Secondary pulmonary syphilis: Case report and review of literature.

INTRODUCTION: Syphilis is a sexually transmitted disease that can affect numerous organs in its secondary or tertiary stages. We describe a case of secondary syphilis with pulmonary involvement and we present a literature review. PATIENTS AND METHODS: A 69-year-old male patient was admitted to hospital for dyspnoea and extended papular exanthema with palmoplantar involvement. The serological test for syphilis was positive. Ocular examination showed bilateral papillitis and retinal haemorrhage. Chest radiography revealed an interstitial alveolar infiltrate predominantly in the upper lobes, mild pleural effusion and hilar adenopathy. These infiltrates were slightly hypermetabolic on PET scan suggesting inflammatory or infectious origin. Treatment with intravenous penicillin G was effective on cutaneous, ocular and pulmonary manifestations. DISCUSSION: Lung involvement in secondary syphilis is poorly known and rarely described. We found 27 cases of pulmonary syphilis reported in English and the main European languages since 1967. Mean age at diagnosis was 46 years with clear male predominance (89%). HIV co-infection was declared in 5 cases. Treponema pallidum was found in 6 patients using PCR on bronchoalveolar lavage (BAL) (3 patients) or on a lung biopsy (1 patient), immunohistochemistry (IHC) on BAL (1 patient) and Giemsa staining on a pleural fluid sample (1 patient). Chest X-rays may show unilateral or bilateral infiltrates or nodules with or without pleural effusion or hilar adenopathy. Sub-pleural involvement is frequent and penicillin is the treatment of choice. CONCLUSION: Pulmonary syphilitic involvement should be suspected where pulmonary symptoms or radiological changes occur in secondary syphilis. IHC, special staining or PCR on BAL, pleural fluid or lung tissue are useful for the identification of spirochetes.

[Nicolau livedoid dermatitis with severe neurological involvement in a child]. / Dermite livédoïde de Nicolau avec atteinte neurologique sévère chez un enfant.

BACKGROUND: Nicolau syndrome is a rare condition consisting in tissue ischemia and necrosis following intramuscular, intra-articular or subcutaneous injection. PATIENTS AND METHODS: Immediately after gluteal intramuscular injection of benzathine-penicillin, a 10-year-old male child presented an extensive painful violaceous lesion on the left buttock associated with urinary incontinence and left lower-limb paresis. Additional underlying muscular damage was supported by high serum levels of creatine kinase and lactate dehydrogenase. Treatment was based on fluid expansion, intravenous steroids and anticoagulants, resulting in improvement of cutaneous and muscular lesions. Improvement in terms of neurological dysfunction was obtained after regular neuromuscular rehabilitation. DISCUSSION: This case underlines the need to prevent Nicolau syndrome by means of compliance with the technical recommendations for intramuscular injections.

Syphilis diagnosis and serological response to Benzathine Penicillin G among patients attending HIV clinics in N'Djaména, Chad.

BACKGROUND: Syphilis is endemic in the Sub-Saharan zone and disproportionately affects at-risk populations such as men who have sex with men, sex workers and HIV infected individuals. In this study, we measure the impact of syphilis among people living with HIV in the Republic of Chad, where no data are currently available. METHOD: Outpatients attending 2 HIV clinics in N'Djamena, Republic of Chad, were tested for syphilis. Subjects who tested positive for both non-treponemal (VDRL) and treponemal (TPHA) received a single dose of Benzathine Penicillin G, 2.4 MU. An additional VDRL test was performed 6 months after treatment to ensure appropriate serological response. RESULTS: Of 207 patients included, 29 (14%) tested positive for VDRL at the first visit, with moderate/low antibody titers (ranging from 1/2 to 1/8); 24 (82.6%) of these had treponemal immunization confirmed by TPHA test. Six months after Benzathine Penicillin treatment, 22/24 of the patients (91.6%) tested negative for VDRL, and 2 showed a 4-fold titer decline. CONCLUSION: This first study in the Republic of Chad suggests that syphilis infection is frequent among people living with HIV in this country. Systematic screening of syphilis should be considered in this population.

[Reached multifocal secondary syphilis: A case presentation]. / Atteinte plurifocale de syphilis secondaire: présentation d'un cas.

