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Hascelik G, Soyletir G, Gulay Z, Sancak B, Yaman A, Gurler N, Aydemir SS, Bayramoglu G, Aydin F, Cekin Y, Birinci A, Ozakin C, Akpolat N, Ozhak Baysan B, Gultekin M, Zer Y, Sanal L, Arabaci C, Ay Altintop Y, Ozturk C, Ceyhan M. Serotype distribution of Streptococcus pneumoniae and pneumococcal vaccine coverage in adults in Turkey between 2015 and 2018. Ann Med 2023; 55:266-275. [PMID: 36579976 PMCID: PMC9809394 DOI: 10.1080/07853890.2022.2160877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To evaluate the serotype distribution and antibiotic resistance in pneumococcal infections in adults and to provide a perspective regarding serotype coverage of both current and future pneumococcal vaccines. PATIENTS AND METHODS This passive surveillance study was conducted with the Streptococcus pneumoniae strains isolated from the specimens of patients with pneumonia (materials isolated from bronchoalveolar lavage), bacteraemia, meningitis, pleuritis and peritonitis between 2015 and 2018. Serogrouping and serotyping were performed by latex particle agglutination and by conventional Quellung reaction using commercial type-specific antisera, respectively. The strains were analysed for penicillin, cefotaxime, erythromycin and moxifloxacin susceptibilities by E-test. RESULTS In the whole study group (410 samples from adults aged ≥18 years), the most frequent serotypes were 3 (14.1%), 19 F (12%) and 1 (9.3%). The vaccine coverage for PCV13, PCV15, PCV20 and PPV23 was 63.9%, 66.6%, 74.1% and 75.9%, respectively, in all isolates. Penicillin non-susceptibility in invasive pneumococcal disease (IPD) was 70.8% and 57.1% in the patients aged <65 and ≥65 years, respectively. About 21.1% and 4.3% of the patients with and without IPD had cefotaxime resistance. Non-susceptibility to erythromycin and moxifloxacin was 38.2% and 1.2%, respectively. CONCLUSIONS The results revealed that novel PCV vaccines may provide improved coverage as compared with the currently available vaccine, PCV13. The significant antibiotic resistance rates imply the need to extend the serotype coverage of the vaccines. Continuing the surveillance in pneumococcal diseases is critical to explore the serotype distribution and incidence changes of IPD cases in the population and to inform policy makers to make necessary improvements in the national immunization programmes.Key messagesThis multicentre study demonstrated the most recent serotype distribution and antibiotic resistance in adult population in Turkey.Shifting from PCV13 to novel conjugated vaccines will significantly increase the coverage.Continuing the surveillance in pneumococcal diseases is critical to explore the serotype distribution changes and the incidence of cases with invasive pneumococcal disease in the population.
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Affiliation(s)
- Gulsen Hascelik
- Department of Medical Microbiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Guner Soyletir
- Department of Medical Microbiology, Marmara University, Pendik Training and Research Hospital, Istanbul, Turkey
| | - Zeynep Gulay
- Department of Medical Microbiology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Banu Sancak
- Department of Medical Microbiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Akgun Yaman
- Department of Medical Microbiology, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Nezahat Gurler
- Department of Microbiology and Clinical Microbiology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sabire Sohret Aydemir
- Department of Medical Microbiology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Gulcin Bayramoglu
- Department of Medical Microbiology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Faruk Aydin
- Department of Medical Microbiology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Yesim Cekin
- Department of Medical Microbiology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Asuman Birinci
- Department of Medical Microbiology, Faculty of Medicine, Samsun Ondokuz Mayıs University, Samsun, Turkey
| | - Cuneyt Ozakin
- Department of Medical Microbiology, Faculty of Medicine, Bursa Uludag University, Bursa, Turkey
| | - Nezahat Akpolat
- Department of Medical Microbiology, Faculty of Medicine, Dicle University, Diyarbakir, Turkey
| | - Betil Ozhak Baysan
- Department of Medical Microbiology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Meral Gultekin
- Department of Medical Microbiology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Yasemin Zer
- Department of Microbiology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Laser Sanal
- Department of Clinical Microbiology, Ankara Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Cigdem Arabaci
- Department of Microbiology and Clinical Microbiology, Istanbul Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Yasemin Ay Altintop
- Department of Medical Microbiology, Kayseri City Training and Research Hospital, Kayseri, Turkey
| | - Candan Ozturk
- Department of Medical Microbiology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Mehmet Ceyhan
- Department of Pediatric Infectious Diseases, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Abu-Helalah M, Al-Mnayyis A, Alzoubi H, Al-Abdallah R, Jdaitawi H, Nafi O, Abu-Sal K, Altawalbeh A, Khlaifat A, Al-Zayadneh E, Almaaitah I, Borghol I, Batarseh F, Okkeh O, Dalal A, Alhendi A, Almaaitah M, Al-Lahham A, Gazo M, Abu Ekteish F, Elnasser Z. Epidemiology of Streptococcus pneumoniae Serotypes in Jordan Amongst Children Younger than the Age of 5: A National Cross-Sectional Study. Vaccines (Basel) 2023; 11:1396. [PMID: 37766074 PMCID: PMC10536609 DOI: 10.3390/vaccines11091396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION Streptococcus pneumoniae infections are a major cause of mortality and morbidity worldwide. In Jordan, pneumococcal conjugate vaccines (PCVs) are not included in the national vaccination program. Due to the current availability of several PCVs, including PCV-10, PCV-13, and PCV-15, along with PCV-20, currently undergoing pediatric approvals globally, the decision to introduce PCVs and their selection should be based on valid local data on the common serotypes of Streptococcus pneumoniae. METHODS This cross-sectional study aimed to identify the frequency of serotypes of Streptococcus pneumoniae in children aged below 5 years hospitalized with invasive pneumococcal diseases (IPDs), including pneumonia, septicemia, and meningitis, during the study's duration in representative areas of Jordan. Serotyping for culture-positive cases was based on the capsular reaction test, known as the Quellung reaction. qPCR was conducted on the blood samples of patients with lobar pneumonia identified via X-ray or on cerebrospinal fluid for those with a positive latex agglutination test for Streptococcus pneumoniae. RESULTS This study was based on the analysis of the serotypes of 1015 Streptococcus pneumoniae cases among children younger than the age of 5: 1006 cases with pneumonia, 6 cases with meningitis, and 3 cases with septicemia. Only 23 culture-positive cases were identified in comparison to 992 lobar pneumonia cases, which were PCR-positive but culture-negative, with a PCR positivity rate of 92%. Serotypes 6B, 6A, 14, and 19F were the most common serotypes identified in this study, with prevalence rates of 16.45%, 13.60%, 12.12%, and 8.18%, respectively. PCV-10, PCV-13, PCV-15, and PCV-20 coverage rates were 45.32%, 61.87%, 64.14%, and 68.47%, respectively. DISCUSSION To the best of our knowledge, this is the largest prospective study from the Middle East and one of the largest studies worldwide showing the serotypes of Streptococcus pneumoniae. It reveals the urgency for the introduction of a PCV vaccination in Jordan, utilizing recently developed vaccines with a broader serotype coverage.
