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Fortuna LBDP, Miranda FM, Antunes IMF, Silva AB, Cabral AS, Dolores ÍM, Cardoso-Marques NT, Teixeira LM, Neves FPG. Prevalence, capsular types, antimicrobial resistance and risk factors associated with pneumococcal carriage among children after long-term 10-valent pneumococcal conjugate vaccine use in Brazil. Vaccine 2023; 41:3111-3118. [PMID: 37061371 DOI: 10.1016/j.vaccine.2023.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/28/2023] [Accepted: 04/06/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND The 10-valent pneumococcal conjugate vaccine (PCV10) was introduced for childhood vaccination in Brazil's National Immunization Program in 2010. After nine years of PCV10 use, we investigated the carriage prevalence, capsular types, antimicrobial resistance and risk factors among children living in Niterói city, RJ, Brazil. METHODS Between September and December 2019, we conducted a cross-sectional study and recruited children under 6 years of age. Antimicrobial susceptibility was evaluated by the disk-diffusion method and MICs to beta-lactams and macrolides were determined by E-test®. Capsular types were deduced by multiplex PCR. Logistic regression was used to predict risk factors for pneumococcal carriage. RESULTS Seventy-five (17.4%) of the 430 children were pneumococcal carriers. The most frequent capsular types were 6C/D (14.7%), 11A/D (13.3%), and 23B (9.3%). PCV10 serotypes represented 5.3%. All isolates were susceptible to levofloxacin, linezolid, rifampicin, and vancomycin. Penicillin non-susceptible pneumococci (PNSP) made up 37.3%, with penicillin and ceftriaxone MICs ranging from 0.12 to 4.0 μg/ml and 0.064-4.0 μg/ml, respectively. Of the 19 (25.3%) erythromycin-resistant (ERY-R) isolates (macrolide MICs of 6 to >256 μg/ml), most had the cMLSB phenotype (84.2%) and carried the erm(B) gene (73.7%). We detected 17 (22.6%) multidrug-resistant (MDR) isolates, strongly associated with serotype 6C/D. Presence of any symptoms, chronic diseases, childcare center attendance, living with young siblings, slum residence, and unstable income were predictors of pneumococcal carriage. CONCLUSIONS Long-term universal childhood use of PCV10 has nearly eliminated carriage with PCV10 serotypes, but the high frequency of MDR isolates, especially associated with serotype 6C/D, remains a concern. Replacing PCV10 with PCV13 should reduce the proportion of ERY-R isolates and PNSP by at least 14% and 18%, respectively.
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Affiliation(s)
- Letícia B D P Fortuna
- Instituto Biomédico, Universidade Federal Fluminense, Alameda Barros Terra, s/n. São Domingos, Niterói, RJ 24020-150, Brazil.
| | - Filipe M Miranda
- Instituto Biomédico, Universidade Federal Fluminense, Alameda Barros Terra, s/n. São Domingos, Niterói, RJ 24020-150, Brazil.
| | - Isa M F Antunes
- Instituto Biomédico, Universidade Federal Fluminense, Alameda Barros Terra, s/n. São Domingos, Niterói, RJ 24020-150, Brazil.
| | - Amanda B Silva
- Instituto Biomédico, Universidade Federal Fluminense, Alameda Barros Terra, s/n. São Domingos, Niterói, RJ 24020-150, Brazil.
| | - Amanda S Cabral
- Instituto Biomédico, Universidade Federal Fluminense, Alameda Barros Terra, s/n. São Domingos, Niterói, RJ 24020-150, Brazil.
| | - Ítalo M Dolores
- Instituto Biomédico, Universidade Federal Fluminense, Alameda Barros Terra, s/n. São Domingos, Niterói, RJ 24020-150, Brazil.
| | - Nayara T Cardoso-Marques
- Instituto Biomédico, Universidade Federal Fluminense, Alameda Barros Terra, s/n. São Domingos, Niterói, RJ 24020-150, Brazil.
| | - Lúcia M Teixeira
- Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro. Av. Carlos Chagas Filho, 373 - bloco I, Cidade Universitária, Ilha do Fundão, Rio de Janeiro, RJ 21941-902, Brazil.
| | - Felipe P G Neves
- Instituto Biomédico, Universidade Federal Fluminense, Alameda Barros Terra, s/n. São Domingos, Niterói, RJ 24020-150, Brazil.
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Reyburn R, Maher J, von Mollendorf C, Gwee A, Mulholland K, Russell F. The impact of the introduction of ten- or thirteen-valent pneumococcal conjugate vaccines on antimicrobial-resistant pneumococcal disease and carriage: A systematic literature review. J Glob Health 2023; 13:05001. [PMID: 36799235 PMCID: PMC9936452 DOI: 10.7189/jogh.13.05001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
Background A systematic review in 2019 found reductions in antimicrobial resistance (AMR) of pneumococcal vaccine serotypes following pneumococcal conjugate vaccine (PCV) introduction. However, few low- or middle-income countries were included as not many had introduced higher valent PCVs (PCV10 or PCV13). The aim of our review is to describe AMR rates in these samples following the introduction of PCV10 or PCV13. Methods We conducted a systematic literature review of published papers that compared AMR for invasive pneumococcal disease (IPD), otitis media (OM) and nasopharyngeal carriage (NPC) samples following introduction of PCV10 or PCV13 to the pre-PCV period. Included studies published from July 2017 to August 2020 had a post-licensure observational study design and reported on our defined outcomes: IPD, OM, NPC and other (sputum or mixed invasive and non-invasive pneumococcal) isolates from people of all ages. Rates of AMR in the pre- and post-period were extracted. Results Data were extracted from 31 studies. Among IPD isolates, penicillin AMR rates following PCV10 or PCV13 introduction declined in 32% (n = 9/29) of included studies, increased in 34% (n = 10/29) and showed no change in 34% (n = 10/29). Cephalosporins AMR declined in 32% (n = 6/19) of studies, increased in 21% (n = 4/19) and showed no change in 47% (n = 9/19). Macrolides AMR declined in 33% (n = 4/12) of studies, increased in 50% (n = 6/12), and showed no change in 17% (n = 2/12). AMR to other antibiotics (including multidrug resistance) declined in 23% (n = 9/39) of studies, increased in 41% (n = 16/39) and showed no change in AMR in 36% (n = 14/39). There were no obvious differences between AMR; in setting which used PCV10 vs PCV13, according to time since PCV introduction or by World Bank income status of the respective country. The only study including OM isolates found no change in penicillin resistance. There were few studies on AMR in NPC (four studies), OM (one study) or other isolates (five studies). The results followed similar patterns to IPD isolates. Conclusions We observed considerable heterogeneity in the findings between and within studies, e.g. no evidence of reduction in amoxicillin AMR with an increase in macrolides AMR. Reasons for such diverse findings include the period covered by different studies and variation in other pressures towards AMR.
