitory medium, e.g., chocolate agar with 1% IsoVitaleX to obtain a pure culture of the specimen. If the subcultured specimen is not pure, serial subcultures of individual colonies must be performed until a pure culture is obtained. After 18 to 20 hrs. incubation, a heavy suspension of growth from the pure culture should be made in trypticase soy broth containing 20% (v/v) glycerol

A presumptive identification of N. gonorrhoeae will be based on the following criteria: (i) growth of typical appearing colonies on a selective medium such as Thayer-Martin at 35oC to 36.5oC in 5% CO2, (ii) a positive oxidase test, and (iii) the observation of gram-negative, oxidase-positive diplococci in stained smears.

NAATs that have been demonstrated to detect commensal Neisseria species might have comparable low specificity when testing oropharyngeal specimens for N gonorrhoeae

pharyngeal infections with N. gonorrhoeae are frequently asymptomatic

Extensive clinical experience indicates that ceftriaxone is safe and effective for the treatment of uncomplicated gonorrhea at all anatomic sites, curing 99.2% of uncomplicated urogenital and anorectal and 98.9% of pharyngeal infections in clinical trials (

Limited data suggest that dual treatment with azithromycin might enhance treatment efficacy for pharyngeal infection when using oral cephalosporins (

Ceftriaxone treatment failures for pharyngeal infections have been reported in Australia

Detection of infection using Gram stain of endocervical, pharyngeal, and rectal specimens also is insufficient and is not recommended.

noculated directly and when the growth medium is promptly incubated in an increased CO2 environment

More than 90% of staphylococcal isolates now produce penicillinase

Penicillin kills bacteria by inhibiting the proteins which cross-link peptidoglycans in the cell wall (Figure 8).•When a bacterium divides i

Two Cases of Invasive Vancomycin-Resistant Group B Streptococcus Infection

Resistance of group B streptococcus (GBS) to antibiotics, particularly erythromycin and clindamycin, w

Overall mortality remains high (20% to 34% in larger series)

Some resistance to er ythromycin, the agentof choice for penicillin-allergic patients with streptococ-cal phar yngitis, has been reported

High-dose penicillin G remains the antibiotic ofchoice for treatment of GAS, with no resistancerecorded.

Proteinases and other enzymes might con-tribute to tissue destruction

Streptococcal toxic shock syndrome (STSS) canbe associated with invasive infections secondar y toGAS infection

Stevens–Johnson syndrome

Gram-positive infections

vancomycin creep

enterococci that became vancomycin resistant, mostly Enterococcus faecium

effective against most Gram-positive cocci and bacilli with

renal toxicity

vancomycin creep

S. aureus, there are only a handful of vancomycin-resistant strains

methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis (MRSE) and amoxicillin-resistant enterococci

Staphylococci failed to develop resistance to 05865

similar in weight

osteomyeliti

endocarditis

ith S. aureus, there are only a handful of vancomycin-resistant strains.

Enterococcus faecium

Thrombocytopenia

Mississippi Mud

fast track approval

armamentarium

MIC

vestibular and renal

APACHE scores

osteomyelitis

Vancomycin-associated nephrotoxicity can still be seen, even in the presence of appropriate serum concentrations, especially when it is co-administered with aminoglycosides, amphotericin B, foscarnet, pentamidine ACE inhibitors, loop diuretics, cyclosporine, cyclophosphamide

it is likely remain effective as long as resistance to vancomycin remains controlled.

open – labeled studies

bacteriostatic

vancomycin exposure after colonization as the strongest predictor of prolonged colonization

only a handful

Neutropenia

APACHE scores

q6h

many side effects including vestibular and renal, most likely due to impurities

It has been speculated that exposure to oral vancomycin is an important contributor to propagation of VRE in the healthcare setting, as it drives prolonged colonization with VRE from a myriad of sources (36, 37).

Vancomycin and the above mentioned compounds inhibit cell wall synthesis in its later stages thus affecting dividing bacteria.

Earlier on, vancomycin was associated with many side effects including vestibular and renal,

Vancomycin resistance among enterococci is attributed to change in the d-alanyl-d-alanine portion of peptide precursor units, transmitted as Van genes, thus rendering it incapable of inhibiting peptidoglycan polymerase and transpeptidation reactions.

Vancomycin is a tricyclic glycopeptide (Figure 1) that consists of seven membered peptide chains forming the tricyclic structure and attached disaccharide composed of vancosamine and glucose.

led to attempts to treat such patients with higher doses of vancomycin

ototoxicity

“slow bactericidal”

red man” syndrome,

major use of vancomycin today is for infections caused by methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis (MRSE) and amoxicillin-resistant enterococci. In its oral form, vancomycin is used to treat diarrhea caused by Clsotridium difficile.

