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Antimicrobial Resistance 

Exerpted from:

Preventing Pneumococcal Disease Among Infants and Young Children

Recommendations of the Advisory Committee on Immunization Practices (ACIP)

CDC Morbidity and Mortality Weekly Recommendations and Reports

Vol. 49 / No. RR-9 Page 6 6oct00

Treatment of pneumococcal disease among young children is complicated by emergence of pneumococcal strains resistant to penicillin and other antibiotics ( 12,62). Among a national sample of invasive pneumococcal isolates, resistance to penicillin (i.e., minimum inhibitory concentration [MIC] 2.0 µg/ml) has increased substantially during the past decade, from 1.3% in 1992 to 13.6% in 1997 ( 62,63). In certain areas of the United States, approximately 35% of invasive isolates are penicillin-nonsusceptible (i.e., intermediate susceptibility [MIC = 0.12–1.0 µg/ml] or resistant [MIC 2.0 µg/ml]) ( 63). In one nasopharyngeal carriage study among children in a rural Kentucky community, 59% of children attending day care centers carried penicillin-nonsusceptible S. pneumoniae ( 64). 

Risk factors associated with infection with penicillin-resistant pneumococci include younger age, attendance at a day care center, higher socioeconomic status, recent (i.e., 3 months) antibiotic use, and recurrent AOM ( 26,34,65,66). Recent day care attendance and recent antibiotic treatment are associated independently with invasive disease as a result of penicillin-resistant pneumococci ( 34). Penicillin resistance has been associated with treatment failures in AOM and meningitis ( 12,67–69); these failures could be because of difficulty in achieving high antimicrobial concentrations in middle ear fluid and cerebrospinal fluid (CSF) ( 70). Additional research is needed to determine the association between penicillin resistance and treatment failure in pneumococcal pneumonia or bacteremia among children ( 12,71–73).

References

12. Dowell SF, Butler JC, Giebink GS, et al. Acute otitis media: management and surveillance in an era of pneumococcal resistance—a report from the Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group. Pediatr Infect Dis J 1999;18:1–9.

26. Hofmann J, Cetron MS, Farley MM, et al. Prevalence of drug-resistant Streptococcus pneumoniae in Atlanta. N Engl J Med 1995;333:481–6.

34. Levine OS, Farley M, Harrison LH, et al. Risk factors for invasive pneumococcal disease in children: a population-based case-control study in North America. Pediatrics 1999;103:e28. Available at < http://www.pediatrics.org/cgi/content/full/103/3/e28 > (also below). Accessed August 4, 2000.

62. Breiman RF, Butler JC, Tenover FC, Elliott JA, Facklam RR. Emergence of drug-resistant pneumococcal infections in the United States. JAMA 1994;271:1831–5.

63. CDC. Geographic variation in penicillin resistance in Streptococcus pneumoniae—selected sites, United States, 1997. MMWR 1999;48:656–61.

64. Duchin JS, Breiman RF, Diamond A, et al. High prevalence of multidrug-resistant Streptococcus pneumoniae among children in a rural Kentucky community. Pediatr Infect Dis J 1995;14:745–50.

65. Arnold KE, Leggiadro RJ, Breiman RF, et al. Risk factors for carriage of drug-resistant Streptococcus pneumoniae among children in Memphis, Tennessee. J Pediatr 1996;128:757–64.

66. Reichler MR, Allphin AA, Breiman RF, et al. Spread of multiply resistant Streptococcus pneumoniae at a day care center in Ohio. J Infect Dis 1992;166:1346–53.

67. Dagan R, Abramson O, Leibovitz E, et al. Impaired bacteriologic response to oral cephalosporins in acute otitis media caused by pneumococci with intermediate resistance to penicillin. Pediatr Infect Dis J 1996;15:980–5.

68. Catalan MJ, Fernandez JM, Vazquez A, Varela de Seijas E, Suárez A, de Quirós JCL. Failure of cefotaxime in the treatment of meningitis due to relatively resistant Streptococcus pneumoniae. Clin Infect Dis 1994;18:766–9.

69. Sloas MM, Barrett FF, Chesney PJ, et al. Cephalosporin treatment failure in penicillin and cephalosporin-resistant Streptococcus pneumoniae meningitis. Pediatr Infect Dis J 1992;11:662–6.

70. Bonafede M, Rice LB. Emerging antibiotic resistance. J Lab Clin Med 1997;130:558–66.

71. Tan TQ, Mason EO, Barson WJ, et al. Clinical characteristics and outcome of children with pneumonia attributable to penicillin-susceptible and penicillin-nonsusceptible Streptococcus pneumoniae. Pediatrics 1998;102:1369–75.

72. Friedland IR. Comparison of the response to antimicrobial therapy of penicillin-resistant and penicillin-susceptible pneumococcal disease. Pediatr Infect Dis J 1995;14:885–90.