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Affiliation(s)
- Rita Reyburn
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Jaclyn Maher
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Claire von Mollendorf
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Amanda Gwee
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia,The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Kim Mulholland
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia,London School of Hygiene and Tropical Medicine, London, UK
| | - Fiona Russell
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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da Silva AB, Cardoso-Marques NT, Dolores ÍDM, Teixeira LM, Neves FPG. Carriage prevalence, serotype distribution, antimicrobial resistance, pspA typing and pilus islets of Streptococcus pneumoniae isolated from adults living in a Brazilian urban slum. Vaccine 2023; 41:1431-1437. [PMID: 36690557 DOI: 10.1016/j.vaccine.2023.01.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/10/2023] [Accepted: 01/16/2023] [Indexed: 01/22/2023]
Abstract
INTRODUCTION For Brazilian adults, pneumococcal vaccines have been usually taken only by those who are at higher risk for development of pneumococcal diseases. Since populations from lower socioeconomic status are at high risk of acquiring pneumococcal infections, we investigated the carriage prevalence, colonization risk factors, capsular and surface protein types, and antimicrobial resistance among pneumococcal isolates recovered from adults living in a Brazilian urban slum. METHODS Between September-December 2016, we conducted a cross-sectional study among individuals aged ≥ 18 years who attended a public primary clinic in Niterói/RJ, Brazil. Pneumococci were isolated by culture on sheep blood agar plates with and without gentamicin. Antimicrobial susceptibility was determined for all isolates. We used PCR to determine capsular types, PspA families (Fam) and pilus islets (PI). RESULTS Of 385 adults, 32 (8.3 %) were pneumococcal carriers. Three carriers had two different pneumococci, totaling 35 isolates. After multivariate analysis, smoking, previous hospitalization, alcohol consumption and co-habitation with children aged < 6 years increased the odds of pneumococcal carriage, but antibiotic use in the previous 2 weeks was found to be a protective factor. Fourteen different serogroups/serotypes were detected and the prevalent ones were 9 N/L, 10A, 15B/C and 35F/47F (n = 3; 8.6 % each). Non-typeable (NT) isolates made up 31.4 %. All isolates were susceptible to chloramphenicol, levofloxacin and vancomycin. We found eight (22.9 %) penicillin non-susceptible pneumococci (PNSP) with minimum inhibitory concentrations (MICs) of 0.38-1.5 μg/mL. The two (5.7 %) erythromycin-resistant isolates had MIC > 256 μg/mL, cMLSB phenotype and the erm(B) gene. Twelve (34.3 %) and 17 (48.6 %) isolates had PspA Fam1 and Fam2, respectively. Three (8.6 %) isolates had genes for pilitwo PI-1 and one PI-2. CONCLUSION We detected a low frequency of pneumococcal carriage among the adult population, but a high diversity of serotypes. Frequencies of PNSP and NT isolates resistant to antimicrobial agents are concerning.
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Affiliation(s)
- Amanda Beiral da Silva
- Department of Microbiology and Parasitology, Instituto Biomédico, Universidade Federal Fluminense, Niterói, RJ, Brazil
| | - Nayara Torres Cardoso-Marques
- Department of Microbiology and Parasitology, Instituto Biomédico, Universidade Federal Fluminense, Niterói, RJ, Brazil
| | - Ítalo de Moraes Dolores
- Department of Microbiology and Parasitology, Instituto Biomédico, Universidade Federal Fluminense, Niterói, RJ, Brazil
| | - Lúcia Martins Teixeira
- Department of Medical Microbiology, Instituto de Microbiologia, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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Kfouri RA, Brandileone MCC, Sáfadi MAP, Richtmann R, Gilio AE, Rossi F, Guimarães T, Bierrenbach AL, Moraes JC. Chronic medical conditions associated with invasive pneumococcal diseases in inpatients in teaching hospitals in São Paulo city: Estimating antimicrobial susceptibility and serotype-coverage of pneumococcal vaccines. Braz J Infect Dis 2023; 27:102746. [PMID: 36758625 PMCID: PMC9943857 DOI: 10.1016/j.bjid.2023.102746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 12/30/2022] [Accepted: 01/13/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Chronic conditions increase the risk of invasive pneumococcal diseases (IPD). Pneumococcal vaccination remarkably reduced IPD morbimortality in vulnerable populations. In Brazil, pneumococcal vaccines are included in the National Immunization Program (PNI): PCV10 for < 2 years-old, and PPV23 for high risk-patients aged ≥ 2 years and institutionalized ≥ 60 years. PCV13 is available in private clinics and recommended in the PNI for individuals with certain underlying conditions. METHODS A retrospective study was performed using clinical data from all inpatients from five hospitals with IPD from 2016 to 2018 and the corresponding data on serotype and antimicrobial-non-susceptibility of pneumococcus. Vaccine-serotype-coverage was estimated. Patients were classified according to presence of comorbidities: healthy, without comorbidities; at-risk, included immunocompetent persons with specific medical conditions; high-risk, with immunocompromising conditions and others RESULTS: 406 IPD cases were evaluated. Among 324 cases with information on medical conditions, children < 5 years were mostly healthy (55.9%), while presence of comorbidity prevailed in adults ≥ 18 years old (> 82.0%). Presence of ≥1 risk condition was reported in ≥ 34.8% of adults. High-risk conditions were more frequent than at-risk in all age groups. Among high-risk comorbidity (n = 211), cancer (28%), HIV/AIDS (25.7%) and hematological diseases (24.5%) were the most frequent. Among at-risk conditions (n = 89), asthma (16.5%) and diabetes (8.1%) were the most frequent. Among 404 isolates, 42.9% belonged to five serotypes: 19A (14.1%), 3 (8.7%), 6C (7.7%), 4 and 8 (6.2% each); 19A and 6C expressed antimicrobial-non-susceptibility. The vaccine-serotype-coverage was: PCV10, 19.1%, PCV13, 43.8%; PCV15, 47.8%; PCV20, 62.9%; PCV21, 65.8%, and PPV23, 67.3%. Information on hospital outcome was available for 283 patients, of which 28.6% died. Mortality was 54.2% for those with meningitis. CONCLUSION Vaccine with expanded valence of serotypes is necessary to offer broad prevention to IPD. The present data contribute to pneumococcal vaccination public health policies for vulnerable patients, mainly those with comorbidity and the elderly.
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Affiliation(s)
- Renato A. Kfouri
- Sociedade Brasileira de Imunizações (SBim), São Paulo, SP, Brazil,Corresponding author.
| | - Maria-Cristina C. Brandileone
- Centro de Bacteriologia, Laboratório Nacional de Meningite e Infecção Pneumocócica, Instituto Adolfo Lutz (IAL), São Paulo, SP, Brazil
| | | | - Rosana Richtmann
- Instituto de Infectologia Emílio Ribas (IIER), São Paulo, SP, Brazil
| | - Alfredo E. Gilio
- Hospital Universitário (HU) da Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | - Flavia Rossi
- Laboratório de Medicina Laboratorial (LIM/03), Hospital das Clínicas da Universidade de São Paulo (HCUSP), São Paulo, SP, Brazil
| | - Thais Guimarães
- Hospital do Servidor Público Estadual (HSPE), São Paulo, SP, Brazil
| | | | - José C. Moraes
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil
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Ktari S, Ben Ayed N, Ben Rbeh I, Garbi N, Maalej S, Mnif B, Rhimi F, Hammami A. Antibiotic resistance pattern, capsular types, and molecular characterization of invasive isolates of Streptococcus pneumoniae in the south of Tunisia from 2012 to 2018. BMC Microbiol 2023; 23:36. [PMID: 36739390 PMCID: PMC9898894 DOI: 10.1186/s12866-023-02784-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/25/2023] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Streptococcus pneumoniae remains a leading cause of morbidity and mortality worldwide. In this study, we sought to analyze serotype distributions, antibiotic resistance, and genetic relationships of 106 clinical invasive pneumococcal isolates recovered in Tunisia between 2012 and 2018, prior to the routine use of pneumococcal conjugate vaccines (PCV). METHODS We used multiplex PCR, the disk diffusion method and/or E-test, and multi-locus sequence typing (MLST). RESULTS The most frequent serotypes were 14 (17%), 19F (14.2%), and 3 (11.3%). Of the 106 S. pneumoniae isolates, 67.9% were penicillin non-susceptible (29.4% were resistant), 45.3% were amoxicillin non-susceptible (17% were resistant), and 16% were cefotaxime non-susceptible. For antibiotics other than β-lactams, resistance rates to erythromycin, tetracycline, cotrimoxazole, and chloramphenicol were 62.3, 33, 22.6, and 4.7%, respectively. Two isolates were non-susceptible to levofloxacin. Among 66 erythromycin-resistant pneumococci, 77.3% exhibited the cMLSB phenotype, and 87.9% carried ermB gene. All tetracycline-resistant strains harbored the tetM gene. The potential coverage by 7-, 10-, and 13-valent pneumococcal conjugate vaccines were 55.7, 57.5, and 81.1%, respectively. A multilocus sequence typing analysis revealed great diversity. Fifty different sequence types (STs) were identified. These STs were assigned to 10 clonal complexes and 32 singletons. The most common STs were 179, 2918, 386, and 3772 - related mainly to 19F, 14, 6B/C, and 19A serotypes, respectively. CONCLUSIONS This study demonstrated that the majority of the serotypes of invasive pneumococci in the Tunisian population were 14, 19F, and 3. Moreover, we noted a high degree of genetic diversity among invasive S. pneumoniae isolates. The highest proportions of antibiotic non-susceptible isolates were for penicillin, erythromycin, and tetracycline. Further molecular characteristics are required to monitor the genetic variations and to follow the emergence of resistant pneumococci for the post-vaccination era in Tunisia.