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Affiliation(s)
- Munir Abu-Helalah
- Department of Family and Community Medicine, Faculty of Medicine, Jordan University, Amman 11942, Jordan
| | - Asma’a Al-Mnayyis
- Department of Clinical Sciences, College of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Hamed Alzoubi
- Department of Pathology and Microbiology, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid 22110, Jordan; (H.A.); (Z.E.)
| | - Ruba Al-Abdallah
- Medical Department, MENA Center for Research & Development and Internship, Amman 11931, Jordan; (R.A.-A.); (F.B.); (O.O.); (A.D.); (A.A.)
| | - Hussein Jdaitawi
- Ministry of Health, Princess Rahma Pediatrics Hospital, Irbid 21163, Jordan;
| | - Omar Nafi
- Faculty of Medicine, Mutah University, Mutah 61110, Jordan;
| | - Kamel Abu-Sal
- Vaccines Department, Ministry of Health, Amman 11931, Jordan;
| | - Alaa Altawalbeh
- Royal Medical Services, Amman 1193, Jordan; (A.A.); (A.K.); (M.A.)
| | - Alia Khlaifat
- Royal Medical Services, Amman 1193, Jordan; (A.A.); (A.K.); (M.A.)
| | - Enas Al-Zayadneh
- Department of Pediatrics, Faculty of Medicine, Jordan University, Amman 11942, Jordan;
| | - Ihsan Almaaitah
- Pediatrics Department, Zarqa Governmental Hospital, Zarqa 13116, Jordan;
| | | | - Fadi Batarseh
- Medical Department, MENA Center for Research & Development and Internship, Amman 11931, Jordan; (R.A.-A.); (F.B.); (O.O.); (A.D.); (A.A.)
| | - Omar Okkeh
- Medical Department, MENA Center for Research & Development and Internship, Amman 11931, Jordan; (R.A.-A.); (F.B.); (O.O.); (A.D.); (A.A.)
| | - Abdallah Dalal
- Medical Department, MENA Center for Research & Development and Internship, Amman 11931, Jordan; (R.A.-A.); (F.B.); (O.O.); (A.D.); (A.A.)
| | - Ahmad Alhendi
- Medical Department, MENA Center for Research & Development and Internship, Amman 11931, Jordan; (R.A.-A.); (F.B.); (O.O.); (A.D.); (A.A.)
| | | | - Adnan Al-Lahham
- Department of Biomedical Engineering, School of Applied Medical Sciences, German-Jordanian University, Amman 11931, Jordan;
| | - Mahmoud Gazo
- Department of Central Laboratories, Ministry of Health, Amman 11931, Jordan
| | - Faisal Abu Ekteish
- Department of Pediatrics, Faculty of Medicine, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid 22110, Jordan;
| | - Ziad Elnasser
- Department of Pathology and Microbiology, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid 22110, Jordan; (H.A.); (Z.E.)
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Karimi A, Hoseini-Alfatemi SM, Tabatabaei SR. A Systematic Review and Meta-Analysis of Serotype Distribution of Streptococcus Pneumoniae in Iran: Practical Evidence to Optimizing Local Vaccination Protocols. Infect Disord Drug Targets 2021; 21:304-310. [PMID: 32310053 DOI: 10.2174/1871526519666191002142953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 02/27/2020] [Accepted: 03/13/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Little is known regarding the burden of predominant circulating serotypes of Streptococcus pneumoniae in Iran. Therefore, this study aimed to investigate the serotype distribution of pneumococcal diseases in Iran by using a comprehensive systematic review of available articles. ; Methods: A systematic literature search was carried out to identify papers published by Iranian authors in the Web of Science, PubMed, Scopus, Embase and Google Scholar electronic databases from January 2000 to December 2018. Then, eight publications that met our inclusion criteria were selected for data extraction and analysis by Comprehensive Meta-Analysis software. ; Results: In total, three studies reported the distribution of S. pneumoniae serotypes among patients, two studies among healthy individuals, and three studies among both groups. Of those studies, serotype 19A/F (17.9%; 95% CI: 13.6-23.0) was the most circulating serotype followed by 23A/F (12.3%; 95% CI: 7.7-19.2), 6A/B (11.0%; 95% CI: 8.0-14.9), and 14 (8.8%; 95% CI: 5.8-13.2). In contrast, the lowest circulating serotype was 60 (0.02%; 95% CI: 0.0-1.2), 29 (0.07%; 95% CI: 0.01-5.0), and 36 (0.09%; 95% CI: 0.04-2.1). Meta-regression results showed that prevalence of serotype 23A/F significantly increased each year about 0.2% (95% CI: 0.1-0.3, P <0.001, tau2 <0.001). ; Conclusion: In the present study, it was found that over the last decade, the most prevalent serotypes in Iran were 19, 23, 6, and 14, respectively. These findings provide practical evidence to select effective pneumococcal vaccine candidates for the prevention of invasive diseases in Iranian patients and also to compare our situation with others.
