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Multidrug-Resistant Streptococcus pneumoniae in a Child Care Center ---Southwest Georgia, December 2000

On December 18, 2000, public health officials in southwest Georgia contacted the Georgia Division of Public Health (GDPH) about a child aged 11 months hospitalized for refractory otitis media. Eight days before hospitalization, a culture of drainage obtained from the child's middle ear revealed Streptococcus pneumoniae resistant to penicillin, clindamycin, erythromycin, trimethoprim/sulfamethoxazole, and tetracycline (index strain). The child attended a local child care center. GDPH and CDC conducted an investigation to determine the rate of pneumococcal carriage among attendees of the child care center, to identify risk factors for carriage of the index strain, and to characterize parental knowledge and use of antibiotics and of pneumococcal conjugate vaccine (PCV7) (Prevnar, Wyeth Lederle Vaccine, Philadelphia, Pennsylvania). GDPH met with parents and physicians of children attending the child care center to discuss the results of the investigation and the importance of vaccination with PCV7. This report summarizes the results of the investigation, which suggest that person-to-person transmission of the index strain had occurred at the child care center and indicate that most parents had been unaware of the dangers of frequent antibiotic use and of the availability of PCV7. A multifaceted intervention targeting parents and health-care providers might improve prescribing practices and vaccination in this community.

The child care center is located in a rural county (1999 population: 6,318) in southwest Georgia and serves approximately 54 children (median age: 26.4 months; age range: 9 months--10 years). The children are divided into two groups on the basis of age (<18 months and >18 months) and the two groups have separate rooms. After obtaining informed consent from parents of children attending the child care center, nasopharyngeal (NP) swabs were collected, inoculated into skim milk, tryptone, glucose, and glycerol medium (STGG), and sent to CDC for serotyping and susceptibility testing. A case of index-strain carriage was defined as occurrence of S. pneumoniae with a susceptibility profile identical to the index-strain profile in a culture from an NP swab of a child who attended the child care center. Parents of children from whom NP swabs were obtained completed a knowledge, attitudes, and practices (KAP) questionnaire. A cross-sectional survey was performed to assess risk factors for pneumococcal carriage.

NP swabs were obtained from five of the 12 children who had shared a room at the child care center with the child who was hospitalized; NP swabs also were obtained from 17 of the 42 children from the other room. One swab was lost during processing. S. pneumoniae was isolated from 19 (90%) of the 21 NP cultures; of these 19, a total of 10 (53%) were serotype 14 and had susceptibility profiles that were identical to the index strain. Of the 19 isolates, 15 (79%) were penicillin nonsusceptible (i.e., intermediate or high-level resistance [minimum inhibitory concentration >0.12 µg/ml]), and 15 (79%) were resistant to more than one antibiotic or class of antibiotic. Five pneumococcal serotypes were identified: serotype 14 (10), 19F (five), 6B (two), 35B (one), and 33F (one). Of the 19 isolates, 17 were serotypes included in PCV7 (14, 19F, 6B, 4, 9V, 23F, and 18C). Four (40%) of the 10 children with index-strain carriage had shared a room at the child care center with the hospitalized child (index patient).

Sixteen parents completed the questionnaire with one parent responding for each child, accounting for 20 (91%) of the 22 children from whom swabs were obtained. The 10 children carrying the index strain were younger than 10 children not carrying the index strain (mean: aged 19 months versus 30 months; p=0.03). Of 20 children in the child care center, 14 (82%) had an illness for which they received antibiotic treatment during the 2 months preceding the questionnaire. No association was identified between carrying the index strain and having received antibiotics during the preceding 2 months.

Of 16 parents, five (31%) were unaware of the health dangers of frequent antibiotic use, and 10 (63%) were unaware of the availability of PCV7. Among the parents of the seven children aware of the availability of PCV7, three had heard about it from their health-care provider, two from their health department, and two from electronic media (e.g., television and radio).

Because of the high carriage rate of pneumococcus among attendees of the child care center (90%), GDPH recommended that children aged <5 years attending the child care center be vaccinated with PCV7 (1). In March 2001, GDPH met with parents and physicians of children attending the child care center to discuss the investigation and the importance of judicious antibiotic use. In addition, treatment guidelines for acute otitis media (AOM) were reviewed with health-care providers, and appropriate therapy for viral infections was reviewed with parents.

Reported by: A Addison, MSN, L Addison, Miller County Health Dept, Colquitt; H Perry, MT, J Jenkins, MPH, Georgia Health District 8-2; S Lance-Parker, DVM, K Arnold, MD, S Kramer, MPH, Notifiable Disease Epidemiology Section, P Blake, MD, State Epidemiologist, Georgia Div of Public Health. Respiratory Disease Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases; and EIS officers, CDC.

