Population-Based Survey of Antimicrobial Susceptibility and Serotype Distribution of Streptococcus pneumoniae from Meningitis Patients in Salvador, Brazil

Abstract

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of the reports of meningitis from the region are reported from that site (secretary of health for the state of Bahia, unpublished case notification records).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 ...

Prevalence of pneumococcal serotypes and resistance to antimicrobial agents in patients with meningitis: ten-year analysis

“…31,32 Serotype 3, associated with severe forms of pneumonia in adults, 13,29 is also an important cause of invasive disease in newborns and infants, justifying its inclusion in a vaccine to protect children under the age of two years. 13 In our survey, serotype 3 is one of the most commonly found in patients with meningitis, and also found in children under the age of two years.…”

“…29 In this study, serotype 18C was detected in children under the age of fi ve years (8.5%) and serotype 19A, in only one patient over that age. Despite its low frequency in Brazil [25][26][27][28][29] and other LatinAmerican countries, serotype 19A is associated with penicillin resistance 13,23,[30][31][32] and is currently an important emerging serotype in the USA, after the release of the heptavalent conjugate vaccine for universal use. 7,13 In this study, the penicillin-resistance rate was 23.6% (17/72 strains) when all age brackets were considered, and 39.4% for ages up to two years (Table 2).…”

“…34 The documented resistance rates for both penicillin and ceftriaxone vary depending on factors, such as geographical location, sample size, time and duration of the assessment, patient's age, and nosology. Usually, resistance tends to predominate in children, 23,[31][32][33] especially in those with meningitis, 23,34 with increasing frequency 23,32,34 and intensity 23 over time in the communities not undergoing universal vaccination.…”

Penicillin Susceptibility and Epidemiological Typing of Invasive Pneumococcal Isolates in the Republic of Ireland

“…These four serotypes accounted for 52.1% of all invasive pneumococcal isolates recovered in 1999 in the Republic of Ireland. These serotypes, among others, have been the most prevalent in studies of IPD in other countries (28,39,41), including England and Wales (34). However, in some countries serotypes 1,6,7,8,19, and 23, along with serotype 14, are the most prevalent (1,5,12,22,43,46).…”

Invasive Pneumococcal Infection in a Healthy Infant Caused by Two Different Serotypes

“…Similarly, in the analysis of 3,066 S. pneumoniae isolates from CSF derived from the Brazilian pneumococcal surveillance system, serotype 23B was identified in only 1% of isolates (2). In contrast, serotype 23F ranks as the second most commonly found serotype in CSF or blood in studies conducted in industrialized countries (1,5) and is the sixth most common serotype in pneumococcal meningitis in children less than 5 years old in Brazil (2,12). The serotype 23B isolate from the CSF of our patient was not only a nonvaccine serotype, it was also not susceptible to penicillin.…”