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Affiliation(s)
- Abdollah Karimi
- Pediatric Infections Research Center, Research Institute for Children̍s Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyedeh Mahsan Hoseini-Alfatemi
- Pediatric Infections Research Center, Research Institute for Children̍s Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sedigheh Rafiei Tabatabaei
- Pediatric Infections Research Center, Research Institute for Children̍s Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Pediatric subdural empyema as a complication of meningitis: could CSF protein/CSF glucose ratio be used to screen for subdural empyema? Eur J Pediatr 2021; 180:415-423. [PMID: 32875444 DOI: 10.1007/s00431-020-03791-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 07/02/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
Subdural empyema (SDE) is a rare condition which can appear secondary to meningitis in childhood, especially in infants. This study was planned to evaluate and compare clinical and laboratory features, treatment, and outcome of children with SDE to those with acute bacterial meningitis (ABM) without SDE. The electronic medical files of 266 patients diagnosed with ABM between January 2009 and December 2019 were evaluated. Patients' demographic and clinical features, laboratory results, cranial imaging findings, treatment, and outcomes were recorded. SDE was identified in 10 patients, 3.7% of all diagnosed with meningitis. The etiology of SDE was identified in eight (80%). The most common responsible pathogen was Streptococcus pneumoniae. Cranial imaging was performed between the 2nd and 13th days of admission, and the most common reason of performing cranial imaging was persistence of fever. Two patients were healed with 4-6 weeks of antibiotic treatment without surgery, eight (80%) needed surgical intervention.Conclusion: The clinical signs and symptoms of SDE may be subtle. If the fever persists or focal neurological findings are seen during the treatment of bacterial meningitis, SDE should be suspected. Furthermore, patients with ABM who are determined to have a protein-to-glucose ratio in the cerebrospinal fluid above 4.65 should be carefully monitored for SDE development. What is known: • Subdural empyema may develop subsequently to meningitis, especially in the infant age group in whom very little is known in terms of disease characteristics. • Delay in diagnosis and treatment can cause long-term neurologic sequelae and mortality. What is new: • Persistence or relapse of fever during the treatment of acute meningitis is an important warning sign for SDE even if there are no other symptoms. • Children with subdural empyema secondary to bacterial meningitis have higher protein-to-glucose ratio in the CSF, and a threshold of ˃ 4.65 was determined to demonstrate 100% sensitivity and 50.7% specificity.
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Pneumococcal serotypes in children, clinical presentation and antimicrobial susceptibility in the PCV13 era. Epidemiol Infect 2020; 148:e279. [PMID: 33148361 PMCID: PMC7770381 DOI: 10.1017/s0950268820002708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The aim was to analyse invasive pneumococcal disease (IPD) serotypes in children aged ⩽17 years according to clinical presentation and antimicrobial susceptibility. We conducted a prospective study (January 2012–June 2016). IPD cases were diagnosed by culture and/or real-time polymerase chain reaction (PCR). Demographic, microbiological and clinical data were analysed. Associations were assessed using the odds ratio (OR) and 95% confidence intervals (CI). Of the 253 cases, 34.4% were aged <2 years, 38.7% 2–4 years and 26.9% 5–17 years. Over 64% were 13-valent pneumococcal conjugate vaccine (PCV13) serotypes. 48% of the cases were diagnosed only by real-time PCR. Serotypes 3 and 1 were associated with complicated pneumonia (P < 0.05) and non-PCV13 serotypes with meningitis (OR 7.32, 95% CI 2.33–22.99) and occult bacteraemia (OR 3.6, 95% CI 1.56–8.76). Serotype 19A was more frequent in children aged <2 years and serotypes 3 and 1 in children aged 2–4 years and 5–17 years, respectively. 36.1% of cases were not susceptible to penicillin and 16.4% were also non-susceptible to cefotaxime. Serotypes 14, 24F and 23B were associated with non-susceptibility to penicillin (P < 0.05) and serotypes 11, 14 and 19A to cefotaxime (P < 0.05). Serotype 19A showed resistance to penicillin (P = 0.002). In conclusion, PCV13 serotypes were most frequent in children aged ⩽17 years, mainly serotypes 3, 1 and 19A. Non-PCV13 serotypes were associated with meningitis and occult bacteraemia and PCV13 serotypes with pneumonia. Non-susceptibility to antibiotics of non-PCV13 serotypes should be monitored.