INTRODUCTION: Syphilis is a sexually transmitted infection (STI) related to Treponema pallidum. Secondary syphilis is the blood-borne systemic spread of Treponema. OBSERVATION: We report the case of secondary syphilis in a patient without risk of STIs factor. The clinical picture began with a genital affection followed by oral erosions and ulcers and an anterior and then posterior uveitis. Serology established the diagnosis and intravenous penicillin G treatment allowed for healing. DISCUSSION: Called the "great pretender" because of its clinical polymorphism, secondary syphilis can lead to formidable neurological and ophthalmological complications. Serological diagnosis is based on the use of treponemal and a nontreponemal tests. Penicillin G remains the treatment of choice and must be adapted according to the clinical damage.

[Soft palate perforation during endemic syphilis, a case study]. / Perforation du palais mou au cours de la syphilis endemique (un cas).

The authors report a case of soft palate perforation during endemic syphilis. The diagnosis of endemic syphilis was based on the absence of factor in favor of venereal syphilis, highly positive results suggesting VDRL/TPHA association, histology of velar perforation banks and the satisfactory response with closure of the perforation velar after 4 weeks of treatment with Benzathine benzylpenicillin.

Les auteurs rapportent un cas de perforation du palais mou au cours de la syphilis endémique. Le diagnostic de la syphilis endémique a été posé sur la base de l'absence de facteurs enfaveur de la syphilis vénérienne, du résultat fortement positif du couplage VDRL/TPHA, des données de l'histologie des berges de la perforation et de la réponse satisfaisante avec la fermeture vélaire à 4 semaines de traitement par benzathine Benzyle Pénicilline.

[Ocular syphilis: A retrospective study of 27 cases in Nantes University Hospital (France) from 2000 to 2013]. / Syphilis oculaire: étude rétrospective de 27 cas au CHU de Nantes (France) de 2000 à 2013.

INTRODUCTION: Syphilis may manifest as several distinct ophthalmological forms. The main objective of our study was to describe the diagnostic, therapeutic data and prognosis of ocular syphilis. PATIENTS AND METHODS: We retrospectively analysed the cases of syphilitic uveitis diagnosed in the University Hospital of Nantes between 2000 and 2013. RESULTS: Twenty-seven patients were included in our study. Their mean age was 53.1 years. Bilateral uveitis was the most frequent clinical presentation (67%). The average diagnostic delay after the first symptoms was 2.8 months. Three patients (11%) presented with an anterior uveitis and 24 (89%) with a posterior uveitis, panuveitis or papillitis. The most frequent clinical signs were papillar lesion (44%), multifocal choroiditis (33%) and chorio-retinitis (37%). Ninety-three percent of the patients were treated with benzathine penicillin intravenously, one patient was treated by intramuscular penicillin injections and another by ceftriaxone intramuscularly. Ocular manifestations alone were sufficient to make the diagnosis of syphilis in 25 patients (93%) and of HIV seroconversion in 3 patients (11%). Forty-one percent of the patients benefited from an adjuvant therapy with corticosteroids. The treatment allowed a visual improvement of -0.48 log MAR (P<0.0001) with an average reduction of retinal central thickness of 70.2 µm (P=0.33). CONCLUSION: We did not find a significant difference neither in management nor in results between the HIV seropositive and HIV seronegative groups. Others studies remains controversial about this aspect. The increased frequency of ocular manifestation as well as the increase of syphilis makes systematic screening in uveitis of a great value.

Tolerability of intracameral cefuroxime during cataract surgery in case of penicillin allergy.

INTRODUCTION: Since the results of the ESCRS study in 2007 and then the AFSSAPS recommendations of 2011, postoperative endophthalmitis prophylaxis in cataract surgery has evolved toward intracameral cefuroxime. Penicillin allergy is frequent and is not considered as a contra-indication to cefuroxime injection, but cross-reactions do exist. The goal of this study was to assess the tolerability of intracameral cefuroxime in patients with a penicillin allergy. MATERIALS AND METHODS: In this monocentric open prospective study, adult patients undergoing cataract surgery and declaring themselves penicillin-allergic were included. A subcutaneous test of cefuroxime was performed preoperatively. If negative, patients received the intracameral injection of cefuroxime at the conclusion of the surgical procedure. The primary assessment criteria, evaluated on the day after the surgery, was the occurrence of allergic reactions. RESULTS: Forty-eight eyes of 40 patients, 72 ± 8 years old, were included. Forty-three skin tests were performed: 1 was positive and one was unreliable. Thirty-six patients were examined in our center the day after the surgery: 2 presented a conjunctival allergic reaction. No severe anaphylactic reaction was reported. DISCUSSION: Of our patients, 95.3% declaring a penicillin allergy had a negative pre-operative cefuroxime test. According to literature, 80 to 90% of presumed penicillin allergic patients would not actually be allergic to cefuroxime. In our population, we reported 2 benign conjunctival cross-reactions. CONCLUSION: Intracameral cefuroxime injection during cataract surgery seems well-tolerated in penicillin-allergic patients with a negative preoperative skin test.

