Active hospital-based surveillance in the city of Salvador, Brazil, from December 1995 through October 1998, identified 221 patients with confirmed pneumococcal meningitis. Of these 221 patients, 29 (13%) had isolates with intermediate-level resistance to penicillin. Infection with these penicillin-nonsusceptible isolates was significantly associated with age of <2 years (P<.0019), previous antibiotic use (P<.0006), and coresistance to trimethoprim-sulfamethoxazole (P<.0000). Serotype 14 was the most prevalent serotype (55.2%) of penicillin-nonsusceptible isolates. Strain typing by repetitive element BOX polymerase chain reaction (PCR) analysis showed that penicillin-nonsusceptible serotype 14 isolates had closely related BOX PCR patterns, whereas penicillin-susceptible serotype 14 isolates each had distinct, unrelated patterns. Penicillin-nonsusceptible serotype 14 isolates from Salvador and other Brazilian cities had similar BOX PCR patterns. These observations indicate that in Brazil a large proportion of cases of penicillin-nonsusceptible pneumococcal meningitis appear to be caused by a closely related group of serotype 14 strains that may have disseminated to widely separate geographic areas.

Penicillin-nonsusceptible strains were isolated from 15% of 303 individuals with pneumococcal meningitis identified during a 4-year surveillance study in Salvador, Brazil. The estimated rate of coverage of the seven-valent conjugate vaccine was 74% among patients <5 years of age and 94% among those infected with nonsusceptible isolates, indicating that the use of conjugate vaccines may be an approach to the control of emerging penicillin resistance in Brazil.Pneumococcal disease is responsible for over 1 million deaths each year in children under 5 years of age (22). Its public health impact has been further compounded by the global emergence of penicillin-resistant Streptococcus pneumoniae (1). Resistant strains have been isolated in all continents (1) and in several countries; over 50% of the clinical isolates demonstrate high-level resistance to penicillin (7,19).With the emergence of penicillin resistance, it is ever more urgent that surveillance be implemented in developing countries, where conditions of poverty contribute to an already large burden of pneumococcal disease (25,26). In Latin America, surveys of reference collections of isolates (13, 24) and laboratory-based surveillance (2, 3, 5, 15) have documented penicillin resistance in up to 20% of clinical isolates. However, significant variabilities in antimicrobial susceptibility and serotype patterns have been observed between and within countries (2, 3, 15). These findings may be due, in part, to regional differences in case ascertainment and isolation procedures (12) and emphasize the importance of population-based information in guiding antibiotic control strategies and national vaccine policies.Active surveillance for pneumococcal meningitis was established at the state infectious disease hospital in the city of Salvador, Brazil. The state health secretary requires that suspected cases of meningitis from the metropolitan region be referred to that hospital, and more than 95% of the reports of meningitis from the region are reported from that site (secretary of health for the state of Bahia, unpublished case notification records). Therefore, patients referred to that hospital represent patients with population-based cases of meningitis occurring in this city. Between December 1995 and November 1999, 317 patients were consecutively identified with cerebrospinal fluid cultures positive for S. pneumoniae, as determined by morphology on Gram staining of smears, susceptibility to optochin (Difco Laboratories, Detroit, Mich.), and bile solubility (BBL Microbiology Systems, Cockeysville, Md.). After enrollment of patients by protocols approved by the institutional review boards of the Brazilian Ministry of Health and Weill Medical College of Cornell University, information on the demographic characteristics and the clinical presentations of the patients was obtained for 305 patients (97% of 317 patients) during interviews or medical chart review. On the basis of the fact that 140 patients who resided within the municipal borders of Salvador (population ...