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The Spread of Multiply Resistant Streptococcus pneumoniae at a Day Care Center in Ohio Mary R. Reichler, Allan A. Allphin, Robert F. Breiman, John R. Schreiber, James E. Arnold, Linda K. McDougal, Richard R. Facklam, Bernard Boxerbaum, Daniel May, Robert O. Walton, and Michael R. Jacobs
Respiratory Diseases Branch. Division ofBacterial and Mycotic Diseases. and Antimicrobics Investigation Branch. Hospital Infections Program. National Center for Infectious Diseases. Centers for Disease Control. Atlanta. Georgia; Departments ofOtolaryngology. Pediatrics. and Pathology. Case Western Reserve University. and Cuyahoga County Health Department. Cleveland. Ohio
Pneumococcal infections are a major cause of morbidity and mortality worldwide. In the United States alone, it is estimated that more than 500,000 cases of pneumonia, 55,000 bacteremias, and 6000 cases of meningitis due to Streptococcus pneumoniae occur annually, with 40,000 deaths [I]. S. pneumoniae is the leading cause ofotitis media, resulting in at least 6 million cases in the United States annually [2]. Strains ofS. pneumoniae resistant to penicillin (MIC, > 1.0 Ilg/mL) and other antimicrobic agents (serotypes 19A and 6A) were first described in 1977 [3, 4] and 1978 [3, 5] in South Africa. Penicillin-resistant pneumococcal strains (type 23F) were reported in Spain in 1987 [6, 7], and resistant types 6A, 14, and 23F have subsequently been described in other European countries [3,6,7-13]. Although there have been occasional reports of infections due to strains of S. pneumoniae intermediately resistant to penicillin (MICs, 0.1-1.0 Ilg/mL) [14-21], including two clusters of meningitis in day care settings [14, 15], infections
Received 2 March 1992; revised 17 June 1992. Presented in part: 91st general meeting of the American Society for Microbiology. May 1991. Dallas (abstract C-373); 11th Lancefield International Symposium on Streptococci and Streptococcal Diseases. September 1990. Siena. Italy (abstract P 157). Written informed consent was obtained from parents of all children before nasopharyngeal cultures were done and before outpatient records at physicians' offices were consulted. Reprints or correspondence: Dr. Mary R. Reichler, Centers for Disease Control. Mailstop E-05. 1600 Clifton Rd .• Atlanta. GA 30333. The Journal of Infectious Diseases 1992;166:1346-53 © 1992 by The Universityof Chicago. All rights reserved. 0022-1899/92/6606-0021 $0 1.00
due to penicillin-resistant pneumococci are rare in the United States [22-26]. Only 1 «0.001 %) of 5459 S. pneumoniae surveillance isolates submitted to the Centers for Disease Control (CDC) between 1979 and 1987 was resistant to penicillin (MIC, > 1.0 Ilg/mL), and none was resistant to chloramphenicol [22]. Penicillin is currently the drug of choice for pneumococcal infections in this country. S. pneumoniae, serotype 23F, resistant to multiple antimicrobial drugs, was isolated in October 1989 from the middle ear fluid of a 17-month-old child with refractory otitis media who attended a day care center in Ohio. The isolate was resistant to penicillin (MIC, 2 ~mL), chloramphenicol, tetracycline, and trimethoprim-sulfamethoxazole. It had decreased susceptibility to cefaclor, cefixime, cefotaxime, and ceftriaxone and was susceptible to erythromycin and vancomycin. Otitis media in young children is usually treated empirically. often with oral antimicrobic agents to which this strain is resistant [27]. Middle ear disease has been correlated in some studies with delays in speech, language, and cognitive development [28, 29], and failure to adequately treat otitis media has been associated with hearing loss and intracranial suppurative sequelae [30,31]. The potential for transmission of respiratory pathogens in day care centers is great [32-35]. Therefore, the presence of this multiply resistant strain of S. pneumoniae in a child at a day care center is of concern. Designing strategies to limit the spread of multiply resistant pneumococcal strains is essential to ensure continued easy and effective treatment of pneumococcal infections. We performed an epidemiologic investigation to determine the extent of spread of this strain and to define risk factors for nasopharyngeal carriage and infection.
Downloaded from http://jid.oxfordjournals.org/ at University of Birmingham on July 14, 2015
Streptococcus pneumoniae, type 23F, resistant to penicillin (MIC, 2 ~g/mL) and multiple other antimicrobic agents, was isolated from middle ear fluid of a child with otitis media attending a day care center in Ohio. To determine the extent of spread of this strain, nasopharyngeal culture surveys were done, and 52 carriers were identified among 250 children attending the index day care center. No carriers were found among 121 children at two other day care centers in the same urban area. Use of prophylactic doses of antibiotics (P < .001) and frequent use of antibiotics (P < .001) were risk factors for nasopharyngeal carriage. Carriers were more likely to have had frequent otitis media episodes (P < .02) and otitis media not responsive to antimicrobial therapy (P < .001). Strategies to limit the spread of highlyresistant pneumococcal strains should include encouraging judicious use of antimicrobic agents and reevaluating indications for prophylactic use of antimicrobic agents.
