Original Article
An Outbreak of Multidrug-Resistant Pneumococcal Pneumonia and Bacteremia among Unvaccinated Nursing Home Residents
N Engl J Med 1998; 338:1861-1868June 25, 1998
- Abstract
Background
Outbreaks of pneumococcal disease are uncommon and have occurred mainly in institutional settings. Epidemic, invasive, drug-resistant pneumococcal disease has not been seen among adults in the United States. In February 1996, there was an outbreak of multidrug-resistant pneumococcal pneumonia among the residents of a nursing home in rural Oklahoma.
Methods
We obtained nasopharyngeal swabs for culture from residents and employees. Streptococcus pneumoniae isolates were serotyped and compared by pulsed-field gel electrophoresis. A retrospective cohort study was conducted to identify factors associated with colonization and disease.
Results
Pneumonia developed in 11 of 84 residents (13 percent), 3 of whom died. Multidrug-resistant S. pneumoniae, serotype 23F, was isolated from blood and sputum from 7 of the 11 residents with pneumonia (64 percent) and from nasopharyngeal specimens from 17 of the 74 residents tested (23 percent) and 2 of the 69 employees tested (3 percent). All the serotype 23F isolates were identical according to pulsed-field gel electrophoresis. Recent use of antibiotics was associated with both colonization (relative risk, 2.3; 95 percent confidence interval, 1.3 to 4.2) and disease (relative risk, 3.6; 95 percent confidence interval, 1.2 to 10.8). Only three residents (4 percent) had undergone pneumococcal vaccination. After residents received pneumococcal vaccine and prophylactic antibiotics, there were no additional cases of pneumonia, and the rates of carriage decreased substantially.
Conclusions
In this outbreak a single pneumococcal strain was disseminated among the residents and employees of a nursing home. The high prevalence of colonization with a virulent organism in an unvaccinated population contributed to the high attack rate. Clusters of pneumococcal disease may be underrecognized in nursing homes, and wider use of pneumococcal vaccine is important to prevent institutional outbreaks of drug-resistant S. pneumoniae infection.
Media in This Article
Figure 1
Cases of Pneumonia among Nursing Home Residents According to the Date of Onset of Illness.Figure 2
Pulsed-Field Gel Electrophoretic Patterns of 12 Isolates of Multidrug-Resistant S. pneumoniae, Serotype 23F.Article Activity
- Article
Pneumococcal disease accounts for more deaths than any other vaccine-preventable bacterial disease.1 Among the elderly, the case fatality rates for bacteremia approach 40 percent.2,3 Most cases are sporadic, and during the antibiotic era outbreaks caused by a single pneumococcal serotype have been rare, occurring mainly in institutions such as hospitals,4 military camps,5,6 shelters,7,8 jails,9 day-care centers,10,11 and nursing homes.12,13
Since 1990, drug-resistant pneumococcal strains have become increasingly common in the United States,14-18 making the selection of empirical treatment for pneumococcal infections difficult.15,18-20 Drug-resistant infections have also been associated with certain institutional settings, particularly day-care centers,21-24 hospitals,25-30 and a pediatric long-term care facility.31 Despite the continuing emergence of drug resistance, epidemics of drug-resistant pneumococcal disease have not been previously reported among adults in the United States. We investigated an outbreak of multidrug-resistant Streptococcus pneumoniae serotype 23F among unvaccinated nursing home residents in a rural Oklahoma community (population, 18,000) where antimicrobial resistance among S. pneumoniae isolates had not previously been observed. We studied factors associated with colonization and disease, assessed modes of transmission, and evaluated the effect of control measures.
Methods
Background
On February 16, 1996, the Centers for Disease Control and Prevention received notification that three residents of a long-term care facility had been hospitalized with pneumococcal bacteremia within a five-day period; two had died of rapidly progressing illness that did not respond to intravenous cefuroxime therapy. Initial testing indicated that all isolates had an intermediate level of susceptibility to penicillin and cefotaxime (minimal inhibitory concentration, 1.0 μg per milliliter for both by the E test), were resistant to trimethoprim–sulfamethoxazole and erythromycin, and were susceptible only to vancomycin. The clinical microbiology laboratory of the community hospital had routinely screened all sterile-site S. pneumoniae isolates for antimicrobial resistance32 since January 1995, but no resistant isolates had been identified previously.
Epidemiologic Investigation
We defined a case as an instance of radiographically documented pneumonia occurring in a resident of the nursing home between February 6 and February 20, 1996 (the outbreak period). A carrier was defined as a resident without lower respiratory illness from whom the outbreak strain was isolated by nasopharyngeal-swab culture. To determine the extent of spread of the outbreak strain within the nursing home, we obtained nasopharyngeal swabs for culture from residents and employees before interventions were carried out and evaluated the effect of the interventions in two follow-up surveys. To identify factors associated with colonization and disease in a retrospective cohort study, we compared attack rates among colonized residents with those among noncolonized residents and attack rates among residents who had pneumonia with those among asymptomatic residents. Information from medical charts was obtained with a standardized form. Five residents who had died between February 1 and February 17 were excluded from the study because no diagnostic testing was performed. One patient with pneumonia was excluded because a penicillin-sensitive strain of S. pneumoniae serotype 16 was isolated from his sputum culture. To assess the presence of the outbreak strain in the community, we obtained nasopharyngeal cultures from children 2 to 59 months of age in two day-care centers and the county health-department clinic.
Laboratory Methods
Nasopharyngeal secretions were obtained with sterile calcium alginate swabs, inoculated directly onto blood-agar plates, and incubated overnight. S. pneumoniae isolates were serotyped with the quellung reaction and tested for antimicrobial susceptibility by broth microdilution.33 For each drug tested, isolates were defined as susceptible, intermediate, or resistant according to cutoff points defined by the National Committee for Clinical Laboratory Standards.34 Multidrug-resistant isolates were compared by pulsed-field gel electrophoresis after digestion with SmaI. The similarity of isolates was assessed by comparing the migration distances of the DNA fragments.35 Paired serum samples were tested for IgG antibodies to human parainfluenza viruses 1, 2, and 3, adenovirus, and respiratory syncytial virus by enzyme immunoassay.36
Statistical Analysis
The data were analyzed with Epi Info37 software. Relative risks and 95 percent confidence intervals were calculated38 and adjusted by the Mantel–Haenszel method.39 P values were calculated with Fisher's two-tailed exact test. To evaluate transmission between residents, we used a binomial probability model to compare the expected number of double-occupancy rooms with zero, one, or two colonized residents with the observed number by the chi-square statistic (goodness-of-fit test).
Interventions
On February 17, pneumococcal polysaccharide vaccine was given to 71 nonhospitalized residents who had no documentation of prior vaccination. Eleven employees with chronic illnesses were also vaccinated.40 Because there were four additional cases of pneumonia during the next three days, all residents were given penicillin (500 mg three times daily) or ofloxacin (400 mg twice a day for 12 residents with penicillin allergy) for one week beginning on February 20. Penicillin was chosen on the basis of the initial susceptibility results, concern about drug interactions with other agents, and the lack of available data at that point regarding the susceptibility of the outbreak strain to other orally administered antibiotics. Although no susceptibility data for ofloxacin were available, it was chosen as the alternative on the basis of its good safety profile and the low prevalence of resistance in the United States.18 Two employees who were colonized with the outbreak strain received a combination of rifampin (600 mg daily) and ofloxacin (400 mg twice daily) for one week.
