PEDIATRICS Vol. 108 No. 4 October 2001, pp. 856-865
High Rates of Multiple Antibiotic Resistance in Streptococcus pneumoniae From Healthy Children Living in Isolated Rural Communities: Association With Cephalosporin Use and Intrafamilial Transmission
Received Oct 24, 2000; accepted Feb 26, 2001.
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From the * Departments of Internal Medicine, Objective. Streptococcus
pneumoniae is one of the most clinically significant pathogens
with emerging antibiotic resistance. We performed a surveillance study
in isolated rural populations of healthy children to estimate the
prevalence of pneumococcal resistance and to contrast factors that
predict pneumococcal carriage with those that specifically predict
resistant pneumococcal carriage.
Methods. The study was conducted in 1998 in 2 rural
communities in Utah. Families were recruited directly for participation
through community canvassing. Surveillance nasopharyngeal cultures were obtained from children who were younger than 8 years. Antibiotic usage
and information on other potential risk factors were obtained from
questionnaires and local pharmacy records. Resistance was determined by
testing isolates for susceptibility to penicillin, cefaclor, trimethoprim-sulfamethoxazole, erythromycin,
ceftriaxone, and trovafloxacin. Selected resistant isolates were
characterized further by serotyping, pulsed field gel electrophoresis,
and Southern blot with DNA probes specific for the pneumococcal
lytA gene and for antibiotic resistance genes.
Results. In April 1998, surveillance nasopharyngeal
cultures were obtained from 368 children aged Conclusions. Young age and intrafamilial transmission were
important risk factors for carriage of both susceptible and resistant
S pneumoniae. In contrast, previous cephalosporin use
was linked specifically to resistant pneumococcal carriage, which
suggests that modifications in antibiotic usage patterns may have
salutary effects on antimicrobial resistance. These results extend
previous observations in large cities regarding the penetration of
multiple-drug-resistant clones of pneumococci into community
populations.
Family and
Preventive Medicine, and § Pathology, University of Utah, Salt Lake
City, Utah; Rockefeller University, New York, New York; and
¶ Department of Health and Medical Science, University of California
Berkeley, Berkeley, California.
8 years in community A
and 369 children in community B. The number of antibiotic courses per
child within 1 year before culture was higher in community B than A
(mean: 2.2 vs 1.7). Conversely, oral cephalosporins were more
frequently used in community A than B (community A: 22% received
cephalosporins within 4 months; community B: 12%). Colonization with
S pneumoniae was detected in 24% of children in
community A and 14% in community B; 36% of isolates from community A
and 28% of isolates from community B were resistant or intermediately
susceptible to at least 1 antibiotic tested. Reduced susceptibility was
most common to trimethoprim-sulfamethoxazole and cefaclor
(28% and 26%, respectively). Pneumococcal carriage (susceptible or
resistant) was independently associated with age <5 years
(odds ratio [OR]: 2.2), child care exposure (OR: 2.4), presence of a
sibling with a positive culture (OR: 3.3), and residence in community A
(OR: 1.7). Among carriers, age <2 years (OR: 2.6), use of
cephalosporins within the preceding 4 months (OR: 2.7), and having a
sibling colonized with resistant S pneumoniae (OR: 5.5)
were independent predictors of reduced susceptibility or resistance.
Each pair of resistant isolates from siblings was indistinguishable by
pulsed field gel electrophoresis and other molecular typing techniques.
Several pneumococcal isolates from these isolated rural areas had the
molecular characteristics of international clones of
multiple-drug-resistant pneumococci that have been associated with
worldwide spread.
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