Clinical and microbiological implications of invasive pneumococcal disease in hospitalized patients (1998–2013)

Medeiros, Marta Inês Cazentini; Negrini, Bento Vidal de Moura; Silva, Jorgete Maria e; Almeida, Samanta Cristine Grassi; Guerra, Maria Luiza Leopoldo Silva; Andrade, Denise de

doi:10.1016/j.bjid.2016.01.011

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Brazilian Journal of Infectious Diseases

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Sumário

Original article • Braz J Infect Dis 20 (3) • May-Jun 2016 • https://doi.org/10.1016/j.bjid.2016.01.011 copy

Clinical and microbiological implications of invasive pneumococcal disease in hospitalized patients (1998–2013)

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction

Infections caused by Streptococcus pneumoniae (pneumococcus) still represent a challenge for health systems around the world.

Objective

The objective of this study was to assess microbiological and clinical aspects in hospitalized patients with invasive pneumococcus disease between 1998 and 2013.

Materials and methods

This was a retrospective study that analyzed the results of pneumococcus identification, serotyping, and susceptibility testing found in the Adolfo Lutz Institute databank. Personal variables, medical history and clinical outcome of patients admitted with invasive pneumococcal disease were analyzed. These were obtained from records of a public teaching hospital – Hospital das Clínicas Faculdade de Medicina Ribeirão Preto.

Results

The sample comprised 332 patients. Patient age ranged from less than one month to 89 years old (mean 20.3 years) and the sample was predominately male. Pneumonia (67.8%) was the most common disease, accounting for 18.2% of deaths. Serotypes 14, 1, 3, 9V, 6B, 6A, 23F, 19A, 18C, 19F, 12F, and 4 were the most common (75.3%). Most patients, or 67.5%, were cured without any complication (success), 6.9% had some type of sequela (failure), and 25.6% died (failure). In the case of deaths due to meningitis, strains of fully penicillin resistant pneumococcus were isolated. Furthermore, 68.2% of patients who died presented some type of comorbidity. The 60 and older age group presented the most significant association (Odds Ratio = 4.2), with outcome failure regardless of the presence of comorbidity. Serotype 18C was the most significant risk factor both in raw analysis (Odds Ratio = 3.8) and when adjusted for comorbidity (Odds Ratio = 5.0) or age (Odds Ratio = 5.4). The same occurred with serotype 12F (respectively, Odds Ratio = 5.1, Odds Ratio = 5.0, and Odds Ratio = 4.7)

Conclusion

The present findings highlight the importance of IPD among young adults and older adults. In the era of conjugate vaccines, monitoring serotypes in different age groups is essential to assess the impact and adequacy of immunization.

Keywords
Streptococcus pneumoniae; Serotypes; Death; Comorbidity

Variable	Category	No.	%
Gender	Male	203	61.1
	Female	126	38.0
	Unknown	3	0.9
Age group (years)	<1	52	15.7
	1–2	59	17.8
	2–5	57	17.2
	Subtotal <5	168	50.7
	5–20	40	12.0
	20–60	83	25.0
	≥60	39	11.7
	Subtotal ≥5	162	48.7
	Unknown	2	0.6
Period	1998–2002	81	24.4
	2003–2010	205	61.7
	2011–2013	46	13.9
Disease	Pneumonia	225	67.8
	Meningitis	76	22.9
	Bacteremia/septicemia	26	7.8
	Others	5	1.5
Total		332	100.0