Results
Epidemiologic Characteristics of the Outbreak
The nursing home in which the outbreak occurred is a 100-bed, single-story building with two wings. The members of the nursing staff frequently work on both wings. The 84 residents at the time of the outbreak ranged in age from 48 to 101 years (median, 85). Ninety-two percent were at least 65 years old; 81 percent were women, and 93 percent were white. There were 78 employees (median age, 41 years).
During the outbreak, 11 residents had illness that met the case definition, giving an attack rate of 13 percent (Figure 1Figure 1
Cases of Pneumonia among Nursing Home Residents According to the Date of Onset of Illness.). The 11 patients were similar to residents who were not ill in mean age, race, and sex. All 11 patients had lobar consolidation evident on chest radiography, and none had symptoms suggestive of meningitis. Multidrug-resistant S. pneumoniae, serotype 23F, was isolated from the blood of four patients and from the respiratory tract of three (Table 1Table 1
Demographic and Clinical Characteristics of Nursing Home Residents with Pneumonia.). Three patients, all with bacteremia, died (case fatality rate, 27 percent). Only 3 residents (4 percent) had had pneumococcal vaccination, although 60 of the 84 residents (71 percent) had received influenzavirus vaccine during the fall of 1995. No cases were identified among the nursing staff.Studies of Nasopharyngeal Carriage
Before any interventions were undertaken, the outbreak strain was isolated from nasopharyngeal specimens from 17 of the 74 residents tested (23 percent), including 3 in whom pneumonia subsequently developed, and 2 of the 69 employees tested (3 percent). All other pneumococcal isolates that were recovered were sensitive to penicillin (Table 2Table 2
Nasopharyngeal Carriage of S. pneumoniae among Nursing Home Residents and Employees in Three Consecutive Culture Surveys, February and March 1996.). In the second nasopharyngeal-culture survey, conducted after the completion of chemoprophylaxis, serotype 23F was recovered from three residents and none of the employees. Five weeks later, two residents were still colonized. All multidrug-resistant isolates from blood, sputum, and nasopharyngeal specimens had identical patterns of antimicrobial susceptibility (Table 3Table 3
Minimal Inhibitory Concentrations of Various Antibiotics against 33 Multidrug-Resistant Isolates of S. pneumoniae Serotype 23F.) and were indistinguishable from one another by pulsed-field gel electrophoresis (Figure 2Figure 2Pulsed-Field Gel Electrophoretic Patterns of 12 Isolates of Multidrug-Resistant S. pneumoniae, Serotype 23F.).In the community, S. pneumoniae was isolated from nasopharyngeal specimens from 62 percent of 97 children tested. Two children, 18 and 20 months old, carried multidrug-resistant serotype 23F that was identical to the outbreak strain according to pulsed-field gel electrophoresis. However, they had no known contact with each other or with the nursing home. No invasive disease developed in any of the children participating in the nasopharyngeal survey.
Risk Factors for Colonization and Disease
Seventy-eight residents were enrolled in the cohort study; 25 were considered colonized with the outbreak strain (11 patients and 14 asymptomatic carriers). The colonization rates (64 percent vs. 28 percent; relative risk, 2.3; 95 percent confidence interval, 1.3 to 4.2) and attack rates of disease (36 percent vs. 10 percent; relative risk, 3.6; 95 percent confidence interval, 1.2 to 10.8) were higher among residents who were taking antibiotics at the time of onset of illness (or at the time of culturing, for residents who were not ill) than among those who had not taken antibiotics within the previous two months. However, there were no significant differences in the frequency of antibiotic use in the two months before the outbreak between colonized and noncolonized residents or between those who were ill and those who were not ill. Although the serum level of IgG antibodies to respiratory syncytial virus in one patient rose to four times the initial level (Patient 10 in Table 1), antecedent respiratory illness within two weeks was not associated with colonization or disease. Disease was more likely to develop in residents who had been hospitalized in the previous year (26 percent vs. 8 percent; relative risk, 3.3; 95 percent confidence interval, 1.1 to 10.3), who had had pneumonia in the previous year (67 percent vs. 12 percent; relative risk, 5.6; 95 percent confidence interval, 2.0 to 15.2), or who needed assistance when taking oral medications (28 percent vs. 8 percent; relative risk, 3.7; 95 percent confidence interval, 1.2 to 11.5). Colonization and attack rates were similar among residents of each wing and among residents in single-occupancy and double-occupancy rooms. On the basis of the binomial probability model, there was no clustering of colonized residents in double rooms. None of the colonized residents had had child visitors after January 1, 1996.
Analysis of interactions between the staff and residents identified two bedridden patients and two other patients who lived in single rooms and had had no contact with other residents or visitors after January 1. Both colonized employees provided direct patient care. Between January 1 and February 17, one was in charge of administering medications to every resident on both wings twice per shift. From January 18 to February 13, she had a febrile respiratory illness that was treated with amoxicillin, but she continued working while ill.
Discussion
In this explosive outbreak, a single multidrug-resistant pneumococcal strain was disseminated among nursing home residents and staff members. Our investigation suggests that several factors contributed to the high attack rate of disease, including a susceptible, unvaccinated population and a high prevalence of colonization with a virulent organism. The epidemic ceased abruptly and carriage was reduced substantially after the administration of antibiotics and pneumococcal vaccine to residents.
Multidrug-resistant S. pneumoniae has become common worldwide,16,18,41,42 and serotype 23F, one of the most common multidrug-resistant serotypes in the United States,43,44 has been associated with outbreaks in day-care centers17,24,45-47 and a pediatric long-term care facility.31 Although the rate of sporadic pneumococcal disease among nursing home residents is almost 14 times as high as that among the noninstitutionalized elderly,14 outbreaks have rarely been reported.12,13 Unrecognized or unreported clusters of cases of pneumococcal disease in nursing homes may be more common than is currently believed, because there is no routine surveillance for respiratory infections. These infections are commonly treated empirically, without microbiologic confirmation of their cause,48-50 and they generally respond promptly to empirical therapy. With the emergence of multidrug-resistant strains, clusters may become more noticeable if the rate of response to empirical therapy declines.
Our findings in an elderly population confirm those of several other studies that have associated prior antimicrobial use with colonization by resistant pneumococci in children17,21,24,31,46 and with drug-resistant disease in children51,52 and adults.26 Because of common50,53,54 and sometimes inappropriate49,50,55,56 antibiotic use, nursing homes may serve as foci for the emergence of drug-resistant bacteria. Residents who are frequently transferred to and from acute care hospitals may also provide a route for the spread of resistant strains from one susceptible population to another. Encouraging the judicious use of antibiotics is an important preventive strategy in institutional settings, where the potential for transmission and outbreaks is high.9,21,23-25,30
Although the dynamics of S. pneumoniae colonization among institutionalized populations have not been well described, transmission from hospital staff to patients has been suggested.57,58 Exactly how and when the epidemic strain was introduced into the nursing home we studied is unknown, but two findings suggest person-to-person transmission from staff members to residents. First, the patients with pneumonia and the carriers were randomly distributed in the facility, so there was no pattern of transmission from colonized roommates. Second, contact with colonized nursing staff was the only potential source of exposure for two bedridden patients, who were not exposed to other residents or visitors.
