1. K. Loens AZ KLINA 12/03/2015 NRC invasive β hemolytic streptococci not belonging to Group B: epidemiology 2009- 2014

2. Role: NRC β-hemolytic streptococci not belonging to Group B Confirmation of identification S. pyogenes Since August 2014 also S. dysgalactiae and zoonotic Streptococci (eg. S. equi) Antibiotic susceptibility testing: MIC, Triple disc Erythromycine and tetracycline resistance genes Monitoring of circulating strains by typing Emm-typing Detection of virulence genes (SpeA, ssA and SpeC) Investigation of outbreaks PFGE Participation in international surveillance-activities Biobank

3. Yearnr of invasive strains received/total nr of strains received Nr of invasive strains received from labs submitting on a regular basis 2009219/467192 2010220/593195 2011213/1597197 2012229/307216 2013221/250215 2014252/308247 Invasive streptococcal strains received at the NRC (2009-2014)

4. Isolation site of invasive β-hemolytic streptococci not belonging to Group B Isolation site% blood74.0 Sterile wounds6.2 tissue4.2 Pleural fluid2.1 Other sterile sites (CSF, peritoneal fluid, synovial fluid, sterile not specified) 13.5

5. Antibiotic resistance in β-hemolytic streptococci not belonging to Group B (2009-2014) YearPenicillins (%) Erythromycin R/I (%) Clindamycin resistance / inducible resistance (%) Tetracycline R/I (%) 2009 a 03.2/00/1.67.1/0 2010 b 02.1/01.4/0.77.0/5.6 2011 c 03.4/0.90.9/0.98.6/6.9 201201.7/5.71.3/6.16.5/4.2 2013*04.83.2/1.814.5 2014*05.31.6/3.416.7 a available for 187/192 strains b available for 143/195 strains c available for 116/197 strains * Norm EU-CAST

6. Emm-types invasive S. dysgalactiae (2009-2014) YearEmm-types 2009*/ 2010*stG643 2011*stG652 (2x), stC74, stG643, stG62647 2012*stC2sk 2013*/ 2014stC74, stG485, stG62647, stG643 *emm-typing only done for GAS associated with invasive infections common emm-types Kittang et al. 2011. Eur. J. Clin. Microbiol. Infect. Dis. Loubinoux et al. 2013. J. Clin. Microbiol. Oppegaard et al. 2014. Eur. J. Clin. Microbiol. Infect. Dis.

7. Top 4 emm-types invasive GAS strains (2009-2014) YearMost frequent (%) 2nd (%)3rd (%)4th (%) 2009emm1 (21.9)emm89 (13.5)emm3 (13.0)emm12 (7.8) 2010emm1 (16.4)emm28 (12.3)emm6 (9.2)emm3 (8.7) 2011emm1 (23.4)emm3 (12.5)emm28 (9.9)emm6 (7.8) 2012emm1 (20.9)emm3 (12.6)emm75 (10.2)emm89 (7.0) 2013emm1 (30.2)emm3 (13.5)emm89 (8.8)emm28 (6.5) 2014emm1 (19.5)emm89 (13.3)emm6 (6.6) emm75 (6.6) emm3 (6.2)

8. Invasive GAS in children <4 years 200920102011201220132014 Children (%)58/467 (12.4) 98/593 (16.5) 27/213 (12.6) 24/229 (10.5) 42/216 (19.4) 28/241 (11.6) Invasive strains (%) 28/58 (48.2) 27/98 (27.6) 27/27 (100) 24/24 (100) 37/42 (88.1) 25/28 (89.2) Emm-type most frequently detected (%) 9/28 (32.1) emm12 7/27 (25.9) emm1 6/27 (22.2) emm12 1/24 (4.2) emm1 19/37 (51.3) emm1 8/25 (32.0) emm1 Emm-type 2nd most frequently detected (%) 5/28 (17.9) emm1 5/27 (18.5) emm6, emm12 5/27 (18.5) emm1, emm4 5/24 (20.8) emm75 3/37 (8.1) emm3, emm12, emm89 5/25 (20.0%) emm4

9. Virulence genes emm 1, 2013 nr formulierregistratieSpeASpeBSpeCSpeFSsa 2013010520-mrt-13++0+0 2013010721-mrt-13++0+0 2013011127-mrt-13++0+0 2013011327-mrt-13++0+0 2013011428-mrt-13++0+0 2013011628-mrt-13++0+0 2013012103-apr-13++0+0 2013012204-apr-13++0+0 2013012805-apr-13++0+0 2013012905-apr-13++0+0 2013013305-apr-13++0+0 2013013409-apr-13++0+0 2013013509-apr-13++0+0 2013013811-apr-13++0+0 2013013911-apr-13++0+0 2013014216-apr-13++0+0 2013014317-apr-13++0+0 2013014417-apr-13++0+0 2013014518-apr-13++0+0 2013015326-apr-13++++0 2013015607-mei-13++0+0 2013015707-mei-13++0+0 2013016008-mei-13++0+0 2013017022-mei-13 + + 0 +0 2013017123-mei-13++0+0 2013017523-mei-13++0+0

10. PFGE emm1 2013 strains, same virulence genes PFGE type 3 already circulating in Belgium in 1993 (Descheemaeker et al. 2000. J. Med. Microbiol.

11. most similar to M1 476, a Japanese sepsis isolate remarkable genomic stability over the last 20 years with minor genomic changes driven by prophages. Whole genome maps of emm1 invasive strains (1994-2013): Longitudinal collection Coppens et al. 2014. ICAAC. #B-2001

12. Fatal outcomes due to β-hemolytic streptococci not belonging to group B YearNumber (%)Emm-types involved 200915 (7.8)emm1 (n=6), emm3 (n=4), emm28 (n=2), emm4, emm5, emm77 (n=1) 201011 (5.6)emm3 (n=3), emm12 (n=3), emm87 (n=2), emm1, emm6, emm28 (n=1) 201118 (9.1)emm3 (n=5), emm89 (n=4), emm1 (n=3), emm6 (n=2), emm9 (n=1), emm12 (n=1), emm108, emm230 (n=1) 201216 (7.4)emm1 (n=8), emm3 (n=2), emm11, emm12, emm29, emm77, emm81, emm87 (n=1) 201316 (7.4)emm1 (n=6), emm3 (n=3), emm4, emm5, emm12, emm75, emm87, emm169, emm219 (n=1) 201414 (5.7)emm1 (n=6), emm6 (n=2), emm3, emm22, emm29, emm44, emm77, emm89 (n=1)

13. Remarks, conclusions and future analyses (1) So far no legal obligation for laboratories to submit invasive strains. Increasing number of GAS strains submitted to the NRC Registration forms not always completed. Helpfull if clinical data would be completed as well. Fatal outcomes based on info on registration forms <10% Emm1 clone was re-emerging in Belgium in 2013: Highly prevalent in children with invasive GAS (±50%) Limited number of S. dysgalactiae strains received so far Future analyses: GAS: Detection of larger number of virulence genes S. dysgalactiae: analysis of virulence genes

14. Remarks, conclusions and future analyses (2) For optimal surveillance the NRC needs YOU!