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Iwata S, Hanada S, Takata M, Morozumi M, Kamei S, Ubukata K. Risk factors and pathogen characteristics associated with unfavorable outcomes among adults with pneumococcal meningitis in Japan, 2006 to 2016. J Infect Chemother 2023; 29:637-645. [PMID: 36907551 DOI: 10.1016/j.jiac.2023.03.003] [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: 12/01/2022] [Revised: 02/03/2023] [Accepted: 03/04/2023] [Indexed: 03/13/2023]
Abstract
PURPOSE In this study, we aimed to clarify the risk factors associated with unfavorable outcomes in adults with pneumococcal meningitis (PnM). METHODS Surveillance was conducted between 2006 and 2016. Adults with PnM (n = 268) were followed up for outcomes within 28 days after admission using the Glasgow Outcome Scale (GOS). After classifying the patients into the unfavorable (GOS1-4) and favorable (GOS5) outcome groups, i) the underlying diseases, ii) biomarkers at admission, and iii) serotype, genotype, and antimicrobial susceptibility for all isolates were compared between both groups. RESULTS Overall, 58.6% of patients with PnM survived,15.3% died, and 26.1% had sequelae. The number of living days in the GOS1 group was highly heterogeneous. Motor dysfunction, disturbance of consciousness, and hearing loss were the commonest sequelae. Of the underlying diseases identified in 68.9% of the PnM patients, liver and kidney diseases were significantly associated with unfavorable outcomes. Of the biomarkers, creatinine and blood urea nitrogen, followed by platelet and C-reactive protein had the most significant associations with unfavorable outcomes. There was a significant difference in the high protein concentrations in the cerebrospinal fluid between the groups. Serotypes 23F, 6C, 4, 23A, 22F, 10A, and 12F were associated with unfavorable outcomes. These serotypes were not penicillin-resistant isolates possessing three abnormal pbp genes (pbp1a, 2x, and 2b), except for 23F. The expected coverage rate of the pneumococcal conjugate vaccine (PCV) was 50.7% for PCV15 and 72.4% for PCV20. CONCLUSIONS In the introduction of PCV for adults, the risk factors for underlying diseases should be prioritized over age, and serotypes with unfavorable outcomes should be considered.
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Affiliation(s)
- Satoshi Iwata
- Department of Infectious Diseases, National Cancer Center Hospital, Tokyo, Japan; Department of Infectious Diseases, Keio University School of Medicine, Tokyo, Japan.
| | - Shigeo Hanada
- Department of Respiratory Medicine, Respiratory Center, Toranomon Hospital, Tokyo, Japan
| | - Misako Takata
- Department of Microbiology, Tokyo Medical University, Japan
| | - Miyuki Morozumi
- Department of Infectious Diseases, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Kamei
- Center for Neuro-Infections, Ageo Central General Hospital, Saitama Pref, Japan
| | - Kimiko Ubukata
- Department of Microbiology, Tokyo Medical University, Japan; Department of General Medicine, Keio University School of Medicine, Tokyo, Japan
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2
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Kopenhagen A, Ramming I, Camp B, Hammerschmidt S, Fulde M, Müsken M, Steinert M, Bergmann S. Streptococcus pneumoniae Affects Endothelial Cell Migration in Microfluidic Circulation. Front Microbiol 2022; 13:852036. [PMID: 35401456 PMCID: PMC8990767 DOI: 10.3389/fmicb.2022.852036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/04/2022] [Indexed: 01/12/2023] Open
Abstract
Bloodstream infections caused by Streptococcus pneumoniae induce strong inflammatory and procoagulant cellular responses and affect the endothelial barrier of the vascular system. Bacterial virulence determinants, such as the cytotoxic pore-forming pneumolysin, increase the endothelial barrier permeability by inducing cell apoptosis and cell damage. As life-threatening consequences, disseminated intravascular coagulation followed by consumption coagulopathy and low blood pressure is described. With the aim to decipher the role of pneumolysin in endothelial damage and leakage of the vascular barrier in more detail, we established a chamber-separation cell migration assay (CSMA) used to illustrate endothelial wound healing upon bacterial infections. We used chambered inlets for cell cultivation, which, after removal, provide a cell-free area of 500 μm in diameter as a defined gap in primary endothelial cell layers. During the process of wound healing, the size of the cell-free area is decreasing due to cell migration and proliferation, which we quantitatively determined by microscopic live cell monitoring. In addition, differential immunofluorescence staining combined with confocal microscopy was used to morphologically characterize the effect of bacterial attachment on cell migration and the velocity of gap closure. In all assays, the presence of wild-type pneumococci significantly inhibited endothelial gap closure. Remarkably, even in the presence of pneumolysin-deficient pneumococci, cell migration was significantly retarded. Moreover, the inhibitory effect of pneumococci on the proportion of cell proliferation versus cell migration within the process of endothelial gap closure was assessed by implementation of a fluorescence-conjugated nucleoside analogon. We further combined the endothelial CSMA with a microfluidic pump system, which for the first time enabled the microscopic visualization and monitoring of endothelial gap closure in the presence of circulating bacteria at defined vascular shear stress values for up to 48 h. In accordance with our CSMA results under static conditions, the gap remained cell free in the presence of circulating pneumococci in flow. Hence, our combined endothelial cultivation technique represents a complex in vitro system, which mimics the vascular physiology as close as possible by providing essential parameters of the blood flow to gain new insights into the effect of pneumococcal infection on endothelial barrier integrity in flow.
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Affiliation(s)
- Anna Kopenhagen
- Institut für Mikrobiologie, Technische Universität Braunschweig, Braunschweig, Germany
| | - Isabell Ramming
- Institut für Mikrobiologie, Technische Universität Braunschweig, Braunschweig, Germany.,Department of Infectious Diseases, Robert Koch Institute, Wernigerode, Germany
| | - Belinda Camp
- Institut für Mikrobiologie, Technische Universität Braunschweig, Braunschweig, Germany.,Department of Pneumology, University Hospital Magdeburg, Magdeburg, Germany
| | - Sven Hammerschmidt
- Institute for Genetics and Functional Genomics, Department of Molecular Genetics and Infection Biology, Universität Greifswald, Greifswald, Germany
| | - Marcus Fulde
- Institute of Microbiology and Epizootics, Department of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany
| | - Mathias Müsken
- Central Facility for Microscopy, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Michael Steinert
- Institut für Mikrobiologie, Technische Universität Braunschweig, Braunschweig, Germany.,Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Simone Bergmann
- Institut für Mikrobiologie, Technische Universität Braunschweig, Braunschweig, Germany
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3
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de Blauw D, Bruning AHL, Wolthers KC, van Wermeskerken AM, Biezeveld MH, Wildenbeest JG, Pajkrt D. Incidence of Childhood Meningoencephalitis in Children With a Suspected Meningoencephalitis in the Netherlands. Pediatr Infect Dis J 2022; 41:290-296. [PMID: 34966139 PMCID: PMC8920014 DOI: 10.1097/inf.0000000000003441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2021] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text.
