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Daminov Turgunpulat Abidovich, professor, Tashkent Medical Academy, Republic of Uzbekistan Tuychiev Laziz Nodirovich, head of the Department of Infectious Diseases, Tashkent Medical Academy, Republic of Uzbekistan Tadjieva Nigora Ubaydullaevna, The senior research associate of Institute of Epidemiology, Microbiology and Infectious Diseases Abduhalilova Gulnara Kudratullaevna, The senior research associate of Institute of Epidemiology, Microbiology and Infectious Diseases Tursunova Dilorom Alimovna, chef of the Head administrative board sanitary-epidemiological supervision, Ministry of Health E-mail: [email protected]
Clinical characteristics of invasive pneumococcal disease in children in Uzbekistan
Abstract: Clinical course of pneumococcal meningitis I s characterized by brain edema, infectious and toxic shock and severe course. It remains one of the main pediatric pathologies with outcomes. Characteristic clinical and laboratory feature of pneumococcal pneumonia is lobar process with frequent right lung lesion and development of pleuritis (6/16,2%), increased number of leucocytes (62,2%) and C-reactive protein (43,7%). Isolated pneumococcal serotypes are included in modern pneumococcal vaccines, which justifies the demand to implement pneumococcal infection vaccination for children in preventive vaccination schedule of Uzbekistan. Keywords: invasive pneumococcal diseases, pneumococcus, serotypes, children.
Streptococcus pneumoniae (S. pneumoniae, pneumococcus) monia, meningitis, bacteremia, and acute otitis media among is one of the frequents agents of community-acquired pneu- children and adults. According to the WHO, about 155 million
Clinical characteristics of invasive pneumococcal disease in children in Uzbekistan
cases of community acquired pneumonia are registered worldwide annually and about 1,4 million lethal cases among children under 5 years old, which constitutes 18% of lethal cases in this age group [1; 2; 3]. Diseases caused by S.pneuomniae are divided into invasive and non-invasive based on the severity of course criteria. Invasive pneumococcal infection includes bacteremia, meningitis, pneumonia and other pathological conditions when a causative agent is extracted from organs and tissues which are normally sterile (blood, cerebrospinal fluid, less common synovial, pleural or pericardial fluid [4; 5].
«The golden standard» of diagnosing invasive pneumococcal infection (IPI) is extraction of pneumococcus from sterile body fluids (cerebrospinal fluid, blood, pleural fluid) by using bacteriological method [4; 5].
Taking into account above mentioned, the goal of our study was to analyze clinical course, study the antibacterial sensitivity of isolated S.pneumoniae serotypes from children with invasive forms of pneumococcal infection.
Study materials and methods. Children with purulent meningitis (n=210) and pneumonia (n=265) aged 3 month to 14 years old and hospitalized to specialized hospitals of Tashkent were studied. Study materials were blood, cerebrospinal fluid and pleural fluid. The study was conducted in specialized microbiological laboratories of Tashkent city infectious diseases hospital № 1 and of the Research Institute of Epidemiology, Microbiology and Infectious Diseases, which have specially trained personnel.
To study clinical features of pneumococcal meningitis and pneumococcal pneumonia, data gathered about the patient were considered and analyzed: age, sex, admission date, discharge date, treatment duration, place of residence, characteristic clinical features and disease outcome. Medical history, clinical and laboratory data characterizing main clinical symptoms of the disease, cerebrospinal fluid, blood count, C-reactive protein level, chest X-ray images were analyzed.
Bacteriological plating of materials taken from patients (cerebrospinal fluid, blood and pleural fluid) was conducted on chocolate and blood agar plates (HiMedia, India), previously taken from refrigerator and heated in thermostat for not less than 30 minutes at a temperature of 37 °C [5; 6].
Determination of serogroups of S.pneumoniae strains was conducted by using 14 and 21 groups diagnostic Pneumotest-Latex serums (Statens Serum Institute, Denmark).
Statistical data processing was performed on personal computer by using descriptive statistics methods on «Microsoft Excel» program.
Results. Out of 210 children with purulent meningitis 98 samples (46.6%) of S.pneumoniae were diagnosed, out of 265 pneumonia patients 37 samples (13.9%) of S.pneumoniae were detected (33 strains from blood, 4 strains from pleural fluid). None of the patients was vaccinated against pneumo-coccal infection.
Clinical features of pneumococcal pneumonia. In the studied group of patients with pneumococcal pneumonia (n=37) morbidity was more frequently registered in the
1-3 years old age group (42,8%), which coincides with the beginning of visiting preschool. Proportion of children going to kinder gardens and schools made 63,7%.
Clinical symptoms of pneumococcal pneumonia were characterized by toxic syndrome and respiratory failure, local physical changes, infiltrative changes on X-Ray and CT.
Among examined children moderately severe form was found in 17 patients (45,9%) and severe form was found in 20 children (54,1%). The disease severity course was determined by various toxic manifestations (cardio respiratory, hyperthermic and abdominal syndromes). 10 children (27,0%) had uncomplicated pneumonia and 27 patients (73,0%) had pneumonia with complications. Complications were characterized by respiratory insufficiency, toxic manifestations and 6 patients were diagnosed with pleuritis.