The subsequent emergence of vancomycin resistance among enterococci in the mid-1980s and failure of such patients even if they had enterococci with vancomycin-intermediate susceptibility was described, resulting in vancomycin losing it omnipotence for all gram-positive cocci (12). The appearance of S. aureus strains with intermediate susceptibility to vancomycin (VISA) and vancomycin-resistant S. aureus (VRSA) (12–14) and vancomycin-resistant S. epidermidis (VRSE) (15, 16), brought an end to the hitherto hegemony of vancomycin in the Gram-positive coccal arena. Fortunately, the occurrence of these difficult to treat Staphylococci remains rare.

oral

toxicity

inhibit cell wall synthesis in its later stages thus affecting dividing bacteria

Vancomycin remains the first-line agent for methicillin-resistant coagulase-negative and coagulase-positive staphylococcal infections

Vancomycin is effective against most Gram-positive cocci and bacilli with the exception of rare organisms as well as enterococci that became vancomycin resistant, mostly Enterococcus faecium

Review ARTICLE

similar molecular weight

compared to β-lactams, this slow activity is reflected also in the worse clinical outcomes of cases of MSSA bacteremia and pneumonia treated with vancomycin

While vancomycin is bactericidal against all susceptible Gram-positive pathogens it exerts only bacteriostatic activity against enterococci and needs to be combined with another agent, usually an aminoglycoside, to achieve bactericidal activity.

bactericidal

MIC

only a handful

trough serum levels

The overall mortality rate was 15%, with no significant difference between groups.

Antibiotic susceptibilities of GBS isolates

Antimicrobial Susceptibilities of Group B Streptococcus Isolates from Prenatal Screening Samples

Group A Streptococci

Streptococcus Penicillinplusclindamycin 2–4 million units every 4–6 h IV (adult)600–900 mg every 8 h IV 60 000–100 000 units/kg/dose every 6 h IV10–13 mg/kg/dose every 8 h IV Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin Staphylococcus aureus Nafcillin 1–2 g every 4 h IV 50 mg/kg/dose every 6 h IV Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin Oxacillin 1–2 g every 4 h IV 50 mg/kg/dose every 6 h IV Cefazolin 1 g every 8 h IV 33 mg/kg/dose every 8 h IV Vancomycin (for resistant strains) 30 mg/kg/d in 2 divided doses IV 15 mg/kg/dose every 6 h IV  

MODE OF TRANSMISSION: Transmission via respiratory droplets, hand contact with nasal discharge and skin contact with impetigo lesions are the most important modes of transmission (5, 9, 13). The pathogen can be found in its carrier state in the anus, vagina, skin and pharynx and contact with these surfaces can spread the infection (5, 14, 15) The bacterium can be spread to cattle and then back to humans through raw milk as well as through contaminated food sources (salads, milk, eggs); however, cattle do not contract the disease (16-18). Necrotizing fasciitis is usually because of contamination of skin lesions or wounds with the infectious agent (12).

Staphylococcus and Streptococcus species:

whereas Streptococcus and Enterococcus spp. are catalase negative.

whereas Streptococcus species and many other organisms are inhibited by high concentrations of NaCl.

Numerous epidemiological studies have identified high rates of invasive S. pyogenes infection in men rather than women, a pattern that can be observed for many other invasive bacterial infections and one that is not fully understood. Age-specific incidence rates show a typical J-shaped distribution, with highest rates in the elderly, followed by infants. Assessment of rates of disease according to patient ethnicity show generally higher rates of disease in individuals of non-white European descent. These observations have been made in a diverse range of populations, including indigenous populations of Australia, New Zealand, the Pacific Islands, and circumpolar regions of the northern hemisphere. The reasons behind these excesses in risk are poorly understood and could reflect differential access to healthcare or general living conditions—but could also encompass some genetic predisposing factors.

Carriage and transmission of group A streptococci

Numerous epidemiological studies have identified high rates of invasive S. pyogenes infection in men rather than women, a pattern that can be observed for many other invasive bacterial infections and one that is not fully understood. Age-specific incidence rates show a typical J-shaped distribution, with highest rates in the elderly, followed by infants. Assessment of rates of disease according to patient ethnicity show generally higher rates of disease in individuals of non-white European descent. These observations have been made in a diverse range of populations, including indigenous populations of Australia, New Zealand, the Pacific Islands, and circumpolar regions of the northern hemisphere. The reasons behind these excesses in risk are poorly understood and could reflect differential access to healthcare or general living conditions—but could also encompass some genetic predisposing factors. Future studies will assist in identifying potential strategies to mitigate this risk.

