2015 HSC Section 1 Book of Articles

The Pediatric Infectious Disease Journal •  Volume 33, Number 10, October 2014

Olarte et al

We did not identify an association with a particular pneumococ- cal serotype and S. pneumoniae -only infections. Moreover, we did not observe a higher rate of recurrence or complications in patients with S. pneumoniae -only infections. H. influenzae (52%) was over- all the most common organism co-isolated with S. pneumoniae . The proportion of sinus cultures positive for S. pneumonia e and H. influenzae remained unchanged in the post-PCV13 era. However, we found an increase of Prevotella spp. (+11%; P = 0.02) after the introduction of PCV13. The importance of anaerobes in chronic sinusitis has been previously described 2,3,5 and their role in pediatric sinusitis seems to be controversial. 4 A recent study from Nether- lands 22 reported that vaccination with PCV7 resulted in a shift in bacterial composition of the nasopharyngeal microbiota of vacci- nated healthy children, with an increase in abundance of anaerobic bacteria, especially Prevotella spp. The change in the isolation rate of Prevotella spp. that we observed could be related to variations in the nasopharyngeal microbiota as a result of the introduction of PCVs or secondary to sampling techniques and improved isolation of anaerobic organisms. Some limitations of our study should be recognized. First, we only studied children with chronic sinusitis, mainly because pediatric patients with acute sinusitis do not usually undergo a sinus tap or endoscopic sinus procedure unless their presentation is complicated with an orbital abscess or an intracranial process that requires surgical drainage. Therefore, we cannot extrapolate these results to patients with acute sinusitis. Second, 3 patients had recur- rence of pneumococcal sinusitis during the study period, but their isolates were not available. Thus, it is possible that we missed some cases of chronic sinusitis positive for S. pneumoniae , underestimat- ing the prevalence of pneumococcal chronic sinusitis. Third, it is possible that cultures positive for S. pneumoniae reflect inadvertent contamination of sinus specimen with nasopharyngeal flora and not a true pathogen. In conclusion, our study provides evidence of important epidemiologic changes of pneumococcal chronic sinusitis among children after the introduction of PCV13. We reported a significant decline of S. pneumoniae isolation rate in children with chronic sinusitis at TCH. This decrease of pneumococcal chronic sinusitis cases was driven by a substantial reduction of PCV13 serotypes, predominantly serotype 19A. S. pneumoniae continues to represent an important pathogen in chronic sinusitis especially in children <5 years of age; however, additional studies are needed to fully under- stand the microbiology of chronic sinusitis in children, particularly in the PCV13 era. ACKNOWLEDGMENTS The authors thank Wendy Hammerman and Andrea Forbes for their assistance obtaining the pneumococcal isolates and immunization records. REFERENCES 1. Wald ER, Applegate KE, Bordley C, et al.; American Academy of Pediatrics. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics . 2013;132: e262–e280. 2. Brook I. Bacteriology of chronic sinusitis and acute exacerbation of chronic sinusitis. Arch Otolaryngol Head Neck Surg . 2006;132:1099–1101.