Pediatric invasive pneumococcal disease in Senegal.

OBJECTIVES: We aimed to describe the clinical, epidemiological, and outcome characteristics of IPD case patients hospitalized at the Albert-Royer National Children's Hospital (French acronym CHNEAR) to evaluate the disease burden of IPDs in a pediatric hospital of Dakar (Senegal). PATIENTS AND METHODS: All children aged 0-15 years hospitalized at the CHNEAR between January 1st, 2008 and December 31st, 2013 for a documented IPD were included in the study. Medical history, risk factors, clinical, bacteriological, and outcome data was collected. Data was then analyzed using the SPSS software, version 16 (Pearson's Chi(2) test: a P-value<0.05 was considered statistically significant). RESULTS: A total of 218 IPD patients were hospitalized at the CHNEAR during the study period (hospital prevalence: 0.79%). The mean age was 36.1 months. The male to female ratio was 1.27 (122 boys and 96 girls). Infants<2 years of age represented 61.46% of patients. Prior antibiotic therapy was found in 54% of patients but details were lacking. Infection sites were mostly meningeal (61%) and pleuropulmonary (28.9%). The main isolated serotypes were 1, 6A, 14, 5, and 23F. Case fatality was 17.4% and it was five times higher for pneumococcal meningitis. CONCLUSION: IPDs are very common in children in Senegal. Infants<2 years of age are particularly affected. The very high case fatality (17%) was significantly associated with meningeal infection sites hence the need for better access to pneumococcal vaccines.

Sífilis por "exposição normal" e inoculação: um médico da equipe do estudo Tuskegee na Guatemala, 1946-1948 / Syphilis from "normal exposure" and inoculation: a physician on the Tuskegee Study Team in Guatemala, 1946-1948 / La syphilis par 'exposition normale' et par inoculation: un médecin de l'équipe d'étude Tuskegee au Guatemala, 1946-1948 / Sífilis por 'exposición normal' e inoculación: un médico del equipo de la investigación Tuskegee en Guatemala, 1946-1948

Entre 1946 e 1948, o Serviço de Saúde Pública dos Estados Unidos (PHS) e a Oficina Sanitária Panamericana, com a colaboração de funcionários de saúde pública do governo da Guatemala, realizaram um estudo sobre o uso da penicilina como possível profilaxia para a sífilis, gonorreia e cancro. Os "sujeitos" do estudo - prisioneiros, doentes mentais e soldados gualtematecos foram inoculados com essas doenças e também pelo contato com prostitutas infectadas. A fraude foi parte do estudo e os abusos éticos foram discutidos no PHS. Os resultados do estudo não foram publicados.(AU)

Between 1946 and 1948, the United States Public Health Service and the PanAmerican Sanitary Office, in cooperation with public health officials of the Guatemalan government, conducted a study on the use of penicillin as a possible prophylaxis for syphilis, gonorrhea and cancer. The "subjects" of the study (prisoners, mental patients and Guatemalan soldiers) were inoculated with these diseases and also acquired them through contact with infected prostitutes. The fraud was part of the study and ethical abuses were discussed at the US Public Health service. The study results were not published.(AU)

Entre 1946 et 1948, le Public Health Service des États-Unis (PHS) et l'Oficina Sanitaria Panamericana, en collaboration avec les responsables de la santé publique du gouvernement guatémaltèque, ont mené une étude sur l'utilisation de la pénicilline à titre préventif contre la syphilis, la gonorrhée et le cancer. Les sujets de l'étude - des prisonniers, des malades mentaux et des soldats guatémaltèques - ont été inoculés directement avec ces maladies, ainsi que par contact avec des prostituées infectées. Cette fraude était partie intégrale de l'étude, dont les abus éthiques ont été discutés par le PHS. Les résultats de l'étude n'ont jamais été publiés.(AU)

