Nasopharyngeal samples were obtained as previously described (9). In brief, we used a flexible Dacron-tipped swab, introduced through the nostrils. These swabs were inoculated into modified Stewart transport medium (Medical Wire and Equipment Co., Ltd, https://www.mwe.co.uk) and were processed within 16 hours at SUMC’s clinical microbiology laboratory. Material from swabs was plated on Columbia agar with 5% sheep blood and 5.0 mg/mL gentamicin and incubated for 48 h.

We presumptively identified S. pneumoniae on the basis of the presence of α-hemolysis and inhibition by optochin; we confirmed the identity of the bacteria present by a positive slide agglutination test result (Phadebact; MKL Diagnostics AB, http://