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Invasive pneumococcal infections in children with asplenia
Gordon E Schutze1, Edward O Mason, William J Barson
1Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, USA. schutzegordone@uams.edu
Insights
Children with asplenia face a high risk of severe Streptococcus pneumoniae infections. Invasive pneumococcal disease in these children, particularly with meningitis, has a significant mortality rate.
Area of Science:
- Pediatric Infectious Diseases
- Immunology
- Epidemiology
Background:
- Asplenia significantly increases the risk of severe infections, especially from Streptococcus pneumoniae.
- Overwhelming pneumococcal infections in asplenic individuals can be rapidly fatal.
Purpose of the Study:
- To investigate the epidemiology and clinical characteristics of invasive Streptococcus pneumoniae infections in children with asplenia.
- To analyze infection patterns before the introduction of the conjugate pneumococcal vaccine.
Main Methods:
- Prospective identification of children with invasive S. pneumoniae infections across eight US children's hospitals (1993-1999).
- Retrospective chart review for demographic, medical, and microbiological data in asplenic patients.
- Analysis of clinical presentations, outcomes, and antimicrobial resistance patterns.
Main Results:
- Twenty-two asplenic children experienced 26 episodes of invasive S. pneumoniae infection (1% of total cases).
- Congenital asplenia (CA) patients were younger at first infection (median 12.5 months) than surgical splenectomy patients (median 69 months).
- High rates of meningitis (8 episodes) and mortality (6 deaths), with 19% of survivors experiencing significant morbidity, primarily from meningitis. 46% of isolates showed penicillin non-susceptibility.
Conclusions:
- Invasive pneumococcal disease poses a high mortality risk for asplenic children, particularly those with meningitis.
- Despite vaccination efforts, serotypes not covered by the heptavalent conjugate vaccine caused disease in 19% of cases.
- Clinicians must maintain vigilance in evaluating unexplained fevers in asplenic pediatric patients.
Background:
Asplenia is associated with an increased risk of infections caused by Streptococcus pneumoniae. Overwhelming infection can be fulminate and lead to a fatal outcome.
Objective:
To review the epidemiology and clinical course of invasive S. pneumoniae infections in children with asplenia before the release of the conjugate pneumococcal vaccine.
Methods:
Children with S. pneumoniae infections from eight children's hospitals in the US were identified prospectively from September, 1993, to August, 1999. Further demographic, medical and microbiologic information was gathered retrospectively from the charts of patients with asplenia.
Results:
Twenty-two asplenic patients with 26 episodes of invasive S. pneumoniae were identified. This represents 1% of the 2,581 episodes of invasive S. pneumoniae infections identified in our study. Twelve had congenital asplenia (CA), and 10 had undergone surgical splenectomy. Nine of the patients with CA had associated complex congenital heart disease. The median age at first infection was 12.5 months for CA patients as compared with 69 months in children with surgical splenectomy (P < 0.001). Seventy-five percent of those eligible had received the polysaccharide pneumococcal vaccine. The most common serotypes isolated were 6B (8), 23F (7), 18C (2) and 19A (2). Antimicrobial prophylaxis had been prescribed for 82% of the study cohort. Clinical presentations of the 26 episodes included fever (22), shock (7), petechiae or purpura (7), disseminated intravascular coagulation (5) and respiratory distress (5). Clinical illness included bacteremia alone (12), meningitis alone (8), bacteremia with otitis media-sinusitis (3), bacteremia with pneumonia (2) and meningitis with osteomyelitis (1). Five of the 6 patients who died had meningitis. Three of the survivors (19%) had significant morbidity, and all of them had meningitis. Two patients had 2 episodes each, and 1 patient had 3 episodes. All but 1 of the multiple episodes was with a different serotype. Forty-six percent of isolates were nonsusceptible to penicillin, and 19% were nonsusceptible to ceftriaxone. There was no association between antimicrobial resistance and mortality.
Conclusions:
Invasive pneumococcal disease in patients with asplenia has a high mortality, especially in those with meningitis. Even though the new conjugate vaccine might increase protection, 19% of patients had disease caused by serotypes not included in the current heptavalent vaccine. Clinicians should continue to be aggressive in evaluating asplenic patients with unexplained fevers.