1. Case Definitions: Reportable Streptococci (DRSP, GBS, GAS)
Maria del Rosario, MD, MPH
WVDHHR/BPH/IDEP
IDEP Training - February 2008

2. Objectives
To distinguish S. pneumoniae, Group A streptococci (GAS) and Group B streptococci (GBS) from each other and the disease they cause.
To describe how to ascertain reportable diseases due to S. pneumoniae, GAS, and GBS.
To illustrate how to complete missing information necessary to ascertain a case.

3. Definition of Terms (1) Sterile site Invasive Disease
Parts of the human body are colonized by various microorganisms. There are parts of the body that are normally sterile (no microorganisms). If there is a defect or a breach in the defenses, organisms can gain entry into these sites.
e.g. brain, spinal fluid, blood, tissues, organ systems
Invasive Disease
Disease signs and symptoms due to the presence of the organism in normally sterile site/s.
e.g. meningitis, septicemia (blood infection)

4. Definition of Terms (2) Antimicrobial susceptibility
Microorganisms are tested to identify the antimicrobial agents that they are susceptible to. This information is used to help appropriately treat the patient.
Susceptible: organism is vulnerable to the antimicrobial
Intermediate: organism is somewhat affected by the antimicrobial (i.e. at high doses, combo drugs)
Resistant (nonsusceptible): organism is unaffected by the antimicrobial
Isolate = organism

5. The Streptococci Gram-positive bacteria that grow in beadlike chains
Many types but only a few cause disease in man
3 types of ‘strep’ that are of interest:
Non -hemolytic streptococci
Streptococcus pneumoniae
-hemolytic streptococci
Group A streptococci
Group B streptococci

6. 3 Types of ‘Strep’ S. pneumoniae S. pyogenes S. agalactiae Other names
Pneumococcus, S. pneumo
Group A strep (GAS), Group A beta-hemolytic strep (GABHS)
Group B strep (GBS)
Clinical Spectrum
Mild – ear infections, URI
Carrier or colonized (throat), impetigo, ‘strep throat’
Carrier or colonized (gut)
Moderate – pneumonia
Rheumatic Fever, Kidney Disease
Severe – invasive disease
Severe – invasive disease, TSS
Severe – invasive disease, fetal demise
Public Health Implication
Increasing drug-resistance
Drug resistance (erythromycin)
Fetal demise, neonatal sepsis
Some serotypes are vaccine-preventable
Susceptible to penicillins
Prophylaxis available (pregnant women)

7. Streptococcal Diseases Reporting (1)
When and what to report:
Immediately for outbreaks
Report all cases
e.g. 2 or more cases occuring in a facility within a short period of time
Within 1 week of diagnosis for sporadic cases
i.e. Invasive disease (refer to slide 6 and 7 for details)
Who should report:
Providers, labs, health departments, etc.
WVEDSS Forms at IDEP website – use for disease reporting
For details see WV rule at

8. Streptococcal Diseases Reporting (2)
A. Streptococcus pneumoniae
Streptococcus pneumoniae, Drug-Resistant Invasive Disease (DRSP)
Invasive Disease Non-Drug Resistant, in Children Less Than 5 Years of Age (Invasive Pneumococcal Disease, IPD)
Invasive Disease Non-Drug Resistant, among those 5 years of age and older

9. Streptococcal Diseases Reporting (3)
B. Streptococcus pyogenes
Invasive Group A Streptococcal (GAS) Disease
Streptococcal Toxic Shock Syndrome (STSS)
C. Streptococcus agalactiae
Invasive Group B Streptococcal (GBS) Disease
Organism isolated from placenta and/or amniotic fluid with fetal demise

10. Streptococcus pneumoniae (1)
Drug-resistant S. pneumoniae (DRSP)
Report in WVEDSS as Drug Resistant Streptococcus pneumoniae
Case Definition:
Clinical description: Invasive disease (meningitis, bacteremia, etc.) at any age +
Lab criteria 1: Isolation of S. pneumo from a normally sterile site (blood, CSF, joint, pleural fluid, etc.) +
Lab criteria 2: "Nonsusceptible" isolate
(i.e., intermediate- or high-level resistance of S. pneumoniae isolate to at least 1 antimicrobial agent currently approved for use in treating pneumococcal infection*)
Lab criteria 2a: determined by oxacillin screening
Lab criteria 2b: determined by quantitative MIC method
*NCCLS recommends that all invasive S. pneumoniae isolates found to be “possibly resistant” to beta-lactams (i.e., an oxacillin zone size of less than 20 mm) by oxacillin screening should undergo further susceptibility testing by using a quantitative MIC method acceptable for penicillin, extended-spectrum cephalosporins, and other drugs as clinically indicated.

