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The results of typing pneumococci from sputum from 450 cases of pneumonia among infants and children
T H E I~ESULTS OF TYPING PNEUMOCOCCI FROM SPUTUM FROM 450 CASES OF PNEUMONIA AMONG INFANTS 2~ND C H I L D R E N W. J. AUGER, M.D. TORONTOj ONTARIO
N G the past year sputum from all the pneumonia cases admitted D Utog Ithe wards of the Hospital for Sick Children has been examined. The sputum was obtained in most cases from the nasopharynx by means of the suction ntethod. 1 I t was examined directly by stained smear and by the Neufeld technique for typing pneumoeocei. Furt her examination included the culturing of suitable particles on a blood agar plate and mouse inoculation. I f no pneumoeocci were to be found directly in the nasopharynx, sputum was then obtained from the larynx, again by means of suction. We have found the nasopharyngeal secretions ideal for typing pneumococci in cases of early severe pneumonia in children, and where confirmation of the type of pneumocoeeus found in the sputum was possible by examination of either pleural exudate, blood culture, or post-mortem lung culture, this method has bee~t found aeem'ate in about 90 per cent of the eases. From Sept. 8, 1938, until June 8, 1939, sputum from 450 pneumonia eases has been examined. In each of these eases a clinical diagnosis of pneumonia was made by a member of the attending m e d i c i staff and checked by x-ray. No attempt was made to differentiate lobar from bronehopneumonia. In addition, a special Study was made of the eases of Type I pneumonia among children. During the winter months of 1937-38 our incidence of Type I pneumonia was 30 per cent, and of these about onefourth developed empyema. This has already been observed by other authors.2, a It was hoped that, by early diagnosis followed by prompt serum or chemical therapy, information might be obtained as to the means of prevention of this serious complication. These results have been tabulated and briefly discussed. TABLE I
SHOWING THE INCIDENCE OF PATHOGENIC OgGANISMS IN PNE,UR[ONIA SPUTA ]~RONI SEPT. 8, 1938 TO J U N E 8, 1939 CASES OF U n d e r 2 yr. Over 2 yr. Total
PNEUM0"
PNEUMONIA
COCCI
286 264 450
141 234 375 83.3%
MOEE T~IAN S TI~EP. O N E TYPE HE~CIOLYTPNEUMO.
32 57 89
ICUS
49 50 99 22.0%
STAPI-I.
B. INFLU-
AUgEUS
ENZAE
49 22 71 15.8%
22 24 46 10.2%
F e l l o w in the B a n t i n g R e s e a r c h F o u n d a t i o n e n g a g e d in pne umoni a r e s e a r c h in t he D e p a r t m e n t of P a t h o l o g y and B a c t e r i o l o g y a t the H o s p i t a l for Sick Children, 646
AUGER:
TYPING
647
P N E U M O C O , C C I FR,O,1Vs S P U T U M RESULTS
Table I shows the incidence of the main pathogenic organisms found in the s p u t u m f r o m 450 eases. The pathogenic organisms other than pneumoeoeei have also been recorded when they occurred in suffleient numbers to be a likely etiological agent of the pneumonia. Pneumoeocei were present in 375 (83.3 per cent) of s p u t a and of these 375 specimens, 89 (23.7 per cent) contained more t h a n one type of pneumoeoccus in the same sputum. Of these 23.7 per cent with more t h a n one type of pneumoeoccus, in half of them the e x t r a t y p e could be f o u n d by direct examination while in the other cases the extra t y p e or types were picked up a f t e r passage through a mouse. Three types of pneumoeoeei on direct examination were only found in one sputum, that of an infant. The problem of deciding which is the likely pathogen when two or more types of pneumoeoeei are present in the same s p u t u m m a y be v e r y difficult. However, one of these types is usually virulent while any other t y p e present is likely acting in the role of a mouth organism. F o r instance, if T y p e I, I I , or V is f o u n d in a sputum, a n y other type also f o u n d in the same s p u t u m can be ignored since these three types, in our experience, are always the cause of the pneumonia. I t is interesting to note the relatively high incidence of Staphylococcus aureus in the 0-2 y e a r age group as compared to the 2 year a n d older age group. This will be reflected in the m o r t a l i t y table. TABLE II SHOWING THE :PvESULTS 0F EARLY TYPE I PNEU1VIONIA CASES TI~EATED IN" SERIES F ~ O ~ OCT. 19, 1 9 3 8 TO J U N E 8, 1 9 3 9 GROUP
NO. OF CASES
Control Serum trea%ed Sulfapyridlne treated Total
25 25 24 74
EMPYEN[A 5 4 2 11
% EI~PYEIvfAS 20.0 16.0 8.3 14.9
SURGICIAL DRAINAGE 5 4 1 10
DEATHS 0 1~ 0 ]
*Died following a bilateral rib resection.
