Invasive pneumococcal disease burden in hospitalized adults in Bogota, Colombia

Epidemiology and clinical burden of invasive pneumococcal disease in older adults in the city of São Paulo, Brazil

BACKGROUND

The Brazilian National Immunization Program does not offer universal pneumococcal vaccination for older adults. We evaluated the incidence, demographics, clinical characteristics, and outcomes of older adults with IPD in São Paulo, Brazil.

METHODS

A retrospective chart review of 94 adults aged 60+ hospitalized with IPD from 2016 to 2018 was conducted. Descriptive statistics summarized demographic and clinical data. Incidence was calculated by dividing the number of IPD patients in São Paulo by the population of individuals aged 60+ using the study hospitals.

RESULTS

Most patients had at least one risk factor, with cancer being the most common. Ninety percent had unknown vaccination status. The incidence rate per 100,000 people declined over the study period. Community-onset disease and bacteremic pneumonia were prevalent, while meningitis occurred in a smaller percentage. Hospitalization lasted a median of ten days, with 53 % of patients requiring ICU admission. Complications, supplemental oxygen, mechanical ventilation, and septic shock were observed during hospitalization. The case fatality rate for IPD was 43 %.

CONCLUSION

The study highlights the significant burden of IPD in older adults in São Paulo and emphasizes the importance of extending pneumococcal vaccination to this population in Brazil to address the associated morbidity, mortality, and healthcare burden.

Pediatric invasive pneumococcal disease in Bolívar, Colombia: a descriptive cross-sectional study

Introduction

Invasive pneumococcal disease (IPD) remains a pediatric health challenge despite national vaccination efforts in Colombia. We described the socio-demographic, epidemiological, and clinical characteristics of children (<18 years of age) with IPD at a pediatric reference center in Bolívar, Colombia.

Methods

Descriptive cross-sectional study of all pediatric patients (under 18 years of age) diagnosed with IPD between 2016 and 2023. Data was collected retrospectively from medical records. IPD was defined as identifying Streptococcus pneumoniae (Spn) in blood, cerebrospinal, pleural, synovial, peritoneal, or pericardial fluid. Spn serotyping data was provided by the Colombian National Institute of Health. Descriptive statistics were performed to describe all variables.

Results

Between 2016-2023, we identified fifty-four pediatric IPD cases. Most cases were reported among children in the 2-9 age group (44.4%), male sex (57.4%), low socio-economic strata (100%), and previous medical conditions (61.1%). Half of the patients were vaccinated. Serotyping data were available from 35 (64.8%) isolates. Fifteen Spn serotypes were identified, Spn19A being the most frequent (20.4%). All Spn isolates were vancomycin sensitive, while 34% had meropenem-decreased sensitivity. Three-quarters of the patients (76.0%) were diagnosed with bacteremia (bacteremic pneumonia/meningitis and bacteremia without known focus). The 79.6% of children were admitted to the pediatric intensive care unit (PICU). The median hospitalization days were 13.5 (IQR 5.5-23.5) while the median PICU length of stay was 9.5 (IQR 4-18) days. Nineteen patients died (35.2%).

Conclusion

IPD disproportionately affects vulnerable children, resulting in high PICU admission and mortality rates and prolonged hospital stay in Bolívar, Colombia. In addition, the emergence of resistance to carbapenems is of concern.

Serotype distribution of invasive pneumococcal disease from countries of the WHO Africa, Americas, Eastern Mediterranean, South-East Asia, and Western Pacific regions: a systematic literature review from 2010 to 2021

Background

Most publications on invasive pneumococcal disease (IPD) serotype distribution are from about 20 countries (Australia, Canada, China, European Union members, Japan, New Zealand, South Korea, and USA). Here, we reviewed the literature among underrepresented countries in the Americas (AMRO), Africa (AFRO), Eastern Mediterranean (EMRO), South-East Asia (SEARO), and Western Pacific (WPRO) WHO regions.