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Affiliation(s)
- Sonia Ktari
- Laboratory of Microbiology, Faculty of Medicine Sfax, University of Sfax-Tunisia, Avenue Majida Boulila, 3027, Sfax, Tunisia. .,Research Laboratory Microorganisms and Human Disease "MPH LR03SP03", Sfax, Tunisia.
| | - Nourelhouda Ben Ayed
- Research Laboratory Microorganisms and Human Disease “MPH LR03SP03”, Sfax, Tunisia ,grid.413497.cLaboratory of Microbiology, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Imen Ben Rbeh
- Research Laboratory Microorganisms and Human Disease “MPH LR03SP03”, Sfax, Tunisia
| | - Nourhène Garbi
- Medical Genetic Department, HediChaker Hospital, Sfax, Tunisia
| | - Sonda Maalej
- Research Laboratory Microorganisms and Human Disease “MPH LR03SP03”, Sfax, Tunisia ,grid.413497.cLaboratory of Microbiology, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Basma Mnif
- Research Laboratory Microorganisms and Human Disease “MPH LR03SP03”, Sfax, Tunisia ,grid.413497.cLaboratory of Microbiology, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Faouzia Rhimi
- Research Laboratory Microorganisms and Human Disease “MPH LR03SP03”, Sfax, Tunisia ,grid.413497.cLaboratory of Microbiology, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Adnene Hammami
- grid.412124.00000 0001 2323 5644Laboratory of Microbiology, Faculty of Medicine Sfax, University of Sfax-Tunisia, Avenue Majida Boulila, 3027 Sfax, Tunisia ,Research Laboratory Microorganisms and Human Disease “MPH LR03SP03”, Sfax, Tunisia ,grid.413497.cLaboratory of Microbiology, Habib Bourguiba University Hospital, Sfax, Tunisia
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Phenotypic and genotypic characteristics of non-invasive S. pneumoniae isolates recovered from PCV10-vaccinated children in Bulgaria. Indian J Med Microbiol 2021; 40:61-67. [PMID: 34772534 DOI: 10.1016/j.ijmmb.2021.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 10/08/2021] [Accepted: 10/10/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE The non-invasive pneumococcal disease (NIPD) is a common infection during childhood. We aimed to define the clonal spread of pediatric non-invasive isolates recovered during the PCV10-period in Bulgaria concerning the serotype and antimicrobial susceptibility. MATERIALS AND METHODS Serogrouping/serotyping were performed using latex agglutination and capsular swelling reaction. Serogroup 6 strains were subjected to serotype-specific PCR's. The antibiotic susceptibilities were assessed by broth microdilution. MLST was performed to define the clonal composition. RESULTS We analyzed 154 pediatrics non-invasive S. pneumoniae isolates. The PCV10-vaccinated children were 94.1%. We disclosed 88% non-vaccine serotypes (NVTs) and 12% PCV10 - serotypes. All common serotypes among PCV10-vaccinated children (n = 145) were non-vaccine types (NVTs): 19A (13.8%), 6C (11.7%), 3 (9.6%), 15A (8.3%) and 23A (5.5%). Antimicrobial non-susceptibility showed highest levels in erythromycin (50.0%), oral penicillin (49.4%), clindamycin (45.4%), trimethoprim-sulfamethoxazole (43.5%), tetracycline (42.2%), and ceftriaxone (14.3%). The multidrug-resistant strains (MDR) were 51.3%. MDR-serotypes were 6C (20.2%), 19A (17.7%), 15A (11.4%), 19F (10.1%), and 23A (8.9%). MLST presented 17 clonal complexes (CCs) with prevalence of CC320, CC386, CC505, CC8029 and CC2613 clustered 83% MDR isolates. CONCLUSIONS All emergent pediatric non-invasive serotypes in our geographic area during the studied PCV10-period were NVTs (19A, 6C, 3, 15A, and 23A). The fifth widespread CCs: CC320, CC386, CC505, CC8029 and CC2613 clustered 83% MDR isolates. Future surveillance of vaccine-induced changes in the clonality and the antimicrobial resistance of the pneumococcal population is needed.
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Almeida SCG, Lo SW, Hawkins PA, Gladstone RA, Cassiolato AP, Klugman KP, Breiman RF, Bentley SD, McGee L, Brandileone MCDC. Genomic surveillance of invasive Streptococcus pneumoniae isolates in the period pre-PCV10 and post-PCV10 introduction in Brazil. Microb Genom 2021; 7. [PMID: 34609274 PMCID: PMC8627213 DOI: 10.1099/mgen.0.000635] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
In 2010, Brazil introduced the 10-valent pneumococcal conjugate vaccine (PCV10) into the national children’s immunization programme. This study describes the genetic characteristics of invasive Streptococcus pneumoniae isolates before and after PCV10 introduction. A subset of 466 [pre-PCV10 (2008–2009): n=232, post-PCV10 (2012–2013): n=234;<5 years old: n=310, ≥5 years old: n=156] pneumococcal isolates, collected through national laboratory surveillance, were whole-genome sequenced (WGS) to determine serotype, pilus locus, antimicrobial resistance and genetic lineages. Following PCV10 introduction, in the <5 years age group, non-vaccine serotypes (NVT) serotype 3 and serotype 19A were the most frequent, and serotypes 12F, 8 and 9 N in the ≥5 years old group. The study identified 65 Global Pneumococcal Sequence Clusters (GPSCs): 49 (88 %) were GPSCs previously described and 16 (12 %) were Brazilian clusters. In total, 36 GPSCs (55 %) were NVT lineages, 18 (28 %) vaccine serotypes (VT) and 11 (17 %) were both VT and NVT lineages. In both sampling periods, the most frequent lineage was GPSC6 (CC156, serotypes 14/9V). In the <5 years old group, a decrease in penicillin (P=0.0123) and cotrimoxazole (P<0.0001) resistance and an increase in tetracycline (P=0.019) were observed. Penicillin nonsusceptibility was predicted in 40 % of the isolates; 127 PBP combinations were identified (51 predicted MIC≥0.125 mg l−1); cotrimoxazole (folA and/or folP alterations), macrolide (mef and/or ermB) and tetracycline (tetM, tetO or tetS/M) resistance were predicted in 63, 13 and 21.6 % of pneumococci studied, respectively. The main lineages associated with multidrug resistance in the post-PCV10 period were composed of NVT, GPSC1 (CC320, serotype 19A), and GPSC47 (ST386, serotype 6C). The study provides a baseline for future comparisons and identified important NVT lineages in the post-PCV10 period in Brazil.
