To limit the selection of resistant organisms, practitioners should use antibiotics in a judicious manner, and prevent infection by immunizing patients at high risk. In essence, a strategy to decrease the use of antibiotics to treat illness is to implement an intervention to decrease the rate of illness. The effectiveness of vaccination to reduce the incidence of infectious disease has been clearly demonstrated with the use of the Haemophilus influenzae type b (Hib) vaccine. Prior to its release in 1988, Hib was the most common cause of bacterial meningitis among young children. Since 1993, invasive disease caused by Hib has declined more than 95% in the United States (48). With the prevalence of invasive Streptococcus pneumoniae infections in adults and children, pneumococcal vaccine is an important method of preventing infection in high-risk populations. It is currently recommended for all persons > 65 yr of age and for those > 2 yr of age with increased risk for invasive pneumococcal disease due to chronic medical conditions. It is not recommended for children < 2 yr of age due to a lack of sufficient antibody response. Future pneumococcal vaccines will couple the polysaccharide to a carrier protein, similar to the Hib vaccine, to increase the immunogenecity (49).
Despite the recommendation for vaccination from various organizations, the vaccine is widely underutilized (50,51). The national campaign, Healthy People 2000, has the goal to increase immunizations rates to 60% of people at high risk, including those 65 or older (52). Several studies have been conducted to impact the frequency of pneumococcal vaccination in at-risk hospitalized patients (53). Chart reminders, integration of vaccine reminders and orders into the hospital computer system, and standing vaccination orders with dedicated nurses to administer the vaccine were all strategies implemented. The most effective strategy appears to be a nurse assigned to vaccinate appropriate patients under the authority of a standing order (53). In the outpatient setting, pneumococcal vaccination rates were improved using a letter reminder and physician education; however, only 28% of the at-risk population were vaccinated (53). In a Canadian study, reminder letters were associated with a $2-3 cost per additional patient vaccinated (53).
Of the 90 pneumococcal serotypes, the vaccine contains the 23 serotypes causing the majority of invasive infections in the United States, and may protect against serologically related serotypes as well (50,51). Of the seven serotypes most commonly associated with drug resistance, all but serotype 6A are found in the vaccine. Preliminary data suggests, however, that protection against serotype 6A may be present due to cross-reactivity with type 6B (54,55). Other sources state that almost 90% of intermediately susceptible isolates are serotyped in the U.S. vaccine (56,57). Despite this information, the pneumococ-cal vaccine has not been reported to reduce the prevalence of penicillin-resistant S. pneumoniae. The pneumococcal vaccine has been shown to prevent pneumococcal pneu monia in low-risk groups, but it has not been consistently effective in the prevention of otitis media in children (57). It has not been shown to consistently reduce the risk of pneumonia in the highest risk population (> 65 yr, long-term care facility residents), nor affect mortality from pneumococcal pneumonia or other pneumococcal infections in any population (58). Until the vaccine is appropriately utilized, the true efficacy in preventing common and serious pneumococcal infections will remain unknown.
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