11. Streptococcus pneumoniae (2)
Drug-resistant S. pneumoniae (DRSP)
Case classification:
Probable: a clinically compatible case caused by laboratory-confirmed culture of S. pneumoniae identified as "nonsusceptible" (i.e., an oxacillin zone size of less than 20 mm) when oxacillin screening is the only method of antimicrobial susceptibility testing performed (lab criteria 1 and 2a only)
Confirmed: a clinically compatible case that is laboratory confirmed (lab criteria 1, 2a, 2b)

12. Streptococcus pneumoniae (3)
Invasive Pneumococcal Disease (IPD), non-drug resistant among < 5 years old
Case definition:
Clinical description: Invasive disease (meningitis, bacteremia, etc.) in children < 5 years of age +
Lab criteria 1: Isolation of S. pneumo from a normally sterile site (blood, CSF, joint, pleural fluid, etc.) +
Lab criteria 2: S. pneumo is drug-susceptible or susceptibility not available
Report in WVEDSS as
Streptococcus pneumoniae in children less than age 5.

13. Streptococcus pneumoniae (4)
Invasive Pneumococcal Disease (IPD) non-drug resistant among < 5 years old
Case classification
Confirmed: a clinically compatible case in a child less than five years of age caused by laboratory-confirmed culture (lab criteria 2) of S. pneumoniae from a normally sterile site (lab criteria 1)

14. Streptococcus pneumoniae (5) Streptococcus pneumoniae, all other
Invasive Pneumococcal Disease (IPD) non-drug resistant among > 5 years old
Case definition:
Clinical description: Invasive disease (meningitis, bacteremia, etc.) in children > 5 years of age +
Lab criteria 1: Isolation of S. pneumo from a normally sterile site (blood, CSF, joint, pleural fluid, etc.) +
Lab criteria 2: S. pneumo is drug-susceptible or susceptibility not available
Report in WVEDSS as
Streptococcus pneumoniae, all other

15. Example 1: S. pneumoniae report
Background:
On 01/16/08, VAMC ICP calls to let you know that she’s faxing you a lab report on Mr. Seek. Mr. Seek is diagnosed with pneumonia, currently on respiratory support and is on multiple antibiotics; may have sepsis. The specimen was from a sputum sample.
Beckley VAMC Laboratory
Microbiology
Name: Seek, Barry Age: 85 years old
Collection Date: Jan. 1, Completed: Jan. 14, 2008
Provider: Dr. Will Treat
Collection sample: sputum
Result:
- Growth of Streptococcus, possible Strep. pneumoniae
What next ?

16. Example 1: S. pneumoniae report
Clinical description:
Invasive disease? Pneumonia, sepsis
Lab Result:
Organism: S. pneumo
Type of test: Culture
Source of specimen: sputum 
What next
Review the protocol. Investigate ?
Pending additional information (labs)? NO  STOP, not reportable
 YES
Blood culture: S. pneumo (collected 1/8/2008, completed 01/17/08)
What next:
Investigate - Clinical information, etc.
Additional info:
Susceptibility available? NO  Strep pneumo, All Other (IPD>5 years)
Next slide

17. Example 1: S. pneumoniae report

18. Example 1: S. pneumoniae report

19. Example 1: S. pneumoniae report

20. Example 1: S. pneumoniae report
Lab Result:
Bacterial sensitivities: Streptococcus pneumoniae (blood)
Type of Test: Oxacillin disk diffusion
Result: Oxacillin zone size 15 mm (reference: > 20 mm) 
What next:
Investigate ?
Pending additional information (labs)? NO  DRSP, probable
 YES
Lab Result
Bacterial sensitivities: Streptococcus pneumoniae
Type of Test: E-test
Result:
Levofloxacin 0.75 susceptible
Penicillin 0.1 intermediate  DRSP, confirmed
Vancomycin 0.38 susceptible
What next:
Complete investigation
Send isolate to OLS for further testing (serotyping)