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Ceyhan M, Aykac K, Gurler N, Ozsurekci Y, Öksüz L, Altay Akısoglu Ö, Öz FN, Emiroglu M, TurkDagi H, Yaman A, Söyletir G, Öztürk C, Akpolat N, Özakin C, Aydın F, Aydemir Ş, Kiremitci A, Gültekin M, Camcıoglu Y, Zer Y, Güdücüoğlu H, Gülay Z, Birinci A, Arabaci C, Karbuz A, Devrim I, Sorguc Y, Baysan BÖ, Karadag Oncel E, Yilmaz N, Altintop YA. Serotype distribution of Streptococcus pneumonia in children with invasive disease in Turkey: 2015-2018. Hum Vaccin Immunother 2020; 16:2773-2778. [PMID: 32530357 PMCID: PMC7734139 DOI: 10.1080/21645515.2020.1747931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objectives: To determine the serotype distribution of pneumococcus causing invasive pneumococcal disease (meningitidis, bacteremia and empyema) in children in Turkey, and to observe potential changes in this distribution in time to guide effective vaccine strategies. Methods: We surveyed S. pneumoniae with conventional bacteriological techniques and with real-time polymerase chain reaction (RT-PCR) in samples of cerebrospinal fluid (CSF), blood and pleural fluid. S. pneumoniae strains were isolated from 33 different hospitals in Turkey, which are giving health services to approximately 60% of the Turkish population. Results: A total of 167 cases were diagnosed with invasive pneumococcal disease between 2015 and 2018. We diagnosed 52 (31.1%) patients with meningitis, 104 (62.2%) patients with bacteremia, and 11 (6.6%) patients with empyema. Thirty-three percent of them were less than 2 years old and 56% less than 5 years old. Overall PCV13 serotypes accounted for 56.2% (94/167). The most common serotypes were 19 F (11.9%), 1 (10.7%) and 3 (10.1%). Conclusions: Besides the increasing frequency of non-vaccine serotypes, vaccine serotypes continue to be a problem for Turkey despite routine and high-rate vaccination with PCV13 and significant reduction reported for the incidence of IPD in young children. Since new candidate pneumococcal conjugate vaccines with more serotype antigens are being developed, continuing IPD surveillance is a significant source of information for decision-making processes on pneumococcal vaccination.
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Affiliation(s)
- Mehmet Ceyhan
- Department of Pediatric Infectious Diseases, Hacettepe University , Ankara, Turkey
| | - Kubra Aykac
- Department of Pediatric Infectious Diseases, Hacettepe University , Ankara, Turkey
| | - Nezahat Gurler
- Department of Microbiology and Clinical Microbiology, Istanbul University , Istanbul, Turkey
| | - Yasemin Ozsurekci
- Department of Pediatric Infectious Diseases, Hacettepe University , Ankara, Turkey
| | - Lütfiye Öksüz
- Department of Microbiology and Clinical Microbiology, Istanbul University , Istanbul, Turkey
| | - Özlem Altay Akısoglu
- Department of Microbiology, Dr. Sami Ulus Children's Health and Diseases Training and Research Hospital , Ankara, Turkey
| | - Fatma Nur Öz
- Department of Pediatric Infectious Diseases, Dr. Sami Ulus Children's Health and Diseases Training and Research Hospital , Ankara, Turkey
| | - Melike Emiroglu
- Department of Pediatric Infectious Diseases, Selcuk University , Konya, Turkey
| | - Hatice TurkDagi
- Department of Microbiology, Selcuk University , Konya, Turkey
| | - Akgün Yaman
- Department of Microbiology, Cukurova University , Adana, Turkey
| | - Güner Söyletir
- Department of Microbiology, Marmara University Pendik Training and Research Hospital , Istanbul, Turkey
| | - Candan Öztürk
- Department of Microbiology, Mersin University , Mersin, Turkey
| | - Nezahat Akpolat
- Department of Microbiology, Dicle University , Diyarbakır, Turkey
| | - Cüneyt Özakin
- Department of Microbiology, Uludag University , Bursa, Turkey
| | - Faruk Aydın
- Department of Microbiology, Karadeniz Technical University , Trabzon, Turkey
| | - Şöhret Aydemir
- Department of Microbiology, Ege University , Izmir, Turkey
| | | | - Meral Gültekin
- Department of Microbiology, Akdeniz University , Antalya, Turkey
| | - Yıldız Camcıoglu
- Department of Pediatric Infectious Disease, Istanbul University Cerrahpasa , Istanbul, Turkey
| | - Yasemin Zer
- Department of Microbiology, Gaziantep University , Gaziantep, Turkey
| | | | - Zeynep Gülay
- Department of Microbiology, Dokuz Eylül University , Izmir, Turkey
| | - Asuman Birinci
- Department of Microbiology, Samsun Ondokuz Mayıs University , Samsun, Turkey
| | - Cigdem Arabaci
- Department of Microbiology, Okmeydani Education and Research Hospital , Istanbul, Turkey
| | - Adem Karbuz
- Department of Pediatric Infectious Diseases, Okmeydani Education and Research Hospital , Istanbul, Turkey
| | - Ilker Devrim
- Department of Pediatric Infectious Diseases, Dr. Behçet Uz Children's Hospital , İzmir, Turkey
| | - Yelda Sorguc
- Department of Microbiology, Dr. Behçet Uz Children's Hospital , İzmir, Turkey
| | | | - Eda Karadag Oncel
- Department of Pediatric Infectious Diseases, University of Health Sciences, Tepecik Training and Research Hospital , İzmir, Turkey
| | - Nisel Yilmaz
- Department of Microbiology, University of Health Sciences, Tepecik Training and Research Hospital , İzmir, Turkey
| | - Yasemin Ay Altintop
- Department of Microbiology, Kayseri Training and Research Hospital , Kayseri, Turkey