The rate of asymptomatic carriage among residents (23 percent) was higher than that generally reported among adults (less than 10 percent).4,7-9,12,13 The available data on the effect of antibiotics on rates of pneumococcal colonization in adults are limited and inconclusive6,9,59 and do not pertain to penicillin-resistant strains or the elderly. In children, attempts to eliminate drug-resistant pneumococci from the respiratory tract with antibiotics have generally been unsuccessful and have resulted in rapid recolonization.21,23,24,60 Therefore, the goal of chemoprophylaxis in our intervention was not to eradicate carriage but rather to provide some protection while vaccine-induced immunity was developing. After the administration of vaccine and antibiotics, no new cases occurred. Surprisingly, carriage was also reduced substantially despite the strain's resistance to penicillin, and no recolonization occurred during follow-up. However, it is not possible to distinguish the separate effects of antibiotics and vaccination in ending the outbreak.
Although pneumococcal polysaccharide vaccine has not been shown to reduce carriage in children,61 one study in adults reported reduced colonization rates after vaccination,62 and an institutional outbreak during the preantibiotic era ended abruptly after residents were vaccinated.63 Vaccination and chemoprophylaxis may both have had a role in reducing carriage. Successful eradication of the organism from the two colonized employees by antibiotics may have eliminated the most likely source of reinfection in this relatively closed environment.
The optimal strategy for controlling drug-resistant pneumococcal outbreaks in nursing homes and other institutions needs to be determined. When possible, grouping of ill patients and exposed staff (cohorting) and closing the facility to new admissions are reasonable while there is ongoing transmission. However, performing nasopharyngeal-culture surveys and isolating colonized residents are generally not feasible. The part that colonized staff members appear to have played in spreading the outbreak strain highlights the importance of keeping health care providers away from nursing homes when they are ill. The decision to administer chemoprophylaxis in an outbreak caused by drug-resistant pneumococci should be made on a case-by-case basis, while taking into consideration the attack rate, whether transmission is ongoing, the susceptibility pattern of the isolate, and the potential for the development of resistance.64,65
S. pneumoniae is the most common cause of nursing home–acquired pneumonia.66 The potential of resistant strains to cause epidemic disease, with high case fatality rates among unvaccinated persons who are susceptible because of the absence of antibodies,67 underscores the importance of prevention by vaccination. Although the data on the efficacy of pneumococcal vaccine in preventing nonbacteremic pneumonia are inconclusive,68,69 and although its efficacy in preventing bacteremia may be limited in the very old,70 the vaccine is efficacious and cost effective in reducing the overall incidence of pneumococcal bacteremia in the elderly.70-73 However, only 30 percent of persons 65 years of age or older have been vaccinated,74 and in all reported nursing home outbreaks less than 5 percent of residents had been vaccinated.12,13 All but six of the residents of the nursing home had indications for pneumococcal vaccination, but only three had documented prior vaccination.
Factors contributing to the underuse of pneumococcal vaccine in nursing homes may include a low priority assigned to the problem among physicians, skepticism about the effectiveness of the vaccine, difficulties in determining the residents' vaccination history, and concern about adverse reactions after unintended revaccination.12,13 However, revaccination is not associated with an increased incidence of serious adverse events.75 In view of the lack of effective means to reduce or prevent transmission, the possible increase in pneumococcal outbreaks,13 and the continuing emergence of drug resistance,18 nursing homes should offer pneumococcal vaccine to all eligible residents and to new residents on admission to the facility. All persons 65 or older should be vaccinated if their vaccination status is unknown.40 Improved vaccine coverage among the 1.38 million elderly people living in U.S. nursing homes76 should be the foundation for preventing outbreaks of pneumococcal disease in long-term care facilities.
Presented in part at the 35th Interscience Conference on Antimicrobial Agents and Chemotherapy, New Orleans, September 15–18, 1996.
We are indebted to the following persons for their assistance in the investigation: Donna Erickson, Jackie Turnbull, and Chris Manschreck, McAlester Regional Health Center, McAlester, Oklahoma; Michael Echelle, Pittsburg County Health Department, McAlester, Oklahoma; Denise Robinson, University of Oklahoma Health Sciences Center, Oklahoma City; and Robert Breiman, George Carlone, Sandra Steiner, Tamar Kvartskhava, Dean Erdman, Steve Monroe, Roger Glass, and Richard Facklam, Centers for Disease Control and Prevention.
Source Information
From the Epidemic Intelligence Service, Epidemiology Program Office (J.P.N.), and the Respiratory Diseases Branch, National Center for Infectious Diseases (J.P.N., J.C.B., R.G., P.H., J.A.E.), Centers for Disease Control and Prevention, Atlanta; Oklahoma State Department of Health, Oklahoma City (J.M.C.); and University of Oklahoma Health Sciences Center, Oklahoma City (D.W.).
Address reprint requests to Dr. Butler at the Respiratory Diseases Branch, MS C-23, Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA 30333.
- References
References
1
Gardner P ,Schaffner W . Immunization of adults. N Engl J Med 1993;328:1252-1258
Full Text | Web of Science | Medline2
Breiman RF ,Spika JS ,Navarro VJ ,Darden PM ,Darby CP . Pneumococcal bacteremia in Charleston County, South Carolina: a decade later. Arch Intern Med 1990;150:1401-1405
CrossRef | Web of Science | Medline3
Plouffe JF ,Breiman RF ,Facklam RR . Bacteremia with Streptococcus pneumoniae: implications for therapy and prevention. JAMA 1996;275:194-198
CrossRef | Web of Science | Medline4
Berk SL ,Gage KA ,Holtsclaw-Berk SA ,Smith JK . Type 8 pneumococcal pneumonia: an outbreak on an oncology ward. South Med J 1985;78:159-161
CrossRef | Web of Science | Medline5
Gray GC ,Mitchell BS ,Tueller JE ,Cross ER ,Amundson DE . Pneumonia hospitalizations in the US Navy and Marine Corps: rates and risk factors for 6,522 admissions, 1981-1991. Am J Epidemiol 1994;139:793-802
Web of Science | Medline6
Musher DM ,Groover JE ,Reichler MR , et al. Emergence of antibody to capsular polysaccharides of Streptococcus pneumoniae during outbreaks of pneumonia: association with nasopharyngeal colonization. Clin Infect Dis 1997;24:441-446
CrossRef | Web of Science | Medline7
DeMaria A Jr ,Browne K ,Berk SL ,Sherwood EJ ,McCabe WR . An outbreak of type 1 pneumococcal pneumonia in a men's shelter. JAMA 1980;244:1446-1449
CrossRef | Web of Science | Medline8
Mercat A ,Nguyen J ,Dautzenberg B . An outbreak of pneumococcal pneumonia in two men's shelters. Chest 1991;99:147-151
CrossRef | Web of Science | Medline9
Hoge CW ,Reichler MR ,Dominguez EA , et al. An epidemic of pneumococcal disease in an overcrowded, inadequately ventilated jail. N Engl J Med 1994;331:643-648
Full Text | Web of Science | Medline10
Cherian T ,Steinhoff MC ,Harrison LH ,Rohn D ,McDougal LK ,Dick J . A cluster of invasive pneumococcal disease in young children in child care. JAMA 1994;271:695-697
CrossRef | Web of Science | Medline11
Hemorrhage and shock associated with invasive pneumococcal infection in healthy infants and children -- New Mexico, 1993-1994MMWR Morb Mortal Wkly Rep 1995;43:949-952[Erratum, WR Morb Mortal Wkly Rep 1995;44:97.]