Methods

We performed a systematic review of the most recent IPD serotype surveillance publications (from 01/01/2010 to 31/12/2021, Medline/Embase) in those WHO regions. Selection criteria were delineated by contemporality, within-country geographical scope, and number of samples. Reported serotype distributions for each country were stratified by age group, pneumococcal conjugate vaccine (PCV) serotype category (considering undifferentiated serotypes), and PCV program period (pre-PCV, intermediate, or PCVhv [higher valency PCV formulation]). Pre-PCV period pooled data estimated PCV serotype category distribution by age group across WHO regions, while for the PCVhv period, country-level dataset tables were prepared.

Results

Of 2,793 publications screened, 107 were included (58 pediatric, 11 adult, 37 all ages, and one comprising every age group). One-third of eligible countries (51/135) published serotype distribution, ranging from 30 to 43% by WHO region. Considering number of samples per WHO region, a few countries prevailed: AMRO (Brazil), AFRO (South Africa, Malawi, and Burkina Faso), and WPRO (Taiwan). In the pre-PCV period, PCV13 formulation serotypes predominated: ranging from 74 to 85% in children and 58-86% in adults in the different WHO regions. The PCVhv period represented half of the most recent IPD surveillance by countries (26/51). Undifferentiated serotypes represented >20% of IPD from most countries (34/51).

Conclusion

Ubiquity of undifferentiated serotypes among the publications could constrain estimates of PCV program impact and of serotype coverage for newer PCVhv formulations; consequently, we recommend that countries favor techniques that identify serotypes specifically and, rather than reporting PCV formulation serotype distributions, provide serotype results individually.

Systematic review registration

The protocol has been prospectively registered at PROSPERO, identifier: CRD42021278501. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=278501.

Invasive pneumococcal disease in Latin America and the Caribbean: Serotype distribution, disease burden, and impact of vaccination. A systematic review and meta-analysis

BACKGROUND

Invasive pneumococcal diseases (IPD) are associated with high morbidity, mortality, and health costs worldwide, particularly in Latin America and the Caribbean (LAC). Surveillance about the distribution of serotypes causing IPD and the impact of pneumococcal vaccination is an important epidemiological tool to monitor disease activity trends, inform public health decision-making, and implement relevant prevention and control measures.

OBJECTIVES

To estimate the serotype distribution for IPD and the related disease burden in LAC before, during, and after implementing the pneumococcal vaccine immunization program in LAC.

METHODS

Systematic literature review following Cochrane methods of studies from LAC. We evaluated the impact of the pneumococcal vaccine on hospitalization and death during or after hospitalizations due to pneumococcal disease and serotype-specific disease over time. We also analyzed the incidence of serotyped IPD in pneumococcal conjugate vaccine PCV10 and PCV13. The protocol was registered in PROSPERO (ID: CRD42023392097).

RESULTS

155 epidemiological studies were screened and provided epidemiological data on IPD. Meta-analysis of invasive diseases in children <5 years old found that 57%-65% of causative serotypes were included in PCV10 and 66%-84% in PCV13. After PCV introduction, vaccine serotypes declined in IPD, and the emergence of non-vaccine serotypes varied by country.

CONCLUSIONS

Pneumococcal conjugate vaccines significantly reduced IPD and shifted serotype distribution in Latin America and the Caribbean. PCV10/PCV13 covered 57-84% of serotypes in children under 5, with marked decline in PCV serotypes post-vaccination. Continuous surveillance remains crucial for monitoring evolving serotypes and informing public health action.

Streptococcus pneumoniae as a colonizing agent of the Nasopharynx - Oropharynx in adults: A systematic review and meta-analysis

BACKGROUND

Streptococcus pneumoniae (Spn) is a commensal pathogen that usually colonizes the upper respiratory tract of children. Likewise, Spn colonization has been considered a critical factor in the development of pneumococcal invasive disease. However, Spn prevalence in adults remains unclear. This study performs a systematic review and meta-analysis to explore the prevalence of Spn Nasopharynx - Oropharynx Colonization (NOC) in adults.

METHODS

A Systematic review of scientific databases was utilized to identify eligible studies that follow strict selection criteria. Subsequently, a meta-analysis was conducted to establish NOC prevalence in adults (≥18 years old). The heterogeneity and sensitivity analyses were assessed using the microorganism identification technique, sample type, and age subgroups.