Entre 1948 y 1948, El Servicio de Salud Pública de los Estados Unidos (PHS) y la Oficina Sanitaria Panamericana, con la colaboración de funcionarios de la salud pública del gobierno de Guatemala realizaron un estudio sobre el uso de la penicilina como una profilaxis posible para el sífilis, gonorrea y cancro. Los "sujetos" del estudio - prisioneros, enfermos mentales y soldados guatemaltecos, fueron inoculados con esas enfermedades y también a través del contacto con prostitutas infectadas. El fraude fue parte del estudio y los abusos éticos fueron discutidos en el PHS. Los resultados del estudio no fueron publicados.(AU)

Sífilis por "exposição normal" e inoculação: um médico da equipe do estudo tuskegee na guatemala, 1946-1948 / Syphilis from "normal exposure" and inoculation: a physician on the tuskegee study team in guatemala, 1946-1948 / La syphilis par 'exposition normale' et par inoculation: un médecin de l'équipe d'étude tuskegee au guatemala, 1946-1948 / Sífilis por 'exposición normal' e inoculación: un médico del equipo de la investigación tuskegee en guatemala, 1946-1948

Entre 1946 e 1948, o Serviço de Saúde Pública dos Estados Unidos (PHS) e a Oficina Sanitária Panamericana, com a colaboração de funcionários de saúde pública do governo da Guatemala, realizaram um estudo sobre o uso da penicilina como possível profilaxia para a sífilis, gonorreia e cancro. Os "sujeitos" do estudo - prisioneiros, doentes mentais e soldados gualtematecos foram inoculados com essas doenças e também pelo contato com prostitutas infectadas. A fraude foi parte do estudo e os abusos éticos foram discutidos no PHS. Os resultados do estudo não foram publicados.

Between 1946 and 1948, the United States Public Health Service and the PanAmerican Sanitary Office, in cooperation with public health officials of the Guatemalan government, conducted a study on the use of penicillin as a possible prophylaxis for syphilis, gonorrhea and cancer. The "subjects" of the study (prisoners, mental patients and Guatemalan soldiers) were inoculated with these diseases and also acquired them through contact with infected prostitutes. The fraud was part of the study and ethical abuses were discussed at the US Public Health service. The study results were not published.

Entre 1946 et 1948, le Public Health Service des États-Unis (PHS) et l'Oficina Sanitaria Panamericana, en collaboration avec les responsables de la santé publique du gouvernement guatémaltèque, ont mené une étude sur l'utilisation de la pénicilline à titre préventif contre la syphilis, la gonorrhée et le cancer. Les sujets de l'étude - des prisonniers, des malades mentaux et des soldats guatémaltèques - ont été inoculés directement avec ces maladies, ainsi que par contact avec des prostituées infectées. Cette fraude était partie intégrale de l'étude, dont les abus éthiques ont été discutés par le PHS. Les résultats de l'étude n'ont jamais été publiés.

Entre 1948 y 1948, El Servicio de Salud Pública de los Estados Unidos (PHS) y la Oficina Sanitaria Panamericana, con la colaboración de funcionarios de la salud pública del gobierno de Guatemala realizaron un estudio sobre el uso de la penicilina como una profilaxis posible para el sífilis, gonorrea y cancro. Los "sujetos" del estudio - prisioneros, enfermos mentales y soldados guatemaltecos, fueron inoculados con esas enfermedades y también a través del contacto con prostitutas infectadas. El fraude fue parte del estudio y los abusos éticos fueron discutidos en el PHS. Los resultados del estudio no fueron publicados.

Serotipos de Streptococcus pneumoniae en Cuba y progresión de la resistencia a la penicilina / Streptococcus pneumoniae serotypes in Cuba and progression of resistance to penicilina