3. Puglisi S, Privitera S, Maiolino L, et al. Bacteriological findings and anti- microbial resistance in odontogenic and non-odontogenic chronic maxillary sinusitis. J Med Microbiol . 2011;60(pt 9):1353–1359. 4. Tinkelman DG, Silk HJ. Clinical and bacteriologic features of chronic sinus- itis in children. Am J Dis Child . 1989;143:938–941. 5. Brook I. Bacteriologic features of chronic sinusitis in children. JAMA . 1981;246:967–969. 6. Kaplan SL, Mason EO Jr, Wald ER, et al. Decrease of invasive pneumococ- cal infections in children among 8 children’s hospitals in the United States after the introduction of the 7-valent pneumococcal conjugate vaccine. Pediatrics . 2004;113(3 pt 1):443–449. 7. Pilishvili T, Lexau C, Farley MM, et al.; Active Bacterial Core Surveillance/ Emerging Infections Program Network. Sustained reductions in inva- sive pneumococcal disease in the era of conjugate vaccine. J Infect Dis . 2010;201:32–41. 8. Casey JR, Pichichero ME. Changes in frequency and pathogens causing acute otitis media in 1995-2003. Pediatr Infect Dis J . 2004;23:824–828. 9. Block SL, Hedrick J, Harrison CJ, et al. Community-wide vaccination with the heptavalent pneumococcal conjugate significantly alters the microbiol- ogy of acute otitis media. Pediatr Infect Dis J . 2004;23:829–833. 10. Brook I, Gober AE. Frequency of recovery of pathogens from the nasophar- ynx of children with acute maxillary sinusitis before and after the introduc- tion of vaccination with the 7-valent pneumococcal vaccine. Int J Pediatr Otorhinolaryngol . 2007;71:575–579. 11. Brook I, Foote PA, Hausfeld JN. Frequency of recovery of pathogens caus- ing acute maxillary sinusitis in adults before and after introduction of vaccination of children with the 7-valent pneumococcal vaccine. J Med Microbiol . 2006;55(pt 7):943–946. 12. McNeil JC, Hulten KG, Mason EO Jr, et al. Serotype 19A is the most com- mon Streptococcus pneumoniae isolate in children with chronic sinusitis. Pediatr Infect Dis J . 2009;28:766–768. 13. Kaplan SL, Barson WJ, Lin PL, et al. Serotype 19A Is the most common serotype causing invasive pneumococcal infections in children. Pediatrics . 2010;125:429–436. 14. Kaplan SL, Barson WJ, Lin PL, et al. Early trends for invasive pneumococ- cal infections in children after the introduction of the 13-valent pneumococ- cal conjugate vaccine. Pediatr Infect Dis J . 2013;32:203–207. 15. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Testing; Twenty-second Informational Supplement, CLSI docu- ment M100-S22 . Wayne, PA: Clinical and Laboratory Standards Institute; 2012. 16. Merino LA, Ronconi MC, Hreñuk GE, et al. Bacteriologic findings in patients with chronic sinusitis. Ear Nose Throat J . 2003;82:798–800, 803– 794, 806. 17. Center for Disease Control and Prevention. Update on effectiveness and impact of PCV13 use among U.S. children. Available at: www.cdc.gov/vac- cines/acip/meetings/downloads//slides-oct-2013/02-Pneumococcal-Moore. pdf. Accessed April 1, 2014. 18. LoughlinAM, Hsu K, SilverioAL, et al. Direct and Indirect Effects of PCV13 on Nasopharyngeal Carriage of PCV13 Unique Pneumococcal Serotypes in Massachusetts’ Children. Pediatr Infect Dis J . 2014;33:504–510. 19. Lee GM, Kleinman K, Pelton SI, et al. Impact of 13-valent pneumococcal conjugate vaccination on Streptococcus pneumoniae carriage in young chil- dren in Massachusetts. J Pediatric Infect Dis Soc . 2014;3:23–32. 20. Dagan R, Leibovitz E, Greenberg D, et al. Mixed pneumococcal-nontype- able Haemophilus influenzae otitis media is a distinct clinical entity with unique epidemiologic characteristics and pneumococcal serotype distribu- tion. J Infect Dis . 2013;208:1152–1160. 21. Xu Q, Casey JR, Chang A, et al. When co-colonizing the nasopharynx Haemophilus influenzae predominates over Streptococcus pneumoniae except serotype 19A strains to cause acute otitis media. Pediatr Infect Dis J . 2012;31:638–640. 22. Biesbroek G, Wang X, Keijser BJ, et al. Seven-valent pneumococcal con- jugate vaccine and nasopharyngeal microbiota in healthy children. Emerg Infect Dis . 2014;20:201–210.

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