RESULTS

Initial selection includes 69 studies, with 37 selected for the meta-analysis, involving 23,724 individuals. The overall prevalence (95 % CI) of Spn NOC among adults was 6 % (5-9). The subgroup analysis revealed that young adults (YA), 18-64 years old, had a prevalence of 10 %, whereas older adults (OA), ≥65 years old, had a prevalence of 2 %. The identification of Spn NOC may vary depending on the method of diagnosis used. High heterogeneity (I2 > 90 %) was observed but diminished to 70 % when the analysis was restricted to oropharyngeal swabs as an identification method. Furthermore, heterogeneity decreased to 58 % when exclusively employing traditional culture as the identification method.

CONCLUSIONS

This study found a low prevalence of Spn NOC in adults. Notably, the prevalence of Spn NOC was higher in younger adults than in older adults. It is essential to highlight a significant heterogeneity among studies, which indicates there is no standardized method of Spn NOC identification.

The potential impact of PCV-13, PCV-15 and PCV-20 vaccines in Colombia

PURPOSE

To provide information about which pneumococcal vaccine could have greater coverage in Colombia.

METHODS

This is a retrospective analysis of patients diagnosed with invasive pneumococcal disease (IPD) between 2015 and 2019 in Bogotá, Colombia. We compared the theoretical serotype coverage of the available anti-pneumococcal vaccines (i.e., PCV-10, PCV-10 SII, PCV-13, PCV-15, PCV-20, PCV-21, PCV24, PPSV-23) and the non-vaccine-covered serotypes stratified by age.

RESULTS

690 IPD cases were included. In children ≤5 y/o, of the approved vaccines PCV-20 showed the most theoretical protection (71.3 % [149/209]), while in adults aged 18-64 y/o was PCV-20 (61.8 % [164/265]), and in those ≥65 y/o was PPSV-23 (58.1 % [100/172]) followed by PCV-20 (55.2 % [95/172]). The non-covered serotypes represented one-third of the cohort (33.9 % [234/690]), being 6C (20.5 % [48/234]), 15A (12.8 % [30/234]), and 23A (11.5 % [27/234]) the most prevalent.

CONCLUSION

Introducing PCV-20 for children and PCV-20 along with a PPSV-23 booster in adults may reduce IPD frequency in all ages in Colombia. The inclusion of non-covered serotypes is required for future vaccines.

Antimicrobial resistance of Streptococcus pneumoniae from invasive pneumococcal diseases in Latin American countries: a systematic review and meta-analysis

Background

Invasive pneumococcal disease has declined since pneumococcal conjugate vaccine introduction in Latin America and the Caribbean (LAC). However, serotype distribution and antimicrobial resistance patterns have changed.

Methods

We conducted a systematic review to evaluate the frequency of antimicrobial resistance of Streptococcus pneumoniae from invasive disease in LAC. Articles published between 1 January 2000, and 27 December 2022, with no language restriction, were searched in major databases and gray literature. Pairs of reviewers independently selected extracted data and assessed the risk of bias in the studies. The quality of antimicrobial resistance (AMR) studies was evaluated according to WHO recommendations (PROSPERO CRD42023392097).

Results

From 8,600 records identified, 103 studies were included, with 49,660 positive samples of S. pneumoniae for AMR analysis processed. Most studies were from Brazil (29.1%) and Argentina (18.4%), were cross-sectional (57.3%), reported data on AMR from IPD cases (52.4%), and were classified as moderate risk of bias (50.5%). Resistance to penicillin was 21.7% (95%IC 18.7-25.0, I2: 95.9), and for ceftriaxone/cefotaxime it was 4.7% (95%IC 3.2-6.9, I2: 96.1). The highest resistance for both penicillin and ceftriaxone/cefotaxime was in the age group of 0 to 5 years (32.1% [95%IC 28.2-36.4, I2: 87.7], and 9.7% [95%IC 5.9-15.6, I2: 96.9] respectively). The most frequent serotypes associated with resistance were 14 for penicillin and 19A for ceftriaxone/cefotaxime.