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Tin Tin Htar M, van Den Biggelaar AHJ, Sings H, Ferreira G, Moffatt M, Hall-Murray C, Verstraeten T, Gessner BD, Schmitt HJ, Jodar L. The impact of routine childhood immunization with higher-valent pneumococcal conjugate vaccines on antimicrobial-resistant pneumococcal diseases and carriage: a systematic literature review. Expert Rev Vaccines 2019; 18:1069-1089. [PMID: 31585049 DOI: 10.1080/14760584.2019.1676155] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: The introduction of 7-valent pneumococcal conjugate vaccine (PCV7) in childhood immunization programs reduced antimicrobial-resistant pneumococcal infections by vaccine serotypes. However, emerging antimicrobial-resistant non-vaccine serotypes, particularly serotype 19A, attenuated the overall effect. In 2010, higher-valent PCVs became available containing serotypes that are prone to become antimicrobial-resistant, like serotype 7F in PCV10 and PCV13, and serotype 19A in PCV13.Areas covered: This review evaluated literature published between June 1, 2008 and June 1, 2017 reporting on the effect of PCV10 or PCV13 implementation in routine infant immunization schedules on antimicrobial-resistant invasive pneumococcal disease (IPD), otitis media (OM), and nasopharyngeal carriage (NPC) in children and adults.Expert opinion: In countries with relatively high prior pneumococcal antimicrobial resistance (AMR), PCV13 childhood vaccination programs have reduced antimicrobial-resistant IPD, OM, and NPC in children and IPD in adults. The effectiveness of PCV13 against serotype 19A is likely an important contributing factor. Only few studies have documented the impact of PCV10 on AMR. Multiple factors may influence observed decreases in pneumococcal AMR including antimicrobial stewardship, case definition, time since PCV10/13 introduction, and pre-PCV10/13 AMR levels. This review emphasizes the importance of including impact on AMR when evaluating the full public health of pneumococcal vaccination programs.
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Affiliation(s)
| | | | - Heather Sings
- Vaccines Medical Development & Scientific/Clinical Affairs, Pfizer Inc, Collegeville, PA, USA
| | - Germano Ferreira
- Department of Epidemiology, P95 Epidemiology and Pharmacovigilance, Leuven, Belgium
| | - Margaret Moffatt
- Department of Health Economic & Outcomes Research, Pfizer Inc, New York, NY, USA
| | - Cassandra Hall-Murray
- Vaccines Medical Development & Scientific/Clinical Affairs, Pfizer Inc, Collegeville, PA, USA
| | - Thomas Verstraeten
- Department of Epidemiology, P95 Epidemiology and Pharmacovigilance, Leuven, Belgium
| | - Bradford D Gessner
- Vaccines Medical Development & Scientific/Clinical Affairs, Pfizer Inc, Collegeville, PA, USA
| | - Heinz-Josef Schmitt
- Vaccines Medical Development & Scientific/Clinical Affairs, Pfizer Inc, Paris, France
| | - Luis Jodar
- Vaccines Medical Development & Scientific/Clinical Affairs, Pfizer Inc, Collegeville, PA, USA
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Gülhan B, Kanik-Yuksek S, Ozkaya-Parlakay A. Mastoiditis with Streptococcus pneumoniae serotype 19A in one-dose PCV13 vaccinated three-month-old infant. Hum Vaccin Immunother 2019; 15:2917-2918. [PMID: 31348728 DOI: 10.1080/21645515.2019.1627823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Pneumococcal conjugate vaccines (PCV) have been widely used in high-income countries for more than a decade, resulting in a dramatic reduction in pneumococcal disease caused by vaccine serotypes. PCV has been included in Turkey's National Immunization Programme since 2009 with PCV7 and continued with PCV13 from 2011. We presented a three-month-old infant who developed mastoiditis secondary to S. pneumoniae serotype 19A after acute otitis media.
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Affiliation(s)
- B Gülhan
- Department of Pediatric Infectious Diseases, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - S Kanik-Yuksek
- Department of Pediatric Infectious Diseases, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - A Ozkaya-Parlakay
- Department of Pediatric Infectious Diseases, University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Ankara, Turkey
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Wang CY, Chen YH, Fang C, Zhou MM, Xu HM, Jing CM, Deng HL, Cai HJ, Jia K, Han SZ, Yu H, Wang AM, Yin DD, Wang CQ, Wang W, Huang WC, Deng JK, Zhao RZ, Chen YP, Yang JH, Wang C, Che YR, Nie XZ, Wang SF, Hao JH, Zhang CH. Antibiotic resistance profiles and multidrug resistance patterns of Streptococcus pneumoniae in pediatrics: A multicenter retrospective study in mainland China. Medicine (Baltimore) 2019; 98:e15942. [PMID: 31192930 PMCID: PMC6587637 DOI: 10.1097/md.0000000000015942] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Emergent resistance to antibiotics among Streptococcus pneumoniae isolates is a severe problem worldwide. Antibiotic resistance profiles for S pneumoniae isolates identified from pediatric patients in mainland China remains to be established.The clinical features, antimicrobial resistance, and multidrug resistance patterns of S pneumoniae were retrospectively analyzed at 10 children's hospitals in mainland China in 2016.Among the collected 6132 S pneumoniae isolates, pneumococcal diseases mainly occurred in children younger than 5 years old (85.1%). The resistance rate of S pneumoniae to clindamycin, erythromycin, tetracycline, and trimethoprim/sulfamethoxazole was 95.8%, 95.2%, 93.6%, and 66.7%, respectively. The resistance rates of S pneumoniae to penicillin were 86.9% and 1.4% in non-meningitis and meningitis isolates, while the proportions of ceftriaxone resistance were 8.2% and 18.1%, respectively. Pneumococcal conjugate vaccine was administered to only 4.1% of patients. Penicillin and ceftriaxone resistance, underling diseases, antibiotic resistant risk factors, and poor prognosis appeared more frequently in invasive pneumococcal diseases. The incidence of multidrug resistance (MDR) was 46.1% in patients with invasive pneumococcal disease which was more than in patients with non-invasive pneumococcal disease (18.3%). Patients with invasive pneumococcal disease usually have several MDR coexistence.S pneumoniae isolates showed high resistance to common antibiotics in mainland China. Penicillin and ceftriaxone resistance rate of invasive streptococcal pneumonia patients were significantly higher than that of non-invasive S pneumoniae patients. Alarmingly, 46.1% of invasive clinical isolates were multidrug resistant, so it is important to continued monitor the resistance of S pneumoniae when protein conjugate vaccine (PCV13) is coming in mainland China.
