brane teichoic acids are believed to be present in many

Transcription

1 JOURNL OF CLINICL MICROBIOLOGY, June 1989, p /89/ $2./ Copyright 1989, mericn Society for Microbiology Vol. 27, No. 6 ntibodies to Stphylococcl Peptidoglycn nd Its Peptide Epitopes, Teichoic cid, nd Lipoteichoic cid in Ser from Blood Donors nd Ptients with Stphylococcl Infections HEIDRUN I. WERGELND,'* LRS R. HHEIM,' OLV B. NTS,2t FINN WESENBERG,3 ND PER OEDING' Deprtment of Microbiology nd Immunology, The Gde Institute,1 nd Deprtment of Medicine2 nd Deprtment of Peditrics,3 University of Bergen, N-521 Bergen, Norwy Received 5 December 1988/ccepted 6 Mrch 1989 ntibodies to the stphylococcl ntigens peptidoglycn, P-ribitol teichoic cid, nd lipoteichoic cid, s well s to the peptidoglycn epitopes L-Lys-D-l-D-l, L-Lys-D-l, nd pentglycine, were found over wide rnge of concentrtions in ser from both blood donors nd ptients with verified or suspected stphylococcl infections. The ptient group ws heterogeneous with regrd to both ge nd type of stphylococcl infections, being representtive for ser sent to our lbortory. In single-ntigen ssys ntibodies to pentglycine hd the highest predictive positive vlue (67%), lthough only 32% of the ptients hd elevted levels of such ntibodies. Combintions of test ntigens could yield positive predictive vlues s high s 1%, but then the frction of positive ser ws low. Indeed, the frction of ptient ser which ws positive in multiple-ntigen tests never exceeded 61%. The clinicl usefulness of these serossys for identifying Stphylococcus ureus s custive gent ws limited, owing to the considerble overlp in the rnge of ntibody concentrtions between ptient nd blood donor ser. Serodignosis of serious Stphylococcus ureus infections hs been reported to be successful for selected groups of ptients (7). vriety of stphylococcl ntigens, including whole stphylococci (15), crude cell wll mteril (5), peptidoglycn (PG) (4, 27, 32), teichoic cid (27, 28, 33), lipoteichoic cid (LT) (32), t-toxin (7, 27, 28),"-toxin (7), nuclese (27), nd lipse (6), hve been used. In ddition, synthetic peptide corresponding to the PG epitope L-Lys- D-l-D-l hs been used (1, 35). In this study we used the cell wll ntigens PG,"-ribitol teichoic cid (P-RT), nd LT. The chemicl structure nd immunologicl properties of these ntigens re well documented (8, 17, 18, 23, 25); neither is exclusive for stphylococci. Bcteril PG, present in most bcteri, is composed of sugr chins with tri-, tetr-, or pentpeptides covlently linked to the sugr chins. These sugr-peptide chins re interlinked by short peptide bridges or directly through dimino cid. The interpeptide bridge in S. ureus PG consists of five glycine residues nd is considered to be specific for stphylococcl PG. Both the NH2 nd COOH termini of the peptide bridge cn bind ntibodies (13, 22, 24, 26) Ḃcteril wll teichoic cids re polymers possessing phosphodiester polyols with or without sugr residues, occsionlly lso with D-lnine ester residues. The teichoic cid from S. ureus contins ribitol with N-cetylglucosminyl residues (3). Membrne LTs consist of glycerol teichoic cid linked t one end to glycolipid. Stphylococcl LT, like most others, is vriously substituted with D-lnine ester residues nd mono- or oligoscchrides (9). The cell wll nd mem- * Corresponding uthor. t Present ddress: Roglnd Sentrlsykehus, N-4 Stvnger, Norwy brne teichoic cids re believed to be present in mny grm-positive bcteri (3). In this study we nlyzed ser from blood donors nd from heterogeneous group of ptients with verified or suspected stphylococcl infections for ntibodies to purified nd chemiclly chrcterized PG, f-rt, nd LT nd to the synthetic PG epitopes