Conclusion

Approximately one-quarter of invasive pneumococcal disease isolates in Latin America and the Caribbean displayed penicillin resistance, with higher rates in young children. Ongoing surveillance is essential to monitor serotype evolution and antimicrobial resistance patterns following pneumococcal conjugate vaccine introduction.

Pneumococcal serotypes and antibiotic resistance in healthy carriage children after introduction of PCV13 in Lima, Peru

OBJECTIVE

To determinate the frequency of Streptococcus pneumoniae nasopharyngeal carriers, serotypes and antimicrobial resistance in healthy children in Lima, Peru, post-PCV13 introduction and to compare the results with a similar study conducted between 2006 and 2008 before PCV7 introduction (pre-PCV7).

METHODS

A cross-sectional multicenter study was conducted between January 2018 and August 2019 in 1000 healthy children under two years of age. We use standard microbiological methods to determinate S. pneumoniae from nasopharyngeal swab, Kirby Bauer and minimum inhibitory concentration methods to determinate antimicrobial susceptibility and whole genomic sequencing to determinate pneumococcal serotypes.

RESULTS

The pneumococcal carriage rate was 20.8 % vs. 31.1 % in pre-PCV7 (p < 0.001). The most frequent serotypes were 15C, 19A and 6C (12.4 %, 10.9 % and 10.9 % respectively). The carriage of PCV13 serotypes after PCV13 introduction decreased from 59.1 % (before PCV7 introduction) to 18.7 % (p < 0.001). Penicillin resistance was 75.5 %, TMP/SMX 75.5 % and azithromycin 50.0 %, using disk diffusion. Penicillin resistance rates using MIC breakpoint for meningitis (MIC ≥ 0.12) increased from 60.4 % to 74.5 % (p = 0.001).

CONCLUSION

The introduction of PCV13 in the immunization program in Peru has decreased the pneumococcal nasopharyngeal carriage and the frequency of PCV13 serotypes; however, there has been an increase in non-PCV13 serotypes and antimicrobial resistance.

Invasive pneumococcal disease in patients from a pediatric hospital in Peru, 2017-2020

OBJECTIVES.

Motivation for the study: there are few reports describing cases of invasive pneumococcal disease after the introduction of the 13-valent conjugate vaccine in Peru. Main findings: cases of invasive pneumococcal disease are still reported in children, more frequently in children under five years of age. The most frequent clinical form was bacteremia and there was greater antibiotic resistance to erythromycin, trimethoprim-sulfamethoxazole, and penicillin. Implications: our findings suggest the need to maintain epidemiological surveillance of invasive pneumococcal disease and to measure the impact of vaccination against pneumococcus in children. This study aimed to describe the clinical characteristics, serotypes, and antibiotic susceptibility in patients with invasive pneumococcal disease (IPD). The medical records of patients with IPD who were hospitalized at the Instituto Nacional de Salud del Niño-Breña (Lima, Peru) were reviewed. We evaluated 29 patients. The median age was 1.9 years (interquartile range: 1 to 4 years). Of the sample, 51.7% were women and the most frequent clinical form of IPD was bacteremia in 18 (62.1%) patients; 65.5% had a complete vaccination schedule, according to the Peruvian Ministry of Health. Germ isolation was performed from blood samples in 82.8% of patients. Antibiotic resistance to erythromycin (55.2%) was the most frequent, followed by resistance to trimethoprim-sulfamethoxazole (48.3%) and penicillin (24.1%). The isolated serotypes were 6C, 19A, 23A and 24F. One patient died of meningitis. In conclusion, IPD was more frequent in children aged one to five years and the most frequent clinical form was bacteremia. Five serotypes reported in previous studies were found to be resistant to penicillin and erythromycin.