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Affiliation(s)
| | | | - Chao Fang
- Clinical Laboratory Department, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou
| | - Ming-ming Zhou
- Clinical Laboratory Department, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou
| | | | - Chun-mei Jing
- Clinical Laboratory Department, Children's Hospital of Chongqing Medical University, Chongqing
| | | | - Hui-jun Cai
- Clinical Laboratory, XI’an Children Hospital, XI’an, Shanxi province
| | - Kai Jia
- Clinical Laboratory, XI’an Children Hospital, XI’an, Shanxi province
| | | | - Hui Yu
- Department of Infectious Diseases
| | - Ai-min Wang
- Clinical Microbiology Laboratory, Children's Hospital of Fudan University
| | - Dan-dan Yin
- Clinical Microbiology Laboratory, Children's Hospital of Fudan University
| | - Chuan-qing Wang
- Clinical Microbiology Laboratory, Children's Hospital of Fudan University
| | | | - Wei-chun Huang
- Department of Clinical Laboratory, Shanghai Children's Medical Center of Shanghai Jiaotong University School of Medicine, Shanghai
| | - Ji-kui Deng
- Department of Infectious Diseases, Shenzhen Children's Hospital, Shenzhen, Guangdong province
| | - Rui-zhen Zhao
- Department of Infectious Diseases, Shenzhen Children's Hospital, Shenzhen, Guangdong province
| | | | - Ji-Hong Yang
- Clinical Laboratory Center, the 2nd Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang province
| | | | - Yan-ran Che
- Department of Gastroenterology and Infectious Diseases, Children's Hospital of Shanghai Jiaotong University School of Medicine, Shanghai
| | | | - Shi-fu Wang
- Department of Children's Medical Laboratory Diagnosis Center, Qilu Children's Hospital of Shandong University, Jinan, Shandong province
| | | | - Cong-hui Zhang
- Microbiological Examination Department, Kaifeng Children's Hospital, Kaifeng, Henan province, China
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10
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Marijam A, Olbrecht J, Ozakay A, Eken V, Meszaros K. Cost-Effectiveness Comparison of Pneumococcal Conjugate Vaccines in Turkish Children. Value Health Reg Issues 2019; 19:34-44. [PMID: 30776766 DOI: 10.1016/j.vhri.2018.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 10/16/2018] [Accepted: 11/29/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The 13-valent pneumococcal conjugate vaccine (PCV13) is used for universal infant vaccination in Turkey. OBJECTIVES To assess the cost effectiveness of replacing PCV13 with pneumococcal nontypeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV). METHODS A Markov cohort model with monthly cycles following 1 cohort of infants over a 10-year time horizon was used. Local input parameters were obtained from published sources and expert consultation whenever possible. The model was adapted to estimate the health benefits and economic impact of each vaccine on invasive pneumococcal disease, pneumonia, and acute otitis media (AOM). An annual discount rate of 3% was used for benefits and costs (2016 euros). RESULTS Under base-case assumptions, vaccinating 1 birth cohort of 1 325 783 infants with PHiD-CV instead of PCV13 was predicted to have the same impact on meningitis and pneumonia, a similar impact on bacteremia (+30 cases), but greater reductions in AOM-related general practitioner visits (-34 955) and hospitalizations (-624). Assuming equal vaccine prices, PHiD-CV was predicted to be dominant over PCV13 (176 additional quality-adjusted life-years while saving €635 330 [discounted]). One-way sensitivity analysis indicated that varying the vaccine price differential had the largest effect on the incremental cost-effectiveness ratio, and then AOM parameters. Probabilistic sensitivity analysis predicted PHiD-CV to be dominant over PCV13 in 92.4% of simulations. CONCLUSIONS Any difference in price between PHiD-CV and PCV13 is expected to be the key driver of vaccine choice for preventing childhood pneumococcal disease in Turkey. At price parity, PHiD-CV use is likely to be a dominant strategy over the use of PCV13.
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11
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Büyükcam A, Güdücüoğlu H, Karaman K, Gürbüz V, Aliyev E, Kara A, Ceyhan M. Invasive pneumococcal infection due to serotype 15A after the pneumococcal conjugate vaccine implementation in Turkey. Hum Vaccin Immunother 2017; 13:1892-1894. [PMID: 28574743 DOI: 10.1080/21645515.2017.1331802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Invasive pneumococcal infections among children are a serious public health problem in many countries, including Turkey. Pneumococcal conjugate vaccine has been included in Turkey's National Immunization Programme since 2009. We report the first two pediatric cases of invasive pneumococcal infection due to non-vaccine serotype 15A after pneumococcal conjugate vaccine implementation in Turkey. It is essential to monitor the countries' own local seroepidemiologic data for detecting selective pressure of non-vaccine serotypes of S. pneumonia.