TABLE III. MicrobiologyAerobicGram-positive cocciStaphylococcus aureus27MRSA3Coagulase-negative Staphylococcus40 (incl S epidermidis, S hemolyticus)StreptococcusBeta-hemolytic70Group A40Group B17 (incl S agalactiae, 1)Group D6 (non-Enterococcus)Group F5Group G2Alpha-hemolytic/S viridans31

ble 2. Pathogens associated with necrotizing fasciiti

1 week after moderate trauma.

group B streptococci (Streptococcus agalactiae) have been reported to cause necrotizing fasciitis in only 4 instances (2 involving neonates) over the past 4 decades

International Journal of Orthodontia and Oral Surgery, Volume 6

Bile-esculin Tes

Vancomycin

Antimicrobial therapy should continue for 48-72h after fever resolves

Necrotizing Fasciitis (Streptococcal Gangrene): GAS necrotizing fasciitis is a rapidly progressing infection of the deep subcutaneous tissues and fascia with extensive and rapidly spreading necrosis. Infections often spare the skin, but 50% of patients may have associated myonecrosis. Necrotizing fasciitis is often associated with severe systemic involvement and an associated high mortality rate (7,80,87). As in other invasive streptococcal and staphylococcal skin infections, the site of inoculation is usually at area of minor trauma or the skin lesions of varicella. Like streptococcal bacteremia, there is a clear association between varicella and necrotizing fasciitis. Varicella is characterized by full-thickness dermal lesions that may induce selective immunosuppression to GAS, though this has not been substantiated (7). Necrotizing fasciitis caused by mixed infections, involving both aerobic and anaerobic Gram negative bacteria, is more likely to occur in the abdominal wall, following abdominal surgery or in diabetic patients.

Early and aggressive surgical debridement of the site of infection as well as appropriate antimicrobial therapy is required. Due to the "inoculum effect," penicillin may be less effective in the treatment of necrotizing fasciitis (83). Appropriate antibiotics include nafcillin and clindamycin (7,83).  

Puerperal Sepsis: Puerperal sepsis occurs during pregnancy or during an abortion, when group A streptococcus colonizing the patient invades the endometrium and surrounding structures as well as the lymphatics and bloodstream. Endometritis and septicemia result and can be complicated by pelvic cellulitis, thrombophlebitis, peritonitis, or pelvic abscess. Therapy consists of aggressive surgical exploration and parenterally administered penicillin or clindamycin (see section on myositis/myonecrosis). Patients allergic to penicillin can be treated with a first generation cephalosporin, clindamycin, or vancomycin (8).  

antibiotic

Antibiotic-killing kinetics of group B streptococci.

S. pyogenes isolates showed complete sensitivity to teicoplanin, vancomycin, and levofloxacin.

only five are known to commonly cause disease in immune-competent human beings: Group A, Group B, both members of Group D, and two groups that lack the Lancefield carbohydrate antigen: Streptococcus pneumoniae and Viridans streptococci.[5]

If the mixture produces bubbles or froth, the organism is said to be 'catalase-positive'

The reagent is a dark-blue to maroon color when oxidized, and colorless when reduced.

Dose-dependentinhibitionofgrowthofS43/192/

Penicillins and other antibiotics in the beta-lactam family contain a characteristic four-membered beta-lactam ring. Penicillin kills bacteria through binding of the beta-lactam ring to DD-transpeptidase, inhibiting its cross-linking activity and preventing new cell wall formation.

s: acetoin production from glucose (positive Vogues-Proskauer reaction), arginine, and sorbitol. These are very useful for the differentiation of this group from oth

Epidemiology of resistance in children.

The ability to invade HUVEC was exhibited by selected strains of S. gordonii, S. sanguis, S. mutans, S. mitis, and S. oralis but only weakly by S. salivarius. Comparison of isogenic pairs of S. gordonii revealed a requirement for several surfa

S mutans and S sanguis (involved in dental caries), S mitis (associated with bacteremia, meningitis, periodontal disease and pneumonia), and “S milleri” (associated with suppurative infections in children and adults).

Symptoms include: tiredness weakness fever weight loss respiratory problems problems with heart function in cases where endocarditis occurs.

How antibiotics kill bacteria: from targets to networks

BS strains resistant to penicillin were found to contain spontaneous mutations that conferred amino-acid substitutions

Lancefield group B antigen

Laboratory Photo Examples

FORMULA Ingredients per liter of deionized water:* Pancreatic Digest of Casein 15.0gm Peptic Digest of Soybean Meal 5.0gm Sodium Chloride 5.0gm Sheep Blood 50.0ml Agar 12.0gm Final pH 7.3 +/- 0.2 at 25ºC.

