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Microbial Interactions During Upper Respiratory Tract Infections Melinda M RESEARCH Microbial Interactions during Upper Respiratory Tract Infections Melinda M. Pettigrew, Janneane F. Gent, Krystal Revai, Janak A. Patel, and Tasnee Chonmaitree CME ACTIVITY Medscape, LLC is pleased to provide online continuing medical education (CME) for this journal article, allowing clinicians the opportunity to earn CME credit. Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide CME for physicians. Medscape, LLC designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. All other clinicians completing this activity will be issued a certifi - cate of participation. To participate in this journal CME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take the post-test and/or complete the evaluation at http://www.medscape.com/cme/eid; (4) view/print certifi cate. Learning Objectives Upon completion of this activity, participants will be able to: • Identify common bacterial isolates from children with upper respiratory infection • Specify signifi cant interactions between colonizing bacteria during upper respiratory infections • Identify variables associated with higher rates of colonization with Streptococcus pneumoniae • Specify which bacteria is more common in the nasopharynx of children who attend day care Editor Beverly Merritt, Technical Writer-Editor, Emerging Infectious Diseases. Disclosure: Beverly Merritt has disclosed no relevant fi nancial relationships. CME Author Charles P. Vega, MD, Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine, California, USA. Disclosure: Charles P. Vega, MD, has disclosed that he has served as an advisor or consultant to Novartis, Inc. Authors Disclosures: Melinda M. Pettigrew, PhD; Janneane F. Gent, PhD; Krystal Revai, MD; Janak A. Patel, MD; and Tasnee Chonmaitree, MD, have disclosed no relevant fi nancial relationships. Streptococcus pneumoniae, Haemophilus infl uenzae, treptococcus pneumoniae, Haemophilus infl uenzae, Moraxella catarrhalis, and Staphylococcus aureus often SMoraxella catarrhalis, and Staphylococcus aureus of- colonize the nasopharynx. Children are susceptible to bac- ten asymptomatically colonize the nasopharynx of young terial infections during or soon after upper respiratory tract children and are also associated with disease. S. pneu- infection (URI). We describe colonization with these 4 bac- moniae, H. infl uenzae, and M. catarrhalis are the 3 most teria species alone or in combination during URI. Data were common otitis media pathogens (1,2). S. pneumoniae are from a prospective cohort of healthy children 6 to 36 months of age followed up for 1 year. Analyses of 968 swabs from also common causes of pneumonia, sepsis, and meningitis 212 children indicated that S. pneumoniae colonization is in young children (3). The proportion of young children negatively associated with colonization by H. infl uenzae. colonized with any of these 3 bacteria species can be >50% Competitive interactions shifted when H. infl uenzae and M. in certain populations (4–6). S. aureus strains colonize up catarrhalis colonized together. In this situation, the likeli- to 35% of young children and are associated with a wide hood of colonization with all 3 species is higher. Negative range of diseases including soft tissue infections, sepsis, associations were identifi ed between S. pneumoniae and S. and pneumonia (7,8). Increases in the incidence of disease aureus and between H. infl uenzae and S. aureus. Polymi- caused by community-acquired methicillin-resistant S. au- crobial interactions differed by number and species of bac- reus are of great concern (9). teria present. Antimicrobial therapy and vaccination strate- Host factors have been shown to infl uence coloniza- gies targeting specifi c bacterial species may alter the fl ora tion with S. pneumoniae, H. infl uenzae, M. catarrhalis, and in unforeseen ways. S. aureus. These include host immunity, age, gender, race, Author affi liations: Yale School of Public Health, New Haven, Con- out-of-home daycare, breastfeeding, and environmental necticut, USA (M.M. Pettigrew, J.F. Gent); and University of Texas exposure to tobacco smoke (10). The magnitude of host Medical Branch, Galveston, Texas, USA (K. Revai, J.A. Patel, T. effects may differ by bacteria species. Chonmaitree) Interactions between bacteria infl uence which species DOI: 10.3201/eid1410.080119 persist in the nasopharynx (11–13). Bacteria species may 1584 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 10, October 2008 Microbial Interactions during URIs be positively associated; this occurs when they are found ascertained environmental exposure to tobacco smoke together more often than would be expected by chance. A based on self-reports of whether any household members negative association could occur when bacteria compete smoked cigarettes in the home. within same environment. Several studies have described The children in our study were followed up for 1 year. a negative association between S. pneumoniae and S. au- We requested that parents notify study staff when the child reus (12–16). Understanding of interactions between S. began to exhibit URI symptoms including nasal conges- pneumoniae, H. infl uenzae, M. catarrhalis, and S. aureus tion, rhinorrhea, cough, sore throat, or fever. A study is limited. physician saw children as soon as possible after the onset The nasopharyngeal fl ora change over time; the level of URI symptoms. At each study visit, the study physi- of bacteria colonization is higher during upper respiratory cian obtained information regarding specifi c URI symp- infection (URI) (6,17). Knowledge is lacking regarding S. toms and examined the child’s ears. The children were pneumoniae, H. infl uenzae, M. catarrhalis, and S. aureus then monitored closely for 3 weeks for the development interactions during URI because colonization studies either of otitis media. The study physician collected a nasopha- do not examine competitive interactions among all 4 patho- ryngeal swab during the visit for each URI episode and gens or focus on healthy children (5,11,16,18). Children when acute otitis media or sinusitis was diagnosed. URI are susceptible to secondary bacterial infections during and episodes were categorized as the same episode if symp- after URI (19–21). toms persisted. An episode of URI was considered new A better understanding of polymicrobial interactions when symptoms of the previous episode subsided and the in the nasopharynx is important for several reasons. Colo- parents noted new symptoms of URI as described above. nization is the initial step in the disease process (22, 23). Given our prospective study design, many children had Colonized children serve as reservoirs for bacterial trans- >1 URI episode and some had >1 visit/URI episode. We mission to others in the community (24). Additionally, an- collected 1 swab/physician visit. Data regarding antimi- tibimicrobial drugs or vaccines, which target specifi c bac- crobial drug therapy during the past 7 days were collected teria species, may alter polymicrobial interactions in the by medical record review. A description of the methods is nasopharynx and have unanticipated consequences (25,26). provided elsewhere (19,26). The goals of our study were to 1) describe the prevalence A total of 294 children were enrolled in the original of colonization with S. pneumoniae, H. infl uenzae, M. ca- study (19,26). Included in these analyses are data from 212 tarrhalis, and S. aureus; 2) evaluate interactions between S. (72%) children who experienced at least 1 URI, were seen pneumoniae, H. infl uenzae, M. catarrhalis, and S. aureus; by a study physician, and had a nasopharyngeal swab col- and 3) estimate the effect of host factors on colonization lected for bacterial culture. Thus, we excluded 82 children with S. pneumoniae, H. infl uenzae, M. catarrhalis, and S. who did not have a URI and a swab for bacterial culture. aureus after a URI in a prospective cohort of young chil- Of these 82 children without URI visits, 35 (59%) were dren. lost to follow-up in the fi rst 6 months, 13 (38%) were lost to follow-up in months 7–11, and 34 (17%) completed 1 Methods year of follow up. Mini-Tip Culturette kits (Becton Dickinson Micro- Study Design and Participants biology Systems, Cockeysville, MD, USA) were used for We used data from a prospective study of otitis media sample collection. Each swab was streaked onto 1 blood complications of URI in children at the University of Texas and 1 chocolate agar plate. We subcultured and identifi ed Medical Branch (UTMB) at Galveston (19,26). The study suspected isolates of each species as follows: S. pneumo- was reviewed and approved by the UTMB Institutional niae isolates were identifi ed by using the optochin disk Review Board. The parents of healthy children 6 months susceptibility test (Taxo P, Becton Dickinson Microbiol- through 3 years of age, who were receiving medical care at ogy Systems), H. infl uenzae isolates were identifi ed by the UTMB from January 2003 through March 2007, were in- Haemophilus ID Quad Plate with Growth Factors (Becton vited to enroll their children. Children with chronic medical Dickinson Microbiology Systems), M. catarrhalis isolates problems and anatomic or physiologic defects of the ear or were identifi ed by the API QuadFerm assay (bioMérieux, nasopharynx were excluded. Inc., Hazelwood, MO, USA), and S. aureus isolates were At enrollment, we collected information about de- identifi ed by coagulase, catalase, and latex agglutination mographic and URI risk factors. Parents were asked to test (Staphaurex Plus, Remel, Lenexa, KS, USA). describe their child’s race and ethnicity. We also ob- tained information regarding the number of weeks the Statistical Methods child had been breast-fed and the number of hours and The main outcomes of interest were the relationships days/week the child currently attended day care. We between bacteria during URI. All statistical analyses were Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No.
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