[Show abstract][Hide abstract] ABSTRACT: Vaccine-serotype (VT) invasive pneumococcal disease (IPD) rates declined substantially following introduction of 7-valent pneumococcal conjugate vaccine (PCV7) into national immunization programs. Increases in non-vaccine-serotype (NVT) IPD rates occurred in some sites, presumably representing serotype replacement. We used a standardized approach to describe serotype-specific IPD changes among multiple sites after PCV7 introduction.
Of 32 IPD surveillance datasets received, we identified 21 eligible databases with rate data ≥2 years before and ≥1 year after PCV7 introduction. Expected annual rates of IPD absent PCV7 introduction were estimated by extrapolation using either Poisson regression modeling of pre-PCV7 rates or averaging pre-PCV7 rates. To estimate whether changes in rates had occurred following PCV7 introduction, we calculated site specific rate ratios by dividing observed by expected IPD rates for each post-PCV7 year. We calculated summary rate ratios (RRs) using random effects meta-analysis. For children <5 years old, overall IPD decreased by year 1 post-PCV7 (RR 0·55, 95% CI 0·46-0·65) and remained relatively stable through year 7 (RR 0·49, 95% CI 0·35-0·68). Point estimates for VT IPD decreased annually through year 7 (RR 0·03, 95% CI 0·01-0·10), while NVT IPD increased (year 7 RR 2·81, 95% CI 2·12-3·71). Among adults, decreases in overall IPD also occurred but were smaller and more variable by site than among children. At year 7 after introduction, significant reductions were observed (18-49 year-olds [RR 0·52, 95% CI 0·29-0·91], 50-64 year-olds [RR 0·84, 95% CI 0·77-0·93], and ≥65 year-olds [RR 0·74, 95% CI 0·58-0·95]).
Consistent and significant decreases in both overall and VT IPD in children occurred quickly and were sustained for 7 years after PCV7 introduction, supporting use of PCVs. Increases in NVT IPD occurred in most sites, with variable magnitude. These findings may not represent the experience in low-income countries or the effects after introduction of higher valency PCVs. High-quality, population-based surveillance of serotype-specific IPD rates is needed to monitor vaccine impact as more countries, including low-income countries, introduce PCVs and as higher valency PCVs are used. Please see later in the article for the Editors' Summary.
PLoS Medicine 09/2013; 10(9):e1001517. DOI:10.1371/journal.pmed.1001517 · 14.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Mycoplasma pneumoniae respiratory infection is a common cause of acute respiratory infection in children and adults. We evaluated the efficacy of increasing dosages of clarithromycin for the optimized therapy of M. pneumoniae respiratory infection in a mouse model.
BALB/c mice were intranasally inoculated once with M. pneumoniae or SP4 broth (control). Groups of mice were treated with increasing dosages of clarithromycin (10, 25 or 75 mg/kg/day) or placebo subcutaneously daily. Groups of mice were evaluated after 1, 2, 3, 6 and 12 days of therapy. Outcome variables included quantitative M. pneumoniae culture, histopathological score of the lungs, bronchoalveolar lavage (BAL) cytokine/chemokine/growth factor concentrations and plethysmography after aerosolized methacholine to assess airway hyperresponsiveness.
Elevated dosages of clarithromycin resulted in greater antimicrobial efficacy with significantly reduced M. pneumoniae quantitative cultures (P < 0.05), as well as greater improvement in markers of disease severity with significantly reduced lung histopathology scores, BAL cytokine concentrations and airway hyperresponsiveness (P < 0.05).
Escalated dosing of clarithromycin resulted in significantly greater therapeutic efficacy in the treatment of experimental M. pneumoniae respiratory infection.
[Show abstract][Hide abstract] ABSTRACT: Invasive pneumococcal disease (IPD) in children with sickle cell disease has decreased with prophylactic penicillin, pneumococcal polysaccharide vaccine, and pneumococcal protein-conjugate vaccine usage. We report 10 IPD cases since pneumococcal protein-conjugate vaccine licensure, including a recent surge of non-vaccine serotypes. IPD continues to be a serious risk in sickle cell disease.
