Nasopharyngeal carriage and antimicrobial resistance in isolates of Streptococcus pneumoniae and Haemophilus influenzae type b in children under 5 years of age in Botswana

      This paper is only available as a PDF. To read, Please Download here.

      Abstract

      Objectives: A prospective survey was conducted to determine the prevalence of asymptomatic nasopharyngeal carriage of Streptococcus pneumoniae and Haemophilus influenzae type b in children under 5 years of age in Botswana and to determine the antibiotic resistance patterns of these organisms to commonly used antimicrobial agents.
      Methods: Children 2 months to 5 years of age (n = 249) were recruited from outpatient clinics in Gaborone and Francistown, and 29 were sampled from the pediatric wards at Princess Marina (Gaborone) and Nyangabgwe (Francistown) Hospitals. Nasopharyngeal specimens were collected and the carriage and antibiotic resistance of S. pneumoniae and H. influenzae type b were determined. Analyses of risk factors associated with carriage and resistance were performed.
      Results: Streptococcus pneumoniae was isolated from 69% of the outpatient children in Gaborone and 85% of the children in Francistown; the carriage rate in hospitalized children was 36% and 33% in Gaborone and Francistown, respectively. Approximately half of the isolates at both sites were resistant to at least one antibiotic, the most common being cotrimoxazole and penicillin. Resistance to three or more antibiotics (multiple resistance) was found in less than 10% of the isolates. Most penicillin resistance at both sites was at the intermediate level; however, almost 20% of the isolates demonstrated high-level resistance to cotrimoxazole. The most prevalent serogroups or serotypes of antibiotic-resistant isolates were 14, 19F, 19A, 6A, 6B, and 4. No risk factors for antibiotic resistance were identified. Haemophilus influenzae type b was isolated from 8% of the children in Gaborone and from 3% of the children in Francistown. Almost a third of the isolates were resistant to ampicillin.
      Conclusions: The high levels of antibiotic resistance in pneumococci isolated from children in Botswana suggest that the clinical management of meningitis and ottis media with a β-lactam antibiotic may fail in a significant proportion of cases and that empiric first-line use of cefotaxime or ceftriaxone for meningitis and higher dose amoxicillin (90 mg/kg/day) for otitis media is recommended. The levels of penicillin resistance in this study would not impact on the management of pneumonia with amoxicillin.

