title: Bacteremic Pneumonia before and after Withdrawal of 13-Valent Pneumococcal Conjugate Vaccine from a Public Vaccination Program in Spain: A Case-Control Study.
abstract: OBJECTIVE
  To compare the incidence and epidemiology of bacteremic community-acquired pneumonia (CAP) in the setting of changes in 13-valent pneumococcal conjugate vaccine (PCV13) coverage.
  
  
  METHODS
  In the region of Madrid, universal immunization with the PCV13 started in May 2010. In July 2012, public funding ceased. Vaccination coverage decreased from >95% to 82% in 2013 and to 67% in 2014. We performed a multicenter surveillance and case-control study from 2009-2014. Cases were hospitalized children with bacteremic CAP. Controls were children selected 1:1 from next-admitted with negative blood cultures and typical, presumed bacterial CAP.
  
  
  RESULTS
  Annual incidence of bacteremic CAP declined from 7.9/100,000 children (95% CI 5.1-11.1) in 2009 to 2.1/100,000 children (95% CI 1.1-4.1) in 2012. In 2014, 2 years after PCV13 was withdrawn from the universal vaccination program, the incidence of bacteremic CAP increased to 5.4/100,000 children (95% CI 3.5-8.4). We enrolled 113 cases and 113 controls. Streptococcus pneumoniae caused most of bloodstream infections (78%). Empyema was associated with bacteremia (P = .003, OR 3.6; 95% CI 1.4-8.9). Simple parapneumonic effusion was not associated with bacteremia. Incomplete PCV immunization was not a risk factor for bacteremic pneumonia.
  
  
  CONCLUSIONS
  High rate of PCV13 immunization was associated with decreased incidence of bacteremic CAP; this incidence increased when rate of immunization fell. Empyema (but not parapneumonic pleural effusion) was associated with bacteremia.
authors.affiliation: Pediatrics Department, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain; Clinical Department, School of Biomedicine, Universidad Europea, Madrid, Spain. Electronic address: alfredo.tagarro@salud.madrid.org.
authors.forename: Alfredo
authors.initials: A
authors.lastname: Tagarro
authors.affiliation: Pediatrics, Tropical and Infectious Diseases Department, Hospital Universitario La Paz, Madrid, Spain.
authors.forename: Andrea
authors.initials: A
authors.lastname: Benito
authors.affiliation: Microbiology Department, Laboratory BR, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain.
authors.forename: Aida
authors.initials: A
authors.lastname: Sánchez
authors.affiliation: Microbiology Department, Laboratory BR, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain.
authors.forename: Esteban
authors.initials: E
authors.lastname: Aznar
authors.affiliation: Pediatrics Department, Hospital Universitario Ramón y Cajal, Madrid, Spain.
authors.forename: Enrique
authors.initials: E
authors.lastname: Otheo
authors.affiliation: Clinical Department, School of Biomedicine, Universidad Europea, Madrid, Spain.
authors.forename: David
authors.initials: D
authors.lastname: Sanz-Rosa
mesh_terms: D016022:Case-Control Studies; D002675:Child, Preschool; D017714:Community-Acquired Infections / Q000453:epidemiology / Q000517:prevention & control; D005260:Female; D006760:Hospitalization; D006801:Humans; D017589:Immunization Programs; D015994:Incidence; D008297:Male; D011008:Pneumococcal Infections / Q000453:epidemiology* / Q000517:prevention & control*; D022242:Pneumococcal Vaccines / Q000627:therapeutic use*; D013030:Spain; D013296:Streptococcus pneumoniae
chemical_list: C538862:13-valent pneumococcal vaccine; D022242:Pneumococcal Vaccines