While the t y p i n g of pneumonia eases commenced Sept. 8, 1938, the t r e a t m e n t of T y p e I pnemnonia eases in series did not start until October 19, p a r t l y due to the difficulty in obtaining sulfapyridine. A f t e r this period we were able to diagnose and t r e a t serially 74 eases of early T y p e I pneumonia according to the following plan. The early Type I pneumonia cases were divided serially into three groups. Group 1 was used as a control group, receiving no serum or sulfapyridine. Group 2 received antipneumoeoceic rabbit serum. Group 3 received sulfapyridine. The other T y p e I p n e u m o n i a eases (21) not included in the series were those eases either with e m p y e m a on admission or with a history of pneumonia eight days or longer before admission. I n addition, there were four eases which were not included in the series because of error in diagnosisl on admission.
648
THE JOURNAL OF PEDIATRICS
The results indicate a 20 per cent chance of a child with early Type I pneumonia developing empyema. This high incidence was only slightly lowered with serum but was considerably lower in the group treated with sulfapyridine. While this series is too small to arrive at any conclusions, still sulfapyridine seems to have lowered the empyema incidence. Based on this one ray of hope, future treatment should depend on either sulfapyridine alone or sulfapyridine in conjunction with serum therapy with a view to reducing the incidence of Type I empyema to a minimum. The importance of this problem is indicated by the fact that from Sept. 8, 1938, there were 375 eases of sputa with pneumoeocei present of which 105 (28.0 per cent) were Type I. Of these 105 eases of both early and late pneumonia 29 (27.6 per cent) developed empyema. Also it should be stated that 80.6 per cent of the pneumoeoccie empyemas were Type I. TABLE
IIl
INCIDENCE OF IMPOI~TANT TYPES OF PNEUh~OOOCCI OCCUI~I~INGSINGLY IN PNEUMONIA SPUTU~f FI~01V~ SEPT. 8, ].935 TO JUNE 8~ 1939
I U n d e r 2 yr. Over 2 yr. Total %
109 177 286
II
IIl
3 0 6 76 16 9 79 16 15 27.0 5.6 5.2
IV
u XIV
XVIII XlX
3 6 9 3.1
6 12 3 10 9 22 3.1 7.7
6 6 12 4.2
14 11 25 8.7
XXIII UTP 6 6 12 4.2
17 8 25 8.7
OTHER TYPES 36 26 62 21.7
Only the incidence of those types occurring most frequently and singly in pneumonia sputum have been included in Table III. The relative infrequency of Type I and II pneumonia among infants is in contrast with the higher types of pneumococci especially Type XIX. U T P refers to pneumoeocei which were untypable yet were bile soluble. In general Types I, XIV, X V I I I , and X I X pneumoeocci were most common. Type VI was often associated with another type of pneumococcus, and its incidence is really higher than the above figure would indicate. The pneumococei occurring with other types in the same sputum could not be included in this table without sacrificing the percentage estimate. TABLE IV ~V[OI%TALITY
I~ATE
OF I~RIMARY
~)NEUIVIONIA
OCCUI~RING
IN THE 4:50
PNEUSf0NIA CASES MIXE~
PNEUI~OCOCCUS AGE
CASES 1
GROUP CASES 0-1 yr. 41 1-2 yr. 32 2 yr. and over 170
0T~IEI~ ORGAI~IS ~S
DIED %
CASES I
DIED ~o
~r OI~TALITY
CASES
1 DIED %
14.6 3.1
50 23
28.0 8.7
30 12
40.0 8.3
121 67
27.5 6.7
2.9
63
3.2
29
10.4
262
5.5
AUGER:
TYPING PNE:U]YIOCOCCI FRO,IV[ SPUTU~I
649
I n Table I V is shown the mortality rate per age group. A postmortem examination was obtained in 75 per cent of the deaths. I n this table the p n e u m o n i a cases have been divided according to their probable bacterial etiology. " P n e u m o e o c c u s " refers to all those cases of p n e u m o n i a with pneumocoeei as the sole likely cause of the pneumonia. " M i x e d " refers to pneumococci plus another organism as the likely causative organism. The t e r m " o t h e r o r g a n i s m s " refers to cases of p n e u m o n i a likely due to some organism other t h a n the pneumoeoceus. The highest m o r t a l i t y occurred a m o n g the i n f a n t s of 0 to 