BACKGROUND: Pneumococci are spread by persons with nasopharyngeal colonization, a necessary precursor to invasive disease. Pneumococcal conjugate vaccines can prevent colonization with vaccine serotype strains. In 2011, Kenya became one of the first African countries to introduce the 10-valent pneumococcal conjugate vaccine (PCV10) into its national immunization program. Serial cross-sectional colonization surveys were conducted to assess baseline pneumococcal colonization, antibiotic resistance patterns, and factors associated with resistance. METHODS: Annual surveys were conducted in one urban and one rural site during 2009 and 2010 among children aged <5 years. To reflect differences in vaccine target population, recruitment was age-stratified in Kibera, whereas a simple random sample of children was drawn in Lwak. Nasopharyngeal swabs were collected from eligible children. Pneumococci were isolated and serotyped. Antibiotic susceptibility testing was performed using the 2009 isolates. Antibiotic nonsusceptibility was defined as intermediate susceptibility or resistance to ≥1 antibiotics (i.e., penicillin, chloramphenicol, levofloxacin, erythromycin, tetracycline, cotrimoxazole, and clindamycin); multidrug resistance (MDR) was defined as nonsusceptibility to ≥3 antibiotics. Weighted analysis was conducted when appropriate. Modified Poisson regression was used to calculate factors associated with antibiotic nonsusceptibility. RESULTS: Of 1,087 enrolled (Kibera: 740, Lwak: 347), 90.0% of these were colonized with pneumococci, and 37.3% were colonized with PCV10 serotypes. There were no differences by survey site or year. Of 657 (of 730; 90%) isolates tested for antibiotic susceptibility, nonsusceptibility to cotrimoxazole and penicillin was found in 98.6 and 81.9% of isolates, respectively. MDR was found in 15.9% of isolates and most often involved nonsusceptibility to cotrimoxazole and penicillin; 40.4% of MDR isolates were PCV10 serotypes. In the multivariable model, PCV10 serotypes were independently associated with penicillin nonsusceptibility (Prevalence Ratio: 1.2, 95% CI 1.1-1.3), but not with MDR. CONCLUSIONS: Before PCV10 introduction, nearly all Kenyan children aged <5 years were colonized with pneumococci, and PCV10 serotype colonization was common. PCV10 serotypes were associated with penicillin nonsusceptibility. Given that colonization with PCV10 serotypes is associated with greater risk for invasive disease than colonization with other serotypes, successful PCV10 introduction in Kenya is likely to have a substantial impact in reducing vaccine-type pneumococcal disease and drug-resistant pneumococcal infection.

In 2014, an acute respiratory illness outbreak affected unaccompanied children from Central America entering the US; 9% of 774 surveyed children were colonized with Streptococcus pneumoniae serotype 5. In our 2015 follow-up survey of 475 children, serotype 5 was not detected, and an interim recommendation to administer 13-valent pneumococcal conjugate vaccine to all unaccompanied children was discontinued.

In 2010, the 10-valent pneumococcal conjugate vaccine (PCV10) was introduced to the Brazilian childhood vaccination program. Concerns have been raised that non-vaccine serotypes could increase in prevalence and reduce the benefits of vaccination; therefore, we examined the non-PCV10 isolates recovered from meningitis during pre (January, 2008-May, 2010) and post-vaccine (June, 2010-December, 2012) periods. Surveillance for pneumococcal meningitis was established at the Reference Hospital of Infectious Diseases in Salvador, Brazil. Serotypes were determined by multiplex PCR and/or Quellung reaction. Antimicrobial susceptibility testing was conducted by E-test and broth microdilution. Genotyping employed pulsed field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). A total of 148 cases of meningitis were identified from January 2008 to December 2012, 77 (52%) of which were due to non-PCV10 isolates, with 50 (52.1%) from pre-vaccine and 27 (52%) post-vaccine periods. In the post-vaccine period, the non-PCV10 serotypes 12F (n = 6; 22.2%), 10A (n = 3; 11.1%), 15B (n = 2; 7.4%), and 18B (n = 2; 7.4%) were the most prevalent. Forty-three isolates (55.8%) were non-susceptible to one or more antibiotics. Non-susceptibility to penicillin was observed among serotypes 19A (3 isolates), 9N (1 isolate), and 12F (1 isolate). PFGE and MLST results demonstrated a wide genetic diversity among the isolates. During the early period following PCV10 introduction, no obvious emergence of a particular serotype was evident among non-PCV10 strains. This study underscores the importance of monitoring any changes among non-PCV10 cases after the introduction of PCV10.

Antimicrobial resistant pneumococcal strains have been detected worldwide since the 1960's. In Brazil, the first penicillin non-susceptible pneumococci (PNSP) were reported in the 1980's, and their emergence and dissemination have been mainly attributed to serogroup 9 and serotype 14 strains, especially those highly related to recognized international clones. In the present study, antimicrobial susceptibility testing and Multilocus Sequence Typing (MLST) were performed on 315 pneumococcal isolates belonging to serogroup 9 (n=99) or serotype 14 (n=216), recovered from patients or asymptomatic carriers between 1988 and 2011 in Brazil, in order to trace changes in antimicrobial resistance and genotypes prior to the full introduction of the pneumococcal conjugate vaccine in the country. Over the 23-year study period, PNSP levels increased and four clonal complexes (CC156, CC66, CC15 and CC5401) have played important roles in the evolution and dissemination of pneumococcal isolates belonging to serogroup 9 and serotype 14, as well as in the emergence of antimicrobial resistance, in the pre-pneumococcal vaccination era. The earliest PNSP strains detected in this study belonged to serotype 9N/ST66 and were single locus variants of the international clone Tennesse14-18 ST67 (CC66). The first serotype 14 PNSP isolates were identified in 1990, and were related to the England14-9 ST9 (CC15) clone. Serotype 14 PNSP variants of the Spain9V-3 ST156 clone with elevated penicillin MICs and non-susceptibility to other beta-lactams were detected in 1995, and showed an increasing trend over the years. The results also indicated that introduction of ST156 in our region was preceded by the emergence of trimethoprim/sulfamethoxazole resistance and by the dissemination of ST162. In addition to the presence of successful international clones, a novel regional serotype 14 genotype (CC5401) has emerged in 1996.

Information on pneumococcal carriage in the pre-vaccine period is essential to predict and assess the impact of PCV in settings where disease surveillance is particularly difficult. Therefore, we present data on pneumococcal carriage before the introduction of the 10-valent-pneumococcal conjugate vaccine (PCV10) in Brazil. We conducted a prospective study on a cohort of 203 children aged <5 years old, randomly selected in an urban community located in the periphery of the city of Salvador, Brazil and followed them from January/2008 to January/2009. Nasopharyngeal swabs were collected from each child at four times. In total, 721 swabs were collected, yielding a pneumococcal carriage prevalence of 55% (n=398). In multivariate analyses, the variables associated with carriage were having contact with three or more children <2 years old (OR, 2.00; 95% CI 1.33-2.89) and living in a house with an average of 3 residents per room (OR, 1.77; 95% CI 1.05-3.10). Also, white participants were more likely to be protected from colonization (OR, 0.52; 95% CI 0.29-0.93), and prevalence of carriage varied over time, with lower prevalence occurring from February to June (OR, 0.53; 95% CI 0.37-0.78) compared to July to January. Contact with children under 2 years of age and living in crowded housing also were associated with colonization by highly invasive serotypes, although this relationship was not significant. The most prevalent vaccine serotypes were 6A/B (25.4%), 19F (10.1%) and 14 (9.0%), while the most prevalent non-vaccine serotypes were 16F (4.8%), 15B/C (4.5%) and 6C/D (3.5%). Overall, 38.4% (153/398) of the isolates were non-susceptible to penicillin, and of those, 73.8% (113/153) were non-susceptible to trimethoprim/sulfamethoxazole. Colonization rate by PCV10 serotypes was 52.2%. Routine PCV10 vaccination can lead to significant changes in pneumococcal serotypes found in NP colonization, indicating a need for continued monitoring, especially in crowded settings, as occurs in Brazil's slums.

Prior antibiotic use, contamination, limited blood volume, and processing delays reduce yield of blood cultures for detection of Streptococcus pneumoniae. We performed immunochromatographic testing (ICT) on broth from incubated blood culture bottles and real-time lytA polymerase chain reaction (PCR) on broth and whole blood and compared findings to blood culture in patients with suspected bacteremia. We selected 383 patients in Mali and 586 patients in Thailand based on their blood culture results: 75 and 31 were positive for pneumococcus, 100 and 162 were positive for other pathogens, and 208 and 403 were blood culture negative, respectively. ICT and PCR of blood culture broth were at least 87% sensitive and 97% specific compared with blood culture; whole blood PCR was 75-88% sensitive and 96-100% specific. Pneumococcal yields in children < 5 years of age increased from 2.9% to 10.7% in Mali with > 99% of additional cases detected by whole blood PCR, and from 0.07% to 5.1% in Thailand with two-thirds of additional cases identified by ICT. Compared with blood culture, ICT and lytA PCR on cultured broth were highly sensitive and specific but their ability to improve pneumococcal identification varied by site. Further studies of these tools are needed before widespread implementation.

Rocky Mountain spotted fever, a tick-borne disease caused by Rickettsia rickettsii, is difficult to diagnose and rapidly fatal if not treated. We describe a decedent who was co-infected with group A beta-hemolytic streptococcus and R. rickettsii. Fatal cases of Rocky Mountain spotted fever may be underreported because they present as difficult to diagnose co-infections.

BACKGROUND: Nasopharyngeal (NP) carriage and invasive pneumococcal disease (IPD) due to serotypes in the 7-valent pneumococcal conjugate vaccine (PCV7) declined dramatically after vaccine introduction, whereas non-PCV7 serotypes increased modestly. Characteristics of pneumococcal carriage and IPD among children in Atlanta were compared during two time periods: pre-PCV7 introduction and pre-PCV13 introduction. METHODS: NP swabs from 231 and 451 children aged 6 to 59 months receiving outpatient medical care were obtained in 1995 and 2009, respectively. A total of 202 and 47 IPD cases were identified in children < 5 years of age in 1995 and 2008-2009, respectively, through active, population-based surveillance in Atlanta. Isolates were serotyped, sequence typed (ST), and tested for antimicrobial susceptibility RESULTS: Forty percent (93/231) of children in 1995 and 31% (139/451) in 2009 were colonized with Streptococcus pneumoniae; 60% and 0.7% were PCV7 serotypes, respectively. In 1995, PCV7 serotypes accounted for 83% and 19A 5% of IPD compared with no PCV7 serotypes and 49% 19A among IPD in 2009 [P<0.001]. In 2009, PCV13 serotypes accounted for 22% of carriage (mostly 19A) and 60% of invasive isolates [P<0.001]. ST320 accounted for 66% and 52% of 19A carriage and IPD isolates in 2009, respectively; all ST320 isolates were multi-drug resistant. No ST320 NP or IPD isolates were identified pre-PCV7. CONCLUSIONS: Serotype distribution among NP and IPD isolates in Atlanta has shifted to non-PCV7 serotypes; 19A was the leading serotype for both. The multi-drug resistant ST320 strain was responsible for two-thirds of 19A carriage isolates and nearly half of IPD isolates. The predominance of serotype 19A in carriage and IPD among children in Atlanta highlights the potential direct and indirect benefits anticipated by implementation of PCV13 in the community.

Monitoring pneumococcal carriage serotype distributions is increasingly used to study pneumococcal biology, disease epidemiology, and vaccine impact....

A 53-year-old man with adult-onset diabetes mellitus developed confusion, fever, pneumonia and loss of vision in his right eye. He was treated intravenously with cefotaxime, levofloxacin and fluconazole. His medical condition stabilized after 2 weeks and he was transferred to our institution. On examination, the right eye had minimal light perception with proptosis, conjunctival oedema and a hypopyon (Fig. 1A). Cultures of the conjunctiva, cornea, aqueous and vitreous resulted in no growth of organisms, presumably because the eye had been sterilized by prior treatment with antibiotics. Vancomycin and ceftazidime were injected intravitreally. After light perception was lost, the painful blind eye was enucleated.

Several of the more recently proposed new species of Enterococcus are nearly identical based on 16S rDNA sequence analysis and phenotypic traits. In the present study, DNA-DNA reassociation experiments, in conjunction with sequencing of the 16S rRNA and rpoB genes, provided evidence that "Enterococcus sanguinicola" and Enterococcus thailandicus actually represent the same species. In contrast, Enterococcus caccae and Enterococcus silesiacus, two other species with nearly identical 16S rRNA gene sequences were confirmed as separate species.

Since the implementation of Haemophilus influenzae (Hi) serotype b vaccine, other serotypes and non-typeable strains have taken on greater importance as a cause of Hi diseases. A rapid and accurate method is needed to detect all Hi regardless of the encapsulation status. We developed 2 real-time PCR (rt-PCR) assays to detect specific regions of the protein D gene (hpd). Both hpd assays are very specific and sensitive for detection of Hi. Of the 63 non-Hi isolates representing 21 bacterial species, none was detected by the hpd #1 assay, and only one of 2 H. aphrophilus isolates was detected by the hpd #3 assay. The hpd #1 and #3 assays detected 97% (229/237) and 99% (234/237) of Hi isolates, respectively, and were superior for detection of both typeable and non-typeable Hi isolates, as compared to previously developed rt-PCR targeting ompP2 or bexA. The diagnostic sensitivity and specificity of these rt-PCR assays were assessed on cerebrospinal fluid specimens collected as part of meningitis surveillance in Ulaanbaatar, Mongolia. The etiology (Neisseria meningitidis, Hi, and Streptococcus pneumoniae) of 111 suspected meningitis cases was determined by conventional methods (culture and latex agglutination), previously developed rt-PCR assays, and the new hpd assays. The rt-PCR assays were more sensitive for detection of meningitis pathogens than other classical methods and improved detection from 50% (56/111) to 75% (83/111). The hpd #3 assay identified a non-b Hi that was missed by the bexA assay and other methods. A sensitive rt-PCR assay to detect both typeable and non-typeable Hi is a useful tool for improving Hi disease surveillance especially after Hib vaccine introduction.

BACKGROUND: A second-generation 13-valent pneumococcal conjugate vaccine, PCV13, was recently licensed. Although PCV13 includes serotype 6A, the usefulness of that antigen may be limited by the emergence of a new serotype, 6C, which was identified among isolates initially characterized (Quellung reaction) as serotype 6A. The epidemiology of serotype 6C prior to and after 7-valent PCV (PCV7) introduction is incompletely understood. METHODS: We analyzed conventionally serotyped 6A (CS6A) pneumococci from invasive disease case patients of all ages and carriage isolates from children and adults obtained in population-based studies among Navajo and White Mountain Apache communities during 1994-2009. Samples were tested by triplex polymerase chain reaction to resolve serotypes 6C and 6A. RESULTS: A total of 74 invasive CS6A episodes occurred. All were retyped by polymerase chain reaction; 40 (54.1%) were serotype 6C. The mean annual incidence of serotype 6C invasive disease was 0.3 (95% confidence interval, 0.03-0.9), 0.7 (95% confidence interval, 0.2-1.3), and 1.5 (95% confidence interval, 1.0-2.1) cases per 100,000 population in the years prior to the PCV7 efficacy trial, during the time the PCV7 trial was conducted, and following PCV7 introduction and routine use, respectively ([Formula: see text]). In the routine vaccination era, 76% of invasive CS6As were serotype 6C; nearly all cases occurred in adults. The proportion of serotype 6C among CS6A carriage isolates increased from 42% to 61% to 94% in the prevaccine, early vaccine, and routine vaccination eras, respectively. CONCLUSION: In the PCV7 routine use era, virtually all serogroup 6 invasive pneumococcal disease and carriage strains among Navajo and White Mountain Apache communities are 6C. Monitoring and evaluation of this and other emerging serotypes among invasive disease and carriage isolates is warranted.

BACKGROUND: During previous influenza pandemics, many deaths were associated with secondary bacterial infection. In April 2009, a previously unknown 2009 influenza A virus (2009 H1N1) emerged, causing a global influenza pandemic. We examined the relationship between circulating 2009 H1N1 and the occurrence of secondary bacterial parapneumonic empyema in children. METHODS: Children hospitalized with parapneumonic empyema from August 2004 to July 2009, including a period when the 2009 H1N1 circulated in Utah, were identified using International Classification of Diseases, Ninth Revision codes. We compared the average number of children diagnosed with influenza A and the number of admissions for empyema per month for the previous 4 seasons to rates of empyema during the 2009 H1N1 outbreak. We identified causative bacteria using culture and polymerase chain reaction (PCR). RESULTS: We observed an increase in hospitalization of children with pneumonia complicated by empyema during a severe outbreak of 2009 H1N1 during the spring and summer of 2009, compared with historical data for the previous 4 seasons. Streptococcus pneumoniae and Streptococcus pyogenes were the predominant bacteria identified. CONCLUSIONS: Similar to previous pandemics, secondary bacterial infection with S. pneumoniae and S. pyogenes were associated with the 2009 H1N1 outbreak. There is an urgent need to better understand bacterial complications of pandemic influenza. In the interim, influenza vaccines, antiviral agents, and pneumococcal vaccines should be used to prevent cases of secondary bacterial pneumonia whenever possible.

The measurement of pneumococcal carriage in the nasopharyngeal reservoir is subject to potential confounders that include low-density and multiple-strain colonization. To compare different methodologies, we picked a random sampling of 100 nasopharyngeal (NP) specimens recovered from infants less than 2 years of age that were previously assessed for pneumococcal carriage and serotypes using a conventional method employing direct plating from the transport/storage medium (50 pneumococcal culture-negative and 50 pneumococcal culture-positive). We used a broth enrichment approach and a conventional PCR approach (with and without broth-enrichment) for determining pneumococcal carriage and serotypes to compare to initial conventional culture-based results. Additionally we used lytA-targeted real time PCR for pneumococcal detection. Broth enrichment for both culture-based and PCR based methods enhanced the isolation of pneumococci and detection of serotype diversity, with the most effective serotype-deduction method employing broth enrichment prior to sequential multiplex PCR. Similarly, we also found that broth enrichment followed by lytA-specific real time PCR was most sensitive for detecting apparent pneumococcal carriage. The broth enrichment, conventional multiplex PCR, and real time PCR approaches used in this study were effective in detecting pneumococcal carriage within the 50 specimens that were negative using conventional direct plating from transport medium (ranging from 8/50 - 22/50 (16-44%) positives), and the 3 different serotyping approaches employing broth-enrichment increased the number of serotype identifications from the 100 specimens (12 - 29 additional identifications). A PCR-based approach that employed a broth enrichment step appeared to best enhance the detection of mixed serotypes and low density pneumococcal carriage.

Detection of GBS strains at various bacterial concentrations was evaluated using three pigment-producing broth media. At 10(3) CFU/ml, StrepB Carrot Broth(TM) (SBCB), Granada Instant Liquid Biphasic (IGLB), and Northeast Laboratory GBS Screening Medium (NEL-GBS) showed 100% detection but at the lower bacterial counts SBCB and IGLB were more sensitive than NEL-GBS after 24hrs.