Group A streptococcal infections in injection drug users in Barcelona, Spain

Epidemiologic, clinical, and microbiologic analysis of 3 clusters of cases from 2000 to 2003

Josep M. Sierra, Francesca Sánchez, Pedro Castro, Margarita Salvadó, Gloria De La Red, Agnes Libois, Manuel Almela, Francesca March, Montserrat Español, Maria Antonia Sambeat, Joan Romeu, Maria Teresa Brugal, Patricia García De Olalla, Jose Maria Gatell, Jordi Vila, Felipe García, Jose Luís López Colomés, Joan A. Caylà, Pere Coll

Research output: Contribution to journalArticle

Abstract

An unexplained resurgence of Group A streptococci (GAS) infections has been observed since the mid-1980s in the United States and Europe, particularly among intravenous drug users (IDUs). Several risk factors have been identified. Mutations in the capsule synthesis regulator genes (csrRS) have been associated with an increase in virulence. From January 1998 to December 2003, we conducted a prospective and retrospective descriptive analysis of invasive GAS soft-tissue infections in IDUs in Barcelona, Spain. Clinical features were collected, and we conducted a surveillance study to identify risk factors associated with GAS soft-tissue infections. We analyzed chromosomal DNA by low cleavage restriction enzymes and used pulsed-field gel electrophoresis (PFGE) and variable gene sequence typing (VGST) of the emm gene to disclose the epidemiologic relationship between the strains. We analyzed the influence of clonality (M-type) and mutations in csrRS genes of these strains on clinical features. We identified 44 cases, all of which were grouped in 3 clusters: fall 2000, fall 2002, and fall 2003. Cellulitis with or without abscesses (75%) and fever (90.9%) were the most common clinical manifestations. Distant septic complications were infrequent (18.2%). Although all patients had severe infections (mainly bacteremic needle abscesses), their outcome with antibiotic therapy, usually β-lactam, was successful in all cases. However, surgery was needed in 40.9% of patients.Through the surveillance study we found that infected patients had a higher number of drug injections per day (odds ratio [OR], 18.84; 95% confidence interval [CI], 4.83-79.4; p <0.00001), shared paraphernalia for drug use more frequently (OR, 11.11; 95% CI, 3.24-39.04; p <0.0001), were in a higher proportion both currently unemployed and homeless (OR, 4.22; 95% CI, 1.5-12.15; p <0.0001), were not in a methadone maintenance program (OR, 0.03; 95% CI, 0-0.19; p <0.00001), and more often bought drugs at a specific site (OR, 33.92; 95% CI, 7.44-174.93; p <0.00001) and from a specific dealer (OR, 72; 95% CI, 8-3090; p <0.00001), compared with patients not infected. The fall 2000 cluster was polyclonal, whereas the other 2 clusters were mainly due to the same strain of GAS (emm 25.2), and were defined as epidemic outbreaks. Clinically, the cases due to the clonal strain presented abscesses and needed surgery more frequently (p <0.001 and p ≤ 0.005, respectively). On the other hand, mutations in the csrRS genes were not associated with invasive GAS soft-tissue infection. There has been an increase in the number of cases of invasive GAS soft-tissue infections in IDUs in Barcelona, which seems to be related to drug users' habits and their socioeconomic status. Clonality (emm 25.2) but not mutations in the csrRS genes was associated with more severe GAS soft-tissue infections.

Original languageEnglish (US)
Pages (from-to)139-146
Number of pages8
JournalMedicine
Volume85
Issue number3
DOIs
StatePublished - May 2006
Externally publishedYes

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Streptococcal Infections
Drug Users
Streptococcus
Spain
Cluster Analysis
Soft Tissue Infections
Odds Ratio
Injections
Confidence Intervals
Regulator Genes
Capsules
Abscess
Mutation
Genes
Pharmaceutical Preparations
Lactams
DNA Cleavage
Cellulitis
Pulsed Field Gel Electrophoresis
Methadone

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Group A streptococcal infections in injection drug users in Barcelona, Spain : Epidemiologic, clinical, and microbiologic analysis of 3 clusters of cases from 2000 to 2003. / Sierra, Josep M.; Sánchez, Francesca; Castro, Pedro; Salvadó, Margarita; De La Red, Gloria; Libois, Agnes; Almela, Manuel; March, Francesca; Español, Montserrat; Sambeat, Maria Antonia; Romeu, Joan; Brugal, Maria Teresa; De Olalla, Patricia García; Gatell, Jose Maria; Vila, Jordi; García, Felipe; Colomés, Jose Luís López; Caylà, Joan A.; Coll, Pere.

In: Medicine, Vol. 85, No. 3, 05.2006, p. 139-146.

