Resistant Pneumococcus in the Nursing Home
ABSTRACT & COMMENTARY
Synopsis: An assessment of the pneumococcal vaccine status of all residents of long-term care facilities is mandatory.
Source: Nuorti JP et al. An outbreak of multi-drug resistant pneumococcal pneumonia and bacteremia among unvaccinated nursing home residents. N Engl J Med 1998;338: 1861-1868.
During a 14-day period in the winter of 1996, 11 of 84 residents (13%) of a nursing home in Oklahoma developed pneumonia. Multiple drug resistant Streptococcus pneumoniae serotype 23F was recovered from blood and/or sputum of seven patients. Three fatalities occurred in bacteremic patients. Seventeen (23%) of 74 residents and two (3%) of 69 employees were nasopharyngeal carriers of the same pneumococcal serotype. All isolates were identical by pulse-field gel electrophoresis and shared a common antibiogram. All were resistant to penicillin (MIC = 2 mcg/mL), cefotaxime, trimethoprim-sulfamethoxazole, ofloxacin, tetracycline, erythromycin, and clindamycin. Only 4% of the resident population had received pneumococcal immunization prior to the outbreak. The outbreak ceased after immunization of all non-immunized residents and chemoprophylaxis with oral penicillin or oral ofloxacin in patients with penicillin allergy. Ten days after intervention, the carriage rate among residents fell from 23% to 4%.
COMMENT BY ROBERT MUDER, MD
Pneumonia is the leading cause of mortality among nursing home patients. Although data as to the precise etiology of nursing-home acquired pneumonia are somewhat contradictory, due in large part to the difficulty in obtaining adequate microbiologic specimens in this patient population, it is clear that S. pneumoniae is an important pathogen. The rate of invasive pneumococcal disease among nursing home residents is several fold higher than that occurring among the elderly living at home.1 This is not surprising, since nursing home patients have a high frequency of diseases associated with an increased risk of pneumococcal infection, such as chronic cardiac and pulmonary disease. Furthermore, the closed environment of the nursing home provides favorable conditions for spread of respiratory pathogens. Indeed, several reports of outbreaks of pneumococcal infection among unimmunized nursing home residents have been previously reported; (2-4) this is the first involving a multiple antibiotic resistant strain.
The results of the intervention warrant some comment. Administration of pneumococcal polysaccharide vaccine to all unimmunized residents was clearly indicated. The role of administration of oral penicillin (or ofloxacin) to patients is less clear, since the outbreak strain was resistant to both agents. Nuorti and colleagues stated that the goal of chemoprophylaxis was not to eradicate carriage but to provide some degree of protection against invasive infection while immunity developed after immunization. The optimal approach to chemoprophylaxis in this situation is uncertain, particularly given the limited susceptibility of the outbreak strain.
Although there is some debate over the protective efficacy of the pneumococcal vaccine, a number of studies indicate a protective efficacy of 60-70%.5,6,7 Side effects other than local pain are exceedingly rare. The Advisory Committee on Immunization Practices recommends administration of vaccine to patients 65 years of age or older if they have not been previously immunized, have unknown immunization status, or have not received the vaccine within five years and were younger than 65 years of age at the time of immunization.8 Those younger than 65 years of age with chronic conditions, including cardiovascular disease, pulmonary disease, diabetes, liver disease, renal failure, malignancy, asplenia, or other immunocompromised states, should also receive pneumococcal immunization. Uncertainty over a patient's prior immunization status is not a reason to defer immunization.
What is clear from this report, and the preceeding reports of outbreaks of pneumococcal disease in nursing homes, is that assessment of the pneumococcal vaccine status of all residents of long-term care facilities is mandatory.
References
1. Muder RR, et al. Bacteremia in a long-term care facility: A five-year prospective study of 163 consecutive episodes. Clin Infect Dis 1992;14:647-654.
2. Jacobson C, Strausbaugh LJ. Incidence and impact of infection in a nursing home care unit. Am J Infect Control 1990;18:151-159.
3. Quick RE, et al. Underutilization of pneumococcal vaccine in nursing homes in Washington state: Report of a serotype specific outbreak and a survey. Am J Med 1993;94:149-152.
4. Kansas Department of Health and Environment. Outbreak of pneumococcal disease in a Kansas nursing home, 1993. Kans Med 1993;94:276.
5. Shapiro ED, et al. The protective efficacy of polyvalent pneumococcal polysaccharide vaccine. N Engl J Med 1991;325:1453-1460.
6. Bolan G, et al. Pneumococcal vaccine efficacy in selected populations in the United States. Ann Intern Med 1986;104:1-6.
7. Sims RV, et al. The clinical effectiveness of pneumococcal vaccine in the elderly. Ann Intern Med 1988;108:653-657.
8. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morb Mortal Wkly Rep 1997;46(No. RR-8):1-24.
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