Serotypes	Periods						Total
	1998–2002		2003–2010		2011–2013		No.	%
	No.	%^a a Refers to the total number of IPD cases in each period.	No.	%^a a Refers to the total number of IPD cases in each period.	No.	%^a a Refers to the total number of IPD cases in each period.
14	31	38.3	51	25.0	3	6.4	85	25.6
1	7	8.6	17	8.3	0	0.0	24	7.2
3	2	2.5	16	7.8	5	10.6	23	6.9
9V	5	6.2	9	4.4	2	4.3	16	4.8
6A	3	3.7	10	4.9	3	6.4	16	4.8
6B	3	3.7	10	4.9	2	4.3	15	4.5
23F	3	3.7	12	5.9	0	0.0	15	4.5
19A	6	7.4	5	2.5	1	2.1	12	3.6
18C	5	6.2	4	2.0	2	4.3	11	3.3
19F	0	0.0	10	4.9	1	2.1	11	3.3
12F	0	0.0	4	2.0	6	12.8	10	3.0
4	1	1.2	8	3.9	1	2.1	10	3.0
Others	15	18.5	48	23.5	21	44.7	84	25.3
Total	81	100.0	204	100.0	47	100.0	332	100.0

Serotypes	Age range (years)																Total
	<1		1–2		2–5		Subtotal <5		5–20		20–60		≥60		Subtotal ≥5		No.	%
	No.	%^a a Refers to the total of cases in each age range, except for two cases that were excluded due to lack of information.	No.	%^a a Refers to the total of cases in each age range, except for two cases that were excluded due to lack of information.	No.	%	No.	%^a a Refers to the total of cases in each age range, except for two cases that were excluded due to lack of information.	No.	%^a a Refers to the total of cases in each age range, except for two cases that were excluded due to lack of information.	No.	%^a a Refers to the total of cases in each age range, except for two cases that were excluded due to lack of information.	No.	%^a a Refers to the total of cases in each age range, except for two cases that were excluded due to lack of information.	No.	%
14	20	38.5	26	44.1	29	50.9	75	44.6	4	10.0	6	7.2	0	0.0	10	6.2	85	25.8
1	1	1.9	2	3.4	10	17.5	13	7.7	8	20.0	2	2.4	1	2.6	11	6.8	24	7.3
3	3	5.8	5	8.5	2	3.5	10	6.0	1	2.5	6	7.2	6	15.4	13	8.0	23	7.0
9V	2	3.8	4	6.8	1	1.8	7	4.2	2	5.0	4	4.8	3	7.7	9	5.5	16	4.8
6A	6	11.5	2	3.4	5	8.8	13	7.7	2	5.0	1	1.2	0	0.0	3	1.8	16	4.8
6B	4	7.7	3	5.1	0	0.0	7	4.2	0	0.0	5	6.0	3	7.7	8	4.9	15	4.5
23F	2	3.8	2	3.4	0	0.0	4	2.4	3	7.5	6	7.2	2	5.1	11	6.8	15	4.5
19A	6	11.5	3	5.1	1	1.7	10	5.9	0	0.0	1	1.2	1	2.6	2	1.2	12	3.6
18C	2	3.8	2	3.4	3	5.3	7	4.2	1	2.5	1	1.2	2	5.1	4	2.5	11	3.3
19F	0	0.0	0	0.0	2	3.5	2	1.2	3	7.5	4	4.8	2	5.1	9	5.5	11	3.3
12F	1	1.9	0	0.0	0	0.0	1	0.6	2	5.0	6	7.2	1	2.6	9	5.5	10	3.0
4	0	0.0	0	0.0	0	0.0	0	0.0	2	5.0	6	7.2	2	5.1	10	6.2	10	3.0
Others	5	9.6	10	16.9	4	7.0	19	11.3	12	30.0	35	42.2	16	41.0	64	39.5	83	25.1
Total	52	100.0	59	100.0	57	100.0	168	100.0	40	100.0	83	100.0	39	100.0	162	100.0	330	100.0

Variable	Category	Cure no sequela		Cure with sequela/death		Total		p-value
		No.	%^a a Refers to the total of each category. IPD, invasive pneumococcal disease; HCRP, Ribeirão Preto Teaching Hospital.	No.	%^a a Refers to the total of each category. IPD, invasive pneumococcal disease; HCRP, Ribeirão Preto Teaching Hospital.	No.	%
Gender	Male	134	66.0	69	34.0	203	61.1	0.568
	Female	87	69.0	39	31.0	126	38.0
	Unknown	3	0.9	0	0.0	3	0.9
Age (years)	<1	38	73.1	14	26.9	52	15.7	<0.001
	1–2	44	74.6	15	25.4	59	17.8
	2–5	48	84.2	9	15.8	57	17.2
	Subtotal <5	130	77.4	38	22.6	168	50.6
	5–20	35	87.5	5	12.5	40	12.0
	20–60	44	53.0	39	47.0	83	25.0
	≥60	15	38.5	24	61.5	39	11.7
	Subtotal ≥5	94	58.0	68	42.0	162	48.7
	Unknown	1	0.3	1	0.3	2	0.6
Comorbidity	No	108	77.1	32	22.9	140	42.2	0.002
	Yes	112	61.2	71	38.8	183	55.1
	Unknown	4	44.4	5	55.6	9	2.7
Total						332	100.0

Serotypes	Cure no sequela		Cure with sequela/death		Total		p-value
	No.	%^a a Refers to the total of each assessed serotype. IPD, invasive pneumococcal disease; HCRP, Ribeirão Preto Teaching Hospital.	No.	%^a a Refers to the total of each assessed serotype. IPD, invasive pneumococcal disease; HCRP, Ribeirão Preto Teaching Hospital.	No.	%
14	68	82.9	14	17.1	82	100.0	0.001
Non-14	156	62.4	94	37.6	250	100.0
1	23	92.0	2	8.0	25	100.0	0.006
Non-1	201	65.5	106	34.5	307	100.0
3	14	58.3	10	41.7	24	100.0	0.321
Non-3	210	68.2	98	31.8	308	100.0
9V	9	52.9	8	47.1	17	100.0	0.189
Non-9V	215	68.3	100	31.7	315	100.0
6B	9	56.2	7	43.8	16	100.0	0.326
Non-6B	215	68.0	101	32.0	316	100.0
6A	12	80.0	3	20.0	15	100.0	0.289
Non-6A	212	66.9	105	33.1	317	100.0
23F	11	73.3	4	26.7	15	100.0	0.620
Non-23F	213	67.2	104	32.8	317	100.0
19F	5	45.5	6	54.5	11	100.0	0.113
Non-19F	219	68.2	102	31.8	321	100.0
19A	9	64.3	5	35.7	14	100.0	0.795
Non-19A	215	67.6	103	32.4	318	100.0
18C	4	36.4	7	63.6	11	100.0	0.025
Non-18C	220	68.5	101	31.5	321	100.0
12F	3	30.0	7	70.0	10	100.0	0.010
Non-12F	221	68.6	101	31.4	322	100.0
4	7	70.0	3	30.0	10	100.0	0.862
Non-4	217	67.4	105	32.6	322	100.0

Variable	Category	Raw OR	OR adjusted for comorbidity	OR adjusted for age
Age (years)	<1	1	1
	1–2	0.9 [0.4; 2.2]	0.9 [0.4; 2.2]
	2–5	0.5 [0.2; 1.3]	0.5 [0.2; 1.4]
	5–20	0.4 [0.2; 1.2]	0.4 [0.1; 1.2]
	20–60	2.4 [1.1; 5.1]	2.1 [0.9; 4.8]
	≥60	4.3 [1.8; 10.6]	4.2 [1.6; 10.9]
Serotype
18C	Yes	3.8 [1.1; 13.3]	5.0 [1.4; 18.0]	5.4 [1.4; 20.9]
	No	1.0	1.0	1.0
12F	Yes	5.1 [1.3; 20.1]	5.0 [1.2; 20.1]	4.7 [1.1; 21.3]
	No	1.0	1.0	1.0
14	Yes	0.3 [0.2; 0.6]	0.4 [0.2; 0.8]	0.5 [0.3; 1.1]
	No	1.0	1.0	1.0
1	Yes	0.2 [0.1; 0.7]	0.2 [0.1; 0.9]	0.3 [0.1; 1.2]
	No	1.0	1.0	1.0

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[1] Corresponding author. micmedeiros@ial.sp.gov.br, micmedeiros@hotmail.com