1 y e a r in whom organisms other t h a n pneumocoeci were the cause of death. I n this age group 12, or 40 per cent, of the patients died, a n d of these 12 deaths, 7 (58.3 p e r cent) were due to Stcbphylococcus aureus, either solely or in combination with Streptococcus he~nolyticus or Bacillus influenza.e. The death r a t e was only 2.9 p e r cent for cases in the age group over 2 years when due to pneumococci alone. Note the rise in the death rate as other organisms are f o u n d along with the pneumococcus, but note that the highest m o r t a l i t y r a t e is f o u n d in the nonpneumococcus group. I t is interesting to note t h a t 27.5 p e r cent of the infants tinder I y e a r of age died while only 6.7 per cent of the infants between I and 2 y e a r s died and 5.5 per cent of children in the age group over 2 years died. SUMMARY
Pneumoeoeci were present in 83.3 per cent of the sputa. The most common types were I, Ill, X I X , X I V , X V I I I in children over 2 years of age, and Types X I X , X I V , and U T P ( u n t y p a b l e pneumococci) were the most common in children under 2 years of age. Of the patients with early cases of T y p e I p n e u m o n i a who received no specific treatment, 20 per cent developed empyema, while 16 per cent developed e m p y e m a with serum t h e r a p y and only 8 per cent with sulfapyridine. I t was found t h a t the m o r t a l i t y rate was very high for infants under 1 year of age especially when the p n e u m o n i a was due either to the pnemnococcus plus another pathogen or to an organism other t h a n the pneumococcus.
Staph~fioca~cus aureus was a cause of death in 58.3 per cent of infants u n d e r 1 y e a r of age when the pneumonia was due to an organism other than pneumoeoccus. REFERENCES 1. A u g e r , W. J . : J. P~DIA~. 15: 640~ ]939. 2. N e m i r , R o s a L e e : J. PEDIAT. 13: 228, 1938. 3. McC]ure, W . B . : Canad. iV[. A. J. 38: 369, 1938.
N G the past year sputum from all the pneumonia cases admitted D Utog Ithe wards of the Hospital for Sick Children has been examined. The sputum was obtained in most cases from the nasopharynx by means of the suction ntethod. 1 I t was examined directly by stained smear and by the Neufeld technique for typing pneumoeocei. Furt her examination included the culturing of suitable particles on a blood agar plate and mouse inoculation. I f no pneumoeocci were to be found directly in the nasopharynx, sputum was then obtained from the larynx, again by means of suction. We have found the nasopharyngeal secretions ideal for typing pneumococci in cases of early severe pneumonia in children, and where confirmation of the type of pneumocoeeus found in the sputum was possible by examination of either pleural exudate, blood culture, or post-mortem lung culture, this method has bee~t found aeem'ate in about 90 per cent of the eases. From Sept. 8, 1938, until June 8, 1939, sputum from 450 pneumonia eases has been examined. In each of these eases a clinical diagnosis of pneumonia was made by a member of the attending m e d i c i staff and checked by x-ray. No attempt was made to differentiate lobar from bronehopneumonia. In addition, a special Study was made of the eases of Type I pneumonia among children. During the winter months of 1937-38 our incidence of Type I pneumonia was 30 per cent, and of these about onefourth developed empyema. This has already been observed by other authors.2, a It was hoped that, by early diagnosis followed by prompt serum or chemical therapy, information might be obtained as to the means of prevention of this serious complication. These results have been tabulated and briefly discussed. TABLE I
SHOWING THE INCIDENCE OF PATHOGENIC OgGANISMS IN PNE,UR[ONIA SPUTA ]~RONI SEPT. 8, 1938 TO J U N E 8, 1939 CASES OF U n d e r 2 yr. Over 2 yr. Total
PNEUM0"
PNEUMONIA
COCCI
286 264 450
141 234 375 83.3%
MOEE T~IAN S TI~EP. O N E TYPE HE~CIOLYTPNEUMO.
32 57 89
ICUS
49 50 99 22.0%
STAPI-I.