L-Lys-D-l-D-l, L-Lys-D-l, nd pentglycine (Gly.). MTERILS ND METHODS ntigens. PG nd LT were purified from S. ureus Cown 1 NCTC 853 s described by Prk nd Hncock (21) nd sjord et l. (2), respectively. P-RT ws isolted from S. ureus Wood 46 NCTC 1344 s described by Oslnd et l. (2). The chemicl compositions of PG, LT, nd P-RT were s described by Wergelnd nd Endresen (31), sjord nd Grov (1), nd Hukenes (12), respectively. The synthetic peptides Gly5 (Sigm Chemicl Co.) nd dicetyl-l-lys-d-l-d-l nd dicetyl-l-lys-d-l (Bioproducts) were covlently coupled to humn lbumin (Sigm) by N-succinimidyl 3-(2-pyridyldithio)propionte (Phrmci, Uppsl, Sweden) in ccordnce with mnufcturer instructions. Free thiol groups from the reduction of the 2-pyridyl disulfide groups introduced on lbumin were determined prior to nd fter peptide couplings with 14Ciodocetmide (New Englnd Nucler Corp., Boston, Mss.). The reduced number of free thiol groups per mole of lbumin thus corresponded to moles of peptides introduced. Between 7 nd 8 mol of peptide were coupled to ech mole of lbumin, for coupling efficiency of more thn 97%. Ser. ll serum smples were obtined from Hukelnd Hospitl, Bergen, Norwy, nd immeditely stored in liquots t -8 C. Ptients were defined s hving verified stphylococcl infection if the clinicl lbortory found significntly rised ntistphylolysin titers or if stphylococci could be isolted from clinicl specimens. Two or more serum smples from ptients with verified (n = 42) or

2 VOL. 27, 1989 suspected (n = 11) stphylococcl infections nd from ptients with other bcteril infections (n = 9) were collected. totl of 36 of the ptients were between 14 nd 78 yers old (dult group), nd 26 were under 14 yers old (child group). The dult ptients with verified stphylococcl infections (n = 31) hd osteomyelitis (n = 16), septicemi (n = 3), rthritis (n = 4), endocrditis (n = 2), nd tissue infections (n = 6). Three of the ptients hd suspected stphylococcl infections like osteomyelitis (n = 2) nd rthritis (n = 1). One ptient hd endocrditis cused by grm-negtive bcteri, nd nother hd streptococcl bursitis. The children with verified stphylococcl infections (n = 11) hd osteomyelitis (n = 7), rthritis (n = 1), nd tissue infections (n = 3). Three of the eight children with suspected stphylococcl infections hd osteomyelitis. Two hd infections cused by meningococci, one hd n infection cused by streptococci, nd four hd infections cused by grm-negtive rods. Serum smples were lso collected from 66 blood donors. liquots of serum smples from 25 rndom donors were pooled nd used s control serum. ntibody ssy. n enzyme-linked immunosorbent ssy (ELIS) ws done by stndrd procedures s described erlier (31) with polystyrene enzyme immunossy pltes (96 wells; Costr, Cmbridge, Mss.). Coting ws performed with sonicted PG (15 min t 2 KHz) diluted in.1 M phosphte-buffered sline (ph 7.2) to concentrtion of 5,ug/ml. The coting concentrtions of LT nd,-rt were 5 nd 25,ug/ml of phosphte-buffered sline, respectively. The optiml coting concentrtions of lbumin-l-lys-d- l-d-l, lbumin-l-lys-d-l, nd lbumin-gly5 were ll found to be 15,ug/ml of phosphte-buffered sline. ELIS redings of opticl densities (ODs) t 492 nm will be referred to s ntibody vlues. The dy-to-dy vrition ws monitored by using the pooled control serum t the sme working dilutions s the test ser. The nonspecific bckground vlues, obtined when phosphte-buffered sline contining.5% Tween 2 ws dded insted of serum smple, resulted in ODs of <.15 in ll ssys. Multiple serum smples from individul ptients were lwys nlyzed with ll ntigens in the sme experimentl set-up. Immunoglobulin concentrtions. Totl immunoglobulin G (IgG), Ig, nd IgM were routinely determined by