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The Pediatric Infectious Disease Journal
• Volume 33, Number 10, October 2014
www.pidj.com|
O
riginal
S
tudies
Background:
The widespread use of the 7-valent pneumococcal conjugate
vaccine has been associated with epidemiologic changes of mucosal and
invasive pneumococcal disease. No study describes the impact of 13-valent
pneumococcal conjugate vaccine (PCV13) on chronic sinusitis in children.
We describe changes in epidemiology of
Streptococcus pneumoniae
chronic
sinusitis after the introduction of PCV13 at Texas Children’s Hospital.
Methods:
We identified patients <18 years with positive sinus culture for
S. pneumoniae
who underwent endoscopic sinus surgery because of chronic
sinusitis fromAugust 2008 to December 2013 at Texas Children’s Hospital.
Isolates were serotyped by the capsular swelling method. Demographic and
clinical information was collected retrospectively. The
χ
2
test and Fisher’s
exact test were used to analyze dichotomous variables.
Results:
We identified 91 cases of chronic sinusitis with positive sinus cul-
ture for
S. pneumoniae
. Sixty-one (67%) isolates were non-PCV13 sero-
types. PCV13 cases decreased 31% in the post-PCV13 period (
P
= 0.003).
Serotype 19A decreased 27% in the post-PCV13 period (
P
= 0.007), but
accounted for all the isolates with penicillin minimal inhibitory concentra-
tion
≥
4
μ
g/mL and ceftriaxone minimal inhibitory concentration
≥
2
μ
g/mL.
Serotypes 19A (38%) and 15C (17%) were the most common in the pre- and
post-PCV13 periods, respectively. The most common organism co-isolated
was
Haemophilus influenzae
(52%). Isolation of
Prevotella
spp. increased
in the post-PCV13 period (
P
= 0.02).
Conclusions:
S. pneumoniae
continues to represent an important pathogen
in chronic sinusitis in children <5 years of age. After the introduction of
PCV13,
S. pneumoniae
isolation declined in children with chronic sinusitis
at Texas Children’s Hospital. We also observed a substantial reduction of
PCV13 serotypes, predominantly serotype 19A.
KeyWords:
Streptococcus pneumoniae
, sinusitis, pneumococcal conjugate
vaccine
(
Pediatr Infect Dis J
2014;33:1033–1036)
S
t
reptococcus pneumoniae
(~30%) has been described as the
most common pathogen in acute bacterial sinusitis in children
followed by
Haemophilus influenza
e and
Moraxella catarrha-
lis
(~20% each).
1
Studies describing the pathogenesis of chronic
sinusitis report a predominance of anaerobes in adults.
2,3
How-
ever, results are variable in children,
4,5
with some studies reporting
bacteriologic characteristics of chronic sinusitis similar to acute
sinusitis.
4
Nevertheless,
S. pneumoniae
continues to represent an
important pathogen among the aerobic isolates in chronic sinusi-
tis, particularly in acute exacerbations of chronic sinusitis and in
younger children.
2,4
After the licensure of the 7-valent pneumococcal conjugate
vaccine (PCV7) in 2000, a sustained decrease in the incidence of
invasive pneumococcal disease and acute otitis media (AOM) was
observed.
6–8
As the isolation of
S. pneumoniae
declined in patients
with AOM, an increase of
H. influenzae
isolations was described.
8,9
A similar shift in the organisms isolated from patients with acute
bacterial sinusitis was reported after the introduction of PCV7.
10,11
Brook et al
10
reported a decrease of
S. pneumoniae
isolated
from nasopharyngeal cultures obtained from children with acute
sinusitis from 43% during 1996–2000 to 25% during 2001–2005
(
P
= 0.0014).
10
Similar results were obtained from patients with
acute sinusitis who underwent endoscopic sinus surgery (ESS).
11
The widespread use of PCV7 not only altered the pathogen-
esis of bacterial sinusitis with respect to the causative pathogens,
but also the serotype distribution within the pneumococcal isolates.
Serotype 19A, which is not included on PCV7, was described as
the most common pneumococcal serotype isolated from pediatric
patients with chronic sinusitis during 2007–2008 undergoing endo-
scopic sinus surgery at Texas Children’s Hospital (TCH)
12
, a finding
that likely reflected the overall high prevalence of serotype 19A
during that time.
13
The 13-valent pneumococcal conjugate vaccine (PCV13)
that added serotypes 1, 3, 5, 6A, 7F and 19A to PCV7 was licensed
in 2010. A multicenter surveillance study showed an early trend in
a decrease of invasive pneumococcal disease in the year after the
introduction of PCV13.
14
To our knowledge, there are no studies
describing the impact of PCV13 on chronic sinusitis in children
to date. The purpose of this study was to compare the distribution
of pneumococcal serotypes, antibiotic susceptibilities of pneumo-
coccal isolates and the distribution of co-isolated organisms from
pediatric patients with chronic sinusitis at TCH before and after the
introduction of PCV13.
MATERIALS AND METHODS
Paranasal sinuses cultures positive for
S. pneumoniae
have
been prospectively identified at TCH as part of a pneumococ-
cal surveillance study that has been approved by the Institutional
Review Board of the Baylor College of Medicine.
Patients with a positive sinus culture for
S. pneumoniae
obtained during ESS because of chronic sinusitis from August
2008 to December 2013 at TCH were included. All patients were
evaluated by an otorhinolaryngologist in the outpatient setting and
diagnosed with chronic sinusitis. Under endoscopic visualization,
patients’ sinuses were cannulated, suctioned and irrigated with
saline solution. A sample of each aspirate obtained was sent for cul-
ture in the TCH Microbiology Laboratory. Pneumococcal isolates
were then serotyped by the capsular swelling method using com-
mercially available antisera (Statens Seruminstitut, Copenhagen,
Copyright © 2014 by Lippincott Williams & Wilkins
ISSN: 0891-3668/14/3310-1033
DOI: 10.1097/INF.0000000000000387
Impact of the 13-valent Pneumococcal
Conjugate Vaccine on Chronic Sinusitis Associated With
Streptococcus pneumoniae
in Children
Liset Olarte, MD,*† Kristina G. Hulten, PhD,*† Linda Lamberth BS,*†
Edward O. Mason, Jr., PhD,*† and Sheldon L. Kaplan, MD*†
Accepted for publication April 16, 2014.
From the *Department of Pediatrics, Section of Pediatric Infectious Diseases,
Baylor College of Medicine; and †Texas Children’s Hospital, Houston, TX.
This study supported in part by grant from Pfizer for
Streptococcus pneumoniae
surveillance study. The authors have no other funding or conflicts of interest
to disclose.
Address for correspondence: Sheldon L. Kaplan, MD, Texas Children’s Hospital,
Feigin Center, Suite 1150, 1102 Bates Ave., Houston, TX 77030. E-mail:
skaplan@bcm.edu.Reprinted by permission of Pediatr Infect Dis J. 2014; 33(10):1033-1036.
143