Learning Center
Plans & pricing Sign in
Sign Out
Get this document free

Nasopharyngeal Carriage of Streptococcus pneumoniae



Original Article

Nasopharyngeal Carriage of Streptococcus pneumoniae
C. Wattal, J.K. Oberoi, P.K. Pruthi1 and Suresh Gupta1

Department of Clinical Microbiology and 1Department of Pediatrics, Sir Ganga Ram Hospital, New Delhi, India

Objective. To determine nasopharyngeal carriage rate and prevalent serogroups/ types (SGT) of S. pneumoniae in healthy
children, assess their antimicrobial susceptibility and its implications over the heptavalent pneumococcal conjugate vaccine.

Methods. 200 healthy children aged between 3 months and 3 years attending Pediatric OPD at Sir Ganga Ram Hospital, New
Delhi were studied. A nasopharyngeal swab was collected from each child which was processed to isolate Streptococcus
pneumoniae. Serotyping was performed by the Quellung reaction. Antimicrobial susceptibility patterns were determined by disk
diffusion and E test methods.

Results. S. pneumoniae carriage rate was 6.5%. Isolates belonged to serotypes 1, 6, 14 and 19, of which serotype 19 was the
most common. None of the strains were totally resistant to penicillin though 2 (15.4%) were intermediately resistant. Overall,
84.6% of the isolates belonged to the strains covered by the heptavalent pneumococcal vaccine.

Conclusion. The heptavalent conjugate vaccine covers most isolated strains, but since the number of strains is very small, it
is suggested that there is need for further studies in different regions to assess the usefulness of this vaccine. [Indian J Pediatr
2007; 74 (10) : 905-907] E-mail :

Key words : S. pneumoniae serotype; Nasopharyngeal carriage; Antimicrobial susceptibility

Acute respiratory infection is a serious problem in India           overuse has been identified as the major risk factor for
accounting for 14.3% deaths during infancy and 15.9%                this phenomenon, especially frequent and prophylactic
deaths between 1-5 years. 1 Streptococcus pneumoniae                use of antibiotics. The serotype distribution data of
remains the major cause of invasive disease, pneumonia              invasive isolates from India is scarce. Hence, there is need
and otitis media, in young children. The nasopharynx of             for additional data on the prevalence of Streptococcus
children has resident microbial flora that do not usually           pneumoniae serotype from India. This study was
harm the child but, sometimes may act as a reservoir of             undertaken to evaluate drug resistance and
pathogens. Moreover, the organisms can easily spread                nasopharyngeal carriage of prevalent serogroups/ types
from one child to another. Therefore, nasopharyngeal                (SGT) of Streptococcus pneumoniae in healthy children at
carriage is a major factor in the pathogenesis of                   New Delhi (India).
pneumococcal disease and its transmission. Studies of the
prevalence of different pathogens and their resistance
                                                                                  MATERIALS AND METHODS
patterns can provide useful information for rational
therapeutic and preventive strategies.
   Strains of S. pneumoniae resistant to antibiotics,               Study was performed on 200 healthy children attending
especially penicillin and co-trimoxazole have been                  Pediatric OPD at Sir Ganga Ram Hospital, New Delhi
reported worldwide. 2Also, nasopharyngeal colonisation              over a period of 4 months. Informed consent was taken
by antibiotic-resistant Streptococcus pneumoniae has                from the parent/guardian prior to inclusion of the subject
steadily increased over the last few years. Antibiotic              in the study. Only one member per family was included
                                                                    to avoid bias of siblings living in the same family
                                                                    Inclusion Criteria
Correspondence and Reprint requests : Dr. C. Wattal, Chairman,
Department of Clinical Microbiology, Sir Ganga Ram Hospital,
                                                                    Criteria of inclusion within the study was children aged
Rajinder Nagar, New Delhi-110060, India, Phone - 011-42251049;      between 3 months and 3 years considered healthy after
Fax : 011- 25730343                                                 general examination by the pediatrician. Recent and past
[Received October 18, 2006; Accepted January 1, 2007]               history of the subject including history of upper

Indian Journal of Pediatrics, Volume 74—October, 2007                                                                          905

                                                              C. Wattal et al

respiratory tract infection, head injury, hospitalisation,             method as per CLSI (Clinical Laboratory Standards
antibiotic usage, immunisation status, family history and              Institute, formerly known as National committee for
environmental history were taken.                                      Clinical Laboratory Standards) guidelines. 3 Estimation of
                                                                       minimum inhibitory concentration (MIC) of various
Exclusion Criteria
                                                                       antibiotics was also determined using E test (biodisk,
Children less than 3 months of age, grade II, III or IV                Solna, Sweden).
malnourishment, underlying clinical illness
(immunologic diseases; neoplastic disorders; renal,
cardiac, hepatic, or hematologic diseases;
bronchodysplasia; Down syndrome; chronic otitis media
with effusion) or even a mild acute upper or lower                     Out of the two hundred nasopharyngeal swabs cultured,
respiratory tract infection at the time of enrollment                  13 (6.5%) grew S. pneumoniae. The median age of
(children with rhinitis without fever were however                     acquisition of S. pneumoniae was 16 months. The youngest
included in the study) were excluded from the study.                   and the oldest child colonized with S. pneumoniae were 8
Children who had received antibiotic treatment in the                  months and 3 years old, respectively.
previous 2 weeks were also excluded from the study.
                                                                          The serogroups/serotypes (SGT) isolated were 1, 6, 14,
Bacteriology                                                           and 19, the most common being SGT 19. Eight (61.5%)
                                                                       cases belonged to SGT 19. One isolate was untypeable.
Nasopharyngeal swabs were obtained from each subject
with calcium alginate swabs (BD, USA) on a flexible                       Majority of the isolates were susceptible to penicillin,
aluminum wire. The swabs were transported                              only 2 (15.4%) were resistant to 1 µg oxacillin disc and
immediately and were inoculated on trypticase soy agar                 were having MICs for penicillin falling in the moderately
with 5% sheep blood and 5µg of gentamicin sulphate per                 susceptible range, viz. 0.125 and 0.75 µg/ml. None was
ml of the medium. Plates were incubated at 37ºC                        totally resistant to Penicillin. The strain with an MIC of
overnight in the CO2 extinction jar and examined for the               0.125 µg/ml to penicillin belonged to SGT 6 and the other
presence of colonies of S. pneumoniae. Morphologically                 with an MIC of 0.75 µg/ml could not be typed. All the
suggestive colonies were examined microscopically using                isolates were resistant to co-trimoxazole. Erythromycin
gram stain. Colonies were further identified by                        and ciprofloxacin resistance was observed in 1 (7.7%) and
susceptibility to optochin and Latex agglutination test for            2 (15.4%) isolates respectively. All isolates were sensitive
S. pneumoniae (BD, USA). Such isolates of S. pneumoniae                to amoxycillin and cefotaxime. Three (23.07%) strains
were subsequently serotyped by Quellung reaction using                 were resistant to two or three antibiotics and none were
Pneumotest kit containing pneumococcal antiserum                       resistant to more than three antibiotics (Table 1).
supplied by the Statens Serum Institute, Copenhagen,
   Antimicrobial susceptibility testing to crystalline
penicillin (1 µg oxacillin disc was used to screen penicillin
susceptibility), cefotaxime (30µg), erythromycin (15µg),               S. pneumoniae nasopharyngeal carriage was observed in
ciprofloxacin (5µg), cotrimoxazole (25µg) and amoxycillin              6.5% of the 200 healthy children enrolled in the study. A
(10µg) was done using Kirby Bauer disk diffusion                       similar study reported a colonization rate of 74% in

TABLE 1. MIC of the S. pneumoniae Isolates to Various Antibiotics

SN            serotype         Penicillin MIC       Erythromycin         Ciprofloxacin   Co-trimoxazole MIC Cefotaxime MIC
                                  (µg/ml)            MIC (µg/ml)         MIC (µg/ml)           (µg/ml)          (µg/ml)

1              19                  0.012 S                 0.064 S              1S             >32 R              0.016 S
2              19                  0.012 S                 0.125 S             1S              >32 R              <.012 S
3              19                  0.008 S                 0.094 S          0.75 S             >32 R            < 0.016 S
4               6                  0.012 S                 0.094 S          0.75 S             >32 R               0.32 S
5              19                  0.008 S                 0.032 S          0.50 S             >32 R              0.016 S
6              19                  0.012 S                 0.016 S           0.5 S             >32 R              <.016 S
7              19                  0.012 S                 0.016 S           0.5 S             >32 R              <.016 S
8              19                  0.023 S                 0.125 S          0.75 S             >32 R              <.016 S
9              19                  0.012 S                 0.064 S           0.5 S             >32 R              0.016 S
10         Nontypeable             0.75 M                      2R              2S              >32 R               0.38 S
11             14                  0.047 S                 0.032 S           0.5 S             >32 R              0.047 S
12              1                  0.012 S                 0.032 S          >32 R              >32 R               0.19 S
13              6                 0.125 M                  0.032 S             8R              >32 R               0.125S

S = Sensitive, M = Moderately susceptible, R = Resistant

906                                                                        Indian Journal of Pediatrics, Volume 74—October, 2007

                               Nasopharyngeal Carriage of Streptococcus pneumoniae

Mumbai, which is much higher than that of our study              causing invasive disease. Most isolated serotypes are
(Mathur et al, abstract at 5th International Symposium on        covered by the heptavalent conjugate vaccine, but since
Pneumococci and Pneumococcal diseases, Alice Springs,            the number of strains is very small and they may not be
Australia, 2-6 April, 2006). Also, the most common               representative of all geographical regions in India, it is
serogroups isolated were SGT 6 and 1 in contrast to our          suggested that there is need for further studies in
study that documents SGT 19 and 6. The study from                different regions to assess the usefulness of this vaccine.
Mumbai depicts the data obtained from children living in
slums as compared to this study, which mainly consisted
of subjects living in an urban area and belonging                We are grateful to Pharmaceuticals, Wyeth Limited for their support
primarily to nuclear families. It appears socioeconomic          in funding this project.
factors may influence Streptococcus pneumoniae
colonization rate and serotype prevalence in India.                                      REFERENCES
   The Invasive Bacterial Infection Surveillance Study
(IBIS) 4, a multicentric study in India has reported that in       1. Narain JP, Sehgal PN. Acute respiratory infection. A priority
children between 2 months and 5 year of age, serotype 6               heath problem in India. J Com Dis 1987; 19 : 381-386.
was the most common serotype isolated followed by                  2. Klugman KP. Pneumococcal resistance to antibiotics. Clin
serotypes 1 and 19. Moreover, in young children                       Microbiol Rev 1990; 3 : 171-196.
                                                                   3. National committee for Clinical Laboratory Standards.
serotypes 6 and 19 were the most common strains causing
                                                                      Performance Standards for Antimicrobial Disk Susceptibility
invasive disease. This could be important, as these are the           Testing: twelfth informational supplement. NCCLS document
serotypes most frequently colonising our healthy children             M100-S13. USA; Pennsylvania, National committee for
as well. Other workers5-7 have also reported that serotypes           Clinical Laboratory Standards, 2004.
14, 6, 19, 18, 23, 9, 1, 7, 4, 5, 3 and 23 are associated with     4. Invasive Bacterial Infection Surveillance (IBIS) Group,
invasive disease. In our study, 92.4% strains belonged to             International Clinical Epidemiology Network (INCLEN).
                                                                      Prospective Multicentre hospital Surveillance of Streptococcus
these invasive serotypes. Kar et al8 have isolated serotypes          pneumoniae diseases in India. Lancet 1999; 353 : 1216-1221.
11, 23, 34, 6, 18, 19, 4 and 39 from nasopharyx of healthy         5. Eskola J, Kilpi T, Palmu A et al. Efficacy of a pneumococcal
school children from Delhi.                                           conjugate vaccine against otitis media. N Eng J Med 2001;
                                                                      344 : 403-409.
   None of our isolate was penicillin or cephalosporin             6. Sleeman K, Knox K, George R et al. Invasive pneumoccal
resistant. However, 2 were having intermediate resistance             disease in England and Wales: vaccination impications. J Infect
to penicillin confirmed subsequently by E test. All the               Dis 2001; 183 : 239-246.
isolates in our study were resistant to co-trimoxazole.            7. Hausdorff WP, Bryant J, Paradiso PR, Siber GR. Which
                                                                      pneumoccal serogroups cause the most invasive disease:
These findings concur with other workers as well.4, 9
                                                                      implications for conjugate vaccine formulation and use., part
   Currently available heptavalent conjugate                          I. Clin Infect Dis 2000; 30 : 100-121.
                                                                   8. Kar UK, Satpathy S, Nayak N, Das BK, Panda SK. Serotype
polysaccharide vaccine protects against colonization or
                                                                      distribution of Streptococcus pneumoniae isolates from
disease caused by serotypes 4, 6, 9, 14, 18, 19 and 23 and            ophthalmic and systemic infections and of commensal origin.
84.6% of our isolated strains are covered by this vaccine.            Ind J Med Res 2006; 124 : 99-104.
                                                                   9. Jain A, Kumar P, Awasthi S. High nasopharyngeal carriage of
  In conclusion, in our experience, although                          drug resistant Streptococcus pneumoniae and Haemophilus
nasopharyngeal carriage is low in healthy children, the               influenzae in North Indian schoolchildren. Trop Med Int Heath
most common circulating serotypes are capable of                      2005; 10 : 234-239.

Indian Journal of Pediatrics, Volume 74—October, 2007                                                                           907

To top