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Affiliation(s)
- Ayşe Büyükcam
- a Hacettepe University Faculty of Medicine , Department of Pediatrics, Unit of Infectious Diseases , Ankara , Turkey
| | - Hüseyin Güdücüoğlu
- b Van Yüzüncü Yıl University Faculty of Medicine , Department of Medical Microbiology , Van , Turkey
| | - Kamuran Karaman
- c Van Yüzüncü Yıl University Faculty of Medicine , Department of Pediatrics , Van , Turkey
| | - Venhar Gürbüz
- a Hacettepe University Faculty of Medicine , Department of Pediatrics, Unit of Infectious Diseases , Ankara , Turkey
| | - Emil Aliyev
- d Hacettepe University Faculty of Medicine , Department of Pediatrics , Ankara , Turkey
| | - Ateş Kara
- a Hacettepe University Faculty of Medicine , Department of Pediatrics, Unit of Infectious Diseases , Ankara , Turkey
| | - Mehmet Ceyhan
- a Hacettepe University Faculty of Medicine , Department of Pediatrics, Unit of Infectious Diseases , Ankara , Turkey
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12
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Cohen R, Cohen JF, Chalumeau M, Levy C. Impact of pneumococcal conjugate vaccines for children in high- and non–high-income countries. Expert Rev Vaccines 2017; 16:625-640. [DOI: 10.1080/14760584.2017.1320221] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Robert Cohen
- Université Paris Est, IMRB-GRC GEMINI, Créteil, France
- ACTIV, Association Clinique et Thérapeutique Infantile du Val de Marne, Saint-Maur des Fossés, France
- Clinical Research Center (CRC), Centre Hospitalier Intercommunal Créteil, France
- Unité Court Séjour, Petits Nourrissons, Service de Néonatologie, Centre Hospitalier Intercommunal Créteil, France
| | - Jérémie François Cohen
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris Descartes University, INSERM U1153, Paris, France
- Service de Pédiatrie Générale, Hôpital Necker-Enfants Malades; AP-HP; Université Paris Descartes, Paris, France
| | - Martin Chalumeau
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Paris Descartes University, INSERM U1153, Paris, France
- Service de Pédiatrie Générale, Hôpital Necker-Enfants Malades; AP-HP; Université Paris Descartes, Paris, France
| | - Corinne Levy
- Université Paris Est, IMRB-GRC GEMINI, Créteil, France
- ACTIV, Association Clinique et Thérapeutique Infantile du Val de Marne, Saint-Maur des Fossés, France
- Clinical Research Center (CRC), Centre Hospitalier Intercommunal Créteil, France
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13
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Tanır Basaranoglu S, Karadag Oncel E, Aykac K, Ozsurekci Y, Cengiz AB, Kara A, Ceyhan M. Invasive pneumococcal disease: From a tertiary care hospital in the post-vaccine era. Hum Vaccin Immunother 2016; 13:962-964. [PMID: 27905836 DOI: 10.1080/21645515.2016.1256519] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
A breakthrough infection occurring with 13-valent pneumococcal conjugate vaccine (PCV13) in Turkey are previously described. A breakthrough infection is defined as IPD in a child who had received ≥ 1 PCV-7 or PCV-13 and for which the pneumococcal isolate was a vaccine serotype. During one year period, among 6 patients with invasive pneumococcal infection, 2 patients were considered to have a vaccine failure with serotype 19F. Antibiotic resistance results were remarkable; macrolide resistance were observed in all strains except one, and high and intermediate penicillin resistance were determined in 2 strains.
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Affiliation(s)
- Sevgen Tanır Basaranoglu
- a Department of Pediatric Infectious Diseases , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - Eda Karadag Oncel
- a Department of Pediatric Infectious Diseases , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - Kubra Aykac
- a Department of Pediatric Infectious Diseases , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - Yasemin Ozsurekci
- a Department of Pediatric Infectious Diseases , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - Ali Bülent Cengiz
- a Department of Pediatric Infectious Diseases , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - Ates Kara
- a Department of Pediatric Infectious Diseases , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - Mehmet Ceyhan
- a Department of Pediatric Infectious Diseases , Hacettepe University Faculty of Medicine , Ankara , Turkey
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14
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Ceyhan M, Dagan R, Sayiner A, Chernyshova L, Dinleyici EÇ, Hryniewicz W, Kulcsár A, Mad'arová L, Pazdiora P, Sidorenko S, Streinu-Cercel A, Tambić-Andrašević A, Yeraliyeva L. Surveillance of pneumococcal diseases in Central and Eastern Europe. Hum Vaccin Immunother 2016; 12:2124-2134. [PMID: 27096714 PMCID: PMC4994721 DOI: 10.1080/21645515.2016.1159363] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Pneumococcal infection is a major cause of morbidity and mortality worldwide. The burden of disease associated with S. pneumoniae is largely preventable through routine vaccination. Pneumococcal conjugate vaccines (e.g. PCV7, PCV13) provide protection from invasive pneumococcal disease as well as non-invasive infection (pneumonia, acute otitis media), and decrease vaccine-type nasopharyngeal colonisation, thus reducing transmission to unvaccinated individuals. PCVs have also been shown to reduce the incidence of antibiotic-resistant pneumococcal disease. Surveillance for pneumococcal disease is important to understand local epidemiology, serotype distribution and antibiotic resistance rates. Surveillance systems also help to inform policy development, including vaccine recommendations, and monitor the impact of pneumococcal vaccination. National pneumococcal surveillance systems exist in a number of countries in Central and Eastern Europe (such as Croatia, Czech Republic, Hungary, Poland, Romania and Slovakia), and some have introduced PCVs (Czech Republic, Hungary, Kazakhstan, Russia, Slovakia and Turkey). Those countries without established programs (such as Kazakhstan, Russia and Ukraine) may be able to learn from the experiences of those with national surveillance systems. The serotype distributions and impact of PCV13 on pediatric pneumococcal diseases are relatively similar in different parts of the world, suggesting that approaches to vaccination used elsewhere are also likely to be effective in Central and Eastern Europe. This article briefly reviews the epidemiology of pneumococcal disease, presents the latest surveillance data from Central and Eastern Europe, and discusses any similarities and differences in these data as well the potential implications for vaccination policies in the region.