      Keywords

      References

        • Garenne M.
        • Ronsmans C.
        • Campbell H.
        The magnitude of mortality from acute respiratory infections in children under 5 years in developing countries.
        World Health Stat Q. 1992; 45: 180-191
        • O'Dempsey T.J.D.
        • McArdle T.F.
        • Lloyd-Evans N.
        • et al.
        Importance of enteric bacteria as a cause of pneumonia.
        Pediatr Infect Dis J. 1994; 13: 122-128
        • Pecoul B.
        • Varaine F.
        • Keita M.
        • et al.
        Long-acting chloramphenicol versus intravenous ampicillin for treatment of bacterial meningitis.
        Lancet. 1991; 338: 862-866
        • Klugman K.P.
        Pneumococcal resistance to antibiotics.
        Clin Microbiol Rev. 1990; 3: 171-196
        • Koornhof H.J.
        • Jacobs M.
        • Isaacson M.
        • et al.
        Follow-up on multiple-antibiotic-resistant pneumococci: South Africa.
        MMWR Morb Mortal Wkly Rep. 1978; 27: 1-7
        • World Health Organization
        Technical basis for the WHO recommendations on the management of pneumonia in children at first-level health facilities.
        in: 3rd ed. WHO/ARI/91.20. WHO, Geneva1991
        • Mastro T.D.
        • Nomani N.K.
        • Ishaq Z.
        • et al.
        Use of nasopharyngeal isolates of Streptococcus pneumoniae and Haemopbilus influenzae from children in Pakistan for surveillance of antimicrobial resistance.
        Pediatr Infect Dis J. 1993; 12: 824-830
        • Koornhof H.J.
        • Wasas A.
        • Klugman K.R.
        Antimicrobial resistance in Streptococcus pneumoniae: a South African perspective.
        Clin Infect Dis. 1992; 15: 84-94
        • Dean A.G.
        • Dean J.A.
        • Coulombier D.
        • et al.
        Epi Info, version 6: a word processing, database, and statistics program for epidemiology on microcomputers.
        Centers for Disease Control and Prevention, Atlanta, GA1994
        • Sondag J.E.
        • Morgens R.K.
        • Hoppe J.E.
        • et al.
        Detection of pneumococci in respiratory secretions: clinical evaluation of gentamicin blood agar.
        J Clin Microbiol. 1977; 5: 397-400
        • National Committee for Clinical Laboratory Standards
        Performance standards for antimicrobial susceptibility testing: eighth informational supplement.
        in: 3rd ed. NCCLS document M100S8. National Committee for Clinical Laboratory Standards, Villanova, Pennsylvania1998
        • Yagupsky P.
        • Peled N.
        • Dagan R.
        Pneumococcal isolates from the nasopharynx of healthy children reflect serogroup distribution and antimicrobial resistance patterns of clinically significant pneumococci in young children.
        in: Presented at 36th Interscience Conference on Antimicrobial Agents and Chemotherapeutics, New Orleans, USASeptember 15–18, 1996
        • Kellner J.D.
        • McGeer A.
        • Wenger J.
        • et al.
        What is the correlation between population-based collections of invasive and nasopharyngeal isolates of Streptococcus pneumoniae?.
        in: Presented at 36th Interscience Conference on Antimicrobial Agents and Chemotherapeutics, New Orleans, USASeptember 15–18, 1996
        • Gray B.M.
        • Converse III, G.M.
        • Dillion Jr., H.C.
        Epidemiologic studies of Streptococcus pneumoniae in infants: acquisition, carriage, and infection during the first 24 months of life.
        J Infect Dis. 1980; 142: 923-933
        • Woolfson A.
        • Huebner R.
        • Wasas A.
        • Chola S.
        • Godfrey-Fausett P.
        • Klugman K.
        Nasopharyngeal carriage of community-acquired antibiotic resistant Streptococcus pneumoniae in a Zambian paediatric population.
        Bull World Health Organ. 1997; 75: 453-462
        • Leach A.J.
        • Boswell J.B.
        • Asche V.
        • Nienhuys T.G.
        • Mathews J.D.
        Bacterial colonization of the nasopharynx predicts very early onset and persistence of otitis media in Australian aboriginal infants.
        Pediatr Infect Dis J. 1994; 13: 983-989
        • Klugman K.P.
        • Koornhof H.J.
        • Kuhnle V.
        Clinical and pharyngeal isolates of unusual resistant pneumococci.
        Am J Dis Child. 1986; 140: 1186-1190
        • Mthwalo M.
        • Wasas A.
        • Huebner R.
        • Koornhof H.
        • Klugman K.
        Antimicrobial resistance of nasopharyngeal isolates of Streptococcuspneumoniae from Lesotho children.
        Bull World Health Organ. 1998; (in press)
        • Jackson M.A.
        • Shelton S.
        • Nelson J.D.
        • et al.
        Relatively penicillin-resistant pneumococcal infections in paediatric patients.
        Pediatr Infect Dis J. 1984; 3: 129-132
        • Arason V.
        • Kristinsson K.
        • Sigurdsson J.
        • et al.
        Do antimicrobials increase the carriage rate of penicillin-resistant pneumococci in children? Cross-sectional prevalence study.
        BMJ. 1996; 313: 387-391
        • Klugman K.P.
        Management of antibiotic-resistant pneumococcal infections.
        J Antimicrob Chemother. 1994; 34: 191-193
        • Dagan R.
        • Abramson O.
        • Leibovitz E.
        • et al.
        Impaired bacteriologic response to oral cephalosporins in acute otitis media caused by pneumococci with intermediate resistance to penicillin.
        Pediatr Infect Dis J. 1996; 15: 980-985
        • Ward J.I.
        • Moellering Jr, R.C.
        Susceptibility of pneumococci to 14 β-lactam agents: comparison of strains resistant, intermediate-resistant, and susceptible to penicillin.
        Antimicrob Agents Chemother. 1981; 20: 204-207
        • Friedland I.R.
        • Klugman K.P.
        Failure of chloramphenicol therapy in penicillin-resistant pneumococcal meningitis.
        Lancet. 1992; 339: 405-408
        • World Health Organization
        Antimicrobial and support therapy for bacterial meningitis in children.
        Report of the Annual Meeting of the World Health Organization, Geneva, Switzerland. June 18–20, 1997;
        • Dowell S.
        • Butler J.
        • Giebink S.
        • et al.
        Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group. Pneumococcal otitis media—management and surveillance in the era of pneumococcal resistance.
        1998 (submitted)
        • Kilian M.
        • Heine-Jensen J.
        • Bulow P.
        Haemophilus in the upper respiratory tract of children. A bacteriologiccal serological and clinical investigation.
        Acta Pathol Microbiol Immunol Scand [B]. 1972; 80: 571-578
        • Turk D.C.
        Naso-pharyngeal carriage of Haemophilus influenzae type b.
        J Hyg Camb. 1963; 61: 247-256
        • Mpairwe Y.
        Observations on the nasopharyngeal carriage of Haemophilus influenzae type b in children in Kampala, Uganda.
        J Hyg Camb. 1970; 68: 337-341
        • Bijlmer H.A.
        • Evans N.L.
        • Campbell H.
        • et al.
        Carriage of Haemophilus influenzae in healthy Gambian children.
        Trans R Soc Trop Med Hyg. 1989; 83: 831-835
        • Michaels R.H.
        • Poziviak C.S.
        • Stonebraker F.E.
        • Norden C.W.
        Factors affecting pharyngeal Haemophilus influenzae type b colonization rates in children.
        J Clin Microbiol. 1976; 4: 413-417
        • Moxon E.R.
        • Wilson R.
        The role of Haemophilus influenzae in the pathogenesis of pneumonia.
        Rev Infect Dis. 1991; 13: S518-S527