B. INFLU-
AUgEUS
ENZAE
49 22 71 15.8%
22 24 46 10.2%
F e l l o w in the B a n t i n g R e s e a r c h F o u n d a t i o n e n g a g e d in pne umoni a r e s e a r c h in t he D e p a r t m e n t of P a t h o l o g y and B a c t e r i o l o g y a t the H o s p i t a l for Sick Children, 646
AUGER:
TYPING
647
P N E U M O C O , C C I FR,O,1Vs S P U T U M RESULTS
Table I shows the incidence of the main pathogenic organisms found in the s p u t u m f r o m 450 eases. The pathogenic organisms other than pneumoeoeei have also been recorded when they occurred in suffleient numbers to be a likely etiological agent of the pneumonia. Pneumoeocei were present in 375 (83.3 per cent) of s p u t a and of these 375 specimens, 89 (23.7 per cent) contained more t h a n one type of pneumoeoccus in the same sputum. Of these 23.7 per cent with more t h a n one type of pneumoeoccus, in half of them the e x t r a t y p e could be f o u n d by direct examination while in the other cases the extra t y p e or types were picked up a f t e r passage through a mouse. Three types of pneumoeoeei on direct examination were only found in one sputum, that of an infant. The problem of deciding which is the likely pathogen when two or more types of pneumoeoeei are present in the same s p u t u m m a y be v e r y difficult. However, one of these types is usually virulent while any other t y p e present is likely acting in the role of a mouth organism. F o r instance, if T y p e I, I I , or V is f o u n d in a sputum, a n y other type also f o u n d in the same s p u t u m can be ignored since these three types, in our experience, are always the cause of the pneumonia. I t is interesting to note the relatively high incidence of Staphylococcus aureus in the 0-2 y e a r age group as compared to the 2 year a n d older age group. This will be reflected in the m o r t a l i t y table. TABLE II SHOWING THE :PvESULTS 0F EARLY TYPE I PNEU1VIONIA CASES TI~EATED IN" SERIES F ~ O ~ OCT. 19, 1 9 3 8 TO J U N E 8, 1 9 3 9 GROUP
NO. OF CASES
Control Serum trea%ed Sulfapyridlne treated Total
25 25 24 74
EMPYEN[A 5 4 2 11
% EI~PYEIvfAS 20.0 16.0 8.3 14.9
SURGICIAL DRAINAGE 5 4 1 10
DEATHS 0 1~ 0 ]
*Died following a bilateral rib resection.
While the t y p i n g of pneumonia eases commenced Sept. 8, 1938, the t r e a t m e n t of T y p e I pnemnonia eases in series did not start until October 19, p a r t l y due to the difficulty in obtaining sulfapyridine. A f t e r this period we were able to diagnose and t r e a t serially 74 eases of early T y p e I pneumonia according to the following plan. The early Type I pneumonia cases were divided serially into three groups. Group 1 was used as a control group, receiving no serum or sulfapyridine. Group 2 received antipneumoeoceic rabbit serum. Group 3 received sulfapyridine. The other T y p e I p n e u m o n i a eases (21) not included in the series were those eases either with e m p y e m a on admission or with a history of pneumonia eight days or longer before admission. I n addition, there were four eases which were not included in the series because of error in diagnosisl on admission.