the immunologicl lbortory for ll blood donor nd ptient ser with Nephelometer-nlyzer (Behring Institute). Norml rnges of immunoglobulin concentrtions in dult ser were, ccording to locl lbortory stndrd, 7 to 18,.5 to 3.3, nd.3 to 2.5 g/liter for IgG, Ig, nd IgM, respectively. locl lbortory stndrd ws lso used for ser from children t vrious ges. Sttistics. rithmetic mens were used throughout. The correltion coefficients (r) were clculted by the lestsqures liner correltion method. Differences between groups were evluted by two-tiled Student t test. Predictive vlues. Positive ntibody vlues were defined s being greter thn or equl to the men plus one stndrd devition (SD) of blood donor ntibody vlues. We defined positive predictive vlue (PV-P) s the percentge of ptients with verified stphylococcl infections who were seropositive mong ll seropositives nd negtive predictive vlue (PV-N) s the percentge of seronegtive noninfected individuls mong ll seronegtives. RESULTS The optiml working dilutions of ser which best seprted the ntibody vlues of blood donors nd ptients were NTIBODIES TO STPHYLOCOCCL NTIGENS 1287 TBLE 1. Rnges of ntibody vlues in ser from blood donors nd ptients with stphylococcl infections tested with vrious stphylococcl ntigens ELIS vlue for: ntigen Blood donors Ptients (working serum dilution) Coefficient Coefficient Men SD" of vri- Men SD of vrition (%) tion (%) LT (1:1,) P-RT (1:16,) PG (1:2,) L-Lys-D-l-D-l (1:25) L-Lys-D-l (1:25) Gly5 (1:25) " Men nd SD re given s ODs t 492 nm. found to be 1:2,, 1:16,, 1:1,, nd 1:25 for PG, 1-RT, LT, nd the lbumin-peptide conjugtes, respectively. ntibodies rective with the stphylococcl ntigens nd the PG epitopes. The ELIS vlues for the ntibodies in blood donor nd ptient ser rective with the vrious ntigens re presented in Tble 1. The results show wide rnges of ntibody vlues, with the highest coefficients of vrition occurring for ntibodies to,b-rt nd PG in both ptients nd blood donors (Tble 1). Figure 1 shows the results of tests of individul ptient ser with the vrious stphylococcl ntigens. Smples of ser from ptients with verified bcteril infections were tken t the time of lbortory dignosis. In the cse of ser from ptients with suspected, but lter not verified, bcteril infections, smples were collected t the time of tenttive clinicl dignosis. Ser from dult ptients (Fig. 1) were considered positive if the OD exceeded the men OD of the blood donor ser plus one SD. Less thn 5% of these smples were positive in ny of the tests, the frctions of positives being 42% (PG), 39% (L- Lys-D-l-D-l), 32% (L-Lys-D-l nd Gly5), 35% (LT), nd 29% (P-RT). Ser from dult ptients with verified nonstphylococcl infections were generlly negtive. The exceptions were one ptient with grm-negtive rod infection who ws positive for ntibodies to L-Lys-D-l nd one ptient with bet-hemolytic streptococcus infection who ws positive for ntibodies to Gly5. For ll ptients in this study t lest two serum smples were vilble. Generlly, no significnt difference in ntibody rectivity in seril smples could be detected. For exmple, 1 serum smples were collected from ech of two ptients with S. ureus osteomyelitis, the smpling periods being 2 yers nd 2 months, respectively. Neither of these seril smples showed ny significnt ntibody fluctutions. ll ser from children contined ntibodies rective with the cell wll ntigens nd the PG epitopes (Fig. 1B), but ntibody vlues were generlly lower thn in dults. Of the 26 children, 7 were 2 yers old or younger, nd ser from them contined low levels of IgG ginst the cell wll ntigens nd the Gly5 epitope but rther high levels of ntibodies to the L-Lys-D-l-D-l nd L-Lys-D-l epitopes. One 7-yer-old child with streptococcl osteomyelitis possessed high levels of ntibodies to PG nd the L-Lys-D-l-D-l nd L-Lys-D-l epitopes but low levels of ntibodies to the other ntigens. bout 5% (16 of 31) of the dult ptients hd stphylococcl osteomyelitis. Six (38%) were positive for ntibodies