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Affiliation(s)
- Mehmet Ceyhan
- a Department of Pediatric Infectious Diseases , School of Medicine, Hacettepe University , Ankara , Turkey
| | - Ron Dagan
- b Pediatric Infectious Disease Unit, Ben-Gurion University of the Negev , Beer-Sheva , Israel
| | - Abdullah Sayiner
- c Department of Chest Diseases , Ege University Faculty of Medicine , Izmir , Turkey
| | - Liudmyla Chernyshova
- d Department of Pediatric Infectious Diseases and Immunology , National Medical Academy for Postgraduate Education , Kiev , Ukraine
| | | | - Waleria Hryniewicz
- f National Medicines Institute, Division of Clinical Microbiology and Infection Prevention , Warsaw , Poland
| | - Andrea Kulcsár
- g Department of Infectology , Joint Hospital Saint László and Saint István , Budapest , Hungary
| | - Lucia Mad'arová
- h National Reference Centre for Pneumococcal and Haemophilus Diseases, Regional Authority of Public Health , Banská Bystrica , Slovak Republic
| | - Petr Pazdiora
- i Department of Epidemiology , Charles University Faculty Hospital , Pilsen , Czech Republic
| | - Sergey Sidorenko
- j Research Institute of Children's Infection , St. Petersburg , Russia
| | | | - Arjana Tambić-Andrašević
- l Department of Clinical Microbiology , University Hospital for Infectious Diseases , Zagreb , Croatia
| | - Lyazzat Yeraliyeva
- m Research Institute of Fundamental and Applied Medicine, Asfendiyarov Kazakh National Medical University , Almaty , Kazakhstan
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15
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Zhou X, Liu J, Zhang Z, Liu Y, Wang Y, Liu Y. Molecular characteristics of penicillin-binding protein 2b, 2x and 1a sequences in Streptococcus pneumoniae isolates causing invasive diseases among children in Northeast China. Eur J Clin Microbiol Infect Dis 2016; 35:633-45. [PMID: 26972430 DOI: 10.1007/s10096-016-2582-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
Abstract
Streptococcus pneumoniae is one of the common pathogens causing severe invasive infections in children. This study aimed to investigate the serotype distribution and variations of penicillin-binding proteins (PBPs) 2b, 2x and 1a in S. pneumoniae isolates causing invasive diseases in Northeast China. A total of 256 strains were isolated from children with invasive pneumococcal disease (IPD) from January 2000 to October 2014. All strains were serotyped and determined for antibiotic resistance. The amplicons of penicillin-binding domains in pbp1a, pbp2b and pbp2x genes were sequenced for variation identification. The most prevalent serotypes of isolates in IPD children were 19A, 14, 19F, 23F and 6B. 19A and 19F were the most frequent serotypes of penicillin-resistant S. pneumoniae (PRSP), which present with high resistance to amoxicillin, cefotaxime, ceftriaxone and meropenem. The numbers of amino acid substitutions of penicillin-non-susceptible S. pneumoniae (PNSP) isolates were higher than those of penicillin-sensitive S. pneumoniae isolates in all the PBP genes (p < 0.01). The patterns of amino acid mutation in PBP2b, PBP2x and PBP1a were unique and different from those of other countries. All of the serotype 19A and 19F PRSP isolates carried 25 amino acid mutations, including Ala618 → Gly between positions 560 and 675 in PBP2b and Thr338 → Ala substitutions in PBP2x. The amino acid alterations in PBP2b, PBP2x and PBP1a from S. pneumoniae were closely associated with resistance to β-lactam antibiotics. This study provides new data for further monitoring of genetic changes related to the emergence and spread of resistance to β-lactam antibiotics in China.
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Affiliation(s)
- X Zhou
- Department of Clinical Laboratory, The Affiliated Shengjing Hospital, China Medical University, No. 36, Sanhao Street, Heping District, Shenyang, 110004, China
| | - J Liu
- Department of Clinical Laboratory, The Affiliated Shengjing Hospital, China Medical University, No. 36, Sanhao Street, Heping District, Shenyang, 110004, China
| | - Z Zhang
- Department of Clinical Laboratory, The Affiliated Shengjing Hospital, China Medical University, No. 36, Sanhao Street, Heping District, Shenyang, 110004, China
| | - Y Liu
- Department of Clinical Laboratory, The Affiliated Shengjing Hospital, China Medical University, No. 36, Sanhao Street, Heping District, Shenyang, 110004, China
| | - Y Wang
- Department of Clinical Laboratory, The Affiliated Shengjing Hospital, China Medical University, No. 36, Sanhao Street, Heping District, Shenyang, 110004, China
| | - Y Liu
- Department of Clinical Laboratory, The Affiliated Shengjing Hospital, China Medical University, No. 36, Sanhao Street, Heping District, Shenyang, 110004, China.
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