The Journal of pediatrics 03/2011; 158(3):505-7. DOI:10.1016/j.jpeds.2010.11.025 · 3.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Mycoplasma pneumoniae was recently discovered to produce an ADP-ribosylating and vacuolating cytotoxin, designated CARDS toxin, which is hypothesized to be a primary pathogenic mechanism responsible for M. pneumoniae-induced pulmonary inflammation. It is unknown if cytotoxin production varies with M. pneumoniae strain or if variation in cytotoxin production affects pulmonary disease severity.
To examine the production of CARDS toxin by various strains of M. pneumoniae and compare the disease manifestations elicited by these strains in an experimental model of M. pneumoniae respiratory infection.
BALB/c mice were inoculated once intranasally with SP4 broth (negative control) or three different M. pneumoniae strains: M129-B7, M129-B9, or S1. Mice were assessed at 1, 2, 4, 7, 10, and 14 days after inoculation. Outcome variables included comparisons among M. pneumoniae strains relative to bronchoalveolar lavage (BAL) M. pneumoniae quantitative culture, CARDS toxin-based PCR, and CARDS toxin protein determinations, as well as cytokine and chemokine concentrations. Graded lung histopathologic score (HPS) was also assessed.
CARDS toxin concentrations were significantly increased in mice inoculated with strain S1 compared with mice inoculated with M129-B7 or M129-B9 strains. Quantitative M. pneumoniae culture and polymerase chain reaction were also significantly greater in mice infected with S1 strain compared with the other two strains, as were lung HPS and concentrations of IFN-γ, IL-12, IL-1α, macrophage inflammatory protein-1α, and keratinocyte-derived chemokine. In addition, a significant positive correlation was found between CARDS toxin concentration and lung HPS.
CARDS toxin concentrations in BAL are directly linked to the ability of specific M. pneumoniae strains to colonize, replicate, and persist, and elicit lung histopathology. This variation among strains may predict the range in severity of pulmonary disease observed among patients.
American Journal of Respiratory and Critical Care Medicine 09/2010; 182(6):797-804. DOI:10.1164/rccm.201001-0080OC · 13.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Respiratory viruses contribute to the seasonal pattern of invasive pneumococcal disease (IPD), but the impact of viral coinfections on the clinical characteristics and outcomes of patients with IPD have not been well defined.
This study was designed to describe and compare the clinical presentations and outcomes of patients with IPD with or without viral coinfections.
Retrospective analyses of records of all children treated at Children's Medical Center Dallas (CMCD) for IPD from July 2005 to June 2008. Viral studies included viral direct fluorescent antibody staining and culture. For comparisons, patients were classified in 3 groups: with positive, negative, and no viral studies performed.
A total of 129 patients were admitted to CMCD with IPD during the 3 year study; 57% were male. Ages ranged from 2 months to 18 years (median 25 months) and 48% were <2 years. Viral studies were performed in 82 (63%) patients, and 28 (34%) had positive results. The most common viruses isolated were influenza (7, 25%), rhinoviruses (6, 21%), adenoviruses (6, 21%), and RSV (5, 18%). Peaks of positive viral studies occurred in February and November which coincided with the peak numbers of patients admitted with IPD. Of 6 with adenovirus coinfection, 5 were admitted to Pediatric Intensive Care Unit (PICU). The most common pneumococcal serotypes were 19A (41, 32.5%), 7F (14, 11%), and 23A (13, 10.3%). Pneumonia (42%), bacteremia (22%), and meningitis (17%) were the most common clinical syndromes. There were no differences in duration of fever before admission, maximum temperatures during hospitalization and white blood cell counts, duration of fever and hospitalization between patients with positive and negative viral studies, but there was a trend for patient with positive viral studies to be admitted to PICU more frequently and to have longer PICU stay. Three of the 6 patients who died had documented viral coinfections (2 adenovirus, 1 parainfluenza 3), and all 3 had no underlying conditions. The other 3 patients who died had no viral studies performed. Duration of treatment ranged from 1 to -210 days (median 14), with no differences among the groups.
Viral coinfections were common in children with IPD. Future prospective studies should include new PCR assays to characterize better the impact of viral coinfections in the occurrence and outcome of IPD.
[Show abstract][Hide abstract] ABSTRACT: The heptavalent pneumococcal conjugate vaccine (PCV7) has significantly reduced vaccine-type invasive pneumococcal disease (IPD) in children. An increasing percentage of IPD cases are now caused by nonvaccine serotypes. The purpose of our observational study was to define the epidemiology of pneumococcal disease in Dallas, TX children for 8 years after implementation of PCV7 immunization.