Haemogram analysis showed anemia in 24 children (64,8%). Leucocytosis was detected in 23 children (62,2%), hyper leucocytosis was registered in patients with pleuritis. Leucopenia was registered in 11 children (29,7%). C-reactive protein level over 10 mg/l was registered in 43,7% of patients.
All patients underwent chest X-ray studies. According to clinical and diagnostic indications 6 patients underwent lung CT study. Depending on the lung tissue lesion size, the patients with lobar process were predominant (19/51.3%), focal processes were detected in 6 cases (16.3%), this group mostly included patients up to 3 years old; segmental processes were observed in 12 cases (32.4%). Six patients were diagnosed with pleuritis.
Pneumococcal meningitis. Age-specific analysis of patients with pneumococcal meningitis (n=98) showed that children in the age range 6 months -1 year composed 1.8%, 1 to 5 years old — 29.7%, 5 to 14 years old — 68.5%, which probably reflects age specific structure of children treated in this hospital. Diseases that had been the primary source of pneumococcal infection have been detected in 57.2% patients. Thus, pneumonia was detected in 35.1%, septicemia (1.8%), otitis media (12.0%), sinusitis (8.3%) cases. Proportion of patients with unfavorable medical history (skull and cerebral traumas, multiple respiratory diseases, previous meningitis) composed 24.3% of cases.
Clinical course of pneumococcal meningitis is characterized severe course: 83.3% of children had severe and 16.7% of children had extremely severe form of meningitis. In 76.3% of cases the beginning was acute, in the background of acute Respiratory viral infection (83.2%) and manifested by increased body temperature, severe headaches, vomiting and acute weakness. As it is shown on picture 1, severity was caused by toxic syndrome (hyperthermia-100%, multiple vomiting- 76.1%, rush- 2.7%), neurological symptoms (meningeal symptoms — 100%, pathological reflexes — 34.5%, focal neurological symptoms- 34.5%, convulsive syndrome -36.3%).
Complications observed in patients in most cases were brain edema (72.2%) and infectious and toxic shock. Me-ningoencephalitis was detected in 29.6% of patients and was predominant among children under 5 years old. The disease
course was severe- prominent meningeal syndrome, brainstem and focal symptoms, damage of II, VI, VII, XII pairs of cranial nerves, convulsive syndrome.
It is known that presence of skull and cranial injuries as well as liquorrhea in medical history are important factors in the development of pneumococcal meningitis [8]. Among observed patients only one had recurrent pneumococcal meningitis related to post traumatic liquorrhea. From medical history: every year during five years, sometimes twice a year the patient had purulent meningitis of pneumococcal etiology, caused by penetration of causative agent from upper respiratory tract to subarachnoid space.
Outcomes of pneumococcal meningitis depended on the age of patients, thus 74 patients (75.5%) were discharged upon recovery; hypertensive-hydrocephalic syndrome was mostly observed in children under 5 years (3/3.1%), cerebral ataxia was observed in 2 cases (2.1%), asthenic-neurological syndrome in 12 cases (12.2%), symptomatic epilepsy — in 2 cases (2.0%), neurosensory hearing loss in 4 cases (4.1%), lethal outcome was observed in one case due to purulent meningoencephalitis, complicated by brain coma, pneumonia and septicemia.
Treatment. Most important role in the etiological treatment of pneumococcal meningitis and pneumonia places antibacterial treatment. Medications of choice were penicillin, cefotaxime, ceftriaxone, reserve medications included vancomycin, rifampicin. One monotherapy course was sufficient in 31.7% of cases, two courses were done in 50.5% of cases, the rest 17.8% of cases patients underwent repeated course with changing antibiotic.
Bacteriological examination data. Based on bacteriological examination 98 strains of S.pneumoniae in liquor, 33 strains of S. pneumoniae in blood and 4 strains of S.pneumoniae in pleural fluid were detected.
It was possible to perform serotyping for 83 pneumococcal strains and detect the following serotypes: 1, 5, 6A, 6B, 17F, 19F, NT. The proportion of notypeable (NT) strains made 19.3%.
When comparing serotypes, comprising 13-valence vaccine (PCV-13), with S.pneumoniae serotypes detected in patients, conjugated vaccines include about 71.1% of detected pneumococci.
Detected serotypes of pneumococci strains are included in modern pneumococcal vaccines, which justify the necessity of implementing vaccination against pneumococcal infection in the preventive vaccination schedule of the Republic of Uzbekistan.
Conclusion:
1. In our study, pneumococcal meningitis was more common in children over 5 years (68.5%). Clinical manifestations of pneumococcal meningitis are characterized by a very severe course, brain edema and an infectious-toxic shock and remain one of the major infectious pathologies in children with aggravating consequences and outcomes.
2. Characteristic clinical and laboratory sign of pneumococcal pneumonia is a presence of a lobar process, with frequent right lung lesion and development of purulent pleuritis (6/16.2%), increased level of white blood cells (62.2%), and C-reactive protein (43.7%).
3. Identified pneumococcal serotypes are included in the modern pneumococcal vaccines, which justifies the necessity to implement in the preventive vaccination schedule of the Republic of Uzbekistan, vaccination of children against pneumococcal infection.
4. To raise awareness of general population on the safety and efficacy of pneumococcal vaccines.
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