JID 1992; 166 (December)
Multiply Resistant Pneumococci in Day Care
Methods
child's carrier status. The 52 children in these groups carrying and the 140 children not carrying the resistant strain were compared. To control for differences in age, these 192 children (median age, 42 months) were also stratified into two age groups:
The Spread of Multiply Resistant Streptococcus pneumoniae at a Day Care Center in Ohio Mary R. Reichler, Allan A. Allphin, Robert F. Breiman, John R. Schreiber, James E. Arnold, Linda K. McDougal, Richard R. Facklam, Bernard Boxerbaum, Daniel May, Robert O. Walton, and Michael R. Jacobs
Respiratory Diseases Branch. Division ofBacterial and Mycotic Diseases. and Antimicrobics Investigation Branch. Hospital Infections Program. National Center for Infectious Diseases. Centers for Disease Control. Atlanta. Georgia; Departments ofOtolaryngology. Pediatrics. and Pathology. Case Western Reserve University. and Cuyahoga County Health Department. Cleveland. Ohio
Pneumococcal infections are a major cause of morbidity and mortality worldwide. In the United States alone, it is estimated that more than 500,000 cases of pneumonia, 55,000 bacteremias, and 6000 cases of meningitis due to Streptococcus pneumoniae occur annually, with 40,000 deaths [I]. S. pneumoniae is the leading cause ofotitis media, resulting in at least 6 million cases in the United States annually [2]. Strains ofS. pneumoniae resistant to penicillin (MIC, > 1.0 Ilg/mL) and other antimicrobic agents (serotypes 19A and 6A) were first described in 1977 [3, 4] and 1978 [3, 5] in South Africa. Penicillin-resistant pneumococcal strains (type 23F) were reported in Spain in 1987 [6, 7], and resistant types 6A, 14, and 23F have subsequently been described in other European countries [3,6,7-13]. Although there have been occasional reports of infections due to strains of S. pneumoniae intermediately resistant to penicillin (MICs, 0.1-1.0 Ilg/mL) [14-21], including two clusters of meningitis in day care settings [14, 15], infections
Received 2 March 1992; revised 17 June 1992. Presented in part: 91st general meeting of the American Society for Microbiology. May 1991. Dallas (abstract C-373); 11th Lancefield International Symposium on Streptococci and Streptococcal Diseases. September 1990. Siena. Italy (abstract P 157). Written informed consent was obtained from parents of all children before nasopharyngeal cultures were done and before outpatient records at physicians' offices were consulted. Reprints or correspondence: Dr. Mary R. Reichler, Centers for Disease Control. Mailstop E-05. 1600 Clifton Rd .• Atlanta. GA 30333. The Journal of Infectious Diseases 1992;166:1346-53 © 1992 by The Universityof Chicago. All rights reserved. 0022-1899/92/6606-0021 $0 1.00
due to penicillin-resistant pneumococci are rare in the United States [22-26]. Only 1 «0.001 %) of 5459 S. pneumoniae surveillance isolates submitted to the Centers for Disease Control (CDC) between 1979 and 1987 was resistant to penicillin (MIC, > 1.0 Ilg/mL), and none was resistant to chloramphenicol [22]. Penicillin is currently the drug of choice for pneumococcal infections in this country. S. pneumoniae, serotype 23F, resistant to multiple antimicrobial drugs, was isolated in October 1989 from the middle ear fluid of a 17-month-old child with refractory otitis media who attended a day care center in Ohio. The isolate was resistant to penicillin (MIC, 2 ~mL), chloramphenicol, tetracycline, and trimethoprim-sulfamethoxazole. It had decreased susceptibility to cefaclor, cefixime, cefotaxime, and ceftriaxone and was susceptible to erythromycin and vancomycin. Otitis media in young children is usually treated empirically. often with oral antimicrobic agents to which this strain is resistant [27]. Middle ear disease has been correlated in some studies with delays in speech, language, and cognitive development [28, 29], and failure to adequately treat otitis media has been associated with hearing loss and intracranial suppurative sequelae [30,31]. The potential for transmission of respiratory pathogens in day care centers is great [32-35]. Therefore, the presence of this multiply resistant strain of S. pneumoniae in a child at a day care center is of concern. Designing strategies to limit the spread of multiply resistant pneumococcal strains is essential to ensure continued easy and effective treatment of pneumococcal infections. We performed an epidemiologic investigation to determine the extent of spread of this strain and to define risk factors for nasopharyngeal carriage and infection.
Downloaded from http://jid.oxfordjournals.org/ at University of Birmingham on July 14, 2015
Streptococcus pneumoniae, type 23F, resistant to penicillin (MIC, 2 ~g/mL) and multiple other antimicrobic agents, was isolated from middle ear fluid of a child with otitis media attending a day care center in Ohio. To determine the extent of spread of this strain, nasopharyngeal culture surveys were done, and 52 carriers were identified among 250 children attending the index day care center. No carriers were found among 121 children at two other day care centers in the same urban area. Use of prophylactic doses of antibiotics (P < .001) and frequent use of antibiotics (P < .001) were risk factors for nasopharyngeal carriage. Carriers were more likely to have had frequent otitis media episodes (P < .02) and otitis media not responsive to antimicrobial therapy (P < .001). Strategies to limit the spread of highlyresistant pneumococcal strains should include encouraging judicious use of antimicrobic agents and reevaluating indications for prophylactic use of antimicrobic agents.
JID 1992; 166 (December)
Multiply Resistant Pneumococci in Day Care
Methods
child's carrier status. The 52 children in these groups carrying and the 140 children not carrying the resistant strain were compared. To control for differences in age, these 192 children (median age, 42 months) were also stratified into two age groups:
