Elsevier

Vaccine

Volume 35, Issue 39, 18 September 2017, Pages 5264-5270
Vaccine

The burden of PCV13 serotypes in hospitalized pneumococcal pneumonia in Spain using a novel urinary antigen detection test. CAPA study

https://doi.org/10.1016/j.vaccine.2017.08.007Get rights and content

Highlights

  • Streptococcus pneumoniae caused 29% of hospitalized CAP in immunocompetent patients.

  • PCV13 serotypes caused 60% of pneumococcal CAP and 74.6% in invasive disease.

  • The most prevalent serotypes were 3, 1, 7F, 19A and 14.

  • No significant changes were found in cases due to PCV7 or PCV13 from 2011 to 2014.

  • Adult pneumococcal vaccination should reduce the burden of pneumococcal CAP.

Abstract

Background

Streptococcus pneumoniae serotypes distribution in community-acquired pneumonia (CAP) requiring hospitalization in adults after introduction of PCV13 in children is not well known. Our aim was to evaluate the distribution of serotypes in pneumococcal pneumonia according to risk factors and comorbidity conditions after the introduction of PCV13 in children in 2010.

Methods

A prospective study from 2011 to 2014 was performed in immunocompetent adults hospitalized with CAP in 3 Spanish hospitals. Microbiological confirmation was obtained using a serotype specific urinary antigen detection test (UAD test), Binax Now and conventional cultures.

Results

1258 adults were enrolled and pneumococcal pneumonia (invasive disease in 17.7%) was confirmed in 368 (29.3%) and 17.6% of the any-cause CAP were caused by PVC13 serotypes (3.5% PCV7 serotypes). Around 60% of pneumococcal CAP were caused by PCV13 serotypes (74.6% in invasive episodes vs 57.4% in non-invasive ones). The most prevalent serotypes in invasive disease were 1, 3, 7F, 19A and 14. No significant differences were observed in the distribution of PCV13 serotypes across the study periods. Regarding comorbidity, the rate of PCV13 serotypes was similar among them, and it was slightly higher in those with no underlying conditions.

Conclusions

Serotypes included in PCV13 caused a significant proportion of CAP in adults with underlying conditions and in healthy adults, with no significant changes in cases due to PCV7 or PCV13 from 2011 to 2014, suggesting an insufficient indirect protection from childhood vaccination. Strategies for implementing pneumococcal vaccination of adults are encouraged to reduce the incidence of pneumococcal episodes.

Introduction

Pneumococcal disease in adults, including community-acquired pneumonia (CAP) and invasive pneumococcal disease (IPD), is a global health problem, mainly affecting individuals with chronic diseases such as COPD, diabetes mellitus and heart disease. The increased risk for pneumococcal pneumonia is present all year around [1] and the total disease burden comes mainly from non-invasive episodes, because IPD represents only a fraction [2].

There are more than 90 different pneumococcal serotypes showing diverse clinical expression, invasiveness and outcome. The distribution of circulating pneumococcal serotypes depends on several factors including the presence of underlying diseases, contact with children, and vaccination status, and changes over time making continuous monitoring necessary. Vaccinating children with the 7-valent pneumococcal conjugate vaccine (PCV7) achieved a reduction in adult invasive pneumococcal disease caused by serotypes included in the vaccine and a drift in others [3]. The impact that the introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) in 2010 for healthy children has had on the burden of pneumococcal pneumonia in adults due to PCV13 serotypes, particularly CAP without bacteraemia and CAP in high risk groups, is not well known [4]. Moreover, its indirect effect on pneumococcal pneumonia in adults is uncertain, although some impact has been found in the UK, where infant PCV coverage is around 95% [5]. In adults aged 65 and older, PCV13 has demonstrated efficacy in the prevention of pneumococcal pneumonia and invasive pneumococcal disease [6].

We hypothesized that the distribution of pneumococcal serotypes in adults, in both invasive and non-invasive pneumonia, might have changed after the introduction of PCV13 for children [7] and that this distribution may vary depending on the patients’ comorbidity and/or risk factors [8]. Given the fact that hospitalization for pneumonia is not decreasing [9] and that S. pneumoniae is the main causative microorganism, updated information will be a key factor for implementing effective strategies to decrease the incidence of CAP.

The aim of our study was to evaluate the burden of pneumococcal pneumonia in adults with regard to the distribution of PCV13 serotypes using the new UAD test in urine according to comorbidities and/or risk habits in immunocompetent patients after the introduction of PCV13 in children.

Section snippets

Patients and methods

A prospective multicentre epidemiological study was performed in three tertiary-care teaching hospitals from the National Spanish Health System, covering a population around 900.000 inhabitants (Hospital La Fe 285.000, Hospital Clinic 300.000, Hospital Galdakao 310.000) in immunocompetent adults aged ≥18 years, hospitalized during November 2011 to November 2014. Patients were considered to have CAP when they presented a new radiologic infiltrate accompanied by acute signs and symptoms suggestive

Results

A total of 1258 patients were recruited from November 2011 to November 2014 (Table 1). Microbiological aetiology was found in 573 patients (45.5%): 368 (29.3%) S. pneumoniae, 24 (1.9%) L. pneumophila, 19 (1.5%) Staphylococcus aureus, 21 (1.7%) Influenza virus, 12 (1.0%) other virus, and 129 (10.3%) others microorganisms (Fig. 1). Pneumococcal CAP was diagnosed in 368 patients. No significant changes were observed in the percentage of all-cause CAP due to S. pneumoniae during the three years of

Discussion

The most outstanding findings of our study are 1. More than 60% of pneumococcal CAP cases in immunocompetent adults were caused by PCV13 serotypes (74.6% in invasive episodes and 57.4% in non-invasive episodes) showing no significant changes from 2011 to 2014. 2. The most frequent serotypes in pneumococcal CAP were 3, 1, 7F and 19A. 3. The percentage of CAP caused by PCV13 serotypes varied slightly according to the presence of underlying conditions (from 49.2% in previous CAP to 64.9% in

Acknowledgements

Members of the CAPA study team are: A. Torres, C. Cilloniz, A. San José, F. Marco, E. Polverino, R. Amaro, (H. Clinic, Barcelona, Spain); R. Menéndez, R. Méndez, I. Amara, J.L. López Hontangas, B. Montull, A. Gimeno, A. Gil (H. Universitario y Politécnico La Fe, Valencia, Spain); PP. España, A. Uranga, A.P. Martínez de la Fuente, (H. Galdakao-Usansolo, Galdácano, Spain); E. Pérez-Trallero, J.M. Marimón, M. Ercibengoa (H. Universitario Donostia, San Sebastián, Spain); A. Fernández-Villar, M.I.

Funding

This study was sponsored by Pfizer.

Disclaimer

The views expressed in this publication are those of the author(s) and not necessarily those of the sponsor.

Competing interests

R.M., A. T., P.P. E. and E. P-T report grants to their Institutions from Pfizer S.L.U., Madrid, Spain, for this study, and support from Pfizer S.L.U. for travelling to meetings for the study or other purposes during the conduction of the study.

C.M., I.C., C.B., A.G., J.S. and M.L. S. are employees of Pfizer S.L.U., Madrid, Spain.

Ethics approval

The ethics committee of each hospital approved the study. Patients provided written informed consent to participate in the study.

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