Streptococcus pneumoniae isolates from normally sterile sites were collected at Children's Medical Center of Dallas from January 1, 1999 to December 31, 2008. Incidence of IPD was calculated using inpatient and emergency center admissions to Children's Medical Center of Dallas as the denominator. Isolates were serotyped and penicillin and cefotaxime susceptibilities were determined. Serotype 19A isolates were further characterized by multilocus sequence typing.
Compared with the prevaccine period of 1999-2000, there was a significant reduction in the incidence of IPD from 2002 to 2008 (P < 0.05), although a significant increase in IPD incidence was observed from 2006 to 2008 (P = 0.038). The number of IPD cases caused by serotype 19A increased from 1999 to 2008 (P < 0.001). There were significant increases in penicillin and cefotaxime nonsusceptible 19A isolates during this 10-year period (P < 0.001 and P = 0.004, respectively). The most common sequence type (ST) of the 19A isolates was ST-199 (42.7%). Clonal complex (cc-156) and cc-320 emerged in the period of 2005-2008 as penicillin and cefotaxime resistant 19A strains.
In Dallas, PCV7 immunization reduced significantly the incidence of IPD caused by vaccine-type strains. A significant increase in IPD caused by serotype 19A was observed. The penicillin and cefotaxime nonsusceptible STs, not previously identified in Dallas, have recently become an important cause of IPD.
[Show abstract][Hide abstract] ABSTRACT: Mycoplasma pneumoniae produces an ADP-ribosylating and vacuolating toxin known as the CARDS (Community Acquired Respiratory Distress Syndrome) toxin that has been shown to be cytotoxic to mammalian cells in tissue and organ culture. In this study we tested the ability of recombinant CARDS (rCARDS) toxin to elicit changes within the pulmonary compartment in both mice and baboons. Animals responded to a respiratory exposure to rCARDS toxin in a dose and activity-dependent manner by increasing the expression of the pro-inflammatory cytokines IL-1alpha, 1beta, 6, 12, 17, TNF-alpha and IFN-gamma. There was also a dose-dependent increase in several growth factors and chemokines following toxin exposure including KC, IL-8, RANTES, and G-CSF. Increased expression of IFN-gamma was observed only in the baboon; otherwise, mice and baboons responded to CARDS toxin in a very similar manner. Introduction of rCARDS toxin to the airways of mice or baboons resulted in a cellular inflammatory response characterized by a dose-dependent early vacuolization and cytotoxicity of the bronchiolar epithelium followed by a robust peribronchial and perivascular lymphocytic infiltration. In mice, rCARDS toxin caused airway hyper-reactivity two days after toxin exposure as well as prolonged airway obstruction. The changes in airway function, cytokine expression, and cellular inflammation correlate temporally and are consistent with what has been reported for M. pneumoniae infection. Altogether, these data suggest that the CARDS toxin interacts extensively with the pulmonary compartment and that the CARDS toxin is sufficient to cause prolonged inflammatory responses and airway dysfunction.
PLoS ONE 10/2009; 4(10):e7562. DOI:10.1371/journal.pone.0007562 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Mycoplasma pneumoniae is one of the causative agents of atypical community-acquired pneumonia. Tigecycline belongs to a new class of glycylcycline
antimicrobials that have activity against a wide range of microorganisms, including in vitro activity against M. pneumoniae. We investigated the effect of tigecycline on microbiologic, histologic, and immunologic indices in a murine model of M. pneumoniae pneumonia. BALB/c mice were inoculated intranasally with M. pneumoniae and treated subcutaneously with tigecycline or placebo for 6 days. Outcome variables included quantitative bronchoalveolar
lavage (BAL) M. pneumoniae culture, lung histopathologic score (HPS), BAL cytokine and chemokine concentrations (tumor necrosis factor alpha [TNF-α],
gamma interferon [IFN-γ], interleukin 1β [IL-1β], IL-2, IL-4, IL-5, IL-6, IL-10, IL-12 [p40/p70], granulocyte-macrophage colony-stimulating
factor, MIP-1α, MIG, KC, MCP-1, and IP-10). BAL M. pneumoniae concentrations in mice treated with tigecycline (MpTige) tended to be reduced compared with mice treated with placebo (MpPl);
however this did not reach statistical significance. The lung HPS was significantly lower, as well as the parenchymal-pneumonia
subscore, in the MpTige mice than in the MpPl mice. MpTige mice had significantly lower BAL cytokine concentrations of IL-1β,
IL-12 (p40/p70), IFN-γ, and TNF-α; of the chemokines, MIG, MIP-1α, and IP-10 were statistically lower in MpTige mice. While
tigecycline treatment demonstrated a modest microbiologic effect, it significantly improved lung histologic inflammation and
reduced pulmonary cytokines and chemokines.
