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What will Happen to Antimicrobial Resistance in Adult Invasive Pneumococcal
Disease after the Introduction of Infant PCV13 Vaccination in Canada?
K. Green1, A. McGeer1,2, K. Wong1, S. Pong-Porter1 , W. Rudnick1, D.E. Low1,2 and
Contact: Karen Green
tel: 1.416.586.5105
the Canadian Bacterial Surveillance Network (CBSN)
1Department of Microbiology, Mount Sinai Hospital, Toronto ON, 2University of Toronto, Toronto ON
Abstract (Updated)
Results (cont'd)
Results (cont'd)
From 2000 to 2011, 10,305 SPN isolates were submitted that were obtained from sterile By 2011, isolates with serotypes included in PCV7 contributed only 6.3% of isolates. If routine infant PCV13 vaccination programs are as effective as PCV7 against the 6 Infant PCV13 vaccination wil likely affect both serotype (ST) distribution and antibiotic sites. These included: 9,527 (92.5%) from blood cultures, 297 (2.9%) from CSF, 208 (2.0%) Although resistance continues to increase in these serotypes, they are uncommon and their serotypes in PCV13 that are not contained in PCV7, and if, as expected, PCV7 serotypes resistance in adult pneumococcal infections. The Canadian Bacterial Surveillance Network from pleural fluid, and 273 (2.7%) from other sterile sites. There were 2,177 (21.2%) incidence continues to decrease. Thus, antimicrobial resistance in S. pneumoniae overall will continue to decline in frequency, PCV13 serotypes would be expected to comprise no more (CBSN) has been monitoring trends in antimicrobial resistance in Canadian pneumococci paediatric isolates, 4,482 (43.7%) isolates from adults aged 15-64 years, and 3,595 (35.1%) be driven by the evolution of resistance in other serotypes. In 2011, isolates from serotypes than 10% of all isolates by the year 2015. since 1993 and in ST distribution since 2000. We analyzed trends in antimicrobial resistance isolates from older adults (>=65 years). Overall, 61% of isolates were from Ontario, 18% included in PCV13 comprised 43.4% of all strains from adult sterile sites in CBSN In this case, if amoxicillin resistance does not emerge in new serotypes, amoxicillin resistance in pneumococcal serotypes (STs) included in PCV13 and other STs causing disease in from the Prairies/Northwest Territories, 8.8% from Atlantic provinces, 6.7% from Quebec, surveillance: serotypes 19A and 7F were the most common conjugate vaccine strains (Figure should remain stable at 2% or less (resistance in serotype 19A may climb from the current Canadian adults.
and 5.5% from British Columbia/Yukon. 4a). Non-conjugate vaccine serotypes comprised 50.3% of all strains; the most common non- 11%, but the proportion of disease due to serotype 19A should decline to less than 10% of conjugate vaccine serotypes were 22F and 6C (Figure 4b).
all isolates). Resistance would be expected to decrease for antibiotics other than amoxicillin.
PCV7 was authorized for use in Canada in June 2001, and introduced into publicly funded CBSN is a collaborative network of Canadian microbiology laboratories from 11 provinces infant immunization programs in provinces and territories between September 2001 and Figure 4a: Frequency of occurrence of serotypes in conjugate vaccines in pneumococci
As shown in Figure 6, resistance to erythromycin can be expected to continue to increase and territories that systematically samples pneumococci for broth microdilution January 2005. Coincident with the introduction of these vaccination programs, the from sterile sites in adult patients, CBSN surveillance, 2011 susceptibility testing performed to CLSI standards. Since 2000, all sterile site isolates (SSI) proportion of strains due to serotypes included in PCV7 declined in all age groups (see Resistance to respiratory fluoroquinolones has remained low, and is distributed among have been serotyped.
multiple serotypes, most likely because resistance arises due to mutations under antibiotic pressure in many individual isolates. Figure 1. Percentage of pneumococcal isolates from sterile sites belonging to serotypes
covered by PCV7, CBSN surveillance, 2000 to 2011 Of 10,305 SSI submitted from 2000–2011, 8,077 (79%) were from adults and 6,951(68%) Trends in resistance to penicil in, cephalosporins and TMP-SMX are more difficult to predict. were PCV13 STs. Antimicrobial susceptibility in PCV13 and non-PCV13 STs from adult SSI Although resistance has not increased significantly in penicillin and ceftriaxone, the significant are shown in Table 1 as percent resistant (R) (non-meningeal breakpoints for amoxicil in and increases in resistance to oral cefuroxime and TMP-SMX are of concern.
Adults aged 15-64 years
ceftriaxone resistance, oral penicil in breakpoints used).
Older adults
Table 1. Trends in antimicrobial resistance in pneumococcal disease, Canada, 2000
Figure 6. Antibiotic resistance in adult sterile site isolates of pneumococci of serotypes not
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
included in any conjugate vaccine, CBSN, surveil ance 2000-2011 Total Number of
4 19F 6B 14 9V 23F 18C
Percent (%) Pen V R*
13 (not 7) 19A 7F
Penicillin (IV, meningitis)
Percent (%) Amox R**
Figure 4b: Frequency of occurrence of serotypes not included in conjugate vaccines in
pneumococci from sterile sites in adult patients, CBSN surveil ance, 2011 Other serotypes (each comprising <1.25% of isolates) in order of While the frequency of all serotypes included in PCV7 decreased over time, the changes Percent (%) of Ctx R**
frequency: 16F, 20, 34, 35F, 15C, 10A, 17F, 18F, 23F, 28A, 7C, 9L were not uniform across serotypes. As shown in Figure 2, serotype 14, which was the most common serotype prior to PCV7 introduction, decreased most rapidly, comprising 32% of all PCV7 isolates in 2000/2001, but only 14% in 2010/11. In contrast, serotype 19F, which Percent (%) of Ery R
comprised 10% of PCV7 isolates in 2000/2001, comprised 21% in 2010/11.
Figure 2. Distribution of serotypes within the PCV7 group over time, CBSN surveillance,
Percent (%) of Levo R
* oral penicil in breakpoint, **NM = non-meningeal breakpoint If infant or adult PCV13 vaccination programs reduce the proportion of PCV13 STs in adult 22F 6C 23A 8
9N 33A 35B 11A 23B 12F 15B 15A 31
IPD, resistance to beta-lactam antibiotics can be expected to decrease, but erythromycin Erythromycin resistance has been increasing steadily. Although PCV13 serotypes are resistance will not change substantially, and resistance to fluoroquinolone antibiotics can be more likely to be erythromycin resistant than other serotypes, the overall, continuing expected to increase.
increase means that the introduction of PCV13 will have little apparent impact. As shown in Figure 5, all amoxicillin resistant isolates are of serotypes 19A and 19F. Serotype 19A and PCV7 serotypes are over-represented in erythromycin resistant isolates ¾Resistance to respiratory fluoroquinolones remains low. PCV13 programs are expected and penicillin resistant isolates, but not isolates with reduced susceptibility to respiratory to have minimal impact on resistance rates.
fluoroquinolones. Serotypes 33A, 35B, 15A, 15C and 6C are over-represented in resistant ¾ The impact of PCV13 programs on amoxicillin resistance in adult sterile site isolates depends essential y entirely on whether these programs wil provide effect herd immunity • Since 1993, CBSN has collected all SPN sterile site isolates, and a sample of non-sterile Antibiotic resistance rates are increasing over time, but are different in different serotypes, Figure 5: Distribution of serotypes in all adult sterile site isolates, compared to resistant
against infections due to serotype 19A. pneumococcal isolates from participating Canadian hospitals and private microbiology and resistance rates change differently over time. Thus, changes in resistance depend on the adult sterile site isolates, CBSN surveillance, 2011 labs (Figure 1). In total, 186 labs have participated with 40 labs submitting for the entire interaction between selective pressure for resistance, and changing serotype distribution.
Figure 3. Percentage of pneumococcal isolates from sterile sites belonging to serotypes
• A single isolate per patient episode is included. British Columbia / Yukon covered by PCV7, CBSN surveillance, 2000 to 2011 Prairies / Northwest Territories • Isolates are shipped to the central lab * Other members of the Canadian Bacterial Surveillance Network and their participating laboratories are as fol ows: Karl Weiss, Hôpital at Mount Sinai Hospital where they Maisonneuve-Rosemont, University of Montreal, Montreal, Quebec; George Zhanel and Daryl Hoban, Health Sciences Centre, Winnipeg, Nunavut (no data) are confirmed as SPN, and broth Manitoba; Magdalena Kuhn, Southeast Healthcare Corp.-Moncton Site, Moncton, New Brunswick; Deirdre Church, Calgary Laboratory Services, Calgary, Alberta; Ross Davidson and Kevin Forward, QEII Elizabeth Health Sciences Centre, Halifax, Nova Scotia; Andrew Simor, microdilution susceptibility testing is Sunnybrook Health Sciences Centre, Toronto, Ontario; H.R. Devlin, St. Michael's Hospital, Toronto, Ontario; R. G. Lewis, Cape Breton performed and interpreted using CLSI Regional Health Care Complex, Sydney, Nova Scotia; P.C. Kibsey, Victoria General Hospital, Victoria, British Columbia; J. Blondeau, Royal University Hospital, Saskatoon, Saskatchewan; G.K. Harding, St. Boniface General Hospital, Winnipeg, Manitoba; L. Thibault, Dr. Georges L. Dumont Hopital, Moncton, New Brunswick; F. Smail , Hamilton Health Sciences Corp., Chedoke-McMaster, Hamilton, Ontario; M. • Since 2000, all sterile site isolates have Gourdeau and G. Murray, Hôpital de l'Enfant-Jesus, Université Laval, Quebec City, Quebec; S. Richardson and A. Matlow, Hospital for Sick Children, Toronto, Ontario; G. J. Hardy, Saint John Regional Hospital, Saint John, New Brunswick; P.R. Laberge, Centre Hospitalier been serotyped. Serotyping is Regional de Sept-Iles, Sept-Iles, Quebec; L. P. Abbott, Queen Elizabeth Hospital, Charlottetown, Prince Edward Island; M. Yorke, Westman performed using latex agglutination Regional Laboratory, Brandon, Manitoba; N. Clerk and Z. Mooloo, Wil iam Osler Health Centre, Etobicoke, Ontario; J. Downey and P. Da Camara, Toronto East General and Orthopedic Hospital, Inc., Toronto, Ontario; M. Bergeron, CHUQ-Ctr Hôpital, Université Laval, Sainte- (Statens Serum Institute, DK) and Figure 1. Canadian regions represented in the
Foy, Québec; J. Hutchinson, Health Care Corp., St. John's, Newfoundland; S. Krajden, St. Joseph's Health Care Centre, Toronto, Ontario; Quellung reaction as required. Canadian Bacterial Surveillance Network R. Price, Royal Victoria Hospital, Barrie, Ontario; J. F. Paradis, Hôpital de Chicoutimi, Chicoutimi, Quebec; L. Bocci, Regional Hospital Centre, Bathurst, New Brunswick; M. Savard and David Thompson Regional Laboratories, Red Deer, Alberta; K. Ostrowska, Tril ium Health Centre, Mississauga, Ontario; P. Pieroni, Provincial Laboratory, Regina, Saskatchewan; B. Mederski and K. Katz, North York General Hospital, Toronto, Ontario; C. Tremblay, Hotel Dieu de Québec, Quebec City, Quebec; P. Leighton, Dr. Everett Chalmers Hospital, Fredericton, Nova Scotia; D. Yamamura and A. Sarabia, MDS Laboratories, Toronto; and D. Noria and A. Gelbloom, The Scarborough Hospital, Toronto. This work has been supported in part by an unrestricted grant from Pfizer Canada Inc.



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Zweiter Projektbericht aus einem Jahr Freiwilligendienst mit ASF in Israel Feldbuschwende 26 Beit Jenny Breuer Moshe Dayan Center Chaim Levanon 55 6997801 Tel Aviv-Jafo Da bin ich wieder. Oder besser gesagt: Da bin ich immer noch. Etwa ein halbes Jahr nachdem ich meinen ersten Projektbericht verschickt habe, melde ich mich wieder zu Wort. Obwohl wir Freiwilligen noch mehr als einen Monat im Land bleiben, fühlt sich dieser Projektbericht schon wie der erste Schritt zu einem Abschied an, den ich alles andere als herbei wünsche. Irgendwie habe ich kurz nicht auf die Uhr geschaut und schon sind zehn Monate vergangen. Ich kann es gar nicht fassen, wenn ich das Datum so vor mir sehe. Mein Gefühl sagt mir, ich sei erst seit etwa zwei Wochen im Land, nur meine Erinnerungen bestätigen mir, dass schon viel passiert ist und ich zahlreiche Erfahrungen gemacht habe. Mit einer leichten Melancholie beim Gedanken an das Ende, die bedeutet, wie tief ich schon Wurzeln in diesem Ort geschlagen habe, möchte ich von meinen Erfahrungen erzählen. Die Arbeit (oder so) In der zweiten Hälfte meines Freiwilligendienstes in Tel Aviv haben sich wie erhofft die Beziehungen zu den Bewohner im Beit Jenny Breuer intensiviert. Ich kann nicht sagen, wer sich da eigentlich um wen kümmert, weil die Arbeit mich so sehr bereichert und erfüllt, dass ich es gar nicht so sehr als Arbeit begreifen kann. Stattdessen fühle ich mich wie ein Enkelkind, das jeden Tag eine Honigdusche abbekommt. Meine Omis haben das Bedürfnis, mich bei jeder Gelegenheit zu herzen und zu umsorgen, da will ich ihnen im Sinne der Nächstenliebe natürlich nicht im Wege stehen und lasse selbstlos den Honig auf mich regnen. Es ist nicht zu unterschätzen, dass ich es täglich mit einer ganz besonders hartnäckigen Art der Großmutter zu tun habe, nämlich der Yiddishen Mame. Man sollte meinen, bei einer Enkelanzahl von bis zu zwanzig sollte die Aufmerksamkeit der Damen ausgelastet sein. Falsch gedacht! Ist gerade kein Enkel anwesend, wird eine nichtsahnende Freiwillige Wasser auf ihren Mühlen. Vor penetranten Modetipps, Ernährungsvorschlägen und natürlich den guten alten Verkupplungsversuchen ist kein Entkommen. Gibt es Chaos in Ihrem Leben, fühlen Sie Sich schwach und antriebslos? Nicht aufgeben, die Yiddishe Mame hat immer Tipps auf Lager, das Schlamassel im Nu gelöst und nebenbei fünfzehn Kippas und sechs Babydecken für die ganze Mischpoke gehäkelt. Doch das ist nicht alles. Die Vibes der Yiddishen Mame durchströmen das ganze Haus und haben schon längst meinen Chef in ihrer Gewalt, denn es wäre eine dramatische Fehlannahme, den Charakterzug der Mame am Geschlecht festmachen zu wollen. „Wenn du bleiben willst, kein Problem! Sag uns Bescheid, und wir machen uns sofort auf die Suche nach einen netten Mann für dich!" Die Ladies in der Ecke, die diesen Kommentar mitgehört hatten, nickten eifrig. Da mein Hebräisch dank Sprachkurs und hingebungsvollen israelischen Großeltern, die mir mit Geduld jedes Wort erklären, schnell besser geworden ist, kann ich mittlerweile auch gut etwas kompliziertere Gespräche führen, wie zum Beispiel über das Judentum, ein unerschöpfliches Thema in einem religiösen Altenheim. Es freut mich immer sehr, wenn ich M. besuchen komme, er dann eifrig auf die Uhr guckt, um zu sehen, wie viel Zeit wir haben und mich fragt, wo wir denn letztes Mal stehen geblieben seien. Beim Messias? Gut. Mach es dir bequem,