Ronald J. Stanek

Bacteremic pneumococcal pneumonia in one American city: a 20-year longitudinal study, 1978–1997

A surveillance of bacteremic pneumococcal pneumonia was conducted in Huntington, West Virginia, from 1978 to 1997 to investigate case-fatality rates, incidence of disease, capsular types, and antibiotic usage. Our study population comprised consecutive inpatients admitted to the hospitals in Huntington, West Virginia, and included 45 children younger than 15 years and 328 adults. All blood isolates were serotyped by capsular swelling procedures; clinical characteristics, treatment, and outcome for all patients were abstracted from hospital charts. The overall case-fatality rate was 20.3%, with most deaths occurring among adults older than 50 years. Case-fatality rates peaked at 37.7% among patients 80 years of age and older. Only 1 of 45 (2.2%) children died. Case-fatality rates declined in each successive 5-year period, from 30.2% in 1978-1982 to 15.6% in 1993-1997. In that same period, incidence rates increased severalfold among children younger than 4 years to 44.5 cases per 100,000 population and among adults 70 years and 80 years of age and older to 38.5 and 76.2 cases per 100,000, respectively. Of the 34 serotypes isolated, 10 accounted for two thirds of the cases of pneumonia: 1, 4, 9, 14, 3, 6, 12, 5, 23, and 19 (in rank order). Chronic renal disease and arteriosclerotic heart disease increased the risk of death. Treatment regimens that included a macrolide and a penicillin or cephalosporin resulted in the lowest case-fatality rate in adults older than 50 years: 6% in 1993-1997. In conclusion, as bacteremic pneumococcal pneumonia evolved over time, the case-fatality rate decreased, its incidence increased, predominant capsular types changed, and treatment regimens that included a macrolide resulted in the lowest fatality rates.

A 20-Year Epidemiological Study of Pneumococcal Meningitis

We conducted a retrospective analysis of 55 community-acquired Streptococcus pneumoniae meningitis illnesses in Huntington, West Virginia, from 1978 to 1997. Fourteen (36.8%) of 38 adults and 2 (11.8%) of 17 children died. Serotypes 6, 23, 3, and 18 accounted for 20 (41.7%) of 48 strains available for serotyping. Of 40 strains available for antimicrobial susceptibility testing, 1 serotype 19 and 1 serotype 23 strain showed intermediate resistance and a second serotype 23 strain showed high resistance to penicillin; all three patients survived. The case-fatality rates among adults who received penicillin alone, gentamicin in combination, or vancomycin and cephalosporin together were 57.1%, 55.5%, and 60%, respectively, and among those who received chloramphenicol or a third-generation cephalosporin, they were 11.1% or nil, respectively. No child died who received chloramphenicol or vancomycin. Two (33%) of 6 children died who received a third-generation cephalosporin; both were critically ill when initially treated. No child and one adult had received pneumococcal vaccine prior to becoming ill.

Lack of Synergy of Erythromycin Combined with Penicillin or Cefotaxime against Streptococcus pneumoniae In Vitro

ABSTRACT We investigated a possible synergistic effect of a macrolide and β-lactams against Streptococcus pneumoniae strains with different resistance profiles. Checkerboard and time-kill assays of erythromycin combined with penicillin or cefotaxime essentially showed indifference, suggesting that these antibiotics in combinations in vitro act substantially as individuals in their activity against S. pneumoniae.

Penicillin Resistance Not a Factor in Outcome from Invasive Streptococcus pneumoniae Community-Acquired Pneumonia in Adults When Appropriate Empiric Therapy Is Started