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Affiliation(s)
- Dirkje de Blauw
- From the Department of Pediatric Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Katja C Wolthers
- Department of Medical Microbiology, OrganoVIR Labs, Amsterdam UMC, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, the Netherlands
| | | | - Maarten H Biezeveld
- Department of Pediatric Diseases, Onze Lieve Vrouwe Gasthuis OLVG, Amsterdam, the Netherlands
| | - Joanne G Wildenbeest
- From the Department of Pediatric Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, Academic Medical Center, Amsterdam, the Netherlands
| | - Dasja Pajkrt
- From the Department of Pediatric Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, Academic Medical Center, Amsterdam, the Netherlands
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4
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Polkowska A, Rinta-Kokko H, Toropainen M, Palmu AA, Nuorti JP. Long-term population effects of infant 10-valent pneumococcal conjugate vaccination on pneumococcal meningitis in Finland. Vaccine 2021; 39:3216-3224. [PMID: 33934915 DOI: 10.1016/j.vaccine.2021.02.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 02/11/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND No previous studies have reported long-term follow-up of ten-valent pneumococcal conjugate vaccine (PCV10) program impact on pneumococcal meningitis (PM). We assessed the effects of infant PCV10 program on PM incidence, mortality and serotype distribution in children and adults during 7 years after introduction. METHODS We conducted a population-based observational study. A case of PM was defined as isolation of Streptococcus pneumoniae from cerebrospinal fluid or, a patient with S. pneumoniae isolated from blood and an ICD-10 hospital discharge diagnosis of bacterial meningitis within 30 days before or after positive culture date.We compared age- and serotype-specific incidence and associated 30-day mortality rates in 2011-2017 (PCV10 period) with those in 2004-2010 (pre-PCV10 baseline) by using Poisson regression models. Absolute rate differences and 95% confidence intervals (CIs) were calculated from the parameter estimates by using delta method. RESULTS During the PCV10 period, the overall incidence of PCV10 serotype meningitis decreased by 68% (95%CI 57%-77%), and the overall PM incidence by 27% (95%CI: 12%-39%). In age groups 0-4, 50-64, and ≥ 18 years, the overall PM incidence was reduced by 64%, 34% and 19%, respectively. In adults ≥ 65 years of age, a 69% reduction in PCV10 serotypes was offset by 157% (56%-342%) increase in non-PCV10 serotypes. The overall PM-related mortality rate decreased by 42% (95%CI 4%-65%). Overall case fatality proportion (CFP) was 16% in pre-PCV10 period and 12% in PCV10 period (p = 0.41); among persons 50-64 years the CFP decreased from 25% to 10% (p = 0.04). CONCLUSIONS We observed substantial impact and herd protection for vaccine-serotype PM and associated mortality after infant PCV10 introduction. However, in older adults ≥ 65 years of age, PM burden remains unchanged due to serotype replacement.
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Affiliation(s)
- Aleksandra Polkowska
- Health Sciences Unit, Faculty of Social Sciences, Tampere University, Arvo Ylpön katu 34, 33520 Tampere, Finland.
| | - Hanna Rinta-Kokko
- Public Health Evaluation and Projection Unit, Department of Public Health Solutions, Finnish Institute for Health and Welfare (THL), Mannerheimintie 166, Helsinki, Finland.
| | - Maija Toropainen
- Infectious Diseases and Vaccinations Unit, Department of Health Security, Finnish Institute for Health and Welfare (THL), Mannerheimintie 166, Helsinki, Finland.
| | - Arto A Palmu
- Public Health Evaluation and Projection Unit, Department of Public Health Solutions, Finnish Institute for Health and Welfare (THL), Mannerheimintie 166, Helsinki, Finland.
| | - J Pekka Nuorti
- Health Sciences Unit, Faculty of Social Sciences, Tampere University, Arvo Ylpön katu 34, 33520 Tampere, Finland; Infectious Diseases and Vaccinations Unit, Department of Health Security, Finnish Institute for Health and Welfare (THL), Mannerheimintie 166, Helsinki, Finland.
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Vadlamudi NK, Patrick DM, Hoang L, Sadarangani M, Marra F. Incidence of invasive pneumococcal disease after introduction of the 13-valent conjugate pneumococcal vaccine in British Columbia: A retrospective cohort study. PLoS One 2020; 15:e0239848. [PMID: 32997698 PMCID: PMC7526878 DOI: 10.1371/journal.pone.0239848] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 09/14/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND A significant reduction in invasive pneumococcal disease (IPD) has been reported, across all ages, following the implementation of 7-valent conjugate pneumococcal vaccine (PCV7) globally, as part of infant immunization programs. We explored the additional impact of PCV13 on IPD over a 14-year period. METHODS Using provincial laboratory surveillance and hospitalization data (N = 5791), we calculated the annual incidence of IPD following the implementation of PCV13 vaccine. Poisson regression was used to evaluate changes in the overall incidence of IPD, and serotype-specific IPD between PCV7 (2004-10) and PCV13 (2011-2015) eras. RESULTS Overall, IPD rates have seen a modest decline in the PCV13 compared to the PCV7 era (IRR 0.84; 95% CI: 0.79-0.89); this was seen in children ≤2 years of age, and the majority of the adult cohort. Rates of vaccine-type IPD (PCV7 and PCV13) also decreased in the PCV13 era. In contrast, IPD incidence related to non-PCV13 (IRR: 1.56; 95%CI:1.43-1.72) and non-vaccine serotypes (IRR: 2.12; 95%CI:1.84-2.45) increased in the PCV13 era compared to the PCV7 era. CONCLUSIONS A modest reduction in IPD from the PCV13 vaccine was observed, with gains limited to the immunized cohort and adults. However, a significant increase in non-vaccine serotypes emphasizes the need for continued surveillance.
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Affiliation(s)
| | - David M. Patrick
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- British Columbia Centre for Disease Control, Vancouver, Canada
| | - Linda Hoang
- British Columbia Centre for Disease Control, Vancouver, Canada
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Manish Sadarangani
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Vaccine Evaluation Center, BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Fawziah Marra
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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6
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Vadlamudi NK, Chen A, Marra F. Impact of the 13-Valent Pneumococcal Conjugate Vaccine Among Adults: A Systematic Review and Meta-analysis. Clin Infect Dis 2020; 69:34-49. [PMID: 30312379 DOI: 10.1093/cid/ciy872] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 10/05/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND A notable reduction of the pneumococcal disease burden among adults was observed after the introduction of a 7-valent pneumococcal conjugate vaccine (PCV7) in childhood immunization programs. In 2010, a 13-valent pneumococcal conjugate vaccine (PCV13) replaced PCV7 in many jurisdictions; a comparative assessment of PCV13's impact was missing. Our objective was to summarize the available data and assess the change in the incidence of invasive pneumococcal disease (IPD) in adults after the introduction of PCV13 in childhood immunization programs. METHODS We conducted a systematic literature search from January 1946 to May 2017 of randomized, controlled trials and observational studies OBS reporting the incidence of IPD, non-invasive pneumococcal disease, hospitalizations, and mortality in adults for the periods before and after the introduction of PCV13. Incidence rate ratios (IRRs) were pooled across studies using restricted, maximum-likelihood, random-effects models. RESULTS From 3306 records,we included 29 OBS studies and 2033961 cases. Significantly lower IPD rates were seen after PCV13 introduction in adults aged <65 years (IRR 0.78, 95% confidence interval [CI] 0.72-0.85) and those aged ≥65 years (IRR 0.86, 95% CI 0.81-0.91). Lower rates of IPD were seen with PCV7 (IRR 0.45, 95% CI 0.38-0.54) and PCV13 serotypes (IRR 0.60, 95% CI 0.54-0.68). A significantly higher IRR of 1.10 (95% CI 1.04-1.17) for non-vaccine serotypes was observed, especially among those aged 65 years and older (IRR 1.20, 95% CI 1.11-1.29). CONCLUSIONS PCV13 use in children had a moderate impact on reducing the overall and vaccine-type IPDs, but there was a significant increase in non-vaccine type IPDs among adults, especially in those over 65 years.