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Affiliation(s)
- Samanta C. G. Almeida
- National Reference Laboratory for Meningitis and Pneumococcal Infections, Institute Adolfo Lutz, São Paulo, Brazil
- *Correspondence: Samanta C. G. Almeida,
| | - Stephanie W. Lo
- Parasites and Microbes Programme, Wellcome Sanger Institute, Hinxton, UK
| | - Paulina A. Hawkins
- Respiratory Diseases Branch, Centers for Disease Control and Prevention, Atlanta, USA
| | | | - Ana Paula Cassiolato
- National Reference Laboratory for Meningitis and Pneumococcal Infections, Institute Adolfo Lutz, São Paulo, Brazil
| | - Keith P. Klugman
- Emeritus Professor of Global Health, Emory University, Atlanta, GA, USA
| | | | - Stephen D. Bentley
- Parasites and Microbes Programme, Wellcome Sanger Institute, Hinxton, UK
| | - Lesley McGee
- Respiratory Diseases Branch, Centers for Disease Control and Prevention, Atlanta, USA
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Càmara J, Grau I, González-Díaz A, Tubau F, Calatayud L, Cubero M, Domínguez MÁ, Liñares J, Yuste J, Pallarés R, Ardanuy C. A historical perspective of MDR invasive pneumococcal disease in Spanish adults. J Antimicrob Chemother 2021; 76:507-515. [PMID: 33254238 DOI: 10.1093/jac/dkaa465] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/11/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To analyse the clonal dynamics and clinical characteristics of adult invasive pneumococcal disease (IPD) caused by MDR and penicillin-non-susceptible (PNS) pneumococci in Spain. METHODS All adult IPD episodes were prospectively collected (1994-2018). Streptococcus pneumoniae isolates were serotyped, genotyped and tested for antimicrobial susceptibility. Changes in the incidence of IPD were analysed and risk factors contributing to MDR were assessed by logistic regression. RESULTS Of 2095 IPD episodes, 635 (30.3%) were caused by MDR/PNS isolates. Over the study period, the incidence of MDR/PNS-IPD decreased (IRR 0.70; 95% CI 0.53-0.93) whereas that of susceptible isolates remained stable (IRR 0.96; 95% CI 0.80-1.16). A reduction of resistance rates to penicillin (-19.5%; 95% CI -37% to 2%) and cefotaxime (-44.5%; 95% CI -64% to -15%) was observed. Two clones, Spain9V-ST156 and Denmark14-ST230, accounted for 50% of current resistant disease. Among current MDR/PNS isolates, 45.8% expressed serotypes not covered by the upcoming PCV15/PCV20 vaccines. MDR/PNS episodes were associated with older patients with comorbidities, nosocomial acquisition and higher 30 day mortality. MDR/PNS pneumococci were not independently associated with 30 day mortality in multivariate analysis [OR 0.826 (0.648-1.054)]. CONCLUSIONS Our study shows an overall reduction of MDR/PNS isolates in adults after the introduction of pneumococcal conjugate vaccines. However, a significant proportion of current resistant isolates are not covered by any of the upcoming PCV15/PCV20 vaccines. The burden of resistant disease is related to older patients with underlying conditions and caused by two major clones. Our data show that MDR is not a statistically significant factor related to increased mortality.
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Affiliation(s)
- Jordi Càmara
- Microbiology Department, Hospital Universitari de Bellvitge, University of Barcelona, IDIBELL, Barcelona, Spain.,Ciber de Enfermedades Respiratorias (CIBERes), ISCIII, Madrid, Spain
| | - Inmaculada Grau
- Ciber de Enfermedades Respiratorias (CIBERes), ISCIII, Madrid, Spain.,Infectious Diseases Department, Hospital Universitari de Bellvitge, University of Barcelona. IDIBELL, Barcelona, Spain
| | - Aida González-Díaz
- Microbiology Department, Hospital Universitari de Bellvitge, University of Barcelona, IDIBELL, Barcelona, Spain.,Ciber de Enfermedades Respiratorias (CIBERes), ISCIII, Madrid, Spain
| | - Fe Tubau
- Microbiology Department, Hospital Universitari de Bellvitge, University of Barcelona, IDIBELL, Barcelona, Spain.,Ciber de Enfermedades Respiratorias (CIBERes), ISCIII, Madrid, Spain
| | - Laura Calatayud
- Microbiology Department, Hospital Universitari de Bellvitge, University of Barcelona, IDIBELL, Barcelona, Spain.,Ciber de Enfermedades Respiratorias (CIBERes), ISCIII, Madrid, Spain
| | - Meritxell Cubero
- Microbiology Department, Hospital Universitari de Bellvitge, University of Barcelona, IDIBELL, Barcelona, Spain.,Ciber de Enfermedades Respiratorias (CIBERes), ISCIII, Madrid, Spain
| | - M Ángeles Domínguez
- Microbiology Department, Hospital Universitari de Bellvitge, University of Barcelona, IDIBELL, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Instituto de Salud Carlos III, Madrid, Spain.,Departament of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain
| | - Josefina Liñares
- Microbiology Department, Hospital Universitari de Bellvitge, University of Barcelona, IDIBELL, Barcelona, Spain.,Ciber de Enfermedades Respiratorias (CIBERes), ISCIII, Madrid, Spain
| | - José Yuste
- Ciber de Enfermedades Respiratorias (CIBERes), ISCIII, Madrid, Spain.,Pneumococcal Reference Laboratory. Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain
| | - Román Pallarés
- Ciber de Enfermedades Respiratorias (CIBERes), ISCIII, Madrid, Spain.,Infectious Diseases Department, Hospital Universitari de Bellvitge, University of Barcelona. IDIBELL, Barcelona, Spain
| | - Carmen Ardanuy
- Microbiology Department, Hospital Universitari de Bellvitge, University of Barcelona, IDIBELL, Barcelona, Spain.,Ciber de Enfermedades Respiratorias (CIBERes), ISCIII, Madrid, Spain.,Departament of Pathology and Experimental Therapeutics, University of Barcelona, Barcelona, Spain
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9
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Dzaraly ND, Mohd Desa MN, Muthanna A, Masri SN, Taib NM, Suhaili Z, Sulaiman N, Baharin NHZ, Shuan CY, Ariffin Z, Rahman NIA, Mohd Rani F, Palanisamy NK, Soh TST, Abdullah FH. Antimicrobial susceptibility, serotype distribution, virulence profile and molecular typing of piliated clinical isolates of pneumococci from east coast, Peninsular Malaysia. Sci Rep 2021; 11:8220. [PMID: 33859249 PMCID: PMC8050075 DOI: 10.1038/s41598-021-87428-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/30/2021] [Indexed: 12/14/2022] Open
Abstract
Pilus has been recently associated with pneumococcal pathogenesis in humans. The information regarding piliated isolates in Malaysia is scarce, especially in the less developed states on the east coast of Peninsular Malaysia. Therefore, we studied the characteristics of pneumococci, including the piliated isolates, in relation to antimicrobial susceptibility, serotypes, and genotypes at a major tertiary hospital on the east coast of Peninsular Malaysia. A total of 100 clinical isolates collected between September 2017 and December 2019 were subjected to serotyping, antimicrobial susceptibility test, and detection of pneumococcal virulence and pilus genes. Multilocus sequence typing (MLST) and phylogenetic analysis were performed only for piliated strains. The most frequent serotypes were 14 (17%), 6A/B (16%), 23F (12%), 19A (11%), and 19F (11%). The majority of isolates were resistant to erythromycin (42%), tetracycline (37%), and trimethoprim-sulfamethoxazole (24%). Piliated isolates occurred in a proportion of 19%; 47.3% of them were multidrug-resistant (MDR) and a majority had serotype 19F. This study showed ST236 was the most predominant sequence type (ST) among piliated isolates, which was related to PMEN clone Taiwan19F-14 (CC271). In the phylogenetic analysis, the piliated isolates were grouped into three major clades supported with 100% bootstrap values. Most piliated isolates belonged to internationally disseminated clones of S. pneumoniae, but pneumococcal conjugate vaccines (PCVs) have the potential to control them.