INTRODUCCIÓN: en Cuba, a partir de 2006, ha sido difícil establecer la incidencia real de las meningitis bacterianas y otras enfermedades invasivas por Streptococcus pneumoniae, como consecuencia del bajo porcentaje de aislamiento e identificación de este agente en la red de laboratorios de microbiología del país. OBJETIVO: alertar sobre la necesidad de revitalizar la vigilancia activa de la enfermedad neumocócica invasiva, epidemiológica y microbiológica, fundamentalmente las meningitis y neumonías, en la etapa previa a la vacunación. MÉTODOS: se compararon la circulación de los serogrupos/serotipos capsulares y la susceptibilidad a penicilina de los aislamientos de S. pneumoniae responsables de infecciones invasivas, en dos períodos de la vigilancia: años 1994-2006 y 2007-2009. RESULTADOS: los serogrupos más frecuentes fueron: 3, 6, 7, 9, 14, 17, 18, 19, 20 y 23, pero se constató durante el segundo período de estudio, la circulación de otros no contenidos en las vacunas conjugadas disponibles comercialmente (serogrupo 15) y asociados a resistencia a antimicrobianos (serotipo 5). Por otra parte, se puso de manifiesto un incremento de la resistencia a la penicilina. CONCLUSIONES: para garantizar una alta efectividad con la inclusión en el calendario de vacunación infantil en Cuba, de alguna de las vacunas conjugadas contra S. pneumoniae, se impone el estudio de un número más representativo de aislamientos. Esto también permitirá hacer una correcta evaluación de la tendencia al incremento de la resistencia a la penicilina y adoptar guías de tratamiento adecuadas en el medio cubano (AU)

INTRODUCTION: since 2006 in Cuba, there has been difficult to determine the actual incidente of bacterial meningitis and other invasive diseases caused by Streptococcus pneumoniae, as a result of the low percentage of isolation and identification of this agent in the domestic microbiology lab network. OBJECTIVE: to warn of the need of revitalizing the active surveillance of invasive, epidemiological and microbiological pneumoccocic diseases, mainly meningitis and pneumoniae in the phase prior to vaccination. METHODS: a comparison was made on the circulation of capsulary serogroups/serotypes and the invasive infection-causing S. pneumoniae isolates susceptibility to penicilline in two periods: 1994-2006 and 2007-2009. RESULTS: the most frequent serogroups were 3, 6, 7, 9, 14, 17, 18, 19, 20 and 23; however, in the second period, it was observed that others not contained in the available conjugate vaccines (serogrup 15) and associated to antimicrobial resistance (serotype 5) were circulating. On the other hand, increased resistance to penicilline was evident. CONCLUSIONS: it is required to study a more representative number of isolates in order to assure high effectiveness with the incorporation of some S. pneumoniae conjugate vaccines in the Cuban infant vaccination schedule. This will also allow duly assessing increased resistance to penicilline and adopting therapeutical guidelines suited to the Cuban setting (AU)

Serotipos de Streptococcus pneumoniae en Cuba y progresión de la resistencia a la penicilina / Streptococcus pneumoniae serotypes in Cuba and progression of resistance to penicilina

INTRODUCCIÓN: en Cuba, a partir de 2006, ha sido difícil establecer la incidencia real de las meningitis bacterianas y otras enfermedades invasivas por Streptococcus pneumoniae, como consecuencia del bajo porcentaje de aislamiento e identificación de este agente en la red de laboratorios de microbiología del país. OBJETIVO: alertar sobre la necesidad de revitalizar la vigilancia activa de la enfermedad neumocócica invasiva, epidemiológica y microbiológica, fundamentalmente las meningitis y neumonías, en la etapa previa a la vacunación. MÉTODOS: se compararon la circulación de los serogrupos/serotipos capsulares y la susceptibilidad a penicilina de los aislamientos de S. pneumoniae responsables de infecciones invasivas, en dos períodos de la vigilancia: años 1994-2006 y 2007-2009. RESULTADOS: los serogrupos más frecuentes fueron: 3, 6, 7, 9, 14, 17, 18, 19, 20 y 23, pero se constató durante el segundo período de estudio, la circulación de otros no contenidos en las vacunas conjugadas disponibles comercialmente (serogrupo 15) y asociados a resistencia a antimicrobianos (serotipo 5). Por otra parte, se puso de manifiesto un incremento de la resistencia a la penicilina. CONCLUSIONES: para garantizar una alta efectividad con la inclusión en el calendario de vacunación infantil en Cuba, de alguna de las vacunas conjugadas contra S. pneumoniae, se impone el estudio de un número más representativo de aislamientos. Esto también permitirá hacer una correcta evaluación de la tendencia al incremento de la resistencia a la penicilina y adoptar guías de tratamiento adecuadas en el medio cubano (AU)