3 1288 WERGELND ET L. J. CLIN. MICROBIOL. B 2. E ETJ E c: f.6. oe o * à *- t. t *. e *, ut à * e.: à. un / -T [ LT P [ vs LL" " J (Iy) FIG. 1. Levels of ntibodies to P-RT, LT, PG, nd the PG epitopes L-Lys-D-l-D-l, L-Lys-D-l, nd Gly5 mesured with n ELIS in ser from ptients with verified S. ureus infections (), suspected stphylococcl infections (), nd nonstphylococcl infections (M). The broken lines correspond to the cutoff vlues (men for blood donors plus one SD). () dult group. (B) Child group. to P-RT, four (25%) were positive for ntibodies to LT, L-Lys-D-l-D-l, nd L-Lys-D-l, nd three (19%) were positive for ntibodies to PG nd Gly5. Immunoglobulin concentrtions in serum. ll blood donors hd serum immunoglobulin concentrtions (IgG, Ig, nd IgM) within the norml rnge. One dult ptient with verified stphylococcl infection hd below-norml concentrtions of IgG nd Ig. On the other hnd, 26, 52, nd 32% hd elevted concentrtions of IgG, Ig, nd IgM, respectively. Two of the children (8%) hd low IgG concentrtions, but none hd low concentrtions of IgM or Ig. Of 17 children with verified or suspected stphylococcl infections, 35% (n = 6), 53% (n = 9), nd 53% (n = 9) hd elevted concentrtions of IgG, Ig, nd IgM, respectively. ll of the seven children less thn 2 yers old hd elevted concentrtions of IgM ntibodies, nd one of them lso hd elevted levels of IgG nd Ig ntibodies. Differences between ntibody levels. nlyses of differences between levels of ntibodies to the vrious ntigens in ser from dult ptients nd blood donors were done. Significnt differences were found for PG (P <.1), L-Lys-D-l (P <.1), L-Lys-D-l-D-l (P <.1), nd Gly5 (P <.5) but not for P-RT nd LT ntibody levels. Correltion coefficients. Positive correltions with r vlues rnging from.484 to.976, were found between ntibodies to the vrious ntigens in ser from dult ptients (Tble 2). Ser from blood donors showed significnt correltion (P.1) between ntibodies to PG nd LT nd lso between ntibodies to the three PG epitopes. Generlly, ll r vlues were higher in the ptient group, the exception being comprisons between peptide epitopes, for which r vlues pproched 1 in both groups. We nlyzed the correltion of totl serum IgG with levels of ntibodies to the vrious ntigens. These nlyses (r vlues not presented) showed tht only ntibodies to PG nd LT were significntly (P <.1) positively correlted with totl IgG in dult ptient ser, the r vlues being.486 nd.458, respectively. The low r vlues nd frctions of positives in ech test indicted tht combining two ntigens would increse the TBLE 2. Coefficients of correltion between ntibodies to vrious stphylococcl ntigens in ser from blood donors nd ptients with stphylococcl infections Correltion coefficient (r) for: ntibodies correlted (ntibodies to:) Blood dult donors ptients (n = 66) (n = 31) PG nd L-Lys-D-l.ll.516b PG nd L-Lys-D-l-D-l c PG nd Gly,.16,.51b PG nd,-rt c PG nd LT.48c.7c LT nd,-rt.425c.732c L-Lys-D-l nd Gly5.991c.976c L-Lys-D-l-D-l nd Gly5.966c.786c L-Lys-D-l-D-l nd L-Lys-D-l.945c.946c LT nd L-Lys-D-l.7.558c LT nd L-Lys-D-l-D-l O.O99.545b LT nd Gly b P-RT nd L-Lys-D-l.324b.587c P-RT nd L-Lys-D-l-D-l.232d.484b P-RT nd Gly5.238d.485b P>.5. *P <.1. P <.1. dp <.5. 1 te t:

4 VOL. 27, 1989 NTIBODIES TO STPHYLOCOCCL NTIGENS Y=. 33xt.52 r=.579 j=-2. B E C3 i.6 (\J oe D16 -i.2-4> O' r. L-J J. E 2. - O- o 1.6' 'O 1.2- G 1 L-J O.8 G J) --J.4 -JM > jb.< le 4> 4..C.8 y=.29xt.57 r=.48 ib e 4>4 e Pr nn 492nm c PG OD 492nm FIG. 2. Selected correltion plots of ntibodies to PG nd L- Lys-D-l-D-l (), PG nd P-RT (B), nd P-RT nd L- Lys-D-l-D-l (C) in serum from 31 dult ptients with verified S. ureus infections. The broken lines represent ELIS cutoff vlues (men for blood donors plus one SD). Clculted regression lines nd correltion coefficients (r) re lso shown. For working serum dilutions, see Tble 1. Predictive vlues. The clinicl usefulness of the ntigens * ^, lone or in combintions ws estimted by clculting PV-P nd PV-N. The results of selected tests re presented in...<r. Tble 3. When one ntigen, the stphylococcus-specific 4>fi * epitope Gly5, ws used, the highest PV-P (67%) nd PV-N :, t *. (74%) were obtined. In ll circumstnces, however, predict tive vlues were low for ll combintions of ntigens. The 4>4> 4> highest PV-P ws 58% nd the highest PV-N ws 77% when the criterion ws seropositive result in t lest one of two tests, nd the respective vlues were 44 nd 78% when the criterion ws seropositive result in t lest one of three tests. Some ptients were seropositive in t lest three tests..,,,, lthough 1% PV-P could be obtined for one of the selected ntigen combintions, the corresponding frction of J n-r -n z nn seropositive ptients ws low (19%). /J-K uu d-t bej nm frctions of positives. Three relevnt correltion plots of ntibody vlues re presented in Fig. 2. PG ws the best ntigen used lone or in combintion with its L-Lys-D- l-d-l epitope: the frction of positives incresed from 42 to 55%. Slightly lower percentges were found for,-rt or LT in combintion with PG. However, such ntigen combintions resulted in high percentges of positives for the blood donor control group s well. Of 31 dult ptients, 12 (8 with osteomyelitis, 3 with tissue infections, nd 1 with septicemi) hd levels of ntibodies to ll ntigens in the norml rnge. When three ntigens, e.g., PG, L-Lys-D- l-d-l, nd,b-rt, were combined, the mximum frction of positives (61%) ws obtined, but 37% of the blood donors were positive s well..j_ Li i... TBLE 3. Predictive vlues of ntibodies ginst selected combintions of ntigens Positive or % % negtive ntibodies to: Posi- Negscore in: tive tive One test Gly t lest one L-Lys-D-l-D-l nd/or L-Lys-D-l test PG nd/or 1-RT nd/or L-Lys-D-l D-l ll tests L-Lys-D-l-D-l nd L-Lys-D-l PG nd,b-rt nd L-Lys-D-l-D-l 1 72

5 129 WERGELND ET L. DISCUSSION The purpose of this study ws to investigte the prevlence of ntibodies to the well-chrcterized stphylococcl cell wll ntigens PG, P-RT, nd LT nd to the PG peptide epitopes in ser from blood donors nd ptients with stphylococcl infections. The ptient group ws heterogeneous with regrd to both ge nd type of stphylococcl infections. This heterogeneity illustrtes one of the problems in stphylococcl serology, s the ntibody response vries with both the ge nd the type of infection. nother problem hs been to identify test ntigens which re specific for stphylococci. In this respect it would be of prticulr interest to study the presence of ntibodies to the stphylococcus-specific epitope Glys locted in PG. The cell wll ntigens used in this study hve previously been chrcterized in our lbortory (1, 12, 31). The synthetic peptides corresponding to the PG epitopes hve ll previously been shown to bind nti-pg ntibodies (13, 31). Our findings of wide rnge of levels of normlly occurring ntibodies to PG, LT, nd,-rt in ll blood donor ser (Tble 1) re in greement with erlier findings (16, 29, 32). Others hve found tht such ser lso contin vrious mounts of ntibodies to the C-terminl L-Lys-D-l-D-l (1). This ws lso the cse in this study for both ptient nd blood donor ser with regrd to ntibodies to ll three PG epitopes. The levels of