Research output: Contribution to journalArticle

Sierra, JM, Sánchez, F, Castro, P, Salvadó, M, De La Red, G, Libois, A, Almela, M, March, F, Español, M, Sambeat, MA, Romeu, J, Brugal, MT, De Olalla, PG, Gatell, JM, Vila, J, García, F, Colomés, JLL, Caylà, JA & Coll, P 2006, 'Group A streptococcal infections in injection drug users in Barcelona, Spain: Epidemiologic, clinical, and microbiologic analysis of 3 clusters of cases from 2000 to 2003', Medicine, vol. 85, no. 3, pp. 139-146. https://doi.org/10.1097/01.md.0000224707.24392.52
Sierra, Josep M. ; Sánchez, Francesca ; Castro, Pedro ; Salvadó, Margarita ; De La Red, Gloria ; Libois, Agnes ; Almela, Manuel ; March, Francesca ; Español, Montserrat ; Sambeat, Maria Antonia ; Romeu, Joan ; Brugal, Maria Teresa ; De Olalla, Patricia García ; Gatell, Jose Maria ; Vila, Jordi ; García, Felipe ; Colomés, Jose Luís López ; Caylà, Joan A. ; Coll, Pere. / Group A streptococcal infections in injection drug users in Barcelona, Spain : Epidemiologic, clinical, and microbiologic analysis of 3 clusters of cases from 2000 to 2003. In: Medicine. 2006 ; Vol. 85, No. 3. pp. 139-146.
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abstract = "An unexplained resurgence of Group A streptococci (GAS) infections has been observed since the mid-1980s in the United States and Europe, particularly among intravenous drug users (IDUs). Several risk factors have been identified. Mutations in the capsule synthesis regulator genes (csrRS) have been associated with an increase in virulence. From January 1998 to December 2003, we conducted a prospective and retrospective descriptive analysis of invasive GAS soft-tissue infections in IDUs in Barcelona, Spain. Clinical features were collected, and we conducted a surveillance study to identify risk factors associated with GAS soft-tissue infections. We analyzed chromosomal DNA by low cleavage restriction enzymes and used pulsed-field gel electrophoresis (PFGE) and variable gene sequence typing (VGST) of the emm gene to disclose the epidemiologic relationship between the strains. We analyzed the influence of clonality (M-type) and mutations in csrRS genes of these strains on clinical features. We identified 44 cases, all of which were grouped in 3 clusters: fall 2000, fall 2002, and fall 2003. Cellulitis with or without abscesses (75{\%}) and fever (90.9{\%}) were the most common clinical manifestations. Distant septic complications were infrequent (18.2{\%}). Although all patients had severe infections (mainly bacteremic needle abscesses), their outcome with antibiotic therapy, usually β-lactam, was successful in all cases. However, surgery was needed in 40.9{\%} of patients.Through the surveillance study we found that infected patients had a higher number of drug injections per day (odds ratio [OR], 18.84; 95{\%} confidence interval [CI], 4.83-79.4; p <0.00001), shared paraphernalia for drug use more frequently (OR, 11.11; 95{\%} CI, 3.24-39.04; p <0.0001), were in a higher proportion both currently unemployed and homeless (OR, 4.22; 95{\%} CI, 1.5-12.15; p <0.0001), were not in a methadone maintenance program (OR, 0.03; 95{\%} CI, 0-0.19; p <0.00001), and more often bought drugs at a specific site (OR, 33.92; 95{\%} CI, 7.44-174.93; p <0.00001) and from a specific dealer (OR, 72; 95{\%} CI, 8-3090; p <0.00001), compared with patients not infected. The fall 2000 cluster was polyclonal, whereas the other 2 clusters were mainly due to the same strain of GAS (emm 25.2), and were defined as epidemic outbreaks. Clinically, the cases due to the clonal strain presented abscesses and needed surgery more frequently (p <0.001 and p ≤ 0.005, respectively). On the other hand, mutations in the csrRS genes were not associated with invasive GAS soft-tissue infection. There has been an increase in the number of cases of invasive GAS soft-tissue infections in IDUs in Barcelona, which seems to be related to drug users' habits and their socioeconomic status. Clonality (emm 25.2) but not mutations in the csrRS genes was associated with more severe GAS soft-tissue infections.",
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T1 - Group A streptococcal infections in injection drug users in Barcelona, Spain

T2 - Epidemiologic, clinical, and microbiologic analysis of 3 clusters of cases from 2000 to 2003

AU - Sierra, Josep M.

AU - Sánchez, Francesca

AU - Castro, Pedro

AU - Salvadó, Margarita

AU - De La Red, Gloria

AU - Libois, Agnes

AU - Almela, Manuel

AU - March, Francesca

AU - Español, Montserrat

AU - Sambeat, Maria Antonia

AU - Romeu, Joan

AU - Brugal, Maria Teresa

AU - De Olalla, Patricia García

AU - Gatell, Jose Maria

AU - Vila, Jordi

AU - García, Felipe

AU - Colomés, Jose Luís López

AU - Caylà, Joan A.