[Show abstract][Hide abstract] ABSTRACT: Background: Administration of the heptavalent pneumococcal conjugate vaccine (PCV7) has reduced vaccine-type (VT) invasive pneumococcal disease (IPD) in children. An increasing percentage of IPD cases is now caused by non-vaccine (NVT) serotypes. We analyzed the serotype and antimicrobial resistance patterns among S. pneumoniae (SP) responsible for IPD at Children’s Medical Center, Dallas (CMCD) from 1999 through 2007. Methods: SP isolated from normally sterile sites were collected from January 1, 1999 through December 31, 2007. Incidence of IPD was calculated using inpatient and emergency center admissions to CMCD as the denominator. SP isolated were serotyped by quellung reaction and penicillin and cefotaxime susceptibility were determined by E-test. Serotype 19A isolates were characterized by PFGE and by multi-locus sequence typing (MLST). Results: The incidence of IPD per 100,000 patients decreased 56% from 93.6 in 1999 to a nadir of 41 in 2003 (P<0.001); subsequently the rates (per 100,000 patients) were 64.2 in 2005 (p=0.039 vs 2003), 45 in 2006, and 60 in 2007. The number of IPD cases caused by serotype 19A increased 85% from 1999 through 2005 (p<0.001) at which time it comprised 20 of the 49 (41%) IPD isolates. The number of 19A isolates causing IPD decreased to 8 of 36 (22%) in 2006 but increased to 16 of 50 (32%) in 2007. As determined by MLST, the most common sequence type (ST) of the 19A isolates was ST-199, representing 35 of 71 (49.3%) isolates. In 2007 there was an increased percentage of IPD cases caused by cephalosporin resistant strains. All serotype 19A isolates in 2007 were penicillin non-susceptible. Conclusions: In Dallas, PCV7 immunization has eliminated IPD caused by VT serotypes but the overall incidence of IPD in 2007 was reduced only 36% compared with that in 1999. Many of the NVT strains are resistant to beta-lactam antibiotics.
Infectious Diseases Society of America 2008 Annual Meeting; 10/2008
[Show abstract][Hide abstract] ABSTRACT: Systemic steroids have been advocated in addition to antimicrobial therapy for severe Mycoplasma pneumoniae pneumonia. We evaluated the efficacy of clarithromycin, dexamethasone, and combination therapy for M. pneumoniae respiratory infection.
Mice infected with M. pneumoniae were treated with clarithromycin, dexamethasone, combined clarithromycin/dexamethasone, or placebo daily; mice were evaluated at baseline and after 1, 3, and 6 days of therapy. Outcome variables included M. pneumoniae culture, lung histopathologic score (HPS), and bronchoalveolar lavage cytokine, chemokine, and growth factor concentrations.
Clarithromycin monotherapy resulted in the greatest reductions in M. pneumoniae concentrations. After 3 days of treatment, combination therapy significantly reduced lung HPS compared with placebo, clarithromycin, and dexamethasone alone, whereas, after 6 days of therapy, clarithromycin alone and combination therapy significantly reduced lung HPS compared with placebo. Concentrations of interleukin (IL)-12 p40, RANTES, macrophage chemotactic protein-1, and cytokine-induced neutrophil chemoattractant were significantly lower in mice treated with clarithromycin alone and/or combination therapy compared with dexamethasone alone and/or placebo; combination therapy resulted in a significantly greater reduction than clarithromycin alone for IL-12 p40 and RANTES.
Although monotherapy with clarithromycin had the greatest effect on reducing concentrations of M. pneumoniae, combination therapy had the greatest effect on decreasing levels of cytokines and chemokines as well as pulmonary histologic inflammation.
The Journal of Infectious Diseases 09/2008; 198(8):1180-8. DOI:10.1086/591915 · 6.00 Impact Factor