SUPPORT PROTOCOLS FOR DIFFERENTIAL IDENTIFICATION OF S. PYOGENES (GAS) (adapted from microbelibrary.org)

NOTE: All steps should be performed using sterile technique. GAS will remain viable on plates for only 5–7 days after streaking if stored at room temperature. GAS does not survive at 4°C.

is a facultative anaerobe and is grown at 37°C in either ambient air or in 5–10% CO2. Like all streptococci, GAS is both catalase and oxidase negative. GAS lacks the necessary enzymes for a functional TCA cycle and oxidative-cytochromes for electron transport; therefore, relies completely on fermentation of sugars for growth and energy production. It is a member of the lactic acid bacteria and is homofermentative for lactic acid production from glucose fermentation. Specific components of a rich growth medium for GAS include neo peptone extracts, glucose as carbon source, and a complex mixture of nutrients from beef heart infusion as first described by Todd & Hewitt (Todd and Hewitt, 1932). GAS is considered a multiple amino acid auxotroph requiring nearly all amino acids to be present in its growth media. A Chemically Defined Medium has been developed for GAS containing all of the necessary amino acids for GAS growth (van de Rijn, 1980).

GAS grows best on complex “rich” medium such as Trypticase Soy Agar (TSA) supplemented with 5% Sheep Blood

Adjust the pH to 7.5.

Optimal growth of GAS is seen in 5% CO2; however, GAS will also grow in ambient air albeit a little slow.

S. pyogenes is a facultative anaerobe and is grown at 37°C in either ambient air or in 5–10% CO2

GAS is considered a multiple amino acid auxotroph requiring nearly all amino acids to be present in its growth media. A Chemically Defined Medium has been developed for GAS containing all of the necessary amino acids for GAS growth

For presumptive identification of S. pyogenes, cultures should be tested for bacitracin susceptibility and PYR activity (as described below). A definitive diagnosis should include a positive Lancefield group A antigen test. Negative results can be confirmed after a total culture time of 48 hours.

To identify S. pyogenes in clinical samples, blood agar plates are screened for the presence of β-hemolytic colonies. The typical appearance of S. pyogenes colonies after 24 hours of incubation at 35-37°C is dome-shaped with a smooth or moist surface and clear margins. They display a white-greyish color and have a diameter of > 0.5 mm, and are surrounded by a zone of β-hemolysis that is often two to four times as large as the colony diameter. Microscopically, S. pyogenes appears as Gram-positive cocci, arranged in chains (Figure 1).

The ability of bacterial species to hydrolyze the compound hippurate was classically tested using ferric chloride indicator to detect benzoic acid, the first byproduct in the hippurate hydrolysis pathway. However, a 2½ hour rapid method as opposed to the 48 hour classical method for detecting hippurate hydrolysis has since been developed. The rapid test employs ninhydrin as the indicator, which detects glycine, the second byproduct of hippurate hydrolysis. The rapid hippurate hydrolysis test has been shown to be as specific and as sensitive as the classical method that detects the benzoic acid byproduct. (4,5,8,9)

Superantigens are potent immunostimulators that cause clonal proliferation of T cells and watershed production of pro-inflammatory cytokines that mediate shock and organ failure.

GBS hyaluronidase degrades pro-inflammatory hyaluronan (HA) fragments to disaccharides•HA disaccharides block TLR2/4 signaling by both HA fragments and TLR2/4 agonists•Hyaluronidases secreted by Gram-positive pathogens promote immune evasion•HA disaccharides and GBS hyaluronidase inhibit inflammation in a lung injury model

Numerous phages are known to carry determinants that increase virulence to the bacterial host. These factors have been predominantly secreted toxins, such as the streptococcal erythrogenic toxin, staphylococcal enterotoxin A, diphtheria toxin, and cholera toxin (10). Other phage-encoded virulence determinants include extracellular enzymes such as staphylokinase and streptococcal hyaluronidase, enzymes that alter the antigenic properties of the host strain, and outer membrane proteins that increases serum resistance (10). It is likely that Pb1A and Pb1B bind platelets directly, although the mechanism by which PblA and PblB mediate platelet binding by S. mitis has not been illustrated. Thus, the encoding of PblA and PblB by lysogenic SM1 may represent a class of phage-mediated virulence determinants (10).

three biochemical reactions:

The attachment of S. pyogenes to the pharyngeal and skin epithelial cell surfaces represents a critical first step in establishing such infections.

human infections that involve the upper respiratory tract and skin, including acute pharyngitis and impetigo.