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Affiliation(s)
- Nurul Diana Dzaraly
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM Serdang, Selangor, Malaysia
| | - Mohd Nasir Mohd Desa
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM Serdang, Selangor, Malaysia.
| | - AbdulRahman Muthanna
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM Serdang, Selangor, Malaysia
| | - Siti Norbaya Masri
- Department of Medical Microbiology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM Serdang, Selangor, Malaysia
| | - Niazlin Mohd Taib
- Department of Medical Microbiology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM Serdang, Selangor, Malaysia
| | - Zarizal Suhaili
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM Serdang, Selangor, Malaysia
- School of Animal Science, Aquatic Science and Environment, Faculty of Bioresources and Food Industry, Universiti Sultan Zainal Abidin, Besut Campus, Besut, Terengganu, Malaysia
| | - Nurshahira Sulaiman
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM Serdang, Selangor, Malaysia
| | - Nurul Hana Zainal Baharin
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM Serdang, Selangor, Malaysia
| | - Cheah Yun Shuan
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM Serdang, Selangor, Malaysia
| | - Zarina Ariffin
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM Serdang, Selangor, Malaysia
| | - Nor Iza A Rahman
- Faculty of Medicine, Universiti Sultan Zainal Abidin, Kuala Terengganu, Terengganu, Malaysia
| | - Farahiyah Mohd Rani
- Faculty of Medicine, Universiti Sultan Zainal Abidin, Kuala Terengganu, Terengganu, Malaysia
| | - Navindra Kumari Palanisamy
- Department of Medical Microbiology and Parasitology, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Sungai Buloh Campus, Jalan Hospital, Sungai Buloh, Selangor, Malaysia
| | - Tuan Suhaila Tuan Soh
- Department of Pathology, Sungai Buloh Hospital, Ministry of Health Malaysia, Jalan Hospital, Sungai Buloh, Selangor, Malaysia
| | - Fatimah Haslina Abdullah
- Department of Pathology, Sultanah Nur Zahirah Hospital, Ministry of Health Malaysia, Jalan Sultan Mahmud, Kuala Terengganu, Terengganu, Malaysia
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10
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Description of optochin-resistant Streptococcus pneumoniae due to an uncommon mutation in the atpA gene and comparison with previously identified atpC mutants from Brazil. Sci Rep 2021; 11:7936. [PMID: 33846478 PMCID: PMC8041871 DOI: 10.1038/s41598-021-87071-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 03/15/2021] [Indexed: 11/09/2022] Open
Abstract
Optochin susceptibility testing is a major assay used for presumptive identification of Streptococcus pneumoniae. Still, atypical optochin-resistant (Optr) pneumococci have been reported and this phenotype has been attributed to nucleotide substitutions in the genes coding for the F0F1ATPase. While substitutions in the atpC gene (c-subunit of ATPase) are more common and better characterized, data on mutations in the atpA (a-subunit) are still limited. We have characterized five Optr isolates presenting alterations in the atpA (Trp206Cys in four isolates and Trp206Ser in one isolate), constituting the first report of such mutations in Brazil. Most of the Optr isolates consisted of heterogeneous populations. Except for Opt MICs and the nucleotide changes in the atpA gene, Optr and Opts subpopulations originating from the same culture had identical characteristics. In addition, we compared phenotypic and genetic characteristics of these atpA mutants with those of atpC mutants previously identified in Brazil. No structural alterations were detected among predicted proteins, regardless of mutations in the coding gene, suggesting that, despite the occurrence of mutations, protein structures tend to be highly conserved, ensuring their functionalities. Phylogenetic analysis revealed that atypical Optr strains are true pneumococci and Opt resistance does not represent any apparent selective advantage for clinical isolates.
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11
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Dynamics of antimicrobial resistance of Streptococcus pneumoniae following PCV10 introduction in Brazil: Nationwide surveillance from 2007 to 2019. Vaccine 2021; 39:3207-3215. [PMID: 33707062 DOI: 10.1016/j.vaccine.2021.02.063] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/22/2021] [Accepted: 02/25/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Brazil introduced 10-valent pneumococcal conjugate vaccine (PCV10) into its immunization program in 2010. We assessed antimicrobial susceptibility of Streptococcus pneumoniae (Spn) obtained from a national surveillance system for invasive pneumococcal diseases (IPD) before/after PCV10 introduction. METHODS Antimicrobial non-susceptible isolates were defined as intermediate or resistant. Minimum inhibitory concentrations (MICs) to penicillin and ceftriaxone were analyzed by year. Antimicrobial susceptibility rates were assessed for each three-year-period using the pre-PCV10-period as reference. Susceptibility of vaccine-types was evaluated for 2017-2019. RESULTS 11,380 isolates were studied. Spn with penicillin ≥ 0.125 mg/L and ceftriaxone ≥ 1.0 mg/L decreased in the three-years after PCV10 introduction (2011-2013: penicillin, 28.1-22.5%; ceftriaxone, 11.3%-7.6%) versus pre-PCV10-years (2007-2009: penicillin, 33.8-38.1%; ceftriaxone, 17.2%-15.6%). After 2013, the proportion of Spn with those MICs to penicillin and ceftriaxone increased to 39.4% and 19.7% in 2019, respectively. Non-susceptibility to penicillin and ceftriaxone increased in 2014-2016, and again in 2017-2019 especially among children < 5 years with meningitis (penicillin, 53.9%; ceftriaxone, 28.0%); multidrug-resistance reached 25% in 2017-2019. Serotypes 19A, 6C and 23A were most associated with antimicrobial non-susceptibility. CONCLUSIONS Antimicrobial non-susceptible Spn decreased in the three-years after vaccination but subsequently increased and was associated with non-PCV10-types. Antimicrobial susceptibility surveillance is fundamental for guiding antibiotic therapy policies.
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Alexandrova AS, Setchanova LP, Pencheva DR, Mitov IG. Phenotypic and genotypic characterization of serogroup 6 Streptococcus pneumoniae isolates collected during 10-valent pneumococcal conjugate vaccine era in Bulgaria. Acta Microbiol Immunol Hung 2020; 67:91-99. [PMID: 31813257 DOI: 10.1556/030.66.2019.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/01/2019] [Indexed: 11/19/2022]
Abstract
Serogroup 6 remains common in the pneumococcal-conjugated vaccine era in Bulgaria; therefore, we investigated its clonal and serotype dynamics. The antibiotic susceptibilities were assessed by broth microdilution. Strains identified as serogroup 6 with latex agglutination method were subjected to serotype-specific PCRs. Erythromycin-resistant strains were analyzed by PCR for presence of ermB and mefE genes. MLST was performed to define clonal composition of the sequence types (STs). Serogroup 6 was represented by 40 (13.3%) from 301 invasive and non-invasive Streptococcus pneumoniae isolates. Molecular serotyping revealed new emerging serotype 6C (6.6%), not detected in pre-vaccine era. Among unvaccinated patients, mostly we observed serotypes 6А (57.1%) and 6В (28.6%). Serotype 6C was distinctive for vaccinated children (64%), followed by 6A (24%). Penicillin and ceftriaxone non-susceptible serogroup 6 strains were 65% and 5%, respectively; erythromycin- and clindamycin-resistant were 70.0% and 52.5%, respectively. Multidrug-resistant strains were 57.5%. Prevalent genetic determinant for macrolide resistance was ermB gene (75%). MLST revealed 17 STs into 5 clonal complexes and 7 singletons. Predominant genetic lineage was CC386, represented by MDR-6C non-invasive strains. Serotype 6B, principally responsible for invasive diseases in the pre-vaccine era, retreated this position to serotype 6A.
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Affiliation(s)
| | - Lena Petrova Setchanova
- Department of Medical Microbiology, Medical Faculty, Medical University of Sofia, Sofia, Bulgaria
| | - Daniela Rosenova Pencheva
- Molecular Medicine Center, Department of Medical Chemistry and Biochemistry, Medical Faculty, Medical University of Sofia, Sofia, Bulgaria
| | - Ivan Gergov Mitov
- Department of Medical Microbiology, Medical Faculty, Medical University of Sofia, Sofia, Bulgaria
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13
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Vorobieva S Jensen V, Furberg AS, Slotved HC, Bazhukova T, Haldorsen B, Caugant DA, Sundsfjord A, Valentiner-Branth P, Simonsen GS. Epidemiological and molecular characterization of Streptococcus pneumoniae carriage strains in pre-school children in Arkhangelsk, northern European Russia, prior to the introduction of conjugate pneumococcal vaccines. BMC Infect Dis 2020; 20:279. [PMID: 32293324 PMCID: PMC7161136 DOI: 10.1186/s12879-020-04998-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/27/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The 13-valent Pneumococcal Conjugate Vaccine (PCV-13) was introduced in the National Immunization Programme (NIP) schedule in Russia in March 2014. Previously, the 7-valent Pneumococcal Conjugate Vaccine (PCV-7) was marketed in Russia in 2009 but has never been offered for mass vaccination. A carriage study was performed among children in Arkhangelsk in 2006. The objective was to determine the prevalence of carriage, serotype distribution, antimicrobial susceptibility and the molecular structure of Streptococcus pneumoniae strains before marketing and introduction of PCV-13. METHODS A cross-sectional study was conducted on a cluster-randomized sample of children and a self-administrated questionnaire for parents/guardians. Nasopharyngeal samples were collected from 438 children younger than 7 years attending nurseries and kindergartens in the Arkhangelsk region, Russia. Detailed demographic data, as well as information about the child's health, traveling, exposure to antimicrobials within the last 3 months and anthropometric measurements were collected for all study subjects. Variables extracted from the questionnaire were analysed using statistic regression models to estimate the risk of carriage. All pneumococcal isolates were examined with susceptibility testing, serotyping and multilocus sequence typing. RESULTS The overall prevalence of asymptomatic carriage was high and peaking at 36 months with a rate of 57%. PCV-13 covered 67.3% of the detected strains. High rates of non-susceptibility to penicillin, macrolides and multidrug resistance were associated with specific vaccine serotypes, pandemic clones, and local sequence types. Nine percent of isolates represented three globally disseminated disease-associated pandemic clones; penicillin- and macrolide-resistant clones NorwayNT-42 and Poland6B-20, as well as penicillin- and macrolide-susceptible clone Netherlands3-31. A high level of antimicrobial consumption was noted by the study. According to the parent's reports, 89.5% of the children used at least one antimicrobial regime since birth. None of the hypothesised predictors of S. pneumoniae carriage were statistically significant in univariable and multivariable logistic models. CONCLUSIONS The study identified a high coverage of the PCV-13-vaccine, but serotype replacement and expansion of globally disseminated disease-associated clones with non-vaccine serotypes may be expected. Further surveillance of antimicrobial resistance and serotype distribution is therefore required.