21. Example 1: S. pneumoniae report

22. Example 1: S. pneumoniae report
Complete the Investigation
Review and edit WVEDSS form as needed

23. Streptococcus pyogenes (1)
Invasive Group A Streptococcal (GAS) disease
Case definition:
Report in WVEDSS as
Streptococcal Disease, Group A Invasive
Invasive disease (e.g. pneumonia, bacteremia/sepsis, myositis or necrotizing fasciitis, meningitis, peritonitis, osteomyelitis, septic arthritis) +
Isolation of group A Streptococcus by culture from a normally sterile site (e.g. blood or cerebrospinal fluid, joint, pleural, or pericardial fluid)
Case Classification
Confirmed - a case that is laboratory confirmed

24. Streptococcus pyogenes (2)
Streptococcal Toxic Shock Syndrome (STSS)
Case definition*:
Clinical manifestations occurring within the first 48 hours of illness or hospitalization
Hypotension, AND
Multi-organ involvement characterized by 2 or more of the following:
Renal impairment
Coagulopathy
Liver involvement
Acute respiratory distress syndrome
A generalized erythematous macular rash that may desquamate
Soft-tissue necrosis (necrotizing fasciitis, myositis, gangrene)
Isolation of group A Streptococcus (S. pyogenes) by culture from a normally sterile site (blood, CSF, joint, pleural, or pericardial fluid).
Report in WVEDSS as Streptococcal Toxic Shock Syndrome.
______________
*See details at
Case Classification
Confirmed - a case that is laboratory confirmed

25. Example 2: Group A strep report
Background:
Provider calls about a child with chickenpox for 5 days. Has had sore throat for a few days; still has fever. Generalized numerous pox lesions. Now right leg is red, tender and swollen, with one draining pox lesions. Provider faxes the lab to you. Child has been on Erythromycin X 1 day.
CAMC Laboratory
Microbiology
Name: Bubu, Mai Age: 6 years old
Collection Date: Jan. 2, Completed: Jan. 8, 2008
Provider: Dr. Babe E. Dock
Collection sample: throat swab
Culture Result:
- Heavy growth of Streptococcus pyogenes
What’s next ?

26. Example 2: Group A strep report
Clinical description:
Invasive disease?
Lab Result:
Organism: S. pyogenes
Type of test: Culture
Source of specimen: throat swab 
What’s next?
Review protocol. Investigate ?
Pending additional information (labs)? NO  STOP, not reportable
 YES
Lab Result?
Blood culture: Streptococcus pyogenes
Streptococcal Disease, Invasive Group A
What next?
Complete investigation
Susceptibility testing

27. Example 2: Group A strep report

28. Example 2: Group A strep report

29. Example 2: Group A strep report

30. Example 2: Group A strep report

31. Example 2: Group A strep report
Complete the investigation.
Review the form and make changes accordingly.

32. Streptococcus agalactiae (1)
Invasive Group B Streptococcal (GBS) disease
Manifest as invasive disease (sepsis, pneumonia, meningitis, osteomyelitis, septic arthritis, amnionitis, urinary tract infection) and stillbirth
Isolation of group B Streptococcus from a non-sterile site such as placenta and/or amniotic fluid with fetal demise +
Isolation of group B Streptococcus by culture from a normally sterile site (blood or CSF, joint, pleural, or pericardial fluid, surgical aspirate, bone, joint fluid, or internal body site )
Report in WVEDSS as
Streptococcal Disease, Group B Invasive
Case Classification
Confirmed - a case that is laboratory confirmed

33. Example 3: Group B strep report
Background:
Laboratory report mailed to your health department
LabCorp
Dublin, OH
Name: Brown, Ann Age: 28 years old
Collection Date: Dec. 21, Completed: Dec. 2 8, 2008
Provider: Dr. Smith
Collection sample: placenta
Culture Result:
- Streptococcus agalactiae
What’s next ?

34. Example 3: Group B strep report
Lab Result:
Organism: S. agalactiae
Type of test: Culture
Source of specimen: placenta 
What’s next?
Review protocol. Investigate ?
What additional information do you need to ascertain a case?
Clinical description fulfilled? NO  STOP, not reportable
 YES
Streptococcal Disease, Invasive Group B
What next?
Complete investigation
Susceptibility testing

35. Example 3: Group B strep report

36. Example 3: Group B strep report

37. References