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Austrian syndrome is defined as the triad consisting of pneumonia, endocarditis and meningitis due to invasive Streptococcus pneumoniae infection. Few case reports have been reported since its first description in 1975 by Robert Austrian, mainly because it is rarely observed. Below we report the case of a 61 year-old male patient who presented with bacterial meningitis due S. pneumoniae followed by bacterial pneumonia and severe mitral regurgitation, associated with four vegetations on the atrial surface of the posterior mitral leaflet; in addition, there was rupture and prolapse of its middle scallop. The S. pneumoniae bacterium was isolated from cerebrospinal fluid and blood cultures. In consequence, the patient was given broad-spectrum antibiotic therapy and had an early valve replacement performed, obtaining a good clinical outcome. The key prognostic factor of the Austrian syndrome is determined by the damage of cardiac valves, particularly in patients with a compromised aortic valve; hence, it is necessary to identify the degree of valve injury and define surgical and antibiotic treatment on a timely fashion. However, in subacute, less frequent clinical cases where the mitral valve is the main valve compromised, usually a directed antibiotic therapy associated with advanced support measures are sufficient to control this infection.

We report the results of pneumococcal meningitis surveillance conducted at the Provincial Pediatric Hospital of Posadas, Misiones (Argentina), before the conjugate vaccine was introduced into the national vaccination schedule. Between January 1994 and December 2009, 167 cases of Streptococcus pneumoniae meningitis were diagnosed in children aged 1 month to 15 years. The attack rate/100,000 children ranged from 19.2 (1997) to 4.3 (2009), with a mean of 10.6 and a tendency to decrease (y=-0.689x+16.52). The number of cases per 100,000 children decreased from 146.6 to 34.8 and particularly involved the group of children aged 1 to 11 months (94/167, 56%). Thirty point seven percent (30.7%) (46/150) of the isolates were resistant to penicillin whereas 16.7% (25/150) were non-susceptible to cefotaxime. β-lactam resistance increased as from 1997 and began to decline in 2005. Nineteen serotypes were detected; type 14 was predominant and accounted for 32% (40/125). Eighty four point eight percent (84.8%) of the isolates were circumscribed to nine serotypes: 14, 5, 1, 7F, 18C, 6B, 9N, 9V and 4. Theoretical coverage for patients aged <2 years and >2 years was 84.1% (74/88) and 83.8% (31/37) for the 10-valent vaccine and 89.8 % (79/88) and 83.8% (31/37) for the 13-valent vaccine respectively. Penicillin resistance was restricted to 8 serotypes (14, 6B, 6A, 9V, 4, 23B, 19A1) and nonsusceptibility to cefotaxime was circumscribed to 3 serotypes (14, 9V and 1). This study will allow to evaluate the impact of the implementation of conjugate vaccines on our area., (Copyright © 2014 Asociación Argentina de Microbiología. Publicado por Elsevier España. All rights reserved.)

Introduction: The aim of this study is to describe the distribution of Streptococcus pneumoniae serotypes, its antimicrobial susceptibility profiles and the relation with vaccines in pneumococcal invasive strains isolated from blood cultures of adult patients., Methods: All pneumococci isolated (67 strains) from blood cultures were serotyped by latex agglutination (Pneumotest latex) and Quellung reaction (Statens Serum Institut, Denmark). Antimicrobial susceptibility testing to penicillin (PEN), cefotaxime (CT), erythromycin (ERY) and levofloxacin (LEV) was performed by the E-test method (Biomèrieux, France)., Results: Among the 67 strains isolated, the most prevalent serotypes were 22F (11.9%) and 3 (11.9%), the second most frequent were 7F (7.5%) and 19A (7.5%). The coverage of the strains by the pneumococcal 7-valent conjugate vaccine (VNC7V), pneumococcal 13-valent conjugate vaccine (VNC13V) and pneumococcal 23-valent polysaccharide (VNP23V) were 16, 49 and 82%, respectively. Serotypes 22F and 3 were responsible for 14 of the 48 episodes of pneumonia with bacteremia (29.2%) and only 2 of the 19 episodes (10.5%) of bacteremia without pneumonia. According to the 2007 CLSI criteria, 12 strains (17.9%) were non-susceptible to penicillin. Eleven of this 12 strains (91.7%) were resistant to erythromycin, simultaneously., Conclusions: The most common serotypes were 22F, 3, 7F y 19A. Three of them (3, 7F y 19A) are serotypes that are covered by the new VNC13V but not by VNC7V. Serotype 22F is a serotype emergent that is not covered by the VNC7V. The percentage of non-susceptibility to penicillin and resistance to erythromycin was comparable to the percentage reported in our country.

Introduction: Haemophilus influenzae, Streptococcus pneumoniae and Neisseria meningitidis are the main human pathogens that cause meningitis., Objective: Primers omp2, lytA and crgA were evaluated with H. influenzae, S. pnumoniae and N. meningitidis DNA in a multiplex PCR, determining the sensitivity and the specificity of the technique., Materials and Methods: Primers for H. influenzae outer membrane protein (omp2, 1000 pb), S. pneumoniae autolysin (lytA, 395 pb) and N. meningitidis, contact regulated gene (crgA, 230 pb) were evaluated in a multiplex PCR, determining the sensitivity and the specificity of the technique., Results: Reproducible results were obtained with 50 nM of each of the three primers and annealing temperature of 57 degrees C in the multiplex PCR, obtaining a sensitivity of 12.5 fg for H. influenzae and S. pneumoniae and 3.12 fg for N. meningitidis. No cross reactions with other microorganisms agents of meningitis or related with the genera, appeared., Conclusions: The results for sensitivity and specificity suggest that the evaluated primers can be used for the development of a PCR in a multiplex format to the identification of the three main pathogens that cause meningitis.

Streptococcus pneumoniae is a rarely recognized cause of neonatal sepsis and/or meningitis, but it is associated with substantial morbidity and mortality. Traditionally, S. pneumoniae is identified in the laboratory by demonstrating susceptibility to optochin. However, the emergence of optochin-resistant organisms makes definite identification difficult when only phenotypic tests are taken as markers. We present the case of a severe early-onset neonatal meningitis due to an atypical strain of S. pneumoniae. Laboratory methods utilized to certify this species diagnosis are discussed.

Despite S. pneumoniae is one of main etiologies of invasive bacterial infection in children, it rarely causes infectious endocarditis in children. Pneumococcal endocarditis is a serious condition that affects mainly the mitral valve, with a rapidly destructive nature and a high fatality rate, demanding prompt medical and surgical treatment. We report a case of pneumococcal endocarditis in a school girl coming from extreme rurality who presented both meningitis and endocarditis, and whose blood cultures isolated penicillin resistant S. pneumoniae.

The pneumococcal heptavalent conjugate vaccine protects children aged less than 2 years old from invasive pneumococcal disease (IPD). Efficacy is 89-93% in the US population and 71-86% in European studies. The vaccine confers active immunization against the main serotypes causing IPD (4, 6B, 9V, 14, 18C, 19F y 23F). We describe 2 children who presented with pneumococcal meningitis caused by nonvaccine serotypes. As a result of the widespread use of the heptavalent vaccine, there may be a shift in the serotypes causing IPD.

Endocarditis caused by Streptococcus pneumoniae in children is an infrequent disease, corresponding to 3-7% of all cases of endocarditis. However, it is highly relevant because of its severity with the possibility of producing valvular ring abscesses and destruction, and high mortality that reaches up to 61% if medical and surgical treatment are not started early in the course of the illness. Over 50% of cases are associated to other sites of infection such as meningitis, pneumonia, sinusitis or mastoiditis. We report a 10-months-old infant who was admitted with meningitis and endocarditis due to S. pneumoniae, who presented with severe heart failure and required aortic valve replacement. A review of the literature of endocarditis caused by S. pneumoniae in pediatrics is presented.

Background: The aim of this study was to assess the local resistance patterns and serotypes of Streptococcus pneumoniae implicated in invasive infections in children in Hospital Provincial de Pediatría in Misiones, Argentina., Methods: A total of 101 strains isolated from sterile sites between June 1998 and June 2001 were studied. Strains were identified according to standard methods. Resistance patterns were determined by disk diffusion and a macrodilution method according to NCCLS guidelines. Capsular typing was based on the Quellung technique., Results: Among the total, 62% of pneumonia cases, 70% of pneumonia with pleural effusion and meningitis, and 78% of sepsis occurred in children younger than 2 years old (74% of the total). Twelve serotypes were detected among 71 strains analyzed. Types 14 (37.1%), 5 (21.4%), 1 (10%), 6A/6B (7.1%), 9N and 19A (5.7%) and 9V (4.3%), were the most frequent. Penicillin (PEN) resistance was detected in 39% of isolates: 17.5% had intermediate levels and 21.5% high levels of resistance. None of the strains had PEN MICs of > 4 microg/ml. PEN resistance was limited to 5 serotypes, with 84% corresponding to type 14. Among the 71 strains, in 50 CTX MICs were < or = 0.5 microg/ml, in 18 the MIC was 1 mg/ml and in 3 the MIC was 2 microg/ml. None of the strains had CTX MICs of > 2 microg/ml. Twenty-two percent of strains were resistant to tetracycline, 48% to trimethoprim-sulfamethoxazole (TMS), 11% to chloramphenicol (CLO) and 6.8% to erythromycin. None of the isolates were resistant to vancomycin, ofloxacin or rifampin. The most common combined resistance patterns were PEN-TMS (20%), PEN-CTX-TMS (7%, 3 strains with a CTX MIC of 2 .g/ml) and PEN-TMS-CLO (5%)., Conclusions: The local drug resistance patterns and serotype distribution defined in this study allow appropriate empirical therapy to be established in our area and provide information that can be used assess vaccination strategies as a preventive tool for the control of invasive pneumococcal infections.

Streptococcus pneumoniae, a common pathogen in pediatric infections, has become resistant to penicillin and make these infections difficult to treat. Rifampin and chloramphenicol have been recommended as alternative therapies, since they are less costly and more accessible to communities with limited resources. However, their use may be restricted by the differing levels of resistance found in target populations. The objective was to determine minimal inhibitory concentration (MIC) and minimal bactericidal concentration (MBC) for chloramphenicol and rifampin in strains of S. pneumoniae. These strains were newly isolated from children under age 5 that had demonstrated systemic infections and meningitis. A subgroup of 107 isolates of S. pneumoniae was selected from 324 strains isolated during a period of 2 years (1994-1996). Among these isolates, 60 were penicillin-resistant and 47 were susceptible; 53 isolates were from children with meningitis. MIC and MBC for chloramphenicol and rifampicin were obtained by standard methods recommended by the National Committee for Clinical Laboratory Standards (NCCLS). S. pneumoniae ATCC strain 49619 served as the control. An isolate was considered susceptible to chloramphenicol when MIC = 4 microg/ml and resistant when MIC = 8 microg/ml. A strain was considered susceptible to rifampin when MIC = 1 microg/ml and resistant when MIC = 4 microg/ml. MBC was determined by recording the lower concentration of the antibiotic that inhibited 99.9% of the initial inoculum. Chloramphenicol resistance was found in 21% of the 107 isolates. In the group susceptible to penicillin, 11% were resistant to chloramphenicol and in the group resistant to penicillin 28% was resistant to chloramphenicol as well. MBC was found > 4 microg/ml in 28% of the isolates susceptible to penicillin and in 60% of the resistant isolates. No isolates were found resistant to rifampin. However, 2 penicillin resistant isolates showed CBM > 1 microg/ml to rifampin, and one with CIM = 1 microg/ml had a MBC to rifampicin of 16 microg/ml. Meningitis isolates showed higher CIM and CBM than the group of total isolates. These data suggest that chloramphenicol is not recommended for invasive infections caused by S. pneumoniae in Colombia. Rifampin is a more effective therapy in combination with other antibiotics for treatment of this kind of infections. Further studies are necessary to clarify the significance of low levels of MBC to rifampin found in some strains, since this may affect the efficacy of therapies that include this antibiotic.

Introduction: The increasing prevalence of high-level cephalosporin-resistant strains of Streptococcus pneumoniae could complicate the treatment of severe infections such as meningitis. There are still questions as to the characteristics of these strains, their ability to produce severe infection, and the inflammatory response they induce in CSF., Methods: Using a rabbit model of meningitis, we sought to determine the pathogenicity and differences in inflammatory parameters in two serotype 23F S. pneumoniae strains with different susceptibility to betalactams. Minimal inhibitory concentrations of the two strains were as follows: strain A--PEN 4 micro g/mL, CRO/CTX 2 micro g/mL--and strain B--PEN 0.12 micro g/mL, CRO/CTX 32 micro g/mL., Results: Strain A resulted in a greater incidence of secondary bacteremia and higher inflammatory parameters during the early phases of infection. Strain B caused brain edema, a more severe inflammatory response and significantly higher mortality at the end of the experiment., Conclusions: Both strains induced meningitis in the animal model. The differences in inflammatory response produced by the two strains could be related to the variations that determine the betalactam resistance level.

Objective: To analyze the epidemiological and clinical features of pneumococcal meningitis., Patients and Methods: We performed a retrospective study of 53 cases of pneumococcal meningitis that occurred in 47 pediatric patients in our hospital between 1977 and 2000. Four children had recurrent meningitis. In all patients Streptococcus pneumoniae was isolated from cerebrospinal fluid culture. The epidemiological, bacteriological and clinical characteristics were studied., Results: Pneumococcal meningitis represented 6 % of bacterial meningitis in our environment with 2-3 cases registered per year. Seventy-two percent of cases occurred in winter and spring. The age of affected children was between 1 month and 13 years. Sixty-five percent of children older than 2 years had a predisposing disease. Penicillin-resistant strains were detected in 1990 and cefotaxime-resistant strains were isolated in 1994. Seven children (13 %) had severe neurological sequels and two (4 %) died., Conclusions: Pneumococcal meningitis produces higher morbidity and mortality than other types of bacterial meningitis. The disease usually affects children younger than 2 years and older children with a predisposing disease. In the last few years, the importance of pneumococcal meningitis has increased due to the lower incidence of other types of bacterial meningitis. Because of beta-lactam resistant strains, initial empirical treatment should include vancomycin. The above data suggest the advisability of the generalized use of heptavalent pneumococcal conjugate vaccine in the pediatric population in our environment.

An 8-year-old boy who had been operated for craniosynostosis was remitted from the pediatric service for two bacterial meningitis episodes. The cause was a meningoencephalocele of the right nasal cavity.