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Affiliation(s)
- V Vorobieva S Jensen
- Research Group for Host-Microbe Interaction, Department of Medical Biology, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway. .,Department of Virus and Microbiological Special Diagnostics, Division of Infectious Disease Preparedness, Statens Serum Institut, Artillerivej 5, DK-2300, Copenhagen S, Denmark.
| | - A-S Furberg
- Faculty of Health and Social Sciences, Molde University College, Molde, Norway.,Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
| | - H-C Slotved
- Department of Bacteria, Parasites and Fungi, Division of Infectious Disease Preparedness, Statens Serum Institute, Copenhagen, Denmark
| | - T Bazhukova
- Department of Clinical Biochemistry, Microbiology and Laboratory Diagnostics, Northern State Medical University, Arkhangelsk, Russia
| | - B Haldorsen
- Norwegian national advisory unit on detection of antimicrobial resistance, Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
| | - D A Caugant
- Division of Infection Control and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway
| | - A Sundsfjord
- Research Group for Host-Microbe Interaction, Department of Medical Biology, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway.,Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway.,Norwegian national advisory unit on detection of antimicrobial resistance, Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
| | - P Valentiner-Branth
- Infectious Disease Epidemiology and Prevention, Statens Serum Institut, Copenhagen, Denmark
| | - G S Simonsen
- Research Group for Host-Microbe Interaction, Department of Medical Biology, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway.,Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway.,Norwegian national advisory unit on detection of antimicrobial resistance, Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
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14
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Dayie NTKD, Tettey EY, Newman MJ, Bannerman E, Donkor ES, Labi AK, Slotved HC. Pneumococcal carriage among children under five in Accra, Ghana, five years after the introduction of pneumococcal conjugate vaccine. BMC Pediatr 2019; 19:316. [PMID: 31488088 PMCID: PMC6727402 DOI: 10.1186/s12887-019-1690-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/26/2019] [Indexed: 12/03/2022] Open
Abstract
Background The study objective was to determine the carriage and serotype distribution of Streptococcus pneumoniae among children in Accra, Ghana, five years after the introduction of the pneumococcal conjugate vaccine (PCV-13) in 2012. Methods Nasopharyngeal swab samples were collected from 410 children below 5 years of age in Accra, Ghana, from September to December, 2016. Pneumococcal isolates were identified by optochin sensitivity and bile solubility. Serotyping was performed using the latex agglutination kit and Quellung reaction. The isolates were furthermore tested for antimicrobial susceptibility for different antimicrobials, including penicillin (PEN). Twelve isolates including seven non-typeable (NT) isolates were characterized using whole-genome sequencing analysis (WGS). Results The overall carriage prevalence was found to be 54% (95% CI, 49–59%), and 20% (95% CI, 49–59%) of the children were carrying PCV-13 included serotypes, while 37% (95% CI, 33–42%) of the children were carrying non-PCV-13 serotypes. Based on the serotype distribution, 33% of all observed serotypes were included in PCV-13 while 66% were non-PCV-13 serotypes. The dominating non-PCV-13 serotypes were 23B, 16F, and 11A followed by PCV-13 serotypes 23F and 19F. The PCV-13 covers the majority of resistant isolates in Accra. A proportion of 22.3% of the isolates showed intermediate resistance to penicillin G, while only one isolate showed full resistance. Forty-five isolates (20.5%) were defined as multidrug-resistant (MDR) as they were intermediate/resistant to three or more classes of antimicrobials. Of the seven NT isolates characterized by WGS, four showed highest match to genotype 38, while the remaining three showed highest match to genotype 14. Four MDR serotype 19A isolates were found to be MLST 320. Conclusion PCV-13 introduced in Ghana did not eliminate PCV-13 covered serotypes, and the carriage rate of 54% in this study is similar to carriage studies from pre PCV-13 period. However, the penicillin non-susceptible isolates have been reduced from 45% of carriage isolates before PCV-13 introduction to 22.3% of the isolates in this study. Continuous monitoring of serotype distribution is important, and in addition, an evaluation of an alternative vaccination schedule from 3 + 0 to 2 + 1 will be important to consider. Electronic supplementary material The online version of this article (10.1186/s12887-019-1690-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicholas T K D Dayie
- Dept. of Medical Microbiology, School of Biomedical and Allied Health Sciences University of Ghana, Accra, Ghana
| | - Elizabeth Y Tettey
- Dept. of Medical Microbiology, School of Biomedical and Allied Health Sciences University of Ghana, Accra, Ghana
| | - Mercy J Newman
- Dept. of Medical Microbiology, School of Biomedical and Allied Health Sciences University of Ghana, Accra, Ghana
| | - Elizabeth Bannerman
- Dept. of Medical Microbiology, School of Biomedical and Allied Health Sciences University of Ghana, Accra, Ghana
| | - Eric S Donkor
- Dept. of Medical Microbiology, School of Biomedical and Allied Health Sciences University of Ghana, Accra, Ghana
| | - Appiah-Korang Labi
- Dept. of Medical Microbiology, School of Biomedical and Allied Health Sciences University of Ghana, Accra, Ghana
| | - Hans-Christian Slotved
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Artillerivej 5, DK-2300, Copenhagen, Denmark.
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15
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Neves FPG, Cardoso NT, Cardoso CAA, Teixeira LM, Riley LW. Direct effect of the 13-valent pneumococcal conjugate vaccine use on pneumococcal colonization among children in Brazil. Vaccine 2019; 37:5265-5269. [PMID: 31337592 DOI: 10.1016/j.vaccine.2019.07.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 07/09/2019] [Accepted: 07/16/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND The 13-valent pneumococcal conjugate vaccine (PCV13) has been commercially available in Brazil since 2010. We investigated the carriage prevalence, capsular types, and antimicrobial resistance among pneumococci isolated from children immunized with PCV13 in Brazil. METHODS We analyzed 500 children < 6 years old attending public (n = 270) and private (n = 230) clinics in Niterói/RJ, Brazil, in 2014. We determined the antimicrobial susceptibility and capsular types for all isolates. RESULTS Thirty-eight (7.6%) of 500 children had received at least one PCV13 dose. Since only two (0.7%) of 270 children at the public clinic were vaccinated with PCV13, major analyses focused on 36 (15.7%) of 230 children attending private clinics. Nine (25%) of 36 children were pneumococcal carriers. Characteristics associated with carriage were age ≥ 2 years, cough/expectoration, and childcare center attendance (p ≤ 0.01). The capsular types found were 15B/C (n = 2), 6C, 11A/D, 16F, 23A, and 23F. Two isolates were non-typeable (NT). Three (33.3%) isolates were multidrug resistant. We found four (44.4%) penicillin non-susceptible pneumococci, with penicillin and ceftriaxone MICs ranging from 0.12 to 4.0 µg/ml and 0.023-0.5 µg/ml, respectively. We also detected two (22.2%) erythromycin-resistant isolates (MICs of 3.0 and 256 µg/ml). CONCLUSIONS Colonization with PCV13 serotype was rare among the vaccinated children. Increasing PCV13 coverage might help reduce the frequency of major serotypes currently associated with invasive pneumococcal diseases in Brazil, such as 3 and 19A. The isolation of multidrug-resistant serotype 6C and NT isolates in carriage, however, requires close monitoring.
