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Outbreak of Drug-Resistant Pneumococcal Pneumonia in a Nursing Home

Pneumococcal pneumonia causes appreciable mortality in the elderly, especially when accompanied by bacteremia. Invasive disease is a serious threat to unvaccinated persons if pneumococci have acquired resistance to multiple antimicrobials. These circumstances coalesced in an outbreak in an Oklahoma nursing home in February 1996 caused by multidrug-resistant Streptococcus pneumoniae serotype 23F.

Pneumonia developed in 11 of the 84 residents. Three patients with bacteremia died; 1 bacteremic patient survived. Only 3 residents had ever received pneumococcal vaccine, but 60 had recently received influenza vaccine. Nasopharyngeal cultures revealed 23F in 17 of 74 residents and 2 of 69 employees. Both 23F colonization and pneumonia were associated with use of antimicrobials at the onset of the outbreak. Community surveillance cultures from 97 well children revealed carriage of 23F in 2, neither of whom had had contact with the nursing home. The outbreak ceased and 23F carriage rates declined after residents were given pneumococcal vaccine and prophylactic oral antibiotics (predominantly penicillin).

Comment: It is virtually certain that this lethal outbreak was aborted by pneumococcal vaccination since 23F is resistant to penicillin, which was chosen for prophylaxis before the strain's drug resistance was known. Pneumococcal vaccine is markedly underused and should be given to all unvaccinated nursing home residents and persons over age 65. As noted in an accompanying editorial, even though pneumococcal vaccine is less immunogenic in the elderly, it still has efficacy rates of 60% to 70%.

— N Blacklow

Published in Journal Watch Infectious Diseases August 1, 1998

Citation(s):

Nuorti JP et al. An outbreak of multidrug-resistant pneumococcal pneumonia and bacteremia among unvaccinated nursing home residents. N Engl J Med 1998 Jun 25 338 1861-1868.

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Musher DM. Pneumococcal outbreaks in nursing homes. N Engl J Med 1998 Jun 25 338 1915-1916.

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• Medline abstract (Free)