INTRODUCTION: since 2006 in Cuba, there has been difficult to determine the actual incidente of bacterial meningitis and other invasive diseases caused by Streptococcus pneumoniae, as a result of the low percentage of isolation and identification of this agent in the domestic microbiology lab network. OBJECTIVE: to warn of the need of revitalizing the active surveillance of invasive, epidemiological and microbiological pneumoccocic diseases, mainly meningitis and pneumoniae in the phase prior to vaccination. METHODS: a comparison was made on the circulation of capsulary serogroups/serotypes and the invasive infection-causing S. pneumoniae isolates susceptibility to penicilline in two periods: 1994-2006 and 2007-2009. RESULTS: the most frequent serogroups were 3, 6, 7, 9, 14, 17, 18, 19, 20 and 23; however, in the second period, it was observed that others not contained in the available conjugate vaccines (serogrup 15) and associated to antimicrobial resistance (serotype 5) were circulating. On the other hand, increased resistance to penicilline was evident. CONCLUSIONS: it is required to study a more representative number of isolates in order to assure high effectiveness with the incorporation of some S. pneumoniae conjugate vaccines in the Cuban infant vaccination schedule. This will also allow duly assessing increased resistance to penicilline and adopting therapeutical guidelines suited to the Cuban setting (AU)

Serotipos de Streptococcus pneumoniae en Cuba y progresión de la resistencia a la penicilina / Streptococcus pneumoniae serotypes in Cuba and progression of resistance to penicilina

INTRODUCCIÓN: en Cuba, a partir de 2006, ha sido difícil establecer la incidencia real de las meningitis bacterianas y otras enfermedades invasivas por Streptococcus pneumoniae, como consecuencia del bajo porcentaje de aislamiento e identificación de este agente en la red de laboratorios de microbiología del país. OBJETIVO: alertar sobre la necesidad de revitalizar la vigilancia activa de la enfermedad neumocócica invasiva, epidemiológica y microbiológica, fundamentalmente las meningitis y neumonías, en la etapa previa a la vacunación. MÉTODOS: se compararon la circulación de los serogrupos/serotipos capsulares y la susceptibilidad a penicilina de los aislamientos de S. pneumoniae responsables de infecciones invasivas, en dos períodos de la vigilancia: años 1994-2006 y 2007-2009. RESULTADOS: los serogrupos más frecuentes fueron: 3, 6, 7, 9, 14, 17, 18, 19, 20 y 23, pero se constató durante el segundo período de estudio, la circulación de otros no contenidos en las vacunas conjugadas disponibles comercialmente (serogrupo 15) y asociados a resistencia a antimicrobianos (serotipo 5). Por otra parte, se puso de manifiesto un incremento de la resistencia a la penicilina. CONCLUSIONES: para garantizar una alta efectividad con la inclusión en el calendario de vacunación infantil en Cuba, de alguna de las vacunas conjugadas contra S. pneumoniae, se impone el estudio de un número más representativo de aislamientos. Esto también permitirá hacer una correcta evaluación de la tendencia al incremento de la resistencia a la penicilina y adoptar guías de tratamiento adecuadas en el medio cubano.

INTRODUCTION: since 2006 in Cuba, there has been difficult to determine the actual incidente of bacterial meningitis and other invasive diseases caused by Streptococcus pneumoniae, as a result of the low percentage of isolation and identification of this agent in the domestic microbiology lab network. OBJECTIVE: to warn of the need of revitalizing the active surveillance of invasive, epidemiological and microbiological pneumoccocic diseases, mainly meningitis and pneumoniae in the phase prior to vaccination. METHODS: a comparison was made on the circulation of capsulary serogroups/serotypes and the invasive infection-causing S. pneumoniae isolates susceptibility to penicilline in two periods: 1994-2006 and 2007-2009. RESULTS: the most frequent serogroups were 3, 6, 7, 9, 14, 17, 18, 19, 20 and 23; however, in the second period, it was observed that others not contained in the available conjugate vaccines (serogrup 15) and associated to antimicrobial resistance (serotype 5) were circulating. On the other hand, increased resistance to penicilline was evident. CONCLUSIONS: it is required to study a more representative number of isolates in order to assure high effectiveness with the incorporation of some S. pneumoniae conjugate vaccines in the Cuban infant vaccination schedule. This will also allow duly assessing increased resistance to penicilline and adopting therapeutical guidelines suited to the Cuban setting.