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Affiliation(s)
| | - Anna Chen
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Fawziah Marra
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
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7
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Bekeredjian-Ding I. Challenges for Clinical Development of Vaccines for Prevention of Hospital-Acquired Bacterial Infections. Front Immunol 2020; 11:1755. [PMID: 32849627 PMCID: PMC7419648 DOI: 10.3389/fimmu.2020.01755] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 06/30/2020] [Indexed: 12/19/2022] Open
Abstract
Increasing antibiotic resistance in bacteria causing endogenous infections has entailed a need for innovative approaches to therapy and prophylaxis of these infections and raised a new interest in vaccines for prevention of colonization and infection by typically antibiotic resistant pathogens. Nevertheless, there has been a long history of failures in late stage clinical development of this type of vaccines, which remains not fully understood. This article provides an overview on present and past vaccine developments targeting nosocomial bacterial pathogens; it further highlights the specific challenges associated with demonstrating clinical efficacy of these vaccines and the facts to be considered in future study designs. Notably, these vaccines are mainly applied to subjects with preexistent immunity to the target pathogen, transient or chronic immunosuppression and ill-defined microbiome status. Unpredictable attack rates and changing epidemiology as well as highly variable genetic and immunological strain characteristics complicate the development. In views of the clinical need, re-thinking of the study designs and expectations seems warranted: first of all, vaccine development needs to be footed on a clear rationale for choosing the immunological mechanism of action and the optimal time point for vaccination, e.g., (1) prevention (or reduction) of colonization vs. prevention of infection and (2) boosting of a preexistent immune response vs. altering the quality of the immune response. Furthermore, there are different, probably redundant, immunological and microbiological defense mechanisms that provide protection from infection. Their interplay is not well-understood but as a consequence their effect might superimpose vaccine-mediated resolution of infection and lead to failure to demonstrate efficacy. This implies that improved characterization of patient subpopulations within the trial population should be obtained by pro- and retrospective analyses of trial data on subject level. Statistical and systems biology approaches could help to define immune and microbiological biomarkers that discern populations that benefit from vaccination from those where vaccines might not be effective.
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Affiliation(s)
- Isabelle Bekeredjian-Ding
- Division of Microbiology, Langen, Germany.,Institute for Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany
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8
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Purwanto DS, Loho T, Tafroji W, Mangunatmadja I, Immanuel S, Timan IS, Yusra Y, Safari D. Isolation and identification of Streptococcus pneumoniae serotype 6B from a patient with bacterial meningitis infection in Jakarta, Indonesia. Access Microbiol 2020; 2:acmi000123. [PMID: 32974581 PMCID: PMC7494185 DOI: 10.1099/acmi.0.000123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 03/03/2020] [Indexed: 11/20/2022] Open
Abstract
CNS infection is a life-threatening condition in developing countries and Streptococcus pneumoniae has been reported as the most common cause of bacterial meningitis; however, there is limited data on pneumococcal meningitis in Indonesia. This cross-sectional study aimed to isolate and identity S. pneumoniae strains from cerebrospinal fluid (CSF) specimens collected as part of routine testing from patients with clinically diagnosed central nervous system infection at a national referral hospital in Jakarta, Indonesia in 2017. S. pneumoniae isolation and identification were performed using conventional culture and molecular tools. Antibiotic susceptibility patterns were monitored through minimum inhibitory concentration testing. From 147 CSF specimens, one S. pneumoniae strain was identified from a patient with bacterial meningitis symptoms. The isolate was serotype 6B (ST5661) and susceptible to 18 antimicrobial agents tested, including penicillin, tetracycline, and the macrolide group. Our data provide insights into the epidemiology of invasive pneumococcal disease in Indonesia.
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Affiliation(s)
- Diana Shintawati Purwanto
- Department of Clinical Pathology, Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.,Department of Biochemistry, Faculty of Medicine Sam Ratulangi University, Manado, Indonesia
| | - Tonny Loho
- Department of Clinical Pathology, Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Wisnu Tafroji
- Molecular Bacteriology Unit, Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | - Irawan Mangunatmadja
- Department of Child Health, Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Suzanna Immanuel
- Department of Clinical Pathology, Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Ina Susianti Timan
- Department of Clinical Pathology, Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Yusra Yusra
- Department of Clinical Pathology, Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Dodi Safari
- Molecular Bacteriology Unit, Eijkman Institute for Molecular Biology, Jakarta, Indonesia
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9
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Oligbu G, Collins S, Djennad A, Sheppard CL, Fry NK, Andrews NJ, Borrow R, Ramsay ME, Ladhani SN. Effect of Pneumococcal Conjugate Vaccines on Pneumococcal Meningitis, England and Wales, July 1, 2000-June 30, 2016. Emerg Infect Dis 2020; 25:1708-1718. [PMID: 31441745 PMCID: PMC6711218 DOI: 10.3201/eid2509.180747] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
We describe the effects of the 7-valent (PCV7) and 13-valent (PCV13) pneumococcal conjugate vaccines on pneumococcal meningitis in England and Wales during July 1, 2000–June 30, 2016. Overall, 84,473 laboratory-confirmed invasive pneumococcal disease cases, including 4,160 (4.9%) cases with meningitis, occurred. PCV7 implementation in 2006 did not lower overall pneumococcal meningitis incidence because of replacement with non–PCV7-type meningitis incidence. Replacement with PCV13 in 2010, however, led to a 48% reduction in pneumococcal meningitis incidence by 2015–16. The overall case-fatality rate was 17.5%: 10.7% among patients <5 years of age, 17.3% among patients 5–64 years of age, and 31.9% among patients >65 years of age. Serotype 8 was associated with increased odds of death (adjusted odds ratio 2.9, 95% CI 1.8–4.7). In England and Wales, an effect on pneumococcal meningitis was observed only after PCV13 implementation. Further studies are needed to assess pneumococcal meningitis caused by the replacing serotypes.
