Nosocomial Outbreak of Drug-Resistant Streptococcus pneumoniae Serotype 9V in an Adult Respiratory Medicine Ward

DOI: 10.1128/JCM.02405-16

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FIG 1
Timeline of confirmed cases of invasive S. pneumoniae. Timeline of patients A, B, C, and D in relation to their admissions, discharges, and onset of confirmed pneumococcal infection. Each small box indicates a single day. Numbers above boxes indicate consecutive days in calendar months; * indicates positive S. pneumoniae culture from a clinical sample.
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FIG 2
Neighbor-joining phylogeny tree of UK ST156 serotype 9V strains showing outbreak strains. SNP-based phylogeny tree of ST156 serotype 9V strains showing three outbreak strains and 19 contemporary strains (see Table S1 in the supplemental material). The branch numbers show bootstrapping, whereas the branch length is indicative of the SNP distance. Outbreak isolates are indicated with red squares. A black square indicates an isolate received earlier in the same year from the same region as the outbreak. The reference used was Streptococcus pneumoniae R6 (NC_003098 ). The average SNP distance between the outbreak strains and contemporary strains was 703 SNPs, with an average of 8,620 SNPs between the outbreak strains and the reference strain.

TABLE 1

Clinical details of patients affected by the nosocomial outbreak of S. pneumoniae

Patient	Days post 1st pneumococcal-positive case	Age (yrs)	Gender^a	Source of pneumococcal isolate	Associated pneumococcal disease^b	Year of pneumococcal vaccination	Underlying condition	FEV1 (%)^c	FVC (%)^d	Antibiotic (prophylaxis)	Previous antibiotic	Steroids at admission (dose)
A	0	60	F	Blood	Pneumonia, sepsis	2000	Asthma	NA^e	NA	Ceftriaxone	None	Budesonide inhaled, prednisolone (20 mg/day)
B	0	76	F	Blood	Pneumonia, sepsis	1998	Asthma, diabetes	0.68 (63)	0.73 (53)	Ceftriaxone	Amoxicillin	Beclomethasone inhaled, prednisolone (4 mg/day)
C	6	73	M	Sputum	Pneumonia	2008	COPD	0.79 (29)	2.07 (58)	(Levofloxacin)	Doxycycline	None
D^f		59	F	NA	None	Unknown	COPD, home NIV^g	0.66 (27)	NA	(Levofloxacin)	Meropenem	Prednisolone (25 mg/day)

↵a F, female; M, male.
↵b Pneumonia was confirmed with chest X-ray for patients A and B and CT scan for patient C.
↵c FEV1, forced expiratory volume in 1 s (% predicted).
↵d FVC, forced vital capacity (% predicted).
↵e NA, not available.
↵f Patient D (close contact of patient C and on the same ward as patients A and B) did not have pneumococcal disease identified but had an acute febrile illness prior to pneumococcal isolation from patients A, B, and C.
↵g NIV, noninvasive ventilation.