648
THE JOURNAL OF PEDIATRICS
The results indicate a 20 per cent chance of a child with early Type I pneumonia developing empyema. This high incidence was only slightly lowered with serum but was considerably lower in the group treated with sulfapyridine. While this series is too small to arrive at any conclusions, still sulfapyridine seems to have lowered the empyema incidence. Based on this one ray of hope, future treatment should depend on either sulfapyridine alone or sulfapyridine in conjunction with serum therapy with a view to reducing the incidence of Type I empyema to a minimum. The importance of this problem is indicated by the fact that from Sept. 8, 1938, there were 375 eases of sputa with pneumoeocei present of which 105 (28.0 per cent) were Type I. Of these 105 eases of both early and late pneumonia 29 (27.6 per cent) developed empyema. Also it should be stated that 80.6 per cent of the pneumoeoccie empyemas were Type I. TABLE
IIl
INCIDENCE OF IMPOI~TANT TYPES OF PNEUh~OOOCCI OCCUI~I~INGSINGLY IN PNEUMONIA SPUTU~f FI~01V~ SEPT. 8, ].935 TO JUNE 8~ 1939
I U n d e r 2 yr. Over 2 yr. Total %
109 177 286
II
IIl
3 0 6 76 16 9 79 16 15 27.0 5.6 5.2
IV
u XIV
XVIII XlX
3 6 9 3.1
6 12 3 10 9 22 3.1 7.7
6 6 12 4.2
14 11 25 8.7
XXIII UTP 6 6 12 4.2
17 8 25 8.7
OTHER TYPES 36 26 62 21.7
Only the incidence of those types occurring most frequently and singly in pneumonia sputum have been included in Table III. The relative infrequency of Type I and II pneumonia among infants is in contrast with the higher types of pneumococci especially Type XIX. U T P refers to pneumoeocei which were untypable yet were bile soluble. In general Types I, XIV, X V I I I , and X I X pneumoeocci were most common. Type VI was often associated with another type of pneumococcus, and its incidence is really higher than the above figure would indicate. The pneumococei occurring with other types in the same sputum could not be included in this table without sacrificing the percentage estimate. TABLE IV ~V[OI%TALITY
I~ATE
OF I~RIMARY
~)NEUIVIONIA
OCCUI~RING
IN THE 4:50
PNEUSf0NIA CASES MIXE~
PNEUI~OCOCCUS AGE
CASES 1
GROUP CASES 0-1 yr. 41 1-2 yr. 32 2 yr. and over 170
0T~IEI~ ORGAI~IS ~S
DIED %
CASES I
DIED ~o
~r OI~TALITY
CASES
1 DIED %
14.6 3.1
50 23
28.0 8.7
30 12
40.0 8.3
121 67
27.5 6.7
2.9
63
3.2
29
10.4
262
5.5
AUGER:
TYPING PNE:U]YIOCOCCI FRO,IV[ SPUTU~I
649
I n Table I V is shown the mortality rate per age group. A postmortem examination was obtained in 75 per cent of the deaths. I n this table the p n e u m o n i a cases have been divided according to their probable bacterial etiology. " P n e u m o e o c c u s " refers to all those cases of p n e u m o n i a with pneumocoeei as the sole likely cause of the pneumonia. " M i x e d " refers to pneumococci plus another organism as the likely causative organism. The t e r m " o t h e r o r g a n i s m s " refers to cases of p n e u m o n i a likely due to some organism other t h a n the pneumoeoceus. The highest m o r t a l i t y occurred a m o n g the i n f a n t s of 0 to 1 y e a r in whom organisms other t h a n pneumocoeci were the cause of death. I n this age group 12, or 40 per cent, of the patients died, a n d of these 12 deaths, 7 (58.3 p e r cent) were due to Stcbphylococcus aureus, either solely or in combination with Streptococcus he~nolyticus or Bacillus influenza.e. The death r a t e was only 2.9 p e r cent for cases in the age group over 2 years when due to pneumococci alone. Note the rise in the death rate as other organisms are f o u n d along with the pneumococcus, but note that the highest m o r t a l i t y r a t e is f o u n d in the nonpneumococcus group. I t is interesting to note t h a t 27.5 p e r cent of the infants tinder I y e a r of age died while only 6.7 per cent of the infants between I and 2 y e a r s died and 5.5 per cent of children in the age group over 2 years died. SUMMARY
Pneumoeoeci were present in 83.3 per cent of the sputa. The most common types were I, Ill, X I X , X I V , X V I I I in children over 2 years of age, and Types X I X , X I V , and U T P ( u n t y p a b l e pneumococci) were the most common in children under 2 years of age. Of the patients with early cases of T y p e I p n e u m o n i a who received no specific treatment, 20 per cent developed empyema, while 16 per cent developed e m p y e m a with serum t h e r a p y and only 8 per cent with sulfapyridine. I t was found t h a t the m o r t a l i t y rate was very high for infants under 1 year of age especially when the p n e u m o n i a was due either to the pnemnococcus plus another pathogen or to an organism other t h a n the pneumococcus.
Staph~fioca~cus aureus was a cause of death in 58.3 per cent of infants u n d e r 1 y e a r of age when the pneumonia was due to an organism other than pneumoeoccus. REFERENCES 1. A u g e r , W. J . : J. P~DIA~. 15: 640~ ]939. 2. N e m i r , R o s a L e e : J. PEDIAT. 13: 228, 1938. 3. McC]ure, W . B . : Canad. iV[. A. J. 38: 369, 1938.