Occasionally, however, these bacteria can cause much more severe and even life threatening diseases such as necrotizing fasciitis (occasionally described as "the flesh-eating bacteria") and streptococcal toxic shock syndrome (STSS).

The skin may be warm with red or purplish areas of swelling that spread rapidly. There may be ulcers, blisters, or black spots on the skin.

Briefly, the organism was plated on blood Mueller-Hinton agar and incubated at 35°C in ambient air (preferred), or with CO2 if required for growth, for 20 to 24 h.

All 50 strains were susceptible to vancomycin

based on alpha-hemolysis, gram-positive reaction, coccus morphology in chains, negative catalase test, and exclusions of pneumococci and enterococci by routine biochemical tests (optochin test, bile solubility, and PYR [N,N-dimethylaminocinnamaldehyde] test).

nutritionally fastidious and mainly alpha-hemolytic on sheep blood agar

Sequencing analysis of the 16S rRNA gene has become an essential part of bacterial taxonomy

Types of Infection and Symptoms

These skin infections may also be accompanied by a fever

Red Swollen or painful Warm to the touch Full of pus or other drainage

invasive group B strep infection (infections where the bacteria have entered a part of the body that is normally not exposed to bacteria)

Spread to Others

chromogenic pigments for the detection of beta-hemolytic GBS using color detection

TransVag broth may be supplemented with 5% defibrinated sheep blood to increase the recovery of GBS

Rapid antigen tests

viridans streptococci are often susceptible to penicillin G and other β-lactams. Resistance is growing, and therapy for such strains should be dictated by results of in vitro susceptibility tests.

Necrotizing fasciitis should be treated in an ICU. Extensive (sometimes repeated) surgical debridement is required. A recommended initial antibiotic regimen is a β-lactam (often a broad-spectrum drug until etiology is confirmed by culture) plus clindamycin. Although streptococci remain susceptible to β-lactam antibiotics, animal studies show that penicillin is not always effective against a large bacterial inoculum because the streptococci are not rapidly growing and lack penicillin-binding proteins, which are the target of penicillin activity.

VGS are presumed to be uniformly susceptible to penicillin

Catalase mediates the breakdown of hydrogen peroxide H2O2 into oxygen and water. 

TheseresultsindicatethatthehyaluronicacidcapsuleofmucoidGASprotectstheorganismfromphagocytosisandenhancesvirulence.

Mproteinhasbeenconsideredtobethemajorsurfacecomponentrespon-sibleforresistanceofGAStophagocytosis(12)

OccasionalstrainsofGASisolatedfromclinicalsourcesgrowaslarge,spreading,wetcoloniesonsolidmedia;

grape-like clusters when viewed through a microscope, and has round, usually golden-yellow colonies

Humans (neonates, elderly, immunocompromised, diabetic, alcoholic, and stroke and cancer patients have a higher risk of infection), cattle (mastitis), dogs, cats, rabbits, horses, guinea pigs, and goats have been shown to contain the infectious agent

Gram-positive

tetracycline, to which 26 strains were resistant

chronic conditions (diabetes, cancer), compromised immune systems (receiving chemotherapy, autoimmune disorders or HIV infection) or open wounds or sores that allow the bacteria to enter the tissue.

"Strep throat," – swollen tonsils possible covered with a grayish-white film, swollen lymph nodes, and fever with or without chills, painful swallowing and headache. Impetigo - mild skin infection accompanied by open, draining sores and other general symptoms of GAS infection such as fever, swollen lymph nodes and a sore throat. Scarlet fever - characterized by a fever, sore throat, red sandpaper-like rash and a red "strawberry" tongue. It is caused by several different strains of the streptococcal bacteria, all of which produce a toxin that cause the characteristic red rash.

Adults who develop invasive GBS infection may develop

The exact source of the infection in nonpregnant adults is often not determined

diabetes, cardiovascular disease, obesity, and cancer.

Group B strep (GBS) are bacteria found normally in the intestine, vagina, and rectal area in about 25% of all healthy adult and pregnant women.

culture of a single throat swab on a blood agar plate yields a sensitivity of 90-95% for the detection of group A streptococci (GAS) in the pharynx

Most laboratories inoculate throat swabs on 5% sheep blood agar containing trimethoprim-sulfamethoxazole

In patients with acute pharyngitis, group A beta-hemolytic streptococcal infection should be ruled out.

antibodies for the detection of group A carbohydrate antigen.

frozen section biopsy

Bartonella henselae

scratch

Typhoidal

Pneumonic

Oropharyngeal