Editorial Commentary: Community-acquired pneumonia, comparison of three mortality prediction scores in the emergency department

Successive measurements of global disease burden have documented that lower respiratory tract infections, including pneumonia, are among the top 10 causes of disability-adjusted life-years, and in 2019, pneumonia was the fourth cause of mortality for all ages. In Colombia, acute respiratory infections are the leading cause of mortality within the group of infectious diseases, 52.3% of the total reported between 2005 and 2019. Notably, the COVID-19 epidemic increased the impact of respiratory tract infections on the global disease burden, with estimates of 18 million excess deaths from January 2020 to December 2021 worldwide. The assessment of an adult with pneumonia or suspected pneumonia demands the identification of the likelihood of death and hospitalization. Several scales have been constructed to estimate this probability to improve the predictive capacity of clinical evaluation. Among these scales, the CRB-65 and the CURB-65 standout, being the first recommended for use with clinical criteria and the second when laboratory data such as urea nitrogen are available. Additionally,  for an individual with sepsis, there have been developed to predict mortality, such as  SOFA (Sequential Organ Failure Assessment) and, more recently, the qSOFA(quick SOFA), which has an accurate prediction of mortality in this population. Hincapié C et al. assessed the CURB-65, CRB-65 and SOFA scales to predict mortality and admission to the intensive care unit in adults with pneumonia in three cohorts of patients admitted in three medium- and high-complexity hospitals in the city of Medellin-Colombia. The study included 1110 patients with suspected pneumonia identified in the emergency department and followed up until discharge and death. The authors found that the highest discrimination capacity, measured by the ROC curve, for the outcome hospitalization in an intensive care unit was 0.61, 0.58, and 0.59 for the CURB-65, CRB-65, and SOFA, respectively. About mortality, the ROC found was 0.66, 0.63, and 0.63 for CURB-65, CRB65, and SOFA, respectively. The calibration was appropriate, that is, the ability to predict mortality and admission to the intensive care unit e for the three scales. Some readers have expressed their disagreement with the possible limited use of the scales, particularly the CURB-65 and the CRB-65, in the evaluation of an adult patient with pneumonia expressed by the authors.

Invasive Pneumococcal Disease Characterization in Adults and Subgroups aged < 60 years and ≥ 60 years in Bogota, Colombia

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The clinical burden of IPD is high in the elderly and adults with comorbidities

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IPD placed a high burden on healthcare resources in the adult population

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The most common types causing IPD in adults were similar to those found in children

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Policy makers should consider pneumococcal vaccination for populations at risk

Background

Methods

Results

Conclusions

Increase of Macrolide-Resistance in Streptococcus pneumoniae Strains After the Introduction of the 13-Valent Pneumococcal Conjugate Vaccine in Lima, Peru

Streptococcus pneumoniae upper respiratory infections and pneumonia are often treated with macrolides, but recently macrolide resistance is becoming an increasingly important problem. The 13-valent pneumococcal conjugate vaccine (PCV13) was introduced in the National Immunization Program of Peru in 2015. This study aimed to evaluate the temporal evolution of macrolide resistance in S. pneumoniae isolates collected in five cross-sectional studies conducted before and after this vaccine introduction, from 2006 to 2019 in Lima, Peru. A total of 521 and 242 S. pneumoniae isolates recovered from nasopharyngeal swabs from healthy carrier children < 2 years old (2 carriage studies) and samples from normally sterile body areas from pediatric patients with invasive pneumococcal disease (IPD) (3 IPD studies), respectively, were included in this study. Phenotypic macrolide resistance was detected using the Kirby-Bauer method and/or MIC test. We found a significant increase in macrolide resistance over time, from 33.5% to 50.0% in carriage studies, and from 24.8% to 37.5% and 70.8% in IPD studies. Macrolide resistance genes [erm(B) and mef(A/E)] were screened using PCR. In carriage studies, we detected a significant decrease in the frequency of mef(A/E) genes among macrolide-resistant S. pneumoniae strains (from 66.7% to 50.0%) after introduction of PCV13. The most common mechanism of macrolide-resistant among IPD strains was the presence of erm(B) (96.0%, 95.2% and 85.1% in the 3 IPD studies respectively). Macrolide resistance was more common in serotype 19A strains (80% and 90% among carriage and IPD strains, respectively) vs. non-serotype 19A (35.5% and 34.4% among carriage and IPD strains, respectively). In conclusion, S. pneumoniae macrolide resistance rates are very high among Peruvian children. Future studies are needed in order to evaluate macrolide resistance trends among pneumococcal strains, especially now after the COVID-19 pandemic, since azithromycin was vastly used as empiric treatment of COVID-19 in Peru.