ntibodies to the stphylococcusspecific epitope Gly5 were lower thn those of ntibodies to both L-Lys-D-l-D-l nd L-Lys-D-l (Fig. 1), confirming our previous findings (31). By our criteri less thn 5% of 31 dult ptients were seropositive for ny of the test ntigens, probbly becuse of the low number of septicemi (n = 3) nd endocrditis (n = 2) cses in our study group. In such cses of stphylococcl infections the highest levels of ntibodies hve been found for PG (4), P-RT (33), nd LT (32). The cutoff level between positive nd negtive ntibody vlues in child ser could not be determined, owing to difficulty in obtining ge-mtched controls. Erlier studies, however, showed tht norml levels of ntibodies to both PG (29) nd P-RT (16) re lowest for children under 5 yers old nd rech mximum t bout 2 yers of ge. In this study we lso observed tht children hd lower nd less-scttered ntibody vlues thn did dults. Stphylococcus-specific IgM ntibodies re generlly not found or re present only t low concentrtions in humn ser (11, 29, 33). Consequently, we investigted the IgG response in n ELIS. The low ntibody rectivity with the stphylococcl ntigens found in mny of the ptient ser could not be ttributed to low production of IgG in generl, since only one of the dult ptients nd two of the children hd below-norml levels of IgG. mong the 26 serum specimens from children under the ge of 14, 7 were from ptients tht did not hve stphylococcl infections. None of our test ntigens llowed us to discriminte between the stphylococcl nd nonstphylococcl infection groups (Fig. 1B). Except for Gly5, the PG epitopes re common for stphylococcl nd streptococcl PGs. ntibodies to the cell wll ntigens PG (31), 1-RT (19), nd LT (32) re known to cross-rect with vrious species becuse of common epitopes. The stphylococcl ntibodies in ser from ptients with nonstphylococcl infections could be cross-rective ntibodies or could be the result of previous stphylococcl infections. Two or more serum smples from ech ptient were nlyzed, but in most cses the ntibody levels remined J. CLIN. MICROBIOL. stble throughout the observtion period. This result contrsts with the findings of others demonstrting significnt seroconversions in the levels of ntibodies to PG (4, 27, 28) nd P-RT (27, 28) in ser from ptients with serious stphylococcl infections. The differences between our dt nd the results of others could be the result of different times of serum smpling nd the fct tht the ptient group in our study ws heterogeneous. One my lso speculte whether so-clled "cute-phse" nd "convlescent-phse" ser re relevnt terms in serology involving bcteril species so frequently belonging to the resident flor. Ptients with osteomyelitis do not usully hve high levels of ntibodies to stphylococcl cell wll ntigens. recent study (14) showed tht such ptients more frequently hd ntibodies to P-RT thn to PG. This ws lso the cse in our study, lthough the frctions of positives for both ntigens were low, 38 nd 19%, respectively. The positive correltions (Tble 2) found between ntibodies to PG nd LT nd between ntibodies to PG nd,-rt re in ccordnce with erlier findings (29, 32). These three cell wll ntigens re ll immunogenic nd re present in considerble mounts on the bcteril surfce. The observed covrition in ntibody response ws therefore s expected. The positive correltion observed between ntibodies to LT nd 1-RT nd between these nd ntibodies to the lnine-contining PG epitopes could lso prtly be the result of cross-rective ntibodies. The correltion between ntibodies to PG nd its peptide epitopes ws sttisticlly significnt (P <.1), lthough none of the correltion coefficients were higher thn.579. The reson might be tht when whole PG is