73. Feikin DR, Schuchat A, Kolczak M, et al. Mortality from invasive pneumococcal pneumonia in the era of antibiotic resistance, 1995–1997. Am J Public Health 2000;90:223–9.

source: http://www.cdc.gov/mmwr/PDF/rr/rr4909.pdf  1jan01

Risk Factors for Invasive Pneumococcal Disease in Children: 

A Population-based Case-Control Study in North America

PEDIATRICS Vol. 103 No. 3 March 1999, p. e28

Orin S. Levine*, Monica FarleyDagger , Lee H. Harrison§, Lewis Lefkowitzparallel , Allison McGeer, Benjamin Schwartz*, and for the Active Bacterial Core Surveillance Teama

From the * Centers for Disease Control and Prevention, Atlanta, Georgia; Dagger  Emory University School of Medicine, Atlanta VA Medical Center, Atlanta, Georgia; § Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland; parallel  Vanderbilt University, Nashville, Tennessee; and  Mount Sinai Hospital, Toronto, Ontario, Canada.

ABSTRACT

Objective.  To identify risk factors for invasive pneumococcal disease, including penicillin-resistant infections, among children 2 to 59 months of age.

Design.  Case-control study.

Participants.  Patients with invasive pneumococcal infections identified by population-based surveillance (n = 187) and controls identified through random-digit telephone dialing (n = 280).

Outcome measures.  Invasive pneumococcal disease was defined as isolation of Streptococcus pneumoniae from a normally sterile site. Patients 2 to 59 months of age who were residents of one of four active surveillance areas were included. S pneumoniae isolates were tested by broth microdilution. Isolates with a minimum inhibitory concentration to penicillin 2 µg/mL were considered resistant.

Results.  Invasive pneumococcal disease was strongly associated with underlying disease and with day care attendance in the previous 3 months. Among 2- to 11-month-olds, current breastfeeding was associated with a decreased likelihood of invasive pneumococcal disease (odds ratio, 0.27; 95% confidence interval: 0.08, 0.90). Penicillin-resistant infections were independently associated with day care attendance, at least one course of antibiotics, and at least one ear infection in the previous 3 months.

Conclusions.  This study shows the association of underlying illnesses, day care attendance, and lack of breastfeeding with risk of invasive pneumococcal disease in children. The association of recent antibiotic use and infection with penicillin-resistant S pneumoniae highlights the need to avoid unnecessary antibiotic use in children.  Key words:  Streptococcus pneumoniae, prevention, risk factors, epidemiology.

The pneumococcus Streptococcus pneumoniae is the leading cause of severe bacterial infections in children in industrialized countries such as the United States. It is the predominant pathogen in acute otitis media, the most common reason for pediatric office visits in the United States. Incidence rates of pneumococcal bacteremia of more than 150 episodes per 100 000 children younger than 2 years of age have been reported from several sites.1-3 With the successful control of Haemophilus influenzae type b meningitis through routine vaccination, S pneumoniae is now the most frequent agent identified from patients with bacterial meningitis in the United States.3 Therefore, the emergence of strains of S pneumoniae that are no longer susceptible to first- and second-line antimicrobial agents is particularly concerning.4

Our ability to prevent pneumococcal infections in young children is quite limited. Available polysaccharide vaccines are not immunogenic in young infants, among whom the incidence is greatest.5-7 Thus, identification of modifiable risk factors may yield other potential strategies for prevention or to identify groups for selective vaccination. However, there is limited information available on factors associated with an increased risk for pneumococcal infections in young children.8,9 To identify risk factors for invasive pneumococcal disease (including penicillin-resistant infections), we conducted a population-based, case-control study comparing a sample of all patients with invasive pneumococcal infections identified through active surveillance with control subjects identified through random digit telephone dialing.

References

1  Zangwill KM, Vadheim CM, Vannier AM, Epidemiology of invasive pneumococcal disease in southern California: implications for the design and conduct of a pneumococcal conjugate vaccine efficacy trial. J Infect Dis 1996; 174:752-759

2  Breiman RF, Spika JS, Navarro VJ, Pneumococcal bacteremia in Charleston County, South Carolina. A decade later. Arch Intern Med 1990; 150:1401-1405

3  Schuchat A, Robinson K, Wenger JD, Bacterial meningitis in the United States in 1995. Active Surveillance Team. N Engl J Med 1997; 337:970-976 

5  Douglas RM, Paton JC, Duncan SJ, Antibody response to pneumococcal vaccination in children younger than five years of age. J Infect Dis 1983; 148:131-137 

6  Koskela M, Leinonen M, Haiva VM, First and second dose antibody responses to pneumococcal polysaccharide vaccine in infants. Pediatr Infect Dis J 1986; 5:45-50 

7  CDC Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices. MMWR 1997; 46:1-24

8  Takala AK, Jero J, Kela E, Risk factors for primary invasive pneumococcal disease among children in Finland. JAMA 1995; 273:859-864 

9  Gessner BD, Ussery XT, Parkinson AJ, Risk factors for invasive disease caused by Streptococcus pneumoniae among Alaska native children younger than two years of age. Pediatr Infect Dis J 1995; 14:123-128 

source: http://www.pediatrics.org/cgi/content/full/103/3/e28 1jan01

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