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Affiliation(s)
- Felipe P G Neves
- Instituto Biomédico, Universidade Federal Fluminense, Rua Professor Hernani Melo, 101. São Domingos, Niterói, RJ 24210-130, Brazil.
| | - Nayara T Cardoso
- Instituto Biomédico, Universidade Federal Fluminense, Rua Professor Hernani Melo, 101. São Domingos, Niterói, RJ 24210-130, Brazil
| | - Claudete A A Cardoso
- Faculdade de Medicina, Universidade Federal Fluminense, Av. Marquês do Paraná, 303. Centro, Niterói, RJ 24033-900, Brazil.
| | - Lúcia M Teixeira
- Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Av. Carlos Chagas Filho, 373 - bloco I, Cidade Universitária, Ilha do Fundão, Rio de Janeiro, RJ 21941-902, Brazil.
| | - Lee W Riley
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, 530E Li Ka Shing Center, Berkeley, CA 94720, USA.
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16
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Whole-Genome Sequencing Analysis of Multidrug-Resistant Serotype 15A Streptococcus pneumoniae in Japan and the Emergence of a Highly Resistant Serotype 15A-ST9084 Clone. Antimicrob Agents Chemother 2019; 63:AAC.02579-18. [PMID: 30803976 DOI: 10.1128/aac.02579-18] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/13/2019] [Indexed: 11/20/2022] Open
Abstract
Since the introduction of pneumococcal conjugate vaccines (PCVs), an increase in the incidence of disease attributable to serotype 15A-ST63 (sequence type 63) pneumococci has been observed in many regions worldwide. We conducted a nationwide pediatric pneumococcal infection surveillance study between 2012 and 2014 in Japan. In the surveillance study, we detected multidrug-resistant serotype 15A-CC63 (clonal complex 63) strains (resistant to macrolides, penicillin, cefotaxime, and meropenem); in this study, we analyzed these resistant isolates to determine the dynamics and mechanism of resistance using whole-genome sequencing. In most of the penicillin-, cefotaxime-, and meropenem-resistant strains, recombination occurred in the pbp2x region, resulting in the acquisition of cefotaxime resistance in addition to penicillin and meropenem resistance. In the multidrug-resistant serotype 15A-CC63 strains, we identified a specific clone with ST9084, and all of the isolates were recovered from the Yamaguchi prefecture in Japan. All of the serotype 15A-ST9084 isolates had a novel pbp2x type (pbp2x-JP3) that was inserted by recombination events. The conserved amino acid motif profiles of pbp1a, pbp2b, and pbp2x of the strains were identical to those of serotype 19A-ST320. A Bayesian analysis-based date estimation suggested that this clone emerged in approximately 2002 before the introduction of the PCV in Japan. This clone should be monitored because serotype 15A is not contained in the currently used 13-valent PCV (PCV13), and it was resistant to beta-lactams, which are often used in a clinical setting.
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17
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Sader HS, Mendes RE, Le J, Denys G, Flamm RK, Jones RN. Antimicrobial Susceptibility of Streptococcus pneumoniae from North America, Europe, Latin America, and the Asia-Pacific Region: Results From 20 Years of the SENTRY Antimicrobial Surveillance Program (1997-2016). Open Forum Infect Dis 2019; 6:S14-S23. [PMID: 30895211 PMCID: PMC6419902 DOI: 10.1093/ofid/ofy263] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background The SENTRY Antimicrobial Surveillance Program monitors the frequency of occurrence and antimicrobial susceptibility of organisms from various infection types worldwide. In this investigation, we evaluated the antimicrobial susceptibility of Streptococcus pneumoniae isolates collected worldwide over 20 years (1997–2016). Methods A total of 65 993 isolates were consecutively collected (1 per infection episode) from North America (NA; n = 34 626; 2 nations), Europe (EUR; n = 19 123; 23 nations), the Asia-Pacific region (APAC; n = 7111; 10 nations), and Latin America (LATAM; n = 5133; 7 nations) and tested for susceptibility using reference broth microdilution methods. Resistant subgroups included multidrug-resistant (MDR; nonsusceptible to ≥3 classes of agents) and extensively drug-resistant (XDR; nonsusceptible to ≥5 classes). Results The isolates were collected primarily from respiratory tract infections (77.3%), and 25.4% were from pediatric patients. Penicillin susceptibility (≤0.06 mg/L) rates varied from 70.7% in EUR to 52.4% in APAC for all years combined. In NA, there was a slight improvement in susceptibility for the first few years of the program, from 66.5% in 1997–1998 to 69.4% in 1999–2000, followed by a decline until 2011–2012 (57.0%). Similar declines in penicillin susceptibility rates were observed in all regions, with the lowest rates of 67.3% in EUR (2011–2012), 41.6% in the APAC region (2007–2008), and 48.2% in LATAM (2013–2014). These declines were followed by improved susceptibility rates in all regions in later program years, with susceptibility rates of 55.6% to 71.8% in 2015–2016 (65.8% overall). Susceptibility rates to ceftriaxone, erythromycin, clindamycin, tetracycline, and trimethoprim-sulfamethoxazole followed a similar pattern, with a decrease in the first 12–14 years and a continued increase in the last 6–8 years of the program. MDR and XDR frequencies were highest in APAC (49.8% and 17.3% overall, respectively) and lowest in LATAM (10.8% and 1.9% overall, respectively). The most active agents for MDR/XDR isolates were ceftaroline (99.7%/99.1% susceptible), tigecycline (96.8%/95.9% susceptible), linezolid (100.0%/100.0% susceptible), and vancomycin (100.0%/100.0% susceptible). Conclusions S. pneumoniae susceptibility to many antibiotics increased in all regions in the last few years, and these increases may be related to PCV13 immunization, which was introduced in 2010.
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Affiliation(s)
| | | | - Jennifer Le
- Skaggs School of Pharmacy, University of California San Diego, San Diego, California
| | - Gerald Denys
- Indiana University School of Medicine, Indianapolis, Indiana
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Pinto TCA, Neves FPG, Souza ARV, Oliveira LMA, Costa NS, Castro LFS, Mendonça-Souza CRDV, Peralta JM, Teixeira LM. Evolution of Penicillin Non-susceptibility Among Streptococcus pneumoniae Isolates Recovered From Asymptomatic Carriage and Invasive Disease Over 25 years in Brazil, 1990-2014. Front Microbiol 2019; 10:486. [PMID: 30930879 PMCID: PMC6427062 DOI: 10.3389/fmicb.2019.00486] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 02/25/2019] [Indexed: 12/02/2022] Open
Abstract
Streptococcus pneumoniae is a major cause of community-acquired pneumonia and meningitis, and it is also found as a commensal, colonizing the human upper respiratory tract of a portion of the human population. Its polysaccharide capsule allows the recognition of more than 90 capsular types and represents the target of the currently available pneumococcal conjugate vaccines (PCVs), such as the 10-valent (PCV10) and the 13-valent (PCV13). Penicillin non-susceptible pneumococci (PNSP) have been listed as one of the current major antimicrobial-resistant pathogen threats. In Brazil, the emergence of PNSP was initially detected in the mid 1990s and PCV10 has been part of the National Immunization Program since 2010. Here, we investigated the distribution of capsular types and penicillin susceptibility profiles of 783 pneumococcal strains isolated in Brazil between 1990 and 2014 to assess the evolution of penicillin non-susceptibility among pneumococci associated with asymptomatic carriage and invasive pneumococcal disease (IPD). The most common serotypes among carriage isolates were 19F, 6B, 6C, 23F, and 14. Among IPD isolates, the most frequent types were 14, 3, 6B, 5, 19F, and 4. We detected 21 types exclusively associated with IPD isolates, whereas non-typeable (NT) isolates were only detected in carriage. Nearly half of the isolates belonged to PCV10 serotypes, which remarkably decreased in occurrence (by nearly 50%) after PCV10 introduction (2011–2014), while non-PCV10 serotypes increased. PNSP frequency and levels were much higher among carriage isolates, but PNSP belonging to PCV10 serotypes were more common in IPD. While the occurrence of PNSP has decreased significantly among IPD isolates since 2011, it kept increasing among carriage strains. Such a difference can be attributed to the serotypes that emerged in each clinical source after PCV10 usage. PNSP with multidrug resistance profiles that emerged within carriage isolates comprised mostly serotypes 6C and 35B, as well as NT isolates. In turn, penicillin-susceptible capsular types 3, 20, and 8 have risen among IPD. Overall, our results reinforce the relevance of PNSP surveillance over a long period of time to better understand the dynamics of antimicrobial resistance in response to PCV introduction and may also contribute to improve control measures toward drug-resistant pneumococci.
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Affiliation(s)
- Tatiana Castro Abreu Pinto
- Instituto de Microbiologia Paulo de Goes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Aline Rosa Vianna Souza
- Instituto de Microbiologia Paulo de Goes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Natália Silva Costa
- Instituto de Microbiologia Paulo de Goes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - José Mauro Peralta
- Instituto de Microbiologia Paulo de Goes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lúcia Martins Teixeira
- Instituto de Microbiologia Paulo de Goes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Milho C, Andrade M, Vilas Boas D, Alves D, Sillankorva S. Antimicrobial assessment of phage therapy using a porcine model of biofilm infection. Int J Pharm 2018; 557:112-123. [PMID: 30590127 DOI: 10.1016/j.ijpharm.2018.12.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/03/2018] [Accepted: 12/04/2018] [Indexed: 12/17/2022]
Abstract
Antibiotic resistant bacterial communities persist in many types of wounds, chronic wounds in particular, in the form of biofilms. Biofilm formation is a major cause of severe infections and the main reason for a negative treatment outcome and slow healing progression. Chronic wounds are a silent epidemic essentially affecting people with co-morbid conditions such as diabetes and obesity and elderly persons particularly those with movement limitations. The development of complementary and alternative effective strategies to antibiotics for the treatment of chronic wounds is highly desired. Phage therapy constitutes a very promising approach in the control of topical microbial populations. In this work newly isolated phages were tested for their efficacy to control bacterial species that predominate in chronic wounds. Phage effectiveness was studied on 24-h old biofilms formed in polystyrene microplates and in porcine skin explants using two treatment approaches: individual phage and a cocktail of phages against four main pathogens commonly isolated from chronic wounds. The two models produced variations in the surface colonization ability, assessed by viable bacterial counts and microscopy visualization after using peptide nucleic acid (PNA) or locked nucleic acid probes (LNA) and 2'-O-methyl (2'-OMe) in fluorescence in situ hybridization (FISH), and in the phage-host interactions. Phages alone and combined caused greater reductions in the number of viable cells when biofilms had been formed on porcine skins and with greater variations detected at 4 h and 24 h of sampling. These results suggest that porcine skin models should be preferentially used to assess the use of phages and phage cocktails intended for topical use in order to understand the fate, throughout treatment time, of the population when dealing with biofilm-related infections.
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Affiliation(s)
- C Milho
- Centre of Biological Engineering, LIBRO - Laboratório de Investigação em Biofilmes Rosário Oliveira, University of Minho, 4710-057 Braga, Portugal
| | - M Andrade
- Centre of Biological Engineering, LIBRO - Laboratório de Investigação em Biofilmes Rosário Oliveira, University of Minho, 4710-057 Braga, Portugal
| | - D Vilas Boas
- Centre of Biological Engineering, LIBRO - Laboratório de Investigação em Biofilmes Rosário Oliveira, University of Minho, 4710-057 Braga, Portugal
| | - D Alves
- Centre of Biological Engineering, LIBRO - Laboratório de Investigação em Biofilmes Rosário Oliveira, University of Minho, 4710-057 Braga, Portugal
| | - S Sillankorva
- Centre of Biological Engineering, LIBRO - Laboratório de Investigação em Biofilmes Rosário Oliveira, University of Minho, 4710-057 Braga, Portugal.
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Birindwa AM, Emgård M, Nordén R, Samuelsson E, Geravandi S, Gonzales-Siles L, Muhigirwa B, Kashosi T, Munguakonkwa E, Manegabe JT, Cibicabene D, Morisho L, Mwambanyi B, Mirindi J, Kabeza N, Lindh M, Andersson R, Skovbjerg S. High rate of antibiotic resistance among pneumococci carried by healthy children in the eastern part of the Democratic Republic of the Congo. BMC Pediatr 2018; 18:361. [PMID: 30453916 PMCID: PMC6241069 DOI: 10.1186/s12887-018-1332-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 10/31/2018] [Indexed: 12/02/2022] Open
Abstract
Background Pneumococcal conjugate vaccines have been introduced in the infant immunisation programmes in many countries to reduce the rate of fatal pneumococcal infections. In the Democratic Republic of the Congo (DR Congo) a 13-valent vaccine (PCV13) was introduced in 2013. Data on the burden of circulating pneumococci among children after this introduction are lacking. In this study, we aimed to determine the risk factors related to pneumococcal carriage in healthy Congolese children after the vaccine introduction and to assess the antibiotic resistance rates and serotype distribution among the isolated pneumococci. Methods In 2014 and 2015, 794 healthy children aged one to 60 months attending health centres in the eastern part of DR Congo for immunisation or growth monitoring were included in the study. Data on socio-demographic and medical factors were collected by interviews with the children’s caregivers. Nasopharyngeal swabs were obtained from all the children for bacterial culture, and isolated pneumococci were further tested for antimicrobial resistance using disc diffusion tests and, when indicated, minimal inhibitory concentration (MIC) determination, and for serotype/serogroup by molecular testing. Results The pneumococcal detection rate was 21%, being higher among children who had not received PCV13 vaccination, lived in rural areas, had an enclosed kitchen, were malnourished or presented with fever (p value < 0.05). The predominant serotypes were 19F, 11, 6A/B/C/D and 10A. More than 50% of the pneumococcal isolates belonged to a serotype/serogroup not included in PCV13. Eighty per cent of the isolates were not susceptible to benzylpenicillin and non-susceptibility to ampicillin and ceftriaxone was also high (42 and 37% respectively). Almost all the isolates (94%) were resistant to trimethoprim-sulphamethoxazole, while 43% of the strains were resistant to ≥3 antibiotics. Conclusions Our study shows alarmingly high levels of reduced susceptibility to commonly used antibiotics in pneumococci carried by healthy Congolese children. This highlights the importance of local antibiotic resistance surveillance and indicates the needs for the more appropriate use of antibiotics in the area. The results further indicate that improved living conditions are needed to reduce the pneumococcal burden, in addition to PCV13 vaccination. Electronic supplementary material The online version of this article (10.1186/s12887-018-1332-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Archippe M Birindwa
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden. .,Panzi Hospital, Bukavu, Democratic Republic of the Congo. .,Université Evangélique en Afrique, Bukavu, Democratic Republic of the Congo. .,Hôpital Général de Référence de Panzi, BP: 266, Bukavu, DR, Congo.
| | - Matilda Emgård
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Rickard Nordén
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Ebba Samuelsson
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Shadi Geravandi
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Lucia Gonzales-Siles
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | | | - Théophile Kashosi
- Université Evangélique en Afrique, Bukavu, Democratic Republic of the Congo
| | | | | | | | | | | | | | - Nadine Kabeza
- Panzi Hospital, Bukavu, Democratic Republic of the Congo
| | - Magnus Lindh
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Rune Andersson
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden.,CARe - Center for Antibiotic Resistance Research, Gothenburg University, Gothenburg, Sweden
| | - Susann Skovbjerg
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
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