AU - Coll, Pere

PY - 2006/5

Y1 - 2006/5

N2 - An unexplained resurgence of Group A streptococci (GAS) infections has been observed since the mid-1980s in the United States and Europe, particularly among intravenous drug users (IDUs). Several risk factors have been identified. Mutations in the capsule synthesis regulator genes (csrRS) have been associated with an increase in virulence. From January 1998 to December 2003, we conducted a prospective and retrospective descriptive analysis of invasive GAS soft-tissue infections in IDUs in Barcelona, Spain. Clinical features were collected, and we conducted a surveillance study to identify risk factors associated with GAS soft-tissue infections. We analyzed chromosomal DNA by low cleavage restriction enzymes and used pulsed-field gel electrophoresis (PFGE) and variable gene sequence typing (VGST) of the emm gene to disclose the epidemiologic relationship between the strains. We analyzed the influence of clonality (M-type) and mutations in csrRS genes of these strains on clinical features. We identified 44 cases, all of which were grouped in 3 clusters: fall 2000, fall 2002, and fall 2003. Cellulitis with or without abscesses (75%) and fever (90.9%) were the most common clinical manifestations. Distant septic complications were infrequent (18.2%). Although all patients had severe infections (mainly bacteremic needle abscesses), their outcome with antibiotic therapy, usually β-lactam, was successful in all cases. However, surgery was needed in 40.9% of patients.Through the surveillance study we found that infected patients had a higher number of drug injections per day (odds ratio [OR], 18.84; 95% confidence interval [CI], 4.83-79.4; p <0.00001), shared paraphernalia for drug use more frequently (OR, 11.11; 95% CI, 3.24-39.04; p <0.0001), were in a higher proportion both currently unemployed and homeless (OR, 4.22; 95% CI, 1.5-12.15; p <0.0001), were not in a methadone maintenance program (OR, 0.03; 95% CI, 0-0.19; p <0.00001), and more often bought drugs at a specific site (OR, 33.92; 95% CI, 7.44-174.93; p <0.00001) and from a specific dealer (OR, 72; 95% CI, 8-3090; p <0.00001), compared with patients not infected. The fall 2000 cluster was polyclonal, whereas the other 2 clusters were mainly due to the same strain of GAS (emm 25.2), and were defined as epidemic outbreaks. Clinically, the cases due to the clonal strain presented abscesses and needed surgery more frequently (p <0.001 and p ≤ 0.005, respectively). On the other hand, mutations in the csrRS genes were not associated with invasive GAS soft-tissue infection. There has been an increase in the number of cases of invasive GAS soft-tissue infections in IDUs in Barcelona, which seems to be related to drug users' habits and their socioeconomic status. Clonality (emm 25.2) but not mutations in the csrRS genes was associated with more severe GAS soft-tissue infections.

AB - An unexplained resurgence of Group A streptococci (GAS) infections has been observed since the mid-1980s in the United States and Europe, particularly among intravenous drug users (IDUs). Several risk factors have been identified. Mutations in the capsule synthesis regulator genes (csrRS) have been associated with an increase in virulence. From January 1998 to December 2003, we conducted a prospective and retrospective descriptive analysis of invasive GAS soft-tissue infections in IDUs in Barcelona, Spain. Clinical features were collected, and we conducted a surveillance study to identify risk factors associated with GAS soft-tissue infections. We analyzed chromosomal DNA by low cleavage restriction enzymes and used pulsed-field gel electrophoresis (PFGE) and variable gene sequence typing (VGST) of the emm gene to disclose the epidemiologic relationship between the strains. We analyzed the influence of clonality (M-type) and mutations in csrRS genes of these strains on clinical features. We identified 44 cases, all of which were grouped in 3 clusters: fall 2000, fall 2002, and fall 2003. Cellulitis with or without abscesses (75%) and fever (90.9%) were the most common clinical manifestations. Distant septic complications were infrequent (18.2%). Although all patients had severe infections (mainly bacteremic needle abscesses), their outcome with antibiotic therapy, usually β-lactam, was successful in all cases. However, surgery was needed in 40.9% of patients.Through the surveillance study we found that infected patients had a higher number of drug injections per day (odds ratio [OR], 18.84; 95% confidence interval [CI], 4.83-79.4; p <0.00001), shared paraphernalia for drug use more frequently (OR, 11.11; 95% CI, 3.24-39.04; p <0.0001), were in a higher proportion both currently unemployed and homeless (OR, 4.22; 95% CI, 1.5-12.15; p <0.0001), were not in a methadone maintenance program (OR, 0.03; 95% CI, 0-0.19; p <0.00001), and more often bought drugs at a specific site (OR, 33.92; 95% CI, 7.44-174.93; p <0.00001) and from a specific dealer (OR, 72; 95% CI, 8-3090; p <0.00001), compared with patients not infected. The fall 2000 cluster was polyclonal, whereas the other 2 clusters were mainly due to the same strain of GAS (emm 25.2), and were defined as epidemic outbreaks. Clinically, the cases due to the clonal strain presented abscesses and needed surgery more frequently (p <0.001 and p ≤ 0.005, respectively). On the other hand, mutations in the csrRS genes were not associated with invasive GAS soft-tissue infection. There has been an increase in the number of cases of invasive GAS soft-tissue infections in IDUs in Barcelona, which seems to be related to drug users' habits and their socioeconomic status. Clonality (emm 25.2) but not mutations in the csrRS genes was associated with more severe GAS soft-tissue infections.

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