Background:Invasive Streptococcus pneumoniae pneumonia among adults due to penicillin-resistant or intermediate resistant strains was investigated to determine whether these patients responded poorly to common antibiotic regimens compared to pneumonia due to susceptible strains. Methods:During a 21-year period (1983–2003), clinical outcome was analyzed among 3 groups of adults, 19 with resistant, 33 with intermediate, and 133 with susceptible invasive S pneumoniae pneumonia admitted to hospitals in Huntington, West Virginia. Adults with resistant and intermediate infections were matched by age and month of admission to a group of 133 adults with penicillin-susceptible infections. All isolates of resistant and intermediate infections were capsular serotypes/serogroups 6, 9, 14, 19, and 23, and isolates of susceptible infections included 24 different serotypes/serogroups. Case fatality rates were calculated for deaths that occurred during the first 7, first 14, and first 21 days of hospitalization. Minimal inhibitory concentration (MIC) was determined by E-test and capsular serotype by Quellung procedures. Results:The resistant and susceptible groups did not differ in several measures of severity of illness, including admission vital signs, duration of fever, mean total leukocyte count, number of lobes involved, preexisting underlying diseases, and antibiotic treatment regimens. There were no significant differences in case fatality rates between the 3 groups of pneumonia by days in hospital, age, severity of illness, and empiric antibiotic treatment regimen with a cephalosporin and a macrolide, the most common antibiotic regimen. Conclusions:These findings provide evidence that combination antibiotic regimens effective in the treatment of invasive susceptible S pneumoniae pneumonia are equally effective in the treatment of invasive resistant (MIC = 2–4 &mgr;g/mL) and of intermediate (MIC = 0.1–1 &mgr;g/mL) S pneumoniae pneumonia.

Effects of chlorhexidine gluconate douche on normal vaginal flora.

The effects of a 0.5% aqueous chlorhexidine gluconate (CHG) douche on the normal vaginal flora of twenty healthy nonpregnant volunteers were investigated. The douche was applied in a premeasured 180-ml quantity daily for 7 consecutive days. Specimens for aerobic and anaerobic culture of the vaginal flora were obtained on 3 occasions from each volunteer, once before and twice after CHG use. The culture results were analyzed qualitatively and quantitatively. A blood sample was also collected within 24 h of the last CHG application to determine serum CHG concentration. Lactobacillus spp., Gardnerella vaginalis and Staphylococcus epidermidis were the most prevalent aerobic bacteria at all phases of the study and Bacteroides spp. were the most prevalent anaerobes. The composition of the normal flora was essentially the same 30 days after the last dose as the pretreatment flora. Small amounts of CHG were detected in the serum of all but one subject. No untoward effects on the participants were observed. Candida albicans counts were slightly higher, but prevalence was not significantly increased at the end of the study.

Clinical features of patients with recurrent invasive Streptococcus pneumoniae disease.

Introduction:Invasive Streptococcus pneumoniae (pneumococcal) disease (IPD) carries a high risk of death, approximately 15% to 20% in pneumonia, 40% in meningitis and 10% to 15% in septicemia. The occurrence of 2 or more IPD (recurrent) in the same individual is uncommon. The authors investigated the clinical features of patients with recurrent IPD to assess whether they possessed risk factors that increased their likelihood of recurrent IPD. Methods:Between 1983 and 2010, the authors identified 27 patients with recurrent IPD during inpatient surveillance of 889 patients with IPD in Huntington, WV, by recovery of pneumococci from otherwise sterile sites. Serotype/serogroup (ST/SG) was determined by capsular swelling and the penicillin MIC by E-strip. Clinical data were abstracted from hospital charts. Results:Sixteen (59%) of 27 patients were 65 years and older at first IPD, males predominated (67%), two-thirds had pneumonia and 21 (78%) had the same clinical diagnosis at both IPD. Four (80%) of 5 patients with the same ST experienced their second IPD 1 to 6 months apart, unlike most patients with discordant ST/SGs (P = 0.047). Eighty-four percent of ST/SGs were included in the 23-valent pneumococcal vaccine and occurred as often during the first and second IPD. Twenty (77%) of 26 adults suffered from comorbid diseases placing them at high risk of IPD, including multiple myeloma, HIV/AIDS, neoplasia of hematological origin and sickle cell disease. Conclusions:Recurrent IPD occurred uncommonly. Comorbid conditions including multiple myeloma and immunosuppressive/immunodeficient conditions, chronic alcoholism and splenectomy represented unique risk factors for recurrent IPD but did not predict recurrences.