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10
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Kasanmoentalib ES, Valls Serón M, Engelen-Lee JY, Tanck MW, Pouw RB, van Mierlo G, Wouters D, Pickering MC, van der Ende A, Kuijpers TW, Brouwer MC, van de Beek D. Complement factor H contributes to mortality in humans and mice with bacterial meningitis. J Neuroinflammation 2019; 16:279. [PMID: 31883521 PMCID: PMC6935240 DOI: 10.1186/s12974-019-1675-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 12/16/2019] [Indexed: 02/08/2023] Open
Abstract
Background The complement system is a vital component of the inflammatory response occurring during bacterial meningitis. Blocking the complement system was shown to improve the outcome of experimental pneumococcal meningitis. Complement factor H (FH) is a complement regulatory protein inhibiting alternative pathway activation but is also exploited by the pneumococcus to prevent complement activation on its surface conferring serum resistance. Methods In a nationwide prospective cohort study of 1009 episodes with community-acquired bacterial meningitis, we analyzed whether genetic variations in CFH influenced FH cerebrospinal fluid levels and/or disease severity. Subsequently, we analyzed the role of FH in our pneumococcal meningitis mouse model using FH knock-out (Cfh−/−) mice and wild-type (wt) mice. Finally, we tested whether adjuvant treatment with human FH (hFH) improved outcome in a randomized investigator blinded trial in a pneumococcal meningitis mouse model. Results We found the major allele (G) of single nucleotide polymorphism in CFH (rs6677604) to be associated with low FH cerebrospinal fluid concentration and increased mortality. In patients and mice with bacterial meningitis, FH concentrations were elevated during disease and Cfh−/− mice with pneumococcal meningitis had increased mortality compared to wild-type mice due to C3 depletion. Adjuvant treatment of wild-type mice with purified human FH led to complement inhibition but also increased bacterial outgrowth which resulted in similar disease outcomes. Conclusion Low FH levels contribute to mortality in pneumococcal meningitis but adjuvant treatment with FH at a clinically relevant time point is not beneficial.
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Affiliation(s)
- E Soemirien Kasanmoentalib
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Mercedes Valls Serón
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Joo Yeon Engelen-Lee
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Michael W Tanck
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Richard B Pouw
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory of the Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
| | - Gerard van Mierlo
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory of the Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Diana Wouters
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory of the Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Matthew C Pickering
- Centre for Inflammatory Disease, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Arie van der Ende
- Department of Medical Microbiology and The Netherlands Reference Laboratory for Bacterial Meningitis, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Taco W Kuijpers
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory of the Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands.,Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory of the Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Matthijs C Brouwer
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands.
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11
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Resurgence of pneumococcal meningitis in Europe and Northern America. Clin Microbiol Infect 2019; 26:199-204. [PMID: 31100424 DOI: 10.1016/j.cmi.2019.04.032] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 04/24/2019] [Accepted: 04/27/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Streptococcus pneumoniae is the most common pathogen causing bacterial meningitis. The routine use of multivalent conjugate pneumococcal vaccines has led to a decline of invasive pneumococcal disease caused by serotypes included in the vaccine serotypes. Recently, several reports have described a concomitant rise in the incidence of non-vaccine serotypes, suggesting serotype replacement. OBJECTIVE We aim to review the effect of pneumococcal vaccination on the incidence of pneumococcal meningitis in Europe and northern America with a particular interest in serotype replacement. SOURCES Articles that include data on invasive pneumococcal disease incidence before and after the introduction of vaccination, or on invasive pneumococcal serotype, are discussed, with a focus on pneumococcal meningitis. CONTENT The introduction of pneumococcal conjugate vaccines has universally resulted in a decline in vaccine-serotype pneumococcal meningitis incidence throughout Europe and northern America. Serotype replacement by non-vaccine serotypes has however been reported following the introduction of the 7-, 10- and 13-valent pneumococcal conjugate vaccines, which in several regions abolished the overall effect of vaccination on pneumococcal meningitis incidence. IMPLICATIONS The promising decline in the incidence of pneumococcal meningitis following the introduction of vaccination seems to have been temporary. Replacement by non-vaccine serotypes illustrates that pneumococcal meningitis continues to pose a major challenge. We need new approaches to prevention, new vaccines and continued efforts to improve treatment for patients with pneumococcal meningitis.
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Drayß M, Claus H, Hubert K, Thiel K, Berger A, Sing A, van der Linden M, Vogel U, Lâm TT. Asymptomatic carriage of Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, Group A Streptococcus and Staphylococcus aureus among adults aged 65 years and older. PLoS One 2019; 14:e0212052. [PMID: 30735539 PMCID: PMC6368330 DOI: 10.1371/journal.pone.0212052] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/10/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The aim of this study was to determine the prevalence of Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, group A Streptococcus (GAS), and Staphylococcus aureus in asymptomatic elderly people and to unravel risk factors leading to colonization. METHODS A multi-centre cross-sectional study was conducted including 677 asymptomatic adults aged 65 years or more, living at home or in nursing homes. Study areas were Greater Aachen (North-Rhine-Westphalia) and Wuerzburg (Bavaria), both regions with medium to high population density. Nasal and oropharyngeal swabs as well as questionnaires were collected from October 2012 to May 2013. Statistical analysis included multiple logistic regression models. RESULTS The carriage rate was 1.9% ([95%CI: 1.0-3.3%]; 13/677) for H. influenzae, 0.3% ([95%CI: 0-1.1%]; 2/677) for N. meningitidis and 0% ([95% CI: 0-0.5%]; 0/677) for S. pneumoniae and GAS. Staphylococcus aureus was harboured by 28.5% of the individuals ([95% CI: 25.1-32.1%]; 193/677) and 0.7% ([95% CI: 0.2-1.7%]; 5/677) were positive for methicillin-resistant S. aureus. Among elderly community-dwellers colonization with S. aureus was significantly associated with higher educational level (adjusted OR: 1.905 [95% CI: 1.248-2.908]; p = 0.003). Among nursing home residents colonization was associated with being married (adjusted OR: 3.367 [1.502-7.546]; p = 0.003). CONCLUSION The prevalence of N. meningitidis, H. influenzae, S. pneumoniae and GAS was low among older people in Germany. The S. aureus rate was expectedly high, while MRSA was found in less than 1% of the individuals.
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Affiliation(s)
- Maria Drayß
- Institute for Hygiene and Microbiology, National Reference Centre for Meningococci and Haemophilus influenzae, University of Wuerzburg, Wuerzburg, Germany
| | - Heike Claus
- Institute for Hygiene and Microbiology, National Reference Centre for Meningococci and Haemophilus influenzae, University of Wuerzburg, Wuerzburg, Germany
| | - Kerstin Hubert
- Institute for Hygiene and Microbiology, National Reference Centre for Meningococci and Haemophilus influenzae, University of Wuerzburg, Wuerzburg, Germany
| | - Katrin Thiel
- Institute for Hygiene and Microbiology, National Reference Centre for Meningococci and Haemophilus influenzae, University of Wuerzburg, Wuerzburg, Germany
| | - Anja Berger
- Bavarian Health and Food Safety Authority, National Consulting Laboratory for Diphtheria, Oberschleißheim, Germany
| | - Andreas Sing
- Bavarian Health and Food Safety Authority, National Consulting Laboratory for Diphtheria, Oberschleißheim, Germany
| | - Mark van der Linden
- Institute of Medical Microbiology, National Reference Centre for Streptococci, University Hospital (RWTH), Aachen, Germany
| | - Ulrich Vogel
- Institute for Hygiene and Microbiology, National Reference Centre for Meningococci and Haemophilus influenzae, University of Wuerzburg, Wuerzburg, Germany
| | - Thiên-Trí Lâm
- Institute for Hygiene and Microbiology, National Reference Centre for Meningococci and Haemophilus influenzae, University of Wuerzburg, Wuerzburg, Germany
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Polkowska A, Skoczyńska A, Paradowska-Stankiewicz I, Stefanoff P, Hryniewicz W, Kuch A, Lyytikäinen O, Nuorti JP. Pneumococcal meningitis before the introduction of 10-valent pneumococcal conjugate vaccine into the National Childhood Immunization Program in Poland. Vaccine 2019; 37:1365-1373. [PMID: 30638798 DOI: 10.1016/j.vaccine.2018.12.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 12/12/2018] [Accepted: 12/13/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Poland introduced the 10-valent conjugate pneumococcal vaccine (PCV10) into the childhood immunization program in January 2017. During previous decades, considerable changes had occurred in the surveillance system for invasive pneumococcal disease. Therefore, to provide baseline data on pneumococcal diseases before PCV10 introduction, we evaluated the epidemiology of pneumococcal meningitis (PM), the only syndrome monitored consistently since 1970. METHODS Based on laboratory-confirmed cases reported during 2005-2015, we calculated the reported rates, serotypes distribution and antimicrobial resistance of pneumococcal meningitis isolates. Data from the mandatory national surveillance system was linked with data on cerebrospinal fluid isolates submitted to the National Reference Centre for Bacterial Meningitis. We used negative binomial regression with Newey West method to test for trend in rates of pneumococcal meningitis notified during 2005-2015 and Chi-squared test to assess changes in the serotype distribution from 2008-2011 to 2012-2015. RESULTS From 2005 to 2015, the overall reported incidence of PM increased from 0.21 to 0.47 cases per 100,000 population, average yearly increase of 7% (rate ratio 1.07; 95% CI 1.06-1.08). The increase was primarily due to annual increase of 3% (1.02-1.05) among 15-49 years of age, 12% (95% CI: 1.10-1.13) among 50-64 years of age, 18% (95% CI: 1.16-1.19) among persons 65-74 years of age and 9% (95% CI 1.07-1.10) among persons ≥75 years of age. In children <5 years of age, serotypes included in PCV10 and PCV13 accounted for 75% and 80% of reported isolates, respectively. From 2008-2011 to 2012-2015, the proportion of PM cases caused by PCV10 serotypes decreased from 52% to 41% (p < 0.01). Overall, 28% of isolates were resistant to penicillin and 13% were non-susceptible to cefotaxime. CONCLUSIONS The introduction of PCV10 into national immunization program may have considerable impact on disease burden, especially on number of cases caused by isolates non-susceptible to antimicrobials.
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Affiliation(s)
- Aleksandra Polkowska
- Health Sciences Unit, Faculty of Social Sciences, University of Tampere, Finland
| | - Anna Skoczyńska
- National Reference Centre for Bacterial Meningitis (NRCBM), Department of Epidemiology and Clinical Microbiology, National Medicines Institute, Warsaw, Poland
| | - Iwona Paradowska-Stankiewicz
- Department of Epidemiology of Infectious Diseases and Surveillance, National Institute of Public Health - National Institute of Hygiene (NIPH - NIH), Warsaw, Poland
| | - Paweł Stefanoff
- Department of Epidemiology of Infectious Diseases and Surveillance, National Institute of Public Health - National Institute of Hygiene (NIPH - NIH), Warsaw, Poland
| | - Waleria Hryniewicz
- National Reference Centre for Bacterial Meningitis (NRCBM), Department of Epidemiology and Clinical Microbiology, National Medicines Institute, Warsaw, Poland
| | - Alicja Kuch
- National Reference Centre for Bacterial Meningitis (NRCBM), Department of Epidemiology and Clinical Microbiology, National Medicines Institute, Warsaw, Poland
| | - Outi Lyytikäinen
- Department of Health Security, National Institute for Health and Welfare (THL), Helsinki, Finland
| | - J Pekka Nuorti
- Health Sciences Unit, Faculty of Social Sciences, University of Tampere, Finland; Department of Health Security, National Institute for Health and Welfare (THL), Helsinki, Finland.
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Carmona Martinez A, Prymula R, Miranda Valdivieso M, Otero Reigada MDC, Merino Arribas JM, Brzostek J, Szenborn L, Ruzkova R, Horn MR, Jackowska T, Centeno-Malfaz F, Traskine M, Dobbelaere K, Borys D. Immunogenicity and safety of 11- and 12-valent pneumococcal non-typeable Haemophilus influenzae protein D-conjugate vaccines (11vPHiD-CV, 12vPHiD-CV) in infants: Results from a phase II, randomised, multicentre study. Vaccine 2018; 37:176-186. [PMID: 30054160 DOI: 10.1016/j.vaccine.2018.07.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/24/2018] [Accepted: 07/11/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND We assessed 2 investigational 11- and 12-valent vaccines, containing capsular polysaccharides of 10 serotypes as in the pneumococcal non-typeable Haemophilus influenzae protein D-conjugate vaccine (PHiD-CV) and CRM197-conjugated capsular polysaccharides of serotypes 19A (11-valent) or 19A and 6A (12-valent). METHODS In this phase II, partially-blind, multicentre study (NCT01204658), healthy infants were randomised (1:1:1:1) to receive 11vPHiD-CV, 12vPHiD-CV, PHiD-CV, or 13-valent CRM197-conjugate pneumococcal vaccine (PCV13), at 2, 3, and 4 (primary series), and 12-15 months of age (booster dose), co-administered with DTPa-HBV-IPV/Hib. Confirmatory objectives assessed non-inferiority of investigational vaccines to comparators (PHiD-CV for common serotypes; PCV13 for 19A and 6A), in terms of percentage of infants with pneumococcal antibody concentrations ≥0.2 μg/mL and antibody geometric mean concentrations, post-primary vaccination. Reactogenicity and safety were assessed. RESULTS 951 children received ≥1 primary dose, 919 a booster dose. Pre-defined immunological non-inferiority criteria were met simultaneously for 9/11 11vPHiD-CV serotypes (all except 23F and 19A) and 10/12 12vPHiD-CV serotypes (all except 19A and 6A); thus, non-inferiority objectives were reached. For each PHiD-CV serotype, percentages of children with antibody concentrations ≥0.2 µg/mL were ≥96.7% post-primary (except 6B [≥75.2%] and 23F [≥81.1%]), and ≥98.1% post-booster vaccination. For each PHiD-CV serotype except serotype 1, ≥81.0% and ≥93.9% of children had opsonophagocytic activity titres ≥8, post-primary and booster vaccination. AEs incidence was similar across all groups. SAEs were reported for 117 children (29 in the 11vPHiD-CV group, 26 in the 12vPHiD-CV group, 38 in the PHiD-CV group and 24 in the PCV13 group); 4 SAEs were considered vaccination-related. No fatal events were recorded. CONCLUSION Addition of 19A and 6A CRM197-conjugates did not alter immunogenicity of the PHiD-CV conjugates; for both investigational vaccines post-booster immune responses to 10 common serotypes appeared similar to those elicited by PHiD-CV. Safety and reactogenicity profiles of the investigational vaccines were comparable to PHiD-CV. Clinical trial registry: NCT01204658.
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Affiliation(s)
| | - Roman Prymula
- Department of Social Medicine, Faculty of Medicine in Hradec Králové, Charles University in Prague, Šimkova 870, 500 38 Hradec Králové, Czech Republic.
| | | | | | | | - Jerzy Brzostek
- Health Care Establishment in Debica, Infectious Diseases Outpatient Clinic, ul. Krakowska 91, 39-200 Debica, Poland.
| | - Leszek Szenborn
- Department of Paediatric Infectious Diseases, Wroclaw Medical University, 2-2A, Chalubinskiego, 50-368 Wroclaw, Poland.
| | - Renata Ruzkova
- Pediatric Office Dr. Renata Ruzkova, Kladenska 53, Medicentrum 6, s.r.o., 160 00 Prague, Czech Republic.
| | - Michael R Horn
- Pediatric Office Dr. Med. Michael Horn, Achenweg 1, 83471 Schönau am Königssee, Germany.
| | - Teresa Jackowska
- Department of Pediatrics, Centre of Postgraduate Medical Education, ul. Marymoncka 99/103, 01-813 Warsaw, Poland.
| | - Fernando Centeno-Malfaz
- Department of Pediatrics, Rio Hortega University Hospital, Calle Dulzaina, 2, 47012 Valladolid, Spain.
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Pneumococcal Meningitis Before and After Universal Vaccination With Pneumococcal Conjugate Vaccines 7/13, Impact on Pediatric Hospitalization in Public and Nonpublic Institutions, in Uruguay. Pediatr Infect Dis J 2017; 36:1000-1001. [PMID: 28661966 DOI: 10.1097/inf.0000000000001671] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This is the first study showing the impact of 13-valent pneumococcal conjugate vaccine on pneumococcal meningitis in Latin America; a significant (63.5%) reduction in hospitalization was observed during the first 6 years after starting vaccination. A 90% reduction of pneumococcal conjugate vaccines 7/13 serotypes was observed (P < 0.0001). After vaccination, all strains were penicillin susceptible. Mortality had a reduction of 71%.
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16
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Lien CY, Huang CR, Tsai WC, Hsu CW, Tsai NW, Chang CC, Lu CH, Chien CC, Chang WN. Epidemiologic trend of adult bacterial meningitis in southern Taiwan (2006–2015). J Clin Neurosci 2017; 42:59-65. [DOI: 10.1016/j.jocn.2017.03.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/06/2017] [Indexed: 12/28/2022]
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Impact of pneumococcal conjugate vaccine (PCV7 and PCV13) on pneumococcal invasive diseases in Italian children and insight into evolution of pneumococcal population structure. Vaccine 2017; 35:4587-4593. [PMID: 28716556 DOI: 10.1016/j.vaccine.2017.07.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 05/29/2017] [Accepted: 07/03/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND The use of PCV7 for children immunization was gradually implemented in the Italian regions starting from 2006 and was replaced by PCV13 in 2010-2011. In this study we aimed to assess the PCV impact on invasive pneumococcal diseases (IPD) incidence, serotype distribution and antibiotic resistance in Italian children under 5years old. METHODS All IPD cases in children from 5 Italian regions (Emilia-Romagna, Lombardia, A. P. Bolzano, A. P. Trento, and Piemonte) reported through the nationwide surveillance system during 2008-2014 were included in this study. Pneumococcal isolates were subjected to serotyping, antibiotic susceptibility testing, and clonal analysis according to standard methods. RESULTS During the study period overall IPD incidence decreased from 7.8 cases/100,000 inhabitants in 2008 to 3.0 cases/100,000 in 2014 (61% decrease, P<0.001). In particular, from 2008 to 2014, PCV7-type IPD decreased from 2.92 to 0.13 cases/100,000 inhabitants (95% decrease, P<0.001) while PCV13-non-PCV7 type IPD decreased from 3.2 to 0.89 cases/100,000 inhabitants (72% decrease, P=0.008). Conversely, non-vaccine serotype (NVS) IPD increased overtime, becoming more common than PCV13 serotype IPD in 2013-2014. Emergent NVS 24F and 12F were the most prevalent in 2014. Antibiotic resistance testing revealed an overall increasing trend in penicillin resistance, from 14% in 2008 to 23% in 2014. Erythromycin resistance showed a downward trend, from 38% in 2008 to 27% in 2014. While in 2008 PCV13 serotypes were the major responsible for antibiotic resistance, during the following years antimicrobial resistance due to NVS increased, mainly as a result of expansion of pre-existing clones. CONCLUSIONS Both PCVs led to a substantial decrease in vaccine-related IPD incidence in the children population. However NVS-related IPD increased, becoming the most prevalent in the last two-years period. Continuous surveillance is an essential tool to monitor evolution of pneumococcal population causing IPD in children.
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Balsells E, Guillot L, Nair H, Kyaw MH. Serotype distribution of Streptococcus pneumoniae causing invasive disease in children in the post-PCV era: A systematic review and meta-analysis. PLoS One 2017; 12:e0177113. [PMID: 28486544 PMCID: PMC5423631 DOI: 10.1371/journal.pone.0177113] [Citation(s) in RCA: 257] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 04/21/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Routine immunisation with pneumococcal conjugate vaccines (PCV7/10/13) has reduced invasive pneumococcal disease (IPD) due to vaccine serotypes significantly. However, an increase in disease due to non-vaccine types, or serotype replacement, has been observed. Serotypes' individual contributions to IPD play a critical role in determining the overall effects of PCVs. This study examines the distribution of pneumococcal serotypes in children to identify leading serotypes associated with IPD post-PCV introduction. METHODS A systematic search was performed to identify studies and surveillance reports (published between 2000 and December 2015) of pneumococcal serotypes causing childhood IPD post-PCV introduction. Serotype data were differentiated based on the PCV administered during the study period: PCV7 or higher valent PCVs (PCV10 or PCV13). Meta-analysis was conducted to estimate the proportional contributions of the most frequent serotypes in childhood IPD in each period. RESULTS We identified 68 studies reporting serotype data among IPD cases in children. We analysed data from 38 studies (14 countries) where PCV7 was administered and 20 (24 countries) where PCV10 or PCV13 have been introduced. Studies reported early and late periods of PCV7 administration (range: 2001∓13). In these settings, serotype 19A was the most predominant cause of childhood IPD, accounting for 21.8% (95%CI 18.6∓25.6) of cases. In countries that have introduced higher valent PCVs, study periods were largely representative of the transition and early years of PCV10 or PCV13. In these studies, the overall serotype-specific contribution of 19A was lower (14.2% 95%CI 11.1∓18.3). Overall, non-PCV13 serotypes contributed to 42.2% (95%CI 36.1∓49.5%) of childhood IPD cases. However, regional differences were noted (57.8% in North America, 71.9% in Europe, 45.9% in Western Pacific, 28.5% in Latin America, 42.7% in one African country, and 9.2% in one Eastern Mediterranean country). Predominant non-PCV13 serotypes overall were 22F, 12F, 33F, 24F, 15C, 15B, 23B, 10A, and 38 (descending order), but their rank order varied by region. CONCLUSION Childhood IPD is associated with a wide number of serotypes. In the early years after introduction of higher valent PCVs, non-PCV13 types caused a considerable proportion of childhood IPD. Serotype data, particularly from resource-limited countries with high burden of IPD, are needed to assess the importance of serotypes in different settings. The geographic diversity of pneumococcal serotypes highlights the importance of continued surveillance to guide vaccine design and recommendations.
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Affiliation(s)
- Evelyn Balsells
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Medical School, Teviot Place, Edinburgh, United Kingdom
| | - Laurence Guillot
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Medical School, Teviot Place, Edinburgh, United Kingdom
| | - Harish Nair
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Medical School, Teviot Place, Edinburgh, United Kingdom
| | - Moe H. Kyaw
- Sanofi Pasteur, Swiftwater, Pennsylvania, United States of America
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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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From Immunologically Archaic to Neoteric Glycovaccines. Vaccines (Basel) 2017; 5:vaccines5010004. [PMID: 28134792 PMCID: PMC5371740 DOI: 10.3390/vaccines5010004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 11/14/2016] [Accepted: 01/22/2017] [Indexed: 12/13/2022] Open
Abstract
Polysaccharides (PS) are present in the outermost surface of bacteria and readily come in contact with immune cells. They interact with specific antibodies, which in turn confer protection from infections. Vaccines with PS from pneumococci, meningococci, Haemophilus influenzae type b, and Salmonella typhi may be protective, although with the important constraint of failing to generate permanent immunological memory. This limitation has in part been circumvented by conjugating glycovaccines to proteins that stimulate T helper cells and facilitate the establishment of immunological memory. Currently, protection evoked by conjugated PS vaccines lasts for a few years. The same approach failed with PS from staphylococci, Streptococcus agalactiae, and Klebsiella. All those germs cause severe infections in humans and often develop resistance to antibiotic therapy. Thereby, prevention is of increasing importance to better control outbreaks. As only 23 of more than 90 pneumococcal serotypes and 4 of 13 clinically relevant Neisseria meningitidis serogroups are covered by available vaccines there is still tremendous clinical need for PS vaccines. This review focuses on glycovaccines and the immunological mechanisms for their success or failure. We discuss recent advances that may facilitate generation of high affinity anti-PS antibodies and confer specific immunity and long-lasting protection.
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Hausdorff WP, Hanage WP. Interim results of an ecological experiment - Conjugate vaccination against the pneumococcus and serotype replacement. Hum Vaccin Immunother 2016; 12:358-74. [PMID: 26905681 PMCID: PMC5049718 DOI: 10.1080/21645515.2015.1118593] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Streptococcus pneumoniae has more than 95 serotypes, each of which presumably can cause sepsis, meningitis, pneumonia, and acute otitis media. Pneumococcal conjugate vaccines (PCV) targeted against a limited number of serotypes have nonetheless revealed an impressive impact on each manifestation of pneumococcal disease. At the same time, growing evidence of significant non-vaccine type (NVT) replacement disease following implementation of infant PCV programs has raised questions about the long-term viability of PCV immunization strategies and how to optimize PCV formulations. We discuss here theoretical and practical considerations regarding serotype replacement, and provide a snapshot of the most important NVT types seen to date after implementation of the 2 higher-valent PCVs.
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Affiliation(s)
| | - William P Hanage
- b Department of Epidemiology ; Center for Communicable Disease Dynamics; Harvard TH Chan School of Public Health ; Boston , MA , USA
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Abstract
In 2015, the World Health Organization (WHO) declared tuberculosis (TB) to be responsible for more deaths than any other single infectious disease. The burden of TB among children has frequently been dismissed as relatively low with resulting deaths contributing very little to global under-five all-cause mortality, although without rigorous estimates of these statistics, the burden of childhood TB was, in reality, unknown. Recent work in the area has resulted in a WHO estimate of 1 million new cases of childhood TB in 2014 resulting in 136,000 deaths. Around 3% of these cases likely have multidrug-resistant TB and at least 40,000 are in HIV-infected children. TB is now thought to be a major or contributory cause of many deaths in children under five years old, despite not being recorded as such, and is likely in the top ten causes of global mortality in this age group. In particular, recent work has shown that TB is an under-lying cause of a substantial proportion of pneumonia deaths in TB-endemic countries. Childhood TB should be given higher priority: we need to identify children at greatest risk of TB disease and death and make more use of tools such as active case-finding and preventive therapy. TB is a preventable and treatable disease from which no child should die.
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Affiliation(s)
- Helen E. Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, MA 02118 USA
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23
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Buchholz G, Koedel U, Pfister HW, Kastenbauer S, Klein M. Dramatic reduction of mortality in pneumococcal meningitis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:312. [PMID: 27716447 PMCID: PMC5045860 DOI: 10.1186/s13054-016-1498-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 09/19/2016] [Indexed: 12/28/2022]
Abstract
Background Acute bacterial meningitis is still a life threatening disease. Methods We performed a retrospective observational study on the clinical characteristics of consecutively admitted patients with acute pneumococcal meningitis in a single tertiary care center in central Europe (from 2003 until 2015). Data were compared with a previously published historical group of 87 patients treated for pneumococcal meningitis at the same hospital (from 1984 until 2002). Results Fifty-five consecutive patients with microbiologically proven pneumococcal meningitis were included. Most striking, mortality was down to 5.5 %, which was significantly lower than in the historical group where 24.1 % of the patients did not survive. Intracranial complications during the course of the disease were common and affected half of the patients. Unlike in the historic group, most of the intracranial complications (except ischemic stroke) were no longer associated with a low Glasgow Outcome Score at discharge. Conclusion The drastic reduction of mortality proves there have been important advances in the treatment of pneumococcal meningitis. Nevertheless, the fact that only 44.2 % of survivors had a full recovery indicates that the search for new adjunctive treatment options must be ongoing.
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Affiliation(s)
- Grete Buchholz
- Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University, Marchioninistr. 15, 81377, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University, Marchioninistr. 15, 81377, Munich, Germany
| | - Hans-Walter Pfister
- Department of Neurology, Klinikum Grosshadern, Ludwig Maximilians University, Marchioninistr. 15, 81377, Munich, Germany
| | | | - Matthias Klein
- Emergency Department, Klinikum Grosshadern, Ludwig Maximilians University, Marchioninistr, 15, 81377, Munich, Germany.
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Kay EJ, Yates LE, Terra VS, Cuccui J, Wren BW. Recombinant expression of Streptococcus pneumoniae capsular polysaccharides in Escherichia coli. Open Biol 2016; 6:150243. [PMID: 27110302 PMCID: PMC4838161 DOI: 10.1098/rsob.150243] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 03/15/2016] [Indexed: 12/13/2022] Open
Abstract
Currently, Streptococcus pneumoniae is responsible for over 14 million cases of pneumonia worldwide annually, and over 1 million deaths, the majority of them children. The major determinant for pathogenesis is a polysaccharide capsule that is variable and is used to distinguish strains based on their serotype. The capsule forms the basis of the pneumococcal polysaccharide vaccine (PPV23) that contains purified capsular polysaccharide from 23 serotypes, and the pneumococcal conjugate vaccine (PCV13), containing 13 common serotypes conjugated to CRM197 (mutant diphtheria toxin). Purified capsule from S. pneumoniae is required for pneumococcal conjugate vaccine production, and costs can be prohibitively high, limiting accessibility of the vaccine in low-income countries. In this study, we demonstrate the recombinant expression of the capsule-encoding locus from four different serotypes of S. pneumoniae within Escherichia coli. Furthermore, we attempt to identify the minimum set of genes necessary to reliably and efficiently express these capsules heterologously. These E. coli strains could be used to produce a supply of S. pneumoniae serotype-specific capsules without the need to culture pathogenic bacteria. Additionally, these strains could be applied to synthetic glycobiological applications: recombinant vaccine production using E. coli outer membrane vesicles or coupling to proteins using protein glycan coupling technology.
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Affiliation(s)
- Emily J Kay
- Department of Pathogen Molecular Biology , London School of Hygiene and Tropical Medicine , Keppel Street, London WC1E 7HT , UK
| | - Laura E Yates
- Department of Pathogen Molecular Biology , London School of Hygiene and Tropical Medicine , Keppel Street, London WC1E 7HT , UK
| | - Vanessa S Terra
- Department of Pathogen Molecular Biology , London School of Hygiene and Tropical Medicine , Keppel Street, London WC1E 7HT , UK
| | - Jon Cuccui
- Department of Pathogen Molecular Biology , London School of Hygiene and Tropical Medicine , Keppel Street, London WC1E 7HT , UK
| | - Brendan W Wren
- Department of Pathogen Molecular Biology , London School of Hygiene and Tropical Medicine , Keppel Street, London WC1E 7HT , UK
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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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26
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Tin Tin Htar M, Christopoulou D, Schmitt HJ. Pneumococcal serotype evolution in Western Europe. BMC Infect Dis 2015; 15:419. [PMID: 26468008 PMCID: PMC4606906 DOI: 10.1186/s12879-015-1147-x] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 09/24/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pneumococcal diseases remain a leading cause of vaccine-preventable death worldwide in children <5 years of age. The seven-valent pneumococcal conjugate vaccine (PCV7) was approved in 2001 in Europe and was introduced into the national immunization programmes of many European countries from 2006-2008. In 2009, higher-valent PCVs (PCV10 and PCV13) became available, replacing PCV7 from 2009-2011. This article describes the evolution of vaccine and non-vaccine serotypes causing invasive pneumococcal disease (IPD) following the introduction of PCVs in Western Europe, based on data from publicly-available medical publications and national surveillance systems from January 2010 to May 2015. DISCUSSION In countries with high vaccine uptake, 5-7 years after PCV7 introduction IPD caused by vaccine serotypes has almost disappeared in children. Non-PCV7 serotypes have emerged, particularly serotypes 19A, 7 F, 3 and 1. A rapid and significant reduction of the additional serotypes included in higher-valent vaccines has been observed consistently following the introduction of these vaccines. A significant and rapid decline of serotypes 19A, 7 F, 1 and 6A in both vaccine-eligible and older age groups has been observed in countries using PCV13 while serotype 19A and 3 has increased in countries using PCV10. Serotype 3 has become one of the most prevalent serotypes in adults, with some reduction only in the UK and France. Serotype diversity increased and varied by age group, the type of vaccine in use, and the time since the introduction of higher-valent PCVs. Serotypes that are currently more frequent include 24 F, 22 F, 8 and 15A in countries that use PCV13, and serotypes 19A and 3 in countries that use PCV10. Compared with the time before the introduction of higher valent PCVs, to date, there is no single '19A-like' serotype emerging across countries and most of the newly emerging non-PCV13 vaccine types are less invasive with a low case-carrier ratio. CONCLUSIONS It is important to closely monitor not only evolving serotypes but also the magnitude of the effect in order to evaluate the overall impact of pneumococcal vaccination programmes and to initiate the appropriate vaccination strategy. Emerging serotypes may also need to be considered for the future development of new vaccines.
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Affiliation(s)
- Myint Tin Tin Htar
- Pfizer Vaccines, Medical Development Group and Scientific Affairs, 23-25 avenue du Dr. Lannelongue, F-75668, Paris, Cedex 14, France.
| | - Dina Christopoulou
- Pfizer Vaccines, Medical Development Group and Scientific Affairs, 23-25 avenue du Dr. Lannelongue, F-75668, Paris, Cedex 14, France.
| | - Heinz-Josef Schmitt
- Pfizer Vaccines, Medical Development Group and Scientific Affairs, 23-25 avenue du Dr. Lannelongue, F-75668, Paris, Cedex 14, France.
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27
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Antibiotic susceptibility rates of invasive pneumococci before and after the introduction of pneumococcal conjugate vaccination in Germany. Int J Med Microbiol 2015; 305:776-83. [DOI: 10.1016/j.ijmm.2015.08.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Kasanmoentalib ES, Valls Seron M, Morgan BP, Brouwer MC, van de Beek D. Adjuvant treatment with dexamethasone plus anti-C5 antibodies improves outcome of experimental pneumococcal meningitis: a randomized controlled trial. J Neuroinflammation 2015; 12:149. [PMID: 26272468 PMCID: PMC4536776 DOI: 10.1186/s12974-015-0372-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 08/06/2015] [Indexed: 11/10/2022] Open
Abstract
Background We compared adjunctive treatment with placebo, dexamethasone, anti-C5 antibodies, and the combination of dexamethasone plus anti-C5 antibodies in experimental pneumococcal meningitis. Methods In this prospective, investigator-blinded, randomized trial, 96 mice were infected intracisternally with 107 CFU/ml Streptococcus pneumoniae serotype 3, treated with intraperitoneal ceftriaxone at 20 h, and randomly assigned to intraperitoneal adjunctive treatment with placebo (saline), dexamethasone, anti-C5 antibodies, or dexamethasone plus anti-C5 antibodies. The primary outcome was survival during a 72-h observational period that was analyzed with the log-rank test. Secondary outcome was clinical severity, scored on a validated scale using a linear mixed model. Results Mortality rates were 16 of 16 mice (100 %) in the placebo group, 12 of 15 mice (80 %) in the dexamethasone group, 25 of 31 mice (80 %) in the anti-C5 antibody group, and 18 of 30 mice (60 %) in the dexamethasone plus anti-C5 antibody group (Fisher’s exact test for overall difference, P = .012). Mortality of mice treated with dexamethasone plus anti-C5 antibodies was lower compared to the anti-C5 antibody-treated mice (log-rank P = .039) and dexamethasone-treated mice (log-rank P = .040). Clinical severity scores for the dexamethasone plus anti-C5 antibody-treated mice increased more slowly (0.199 points/h) as compared to the anti-C5 antibody-treated mice (0.243 points/h, P = .009) and dexamethasone-treated mice (0.249 points/h, P = .012). Modeling of severity data suggested an additive effect of dexamethasone and anti-C5 antibodies. Conclusion Adjunctive treatment with dexamethasone plus anti-C5 antibodies improves survival in severe experimental meningitis caused by S. pneumoniae serotype 3, posing an important new treatment strategy for patients with pneumococcal meningitis.
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Affiliation(s)
- E Soemirien Kasanmoentalib
- Center for Immunity and Infection (CINIMA): Department of Neurology, Center for Immunity and Infection (CINIMA), Academic Medical Center, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, The Netherlands.
| | - Mercedes Valls Seron
- Center for Immunity and Infection (CINIMA): Department of Neurology, Center for Immunity and Infection (CINIMA), Academic Medical Center, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, The Netherlands.
| | - B Paul Morgan
- Institute of Infection and Immunity, Cardiff University School of Medicine, Cardiff, Wales, UK.
| | - Matthijs C Brouwer
- Center for Immunity and Infection (CINIMA): Department of Neurology, Center for Immunity and Infection (CINIMA), Academic Medical Center, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, The Netherlands.
| | - Diederik van de Beek
- Center for Immunity and Infection (CINIMA): Department of Neurology, Center for Immunity and Infection (CINIMA), Academic Medical Center, University of Amsterdam, PO Box 22660, 1100DD, Amsterdam, The Netherlands.
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