used s n ntigen, ntibodies rective with the crbohydrte determinnts re lso detected (34). The findings of significnt differences between mens of levels of ntibodies to PG nd its peptide epitopes in ser from dult ptients nd blood donors indicted tht these ntigens could be used for serodignostic purposes. However, the coefficients of vrition (Tble 1) rnged from 37 to 55%, indicting tht the two min groups of ser could not be esily seprted. The frction of seropositive ptients, which ws low for ech ntigen used lone ('42%), incresed when two (55%) or three (61%) ntigens were combined. similr increse ws observed for the blood donor ser in multiplentigen ssys. Consequently, the predictive vlues for these stphylococcl ntibodies were too low to be of dignostic vlue. Disppointingly, even the stphylococcusspecific epitope Gly5 did not stnd out s convincing dignostic test ntigen, s the PV-P in the single-ntigen ssy ws 67% when 32% of the dult ptients nd 6% of the blood donors were seropositive. Our results, however, do not exclude the possibility tht there re other stphylococcl ntigens or epitopes which could perform stisfctorily for serodignostic purposes. nother solution might be to detect ntigens insted of ntibodies in biologicl mteril by use of stphylococcus-specific monoclonl ntibodies. LITERTURE CITED 1. sjord, P., nd. Grov Immunochemicl studies on Stphylococcus ureus plsm membrne. 1. Isoltion nd chemicl chrcteriztion. ct Pthol. Microbiol. Scnd. Sect. B 86: sjord, P., H. Nylnd, nd S. Mork Encephlitis induced in rbbits by stphylococcl lipoteichoic cid. ct Pthol. Microbiol. Scnd. Sect. C 88: Bddiley, J., J. G. Buchnn, U. L. RjBhndry, nd. R. Snderson Teichoic cid from the wlls of Stphylococcus ureus H. Structure of the N-cetylglucosminylribitol residues. Biochem. J. 82:

6 VOL. 27, Christensson, B., F. Espersen, S. À. Hedstrom, nd G. Kronvll Solid-phse rdioimmunossy of immunoglobulin G ntibodies to Stphylococcus ureus peptidoglycn in ptients with stphylococcl infections. ct Pthol. Microbiol. Immunol. Scnd. Sect. B 91: Christensson, B., F. Espersen, S. À. Hedstrom, nd G. Kronvll Serologicl ssys ginst Stphylococcus ureus peptidoglycn, crude stphylococcl ntigen nd stphylolysin in the dignosis of serious S. ureus infections. Scnd. J. Infect. Dis. 17: Christensson, B., F. J. Fehrenbch, nd S. À. Hedstrom new serologicl ssy for Stphylococcus ureus infections: detection of IgG ntibodies to S. ureus lipse with n enzymelinked immunosorbent ssy. J. Infect. Dis. 152: Christensson, B., S. À. Hedstrom, nd G. Kronvll ntibody response to lph- nd bethemolysin from Stphylococcus ureus in ptients with stphylococcl infections nd in normls. ct Pthol. Microbiol. Immunol. Scnd. Sect. B 91: Coley, J., E. Trelli,. R. rchibld, nd J. Bddiley The linkge between teichoic cid nd peptidoglycn in bcteril cell wlls. FEBS Lett. 88: Fischer, W., nd H. U. Koch lnine ester substitution nd its effect on the biologicl properties of lipoteichoic cids, p In G. D. Shockmn nd. J. Wicken (ed.), Chemistry nd biologicl ctivities of bcteril surfce mphiphiles. cdemic Press, Inc., New York. 1. Frnken, N., P. H. Seidel, E. Zuner, H. B. Kolb, K. H. Schleifer, nd L. Weiss Quntittive determintion of humn IgG ntibodies to the peptide subunit determinnt of peptidoglycn by enzyme-linked immunosorbent ssy. Mol. Immunol. 22: Grnstrom, M., I. G. Julnder, S. À. Hedstrom, nd R. Molbye Enzyme-linked immunosorbent ssy for ntibodies ginst teichoic cid in ptients with stphylococcl infections. J. Clin. Microbiol. 17: Hukenes, G Immunochemicl studies on polyscchride of Stphylococcus ureus. ct Pthol. Microbiol. Scnd. 55: Helgelnd, S.,. Grov, nd K. H. 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