Editorial Note:

S. pneumoniae is a leading cause of community-acquired respiratory infection. Asymptomatic nasopharyngeal carriage of pneumococcus is intermittent. Cross-sectional studies suggest that pneumococcus can be found among 15% of adults; in child care settings, up to 65% of children are colonized (2). Although pneumococcal carriage can lead to invasive disease (e.g., meningitis or bacteremia), AOM is the most common clinical manifestation of pneumococcal infection among children and the most common outpatient diagnosis resulting in antibiotic prescriptions among children (1). Pneumococcal resistance to penicillin and other antibiotics has increased since 1995 (3).

In the United States, recent antibiotic use, child care center attendance, and being white are risk factors for carriage of and infection with drug-resistant pneumococcus among children (4,5). Of the 21 children from whom NP swabs were collected for culture, 90% were carrying pneumococcus, and approximately half of the isolates were serotype 14 with the same susceptibility pattern as the index strain. The similarity of the 10 isolates obtained from this child care center suggests person-to-person transmission.

PCV7 offers protection against the seven serotypes that most commonly cause invasive disease in children in the United States (1). Licensed for use in February 2000, PCV7 is effective in children aged <2 years. Although the efficacy of PCV7 against all AOM episodes is 6%, efficacies against PCV7 serotype-related pneumococcal AOM and invasive pneumococcal disease are 57% and 94%, respectively (6,7). Of the pneumococcal isolates carried by children in the child care center, 90% belonged to PCV7-related serotypes. PCV7 became readily available to the community in February 2001, 2 months after the investigation.

The findings in this report are subject to at least two limitations. First, because of the winter holidays, some children who ordinarily attended the child care center were not available for NP culturing. Second, the small sample size limited the ability to draw other conclusions (e.g., an association between recent antibiotic use and drug-resistant pneumococcal carriage).

In addition to groups who are recommended to receive PCV7 routinely, the Advisory Committee on Immunization Practices recommends that health-care providers consider PCV7 for children aged 24--59 months who attend group child care centers (1). Health-care and child care providers and local health departments should inform parents about the availability of PCV7. Interim recommendations have been published about PCV7 use during the current temporary shortage (8). To ensure that vaccine reaches children at highest risk, only children aged <2 years and aged >2 years with high-risk medical conditions should receive vaccine until the shortage is resolved.

In the United States, children aged 0--4 years receive approximately half of all out-patient antibiotic prescriptions, and 30% of all antibiotic prescriptions are used to treat presumptive AOM in this age group (9). Substantial decreases in overall antibiotic exposure could be achieved through the use of criteria for the diagnosis and treatment of upper respiratory infection, including AOM (10). The results of the KAP survey suggest that parents might benefit from improved communication with their health-care providers about appropriate use of antibiotics.

CDC is tracking potential pneumococcal conjugate vaccine failures among children aged <5 years who have had invasive pneumococcal infections (e.g., meningitis or bacteremia) following 1 or more doses of PCV7, and for whom pneumococcal isolates and reliable vaccination information are available. The pneumococcal conjugate vaccine failure report form and instructions on completing the form and sending pneumococcal isolates to CDC are available at http://www.cdc.gov/nip/diseases/pneumo/PCV-survrpts/default.htm.

Information about practices that might prevent person-to-person transmission in child care settings, such as hand washing and group separation of children, is available at http://www.cdc.gov/ncidod/hip/abc/abc.htm. Additional resources are available at http://www.cdc.gov/antibioticresistance.

References

  1. CDC. Preventing pneumococcal disease among infants and young children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2000;49(no. RR-9).
  2. Craig AS, Erwin PC, Schaffner W, et al. Carriage of multidrug-resistant Streptococcus pneumoniae and impact of chemoprophylaxis during an outbreak of meningitis at a day care center. Clin Infect Dis 1999;29:1257--64.
  3. Whitney CG, Farley MM, Hadler J, et al. Increasing prevalence of multidrug-resistant Streptococcus pneumoniae in the United States. N Engl J Med 2000;343:1917--24.
  4. Levine O, Farley M, Harrison L, Lefkowitz L, McGeer A, Schwartz B. Risk factors for invasive pneumococcal disease in children: a population-based case-control study in North America. Pediatr 1999;103:28.
  5. Arnold KE, Leggiadro RJ, Breiman RF, et al. Risk factors for carriage of drug-resistant Streptococcus pneumoniae among children in Memphis, Tennessee. J Pediatr 1996;128:757--64.
  6. Eskola J, Kilpi T, Palmu A, et al. Efficacy of a pneumococcal conjugate vaccine against acute otitis media. N Engl J Med 2001;344:403--9.
  7. Black S, Shinefield H, Fireman B, et al. Efficacy, safety, and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Pediatr Infect Dis J 2000;19:187--95.
  8. CDC. Updated recommendations on the use of pneumococcal conjugate vaccine in a setting of vaccine shortage---Advisory Committee on Immunization Practices. MMWR 2001;50:1140--2.
  9. Nyquist AC, Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 1998;279:875--7.
  10. Dowell S, Marcy S, Phillips W, Gerber M, Schwartz B. Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections. Pediatr 1998;101:163--5.

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