Infection With Streptococcus Pneumoniae Moderately Resistant to Penicillin Does Not Alter Clinical Outcome

Increasingly, drug-resistant Streptococcus pneumoniae is an identified pathogen causing pneumonia, sepsis, and meningitis. Our study evaluated outcome variables of patients infected with strains of S. pneumoniae moderately resistant to penicillin. We retrospectively analyzed the data on 110 Huntington, West Virginia, community patients who had types 6, 9, 14, 19, and 23 pneumococcal infections between 1982 and 1994. These strains are most likely to demonstrate resistance. Comparing patients infected with sensitive vs. moderately resistant pneumococcal strains, we found no significant difference in days in the hospital (10.9 vs. 11.1, P =.96), days of fever (2.4 vs. 2.8, P =.74), or mortality (21% vs. 19%, P =.15). Antibiotic selection did not significantly affect case fatality rates in the two groups—treated with penicillin or ampicillin alone, 16% vs. 11%, Odds Ratio = 1.50 ± 1.73; P =.38; treated with an antibiotic other than penicillin, 24% vs. 28%, Odds Ratio = 0.77 ± 0.69; P =.27). No significant differences occurred between groups regarding type of infectious process (P =.94). We conclude that infection with pneumococcal strains of moderate resistance to penicillin does not affect clinical outcome.

Routine Pneumococcal Vaccination of Children Provokes New Patterns of Serotypes Causing Invasive Pneumococcal Disease in Adults and Children

Introduction:Routine vaccination of infants with protein-conjugated 7-valent pneumococcal vaccine (PCV7) begun in 2000 initiated a sea change of prevalent serotypes (STs) in invasive pneumococcal disease (IPD). The authors investigated in 1 community all STs causing IPD during 5 years before (PRE) and 2, 5-year periods after (POST1 and POST2) its initiation and found that PCV7 adversely affected ST coverage of 23-valent pneumococcal polysaccharide vaccine (PPV23) among adults. Methods:From 1996–2010, 620 consecutive Streptococcus pneumoniae IPD strains from adults (521) and children (99) hospitalized with IPD in Huntington, WV, were collected. Each strain was typed by Quellung reaction. The Marshall University Institutional Review Board approved this study. Results:By 6 to 10 years after the initiation of PCV7, IPD in children decreased significantly, whereas IPD in adults increased significantly. In both adults and children, IPD due to PCV7 STs decreased significantly. In adults with IPD, PCV7 STs were replaced by several non-PCV7 STs including STs contained in PPV23 but not in PCV7 and STs not contained in either vaccine. IPD due to 4 nonsusceptible STs included in PCV7 decreased from PRE to POST1 and POST2. IPD due to nonsusceptible STs not included in PCV7 increased from PRE to POST1 and POST2. Conclusions:Routine PCV7 decreased IPD in children but not in adults. Predominant STs changed—children exhibited fewer PCV7 STs and adults exhibited fewer PCV7 and PPV23 STs—reducing vaccine coverage and increasing the risk of replacement STs causing IPD in adults.

Surveillance of Penicillin-Resistant Streptococcus pneumoniae in One American Metropolitan Area, 1989–1998

Abstract The emergence of invasive penicillin-resistant (PRSP) and multidrug-resistant (MDRP) Streptococcus pneumoniae was tracked from 1989 to 1998 in one medium-sized metropolitan area in the USA, encompassing western West Virginia, including Huntington, the only major city, and neighboring sections of Kentucky and Ohio. Capsular serotyping and antibiotic sensitivity tests were performed on 350 community-acquired isolates comprising 93.1% of all pneumococcal isolates identified. The incidence of PRSP increased from 3 to 10% during the 10 years of the study. Twenty-nine (22.1%) of 131 isolates of serotypes 6, 9, 14, 19, and 23 were PRSP (one-fourth were MDRP) and 1 (0.5%) of 219 other serotypes was PRSP (serotype 35). Invasive PRSP occurred most frequently in young children and in adults aged 80 years and older, 8.9 and 10.9 cases per 100,000 persons, respectively.

Epidemiology of invasive Streptococcus pneumoniae infections and vaccine implications among children in a West Virginia community, 1978-2003.

From 1978 to 2003, in Huntington, WV, we investigated Streptococcus pneumoniae invasive disease and the effect of conjugated pneumococcal vaccine among 161 children 14 years of age and younger admitted to the hospital. During 2002 and 2003, the number and proportion of invasive disease caused by vaccine strains declined; and in 2003, no invasive disease occurred in young children, suggesting a vaccine effect.