Medline12
Quick RE ,Hoge CW ,Hamilton DJ ,Whitney CJ ,Borges M ,Kobayashi JM . Underutilization of pneumococcal vaccine in nursing home in Washington State: report of a serotype-specific outbreak and a survey. Am J Med 1993;94:149-152
CrossRef | Web of Science | Medline13
Outbreaks of pneumococcal pneumonia among unvaccinated residents in chronic-care facilities -- Massachusetts, October 1995, Oklahoma, February 1996, and Maryland, May-June 1996MMWR Morb Mortal Wkly Rep 1997;46:60-62
Medline14
Haglund LA ,Istre GR ,Pickett DA ,Welch DF ,Fine DP . Invasive pneumococcal disease in central Oklahoma: emergence of high-level penicillin resistance and multiple antibiotic resistance. J Infect Dis 1993;168:1532-1536
CrossRef | Web of Science | Medline15
Breiman RF ,Butler JC ,Tenover FC ,Elliott JA ,Facklam RR . Emergence of drug-resistant pneumococcal infections in the United States. JAMA 1994;271:1831-1835
CrossRef | Web of Science | Medline16
Hofmann J ,Cetron MS ,Farley MM , et al. The prevalence of drug-resistant Streptococcus pneumoniae in Atlanta. N Engl J Med 1995;333:481-486
Full Text | Web of Science | Medline17
Duchin JS ,Breiman RF ,Diamond A , et al. High prevalence of multidrug-resistant Streptococcus pneumoniae among children in a rural Kentucky community. Pediatr Infect Dis J 1995;14:745-750
CrossRef | Web of Science | Medline18
Butler JC ,Hofmann J ,Cetron MS ,Elliott JA ,Facklam RR ,Breiman RF . The continued emergence of drug-resistant Streptococcus pneumoniae in the United States: an update from the Centers for Disease Control and Prevention's Pneumococcal Sentinel Surveillance System. J Infect Dis 1996;174:986-993
CrossRef | Web of Science | Medline19
Friedland IR ,McCracken GH Jr . Management of infections caused by antibiotic-resistant Streptococcus pneumoniae. N Engl J Med 1994;331:377-382
Full Text | Web of Science | Medline20
Caputo GM ,Appelbaum PC ,Liu HH . Infections due to penicillin-resistant pneumococci: clinical, epidemiologic, and microbiologic features. Arch Intern Med 1993;153:1301-1310
CrossRef | Web of Science | Medline21
Radetsky MS ,Istre GR ,Johansen TL , et al. Multiply resistant pneumococcus causing meningitis: its epidemiology within a day-care centre. Lancet 1981;2:771-773
CrossRef | Web of Science | Medline22
Henderson FW ,Gilligan PH ,Wait K ,Goff DA . Nasopharyngeal carriage of antibiotic-resistant pneumococci by children in group day care. J Infect Dis 1988;157:256-263
CrossRef | Web of Science | Medline23
Rauch AM ,O'Ryan M ,Van R ,Pickering LK . Invasive disease due to multiply resistant Streptococcus pneumoniae in a Houston, Tex, day-care center. Am J Dis Child 1990;144:923-927
Web of Science | Medline24
Reichler MR ,Allphin AA ,Breiman RF , et al. The spread of multiply resistant Streptococcus pneumoniae at a day care center in Ohio. J Infect Dis 1992;166:1346-1353
CrossRef | Web of Science | Medline25
Jacobs MR ,Koornhof HJ ,Robins-Browne RM , et al. Emergence of multiply resistant pneumococci. N Engl J Med 1978;299:735-740
Full Text | Web of Science | Medline26
Pallares R ,Gudiol F ,Linares J , et al. Risk factors and response to antibiotic therapy in adults with bacteremic pneumonia caused by penicillin-resistant pneumococci. N Engl J Med 1987;317:18-22
Full Text | Web of Science | Medline27
Gould FK ,Magee JG ,Ingham HR . A hospital outbreak of antibiotic-resistant Streptococcus pneumoniae. J Infect 1987;15:77-79
CrossRef | Web of Science | Medline28
Mandigers CM ,Diepersloot RJ ,Dessens M ,Mol SJ ,van Klingeren B . A hospital outbreak of penicillin-resistant pneumococci in the Netherlands. Eur Respir J 1994;7:1635-1639
CrossRef | Web of Science | Medline29
Millar MR ,Brown NM ,Tobin GW ,Murphy PJ ,Windsor AC ,Speller DC . Outbreak of infection with penicillin-resistant Streptococcus pneumoniae in a hospital for the elderly. J Hosp Infect 1994;27:99-104
CrossRef | Web of Science | Medline30
Reichler MR ,Rakovsky J ,Slacikova M , et al. Spread of multidrug-resistant Streptococcus pneumoniae among hospitalized children in Slovakia. J Infect Dis 1996;173:374-379
CrossRef | Web of Science | Medline31
Mannheimer SB ,Riley LW ,Roberts RB . Association of penicillin-resistant pneumococci with residence in a pediatric chronic care facility. J Infect Dis 1996;174:513-519
CrossRef | Web of Science | Medline32
Defining the public health impact of drug-resistant Streptococcus pneumoniae: report of a working groupMMWR Morb Mortal Wkly Rep 1996;45:1-20
Medline33
Facklam RR, Washington JA II. Streptococcus and related catalase-negative gram-positive cocci. In: Balows A, ed. Manual of clinical microbiology. 5th ed. Washington, D.C.: American Society for Microbiology, 1991:238-57.
34
Methods for dilution antimicrobial susceptibility tests for bacteria that grow aerobically. 3rd ed. Approved standard. Villanova, Pa.: National Committee for Clinical Laboratory Standards, 1993. (NCCLS document M7-A3.)
35
Tenover FC ,Arbeit RD ,Goering RV , et al. Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: criteria for bacterial strain typing. J Clin Microbiol 1995;33:2233-2239
Web of Science | Medline36
Herrmann KL, Erdman DD. Diagnosis by serologic assays. In: Lennette EH, Lennette DA, Lennette ET, eds. Diagnostic procedures for viral, rickettsial, and chlamydial infections. 7th ed. Washington, D.C.: American Public Health Association, 1995:121-38.
37
Dean AG, Dean JA, Coulombier D, et al. Epi Info, version 6: a word processing program for public health on IBM-compatible microcomputers. Atlanta: Centers for Disease Control and Prevention, 1994.
38
Greenland S ,Robins JM . Estimation of a common effect parameter from sparse follow-up data. Biometrics 1985;41:55-68
CrossRef | Web of Science | Medline39
Stratified analysis. In: Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic research: principles and quantitative methods. New York: Van Nostrand Reinhold, 1982:320-76.
40
Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP)
Medline41
Fenoll A ,Martin Bourgon C ,Munoz R ,Vicioso D ,Casal J . Serotype distribution and antimicrobial resistance of Streptococcus pneumoniae isolates causing systemic infections in Spain, 1979-1989. Rev Infect Dis 1991;13:56-60
CrossRef | Medline42
Geslin P ,Buu-Hoi A ,Fremaux A ,Acar JF . Antimicrobial resistance in Streptococcus pneumoniae: an epidemiological survey in France, 1970-1990. Clin Infect Dis 1992;15:95-98
CrossRef | Web of Science | Medline43
McDougal LK ,Rasheed JK ,Biddle JW ,Tenover FC . Identification of multiple clones of extended-spectrum cephalosporin-resistant Streptococcus pneumoniae isolates in the United States. Antimicrob Agents Chemother 1995;39:2282-2288
Web of Science | Medline44
McDougal LK ,Facklam R ,Reeves M , et al. Analysis of multiply antimicrobial-resistant isolates of Streptococcus pneumoniae from the United States. Antimicrob Agents Chemother 1992;36:2176-2184
Web of Science | Medline45
Drug-resistant Streptococcus pneumoniae -- Kentucky and Tennessee, 1993MMWR Morb Mortal Wkly Rep 1994;43:23-26
Medline46
Arnold KE ,Leggiadro RJ ,Breiman RF , et al. Risk factors for carriage of drug-resistant Streptococcus pneumoniae among children in Memphis, Tennessee. J Pediatr 1996;128:757-764
CrossRef | Web of Science | Medline47
Barnes DM ,Whittier S ,Gilligan PH ,Soares S ,Tomaz A ,Henderson FW . Transmission of multidrug-resistant serotype 23F Streptococcus pneumoniae in group day care: evidence suggesting capsular transformation of the resistant strain in vivo. J Infect Dis 1995;171:890-896
CrossRef | Web of Science | Medline48
Beck-Sague C ,Villarino E ,Giuliano D , et al. Infectious diseases and death among nursing home residents: results of surveillance in 13 nursing homes. Infect Control Hosp Epidemiol 1994;15:494-496
CrossRef | Web of Science | Medline49
Zimmer JG ,Bentley DW ,Valenti WM ,Watson NM . Systemic antibiotic use in nursing homes: a quality assessment. J Am Geriatr Soc 1986;34:703-710
Web of Science | Medline50
Nicolle LE ,Bentley D ,Garibaldi R ,Neuhaus E ,Smith P . Antimicrobial use in long-term-care facilities. Infect Control Hosp Epidemiol 1996;17:119-128
CrossRef | Web of Science | Medline51
Tan TQ ,Mason EO Jr ,Kaplan SL . Penicillin-resistant systemic pneumococcal infections in children: a retrospective case-control study. Pediatrics 1993;92:761-767
Web of Science | Medline52
Reichler MR ,Rakovsky J ,Sobotova A , et al. Multiple antimicrobial resistance of pneumococci in children with otitis media, bacteremia, and meningitis in Slovakia. J Infect Dis 1995;171:1491-1496
CrossRef | Web of Science | Medline53
Strausbaugh LJ ,Crossley KB ,Nurse BA ,Thrupp LD . Antimicrobial resistance in long-term-care facilities. Infect Control Hosp Epidemiol 1996;17:129-140
CrossRef | Web of Science | Medline54
Garibaldi RA ,Brodine S ,Matsumiya S . Infections among patients in nursing homes: policies, prevalence, and problems. N Engl J Med 1981;305:731-735
Full Text | Web of Science | Medline55
Katz PR ,Beam TR Jr ,Brand F ,Boyer K . Antibiotic use in the nursing home: physician practice patterns. Arch Intern Med 1990;150:1465-1468
CrossRef | Web of Science | Medline56
Jones SR ,Parker DF ,Liebow ES ,Kimbrough RC III ,Frear RS . Appropriateness of antibiotic therapy in long-term care facilities. Am J Med 1987;83:499-502
CrossRef | Web of Science | Medline57
Finland M . Recent advances in the epidemiology of pneumococcal infections. Medicine (Baltimore) 1942;21:307-344
CrossRef | Web of Science58
Moore EP ,Williams EW . Hospital transmission of multiply antibiotic-resistant Streptococcus pneumoniae. J Infect 1988;16:199-200
CrossRef | Web of Science | Medline59
Austrian R . Some aspects of the pneumococcal carrier state. J Antimicrob Chemother 1986;18:Suppl A:35-45
CrossRef | Web of Science | Medline60
Craig AS, Erwin PC, Schaffner W, et al. An outbreak of multidrug resistant pneumococcal meningitis in a day care center. In: Abstracts of the Infectious Diseases Society of America 35th Annual Meeting, San Francisco, September 13–16, 1997:77. abstract.
61
Douglas RM ,Hansman D ,Miles HB ,Paton JC . Pneumococcal carriage and type-specific antibody: failure of a 14-valent vaccine to reduce carriage in healthy children. Am J Dis Child 1986;140:1183-1185
Web of Science | Medline62
MacLeod CM ,Hodges RG ,Heidelberger M ,Bernhard WG . Prevention of pneumococcal pneumonia by immunization with specific capsular polysaccharides. J Exp Med 1945;82:445-465
CrossRef | Web of Science | Medline63
Smillie WG ,Warnock GH ,White HJ . A study of a type I pneumococcus epidemic at the State Hospital at Worcester, Mass. Am J Public Health 1938;28:293-302
CrossRef64
Koornhof HJ ,Wasas A ,Klugman K . Antimicrobial resistance in Streptococcus pneumoniae: a South African perspective. Clin Infect Dis 1992;15:84-94
CrossRef | Web of Science | Medline65
Carter R, Sorenson G, Kornblum J, Kiehlbauch J, Leggiardo R, Layton M. Outbreak of multidrug-resistant Streptococcus pneumoniae (MDRSP) at a long-term care facility for persons with AIDS. In: Program and abstracts of the 37th Interscience Conference on Antimicrobial Agents and Chemotherapy, Toronto, September 28–October 1, 1997. Washington, D.C.: American Society for Microbiology, 1997:55. abstract.
66
Marrie TJ ,Slayter KL . Nursing home-acquired pneumonia: treatment options. Drugs Aging 1996;8:338-348
CrossRef | Web of Science | Medline67
Musher DM ,Groover JE ,Rowland JM , et al. Antibody to capsular polysaccharides of Streptococcus pneumoniae: prevalence, persistence, and response to revaccination. Clin Infect Dis 1993;17:66-73
CrossRef | Web of Science | Medline68
Simberkoff MS ,Cross AP ,Al-Ibrahim M , et al. Efficacy of pneumococcal vaccine in high-risk patients: results of a Veterans Administration cooperative study. N Engl J Med 1986;315:1318-1327
Full Text | Web of Science | Medline69
Ortqvist A ,Hedlund J ,Burman LA , et al. Randomised trial of 23-valent pneumococcal capsular polysaccharide vaccine in prevention of pneumonia in middle-aged and elderly people. Lancet 1998;351:399-403
CrossRef | Web of Science | Medline70
Shapiro ED ,Berg AT ,Austrian R , et al. The protective efficacy of polyvalent pneumococcal polysaccharide vaccine. N Engl J Med 1991;325:1453-1460
Full Text | Web of Science | Medline71
Sims RV ,Steinmann WC ,McConville JH ,King LR ,Zwick WC ,Schwartz JS . The clinical effectiveness of pneumococcal vaccine in the elderly. Ann Intern Med 1988;108:653-657[Erratum, Ann Intern Med 1988;109:762-3.]
Web of Science | Medline72
Butler JC ,Breiman RF ,Campbell JF ,Lipman HB ,Broome CV ,Facklam RR . Pneumococcal polysaccharide vaccine efficacy: an evaluation of current recommendations. JAMA 1993;270:1826-1831
CrossRef | Web of Science | Medline73
Sisk JE ,Moskowitz AJ ,Whang W , et al. Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people. JAMA 1997;278:1333-1339
CrossRef | Web of Science | Medline74
Pneumococcal and influenza vaccination levels among adults aged greater/equal 65 years -- United States, 1993
Medline75
Snow R ,Babish JD ,McBean AM . Is there any connection between a second pneumonia shot and hospitalization among Medicare beneficiaries? Public Health Rep 1995;110:720-725
Web of Science | Medline76
Strahan GW. An overview of nursing homes and their current residents: data from the 1995 National Nursing Home Survey. Advance data from vital and health statistics. No. 280. Hyattsville, Md.: National Center for Health Statistics, 1997. (DHHS publication no. (PHS) 97-1250.)
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CrossRef2
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CrossRef3
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CrossRef4
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CrossRef5
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CrossRef6
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CrossRef7
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CrossRef8
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CrossRef9
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CrossRef10
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CrossRef11
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CrossRef12
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CrossRef13
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CrossRef15
W.J. Olver, J. Cavanagh, M. Quinn, M. Diggle, G.F.S. Edwards. (2008) Investigation and control of a cluster of penicillin non-susceptible Streptococcus pneumoniae infections in a care home. Journal of Hospital Infection 70:1, 80-83
CrossRef16
Jennifer C. Nelson, Michael Jackson, Onchee Yu, Cynthia G. Whitney, Lora Bounds, Rachel Bittner, Ann Zavitkovsky, Lisa A. Jackson. (2008) Impact of the introduction of pneumococcal conjugate vaccine on rates of community acquired pneumonia in children and adults. Vaccine 26:38, 4947-4954
CrossRef17
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CrossRef18
Jordi Carratalà, Carolina Garcia-Vidal. (2008) What is healthcare-associated pneumonia and how is it managed?. Current Opinion in Infectious Diseases 21:2, 168-173
CrossRef19
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CrossRef20
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CrossRef21
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CrossRef22
Y. Hansmann, A. Doyle, V. Remy, B. Jaulhac, D. Christmann, O. Lesens, A. Perrocheau. (2006) An Outbreak of Pneumococcal Pneumonia Among Residents of a Retirement Home in France During October 2003 • . Infection Control and Hospital Epidemiology 27:11, 1252-1254
CrossRef23
Steven C. Castle, Koichi Uyemura, Takashi Makinodan. 2006. Impaired Immunity and Increased Risk of Infections in Older Adults: Impact of Chronic Disease on Immunosenescence. , 49-70.
CrossRef24
L. J. Strausbaugh, J. D. Siegel, R. A. Weinstein, R. A. Weinstein. (2006) Preventing Transmission of Multidrug-Resistant Bacteria in Health Care Settings: A Tale of Two Guidelines. Clinical Infectious Diseases 42:6, 828-835
CrossRef25
Chesley L. Richards. (2006) Preventing Antimicrobial-Resistant Bacterial Infections Among Older Adults in Long-term Care Facilities. Journal of the American Medical Directors Association 7:3, S89-S96
CrossRef26
Jos?? Edward Hagan, Cynthia G. Whitney. (2006) First Line of Defense. Infectious Diseases in Clinical Practice 14:1, 1-5
CrossRef27
A ALANIS. (2005) Resistance to Antibiotics: Are We in the Post-Antibiotic Era?. Archives of Medical Research 36:6, 697-705
CrossRef28
D. R. Feikin, K. P. Klugman, R. R. Facklam, E. R. Zell, A. Schuchat, C. G. Whitney, . (2005) Increased Prevalence of Pediatric Pneumococcal Serotypes in Elderly Adults. Clinical Infectious Diseases 41:4, 481-487
CrossRef29
Javier Aspa, Olga Rajas, Felipe Rodr??guez de Castro, Antoni Torres. (2005) Current Perspectives on Streptococcus pneumoniae Antibiotic Resistance, With Particular Reference to Isolates From Spain. Clinical Pulmonary Medicine 12:4, 210-219
CrossRef30
(2005) Australian Society for Geriatric Medicine Position Statement No. 7 Immunisation of Older People Revised 2004. Australasian Journal on Ageing 24:1, 47-52
CrossRef31
Chesley L. Richards. (2005) Preventing antimicrobial-resistant bacterial infections among older adults in long-term care facilities. Journal of the American Medical Directors Association 6:2, 144-151
CrossRef32
Alicia M. Fry, Chi Chi N. Udeagu, Montse Soriano‐Gabarro, Scott Fridkin, Diana Musinski, Leslie LaClaire, John Elliott, Debra J. P. Cook, John Kornblum, Marcelle Layton, Cynthia G. Whitney. (2005) Persistence of Fluoroquinolone‐Resistant, Multidrug‐Resistant Streptococcus pneumoniae in a Long‐Term‐Care Facility: Efforts to Reduce Intrafacility Transmission • . Infection Control and Hospital Epidemiology 26:3, 239-247
CrossRef33
Rosalind J. Carter, Genevieve Sorenson, Richard Heffernan, Julia A. Kiehlbauch, John S. Kornblum, Robert J. Leggiadro, Lucia J. Nixon, William A. Wertheim, Cynthia G. Whitney, Marcelle Layton, . (2005) Failure To Control an Outbreak of Multidrug‐Resistant Streptococcus pneumoniae in a Long‐Term‐Care Facility: Emergence and Ongoing Transmission of a Fluoroquinolone‐Resistant Strain • . Infection Control and Hospital Epidemiology 26:3, 248-255
CrossRef34
Suzanne F. Bradley. (2005) Double, Double, Toil and Trouble: Infections Still Spreading in Long‐Term–Care Facilities • . Infection Control and Hospital Epidemiology 26:3, 227-230
CrossRef35
M. Patricia deHart, Sandra K. Salinas, Leslie J. Barnette, Kristen D.C. Lewis, Henry D. Mustin, Constance Corbett, Pamela K. Green. (2005) Project Protect: Pneumococcal vaccination in Washington State nursing homes* *A collaboration between Qualis Health, Washington State Department of Health, and the Immunization Coalition of Washington.. Journal of the American Medical Directors Association 6:2, 91-96
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Ralph Gonzales, Kitty K. Corbett, Bonnie A. Leeman-Castillo, Judith Glazner, Kathleen Erbacher, Carol A. Darr, Shale Wong, Judith H. Maselli, Angela Sauaia, Karen Kafadar. (2005) The "Minimizing Antibiotic Resistance in Colorado" Project: Impact of Patient Education in Improving Antibiotic Use in Private Office Practices. Health Services Research 40:1, 101-116
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M. Patricia deHart, Sandra K. Salinas, Leslie J. Barnette, Kristen D.C. Lewis, Henry D. Mustin, Constance Corbett, Pamela K. Green. (2005) Project Protect. Journal of the American Medical Directors Association 6:2, 91???96
CrossRef38
Chesley L. Richards. (2005) Preventing Antimicrobial-Resistant Bacterial Infections Among Older Adults in Long-term Care Facilities. Journal of the American Medical Directors Association 6:2, 144???151
CrossRef39
A Banerjee, AT Kalghatgi, GS Saiprasad, A Nagendra, BN Panda, SK Dham, A Mahen, KD Menon, MA Khan. (2005) Outbreak of pneumococcal pneumonia among military recruits. Medical Journal Armed Forces India 61:1, 16-21
CrossRef40
Eva Aagaard, Ralph Gonzales. (2004) Management of acute bronchitis in healthy adults. Infectious Disease Clinics of North America 18:4, 919-937
CrossRef41
Cynthia G. Whitney, Scott A. Harper. (2004) Lower respiratory tract infections: prevention using vaccines. Infectious Disease Clinics of North America 18:4, 899-917
CrossRef42
Angela Pires Brandão, Tânia Cristina de Oliveira, Maria Cristina de Cunto Brandileone, Jorge Emílio Gonçalves, Teresa Ikuko Yara, Vera Simonsen. (2004) Persistence of antibody response to pneumococcal capsular polysaccharides in vaccinated long term-care residents in Brazil. Vaccine 23:6, 762-768
CrossRef43
Mark Loeb, Kurt B. Stevenson, . (2004) Pneumococcal Immunization in Older Adults: Implications for the Long‐Term–Care Setting • . Infection Control and Hospital Epidemiology 25:11, 985-994
CrossRef44
Robert R. Muder, Richard V. Aghababian, Mark B. Loeb, Jerald A. Solot, Martin Higbee. (2004) Nursing home-acquired pneumonia: an emergency department treatment algorithm. Current Medical Research and Opinion 20:8, 1309-1320
CrossRef45
D Bogaert, P.W.M Hermans, P.V Adrian, H.C Rümke, R de Groot. (2004) Pneumococcal vaccines: an update on current strategies. Vaccine 22:17-18, 2209-2220
CrossRef46
Mark Loeb. (2004) Pneumonia in the elderly. Current Opinion in Infectious Diseases 17:2, 127-130
CrossRef47
Gili Regev‐Yochay, Meir Raz, Ron Dagan, Nurith Porat, Bracha Shainberg, Erica Pinco, Nathan Keller, Ethan Rubinstein. (2004) Nasopharyngeal Carriage of Streptococcus pneumoniae by Adults and Children in Community and Family Settings. Clinical Infectious Diseases 38:5, 632-639
CrossRef48
Sridhar Neralla, Keith C Meyer. (2004) Drug Treatment of Pneumococcal Pneumonia in the Elderly. Drugs & Aging 21:13, 851-864
CrossRef49
Ralph Gonzales, Angela Sauaia, Kitty K. Corbett, Judith H. Maselli, Kathleen Erbacher, Bonnie A. Leeman-castillo, Carol A. Darr, Peter M. Houck. (2004) Antibiotic Treatment of Acute Respiratory Tract Infections in the Elderly: Effect of a Multidimensional Educational Intervention. Journal of the American Geriatrics Society 52:1, 39-45
CrossRef50
S GALL. (2003) Maternal immunization. Obstetrics and Gynecology Clinics of North America 30:4, 623-636
CrossRef51
Kristin L. Nichol. (2003) First Do No Harm: Ensuring That Healthcare Workers Vaccinate and Are Vaccinated • . Infection Control and Hospital Epidemiology 24:11, 799-800
CrossRef52
Benjamin A. Kupronis, Chesley L. Richards, Cynthia G. Whitney, . (2003) Invasive Pneumococcal Disease in Older Adults Residing in Long-Term Care Facilities and in the Community. Journal of the American Geriatrics Society 51:11, 1520-1525
CrossRef53
Mark B. Loeb. (2003) Older Adults Who Reside in Long-Term Care Facilities: A High- Risk Population for Invasive Pneumococcal Disease. Journal of the American Geriatrics Society 51:11, 1669-1670
CrossRef54
Christina G. Tan, Stanley Ostrawski, Eddy A. Bresnitz. (2003) A Preventable Outbreak of Pneumococcal Pneumonia Among Unvaccinated Nursing Home Residents in New Jersey During 2001 • . Infection Control and Hospital Epidemiology 24:11, 848-852
CrossRef55
Daniel G. Dauner, James J. Gibson, Dixie F. Roberts, George S. Kotchmar. (2003) Laboratory Survey of Antibiotic Nonsusceptibility among Streptococcus pneumoniae Isolates in South Carolina, 1998 versus 2000. Southern Medical Journal 96:10, 960-967
CrossRef56
D Subramanian, J.A.T Sandoe, V Keer, M.H Wilcox. (2003) Rapid spread of penicillin-resistant Streptococcus pneumoniae among high-risk hospital inpatients and the role of molecular typing in outbreak confirmation. Journal of Hospital Infection 54:2, 99-103
CrossRef57
M. Kate Dunn, Sumi Misra, Ralf Habermann, Marie R. Griffin. (2003) Pneumococcal Vaccination in Nursing Homes: Does Policy Change Practice?. Journal of the American Medical Directors Association 4:3, 135-138
CrossRef58
L. Richards Chesky, Lynn Stede. (2003) Antimicrobial-Resistant Bacteria in Long-Term Care Facilities: Infection Control Considerations. Journal of the American Medical Directors Association 4:3, 110-114
CrossRef59
Larry J. Strausbaugh, Shirin R. Sukumar, Carol L. Joseph. (2003) Infectious Disease Outbreaks in Nursing Homes: An Unappreciated Hazard for Frail Elderly Persons. Clinical Infectious Diseases 36:7, 870-876
CrossRef60
Musher, Daniel M., . (2003) How Contagious Are Common Respiratory Tract Infections?. New England Journal of Medicine 348:13, 1256-1266
Full Text61
Thomas E. Lackner, Robert G Hamilton, John J Hill, Cynthia Davey, David R. P. Guay. (2003) Pneumococcal Polysaccharide Revaccination: Immunoglobulin G Seroconversion, Persistence, and Safety in Frail, Chronically Ill Older Subjects. Journal of the American Geriatrics Society 51:2, 240-245
CrossRef62
Chesley L. Richards, Lynn Steele. (2003) Antimicrobial-Resistant Bacteria in Long-Term Care Facilities:. Journal of the American Medical Directors Association 4:SUPPLEMENT, S110
CrossRef63
Amy B. Jessop, Alice J. Hausman. (2002) Pneumococcal Vaccination in Pennsylvania Nursing Homes: Factors Associated with Vaccination Level. Journal of the American Medical Directors Association 3:6, 347-351
CrossRef64
Joan‐Josep Canet, Natalia Juan, Mariona Xercavins, Núria Freixas, Javier Garau. (2002) Hospital‐Acquired Pneumococcal Bacteremia. Clinical Infectious Diseases 35:6, 697-702
CrossRef65
Susan C Nicholson, Walter R Wilson, Bruce J Naughton, Samantha Gothelf, C.Douglas Webb. (2002) Efficacy and safety of gatifloxacin in elderly outpatients with community-acquired pneumonia. Diagnostic Microbiology and Infectious Disease 44:1, 117-125
CrossRef66
T. Wuorimaa, H. Käyhty. (2002) Current State of Pneumococcal Vaccines. Scandinavian Journal of Immunology 56:2, 111-129
CrossRef67
Thomas W. Hennessy, Kenneth M. Petersen, Dana Bruden, Alan J. Parkinson, Debby Hurlburt, Marilyn Getty, Benjamin Schwartz, Jay C. Butler. (2002) Changes in Antibiotic‐Prescribing Practices and Carriage of Penicillin‐Resistant Streptococcus pneumoniae: A Controlled Intervention Trial in Rural Alaska. Clinical Infectious Diseases 34:12, 1543-1550
CrossRef68
Moe H. Kyaw, Beverley Wayne, Eileen M. Holmes, Ian G. Jones, Harry Campbell. (2002) Influenza and pneumococcal vaccination in Scottish nursing homes: coverage, policies and reasons for receipt and non-receipt of vaccine. Vaccine 20:19-20, 2516-2522
CrossRef69
Helena K. Parsons, David H. Dockrell. (2002) The burden of invasive pneumococcal disease and the potential for reduction by immunisation. International Journal of Antimicrobial Agents 19:2, 85-93
CrossRef70
Micha C. J. Schoenmakers, Jeanne-Marie Hament, Andre Fleer, Piet C. Aerts, Hans van Dijk, Jan L. L. Kimpen, Tom F. W. Wolfs. (2002) Risk factors for invasive pneumococcal disease. Reviews in Medical Microbiology 13:1, 29-36
CrossRef71
Cynthia G. Whitney, William Schaffner, Jay C. Butler. (2001) Rethinking Recommendations for Use of Pneumococcal Vaccines in Adults. Clinical Infectious Diseases 33:5, 662-675
CrossRef72
Karl Weiss, C. Restieri, Richard Gauthier, Michel Laverdière, Allison McGeer, Ross J. Davidson, Laurie Kilburn, Darrin J. Bast, Joyce de Azavedo, Donald E. Low. (2001) A Nosocomial Outbreak of Fluoroquinolone‐Resistant Streptococcus pneumoniae. Clinical Infectious Diseases 33:4, 517-522
CrossRef73
Andrew E. Simor. (2001) The Role of the Laboratory in Infection Prevention and Control Programs in Long‐Term–Care Facilities for the Elderly • . Infection Control and Hospital Epidemiology 22:7, 459-463
CrossRef74
Joseph R. Lentino. (2001) Nosocomial pneumonia: More than just ventilator-associated. Current Infectious Disease Reports 3:3, 266-273
CrossRef75
John E. McGowan. (2001) Increasing threat of Gram-positive bacterial infections in the intensive care unit setting. Critical Care Medicine 29:Supplement, N69-N74
CrossRef76
Robert A. Bonomo. (2000) Multiple Antibiotic–Resistant Bacteria in Long‐Term‐Care Facilities: An Emerging Problem in the Practice of Infectious Diseases. Clinical Infectious Diseases 31:6, 1414-1422
CrossRef77
Kurt B. Stevenson, John W. McMahon, Jan Harris, J. Richard Hillman, Steven D. Helgerson. (2000) Increasing Pneumococcal Vaccination Rates Among Residents of Long‐Term–Care Facilities: Provider‐Based Improvement Strategies Implemented by Peer‐Review Organizations in Four Western States • . Infection Control and Hospital Epidemiology 21:11, 705-710
CrossRef78
Sheldon Gleich, Yosef Morad, Ramon Echague, James R. Miller, John Kornblum, Jacquelyn S. Sampson, Jay C. Butler. (2000) Streptococcus pneumoniae Serotype 4 Outbreak in a Home for the Aged: Report and Review of Recent Outbreaks • . Infection Control and Hospital Epidemiology 21:11, 711-717
CrossRef79
C E Chenoweth, S Saint, F Martinez, J P Lynch, A M Fendrick. (2000) Antimicrobial resistance in Streptococcus pneumoniae: implications for patients with community-acquired pneumonia.. Mayo Clinic Proceedings 75:11, 1161-1168
CrossRef80
Larry J. Strausbaugh, Carol L. Joseph. (2000) The Burden of Infection in Long‐Term Care • . Infection Control and Hospital Epidemiology 21:10, 674-679
CrossRef81
J. E. McGowan. (2000) The Impact of Changing Pathogens of Serious Infections in Hospitalized Patients. Clinical Infectious Diseases 31:Supplement 4, S124-S130
CrossRef82
Vanya Gant, Simon Parton. (2000) Community-acquired pneumonia. Current Opinion in Pulmonary Medicine 6:3, 226-233
CrossRef83
Robert J Leggiadro. (2000) Penicillin-nonsusceptible Pneumococcus. International Journal of Antimicrobial Agents 14:2, 123-127
CrossRef84
Abinash Virk, James M. Steckelberg. (2000) Clinical Aspects of Antimicrobial Resistance. Mayo Clinic Proceedings 75:2, 200-214
CrossRef85
A Virk, J M Steckelberg. (2000) Clinical aspects of antimicrobial resistance.. Mayo Clinic Proceedings 75:2, 200-214
CrossRef86
R.A. Garibaldi. (1999) Residential care and the elderly: the burden of infection. Journal of Hospital Infection 43, S9-S18
CrossRef87
A. S. Craig, P. C. Erwin, W. Schaffner, J. A. Elliott, W. L. Moore, X. T. Ussery, L. Patterson, A. D. Dake, S. G. Hannah, J. C. Butler. (1999) Carriage of Multidrug-Resistant Streptococcus pneumoniae and Impact of Chemoprophylaxis During an Outbreak of Meningitis at a Day Care Center. Clinical Infectious Diseases 29:5, 1257-1264
CrossRef88
Candace Friedman, Marcie Barnette, Alfred S. Buck, Rosemary Ham, Jo‐Ann Harris, Peggy Hoffman, Debra Johnson, Farrin Manian, Lindsay Nicolle, Michele L. Pearson, Trish M. Perl, Steven L. Solomon. (1999) Requirements for Infrastructure and Essential Activities of Infection Control and Epidemiology in Out‐of‐Hospital Settings: A Consensus Panel Report • . Infection Control and Hospital Epidemiology 20:10, 695-705
CrossRef89
Michael E. Ernst, Erika J. Ernst. (1999) Effectively Treating Common Infections in Residents of Long-Term Care Facilities. Pharmacotherapy 19:9, 1026-1035
CrossRef90
Heikki Peltola. (1999) PROPHYLAXIS OF BACTERIAL MENINGITIS. Infectious Disease Clinics of North America 13:3, 685-710
CrossRef91
Chesley L. Richards, William R. Jarvis. (1999) Lessons from recent nosocomial epidemics. Current Opinion in Infectious Diseases 12:4, 327-334
CrossRef92
Lindsay E. Nicolle. (1999) Nosocomial pneumonia. Current Opinion in Infectious Diseases 12:4, 335-340
CrossRef93
B.E.de Galan, P.M.B.van Tilburg, M Sluijter, S.J.M Mol, R.de Groot, P.W.M Hermans, A.R Jansz. (1999) Hospital-related outbreak of infection with multidrug-resistant Streptococcus pneumoniae in the Netherlands. Journal of Hospital Infection 42:3, 185-192
CrossRef94
Pekka O. Honkanen, Timo Keistinen, Liisa Miettinen, Elja Herva, Ulla Sankilampi, Esa Läärä, Maija Leinonen, Sirkka-Liisa Kivelä, P. Helena Mäkelä. (1999) Incremental effectiveness of pneumococcal vaccine on simultaneously administered influenza vaccine in preventing pneumonia and pneumococcal pneumonia among persons aged 65 years or older. Vaccine 17:20-21, 2493-2500
CrossRef95
Suzanne F. Bradley. (1999) Issues in the Management of Resistant Bacteria in Long‐Term–Care Facilities • . Infection Control and Hospital Epidemiology 20:5, 362-367
CrossRef96
Amorn Leelarasamee, Chertsak Dhiraputra, Saowalak Hunnangkul. (1999) Severe pneumococcal infection at a Thai hospital. International Journal of Infectious Diseases 3:3, 147-152
CrossRef97
Elaine Tuomanen. (1999) Molecular and cellular biology of pneumococcal infection. Current Opinion in Microbiology 2:1, 35-39
CrossRef98
Maurice A. Mufson. (1999) Pneumococcal pneumonia. Current Infectious Disease Reports 1:1, 57-64
CrossRef99
Musher, Daniel M., . (1998) Pneumococcal Outbreaks in Nursing Homes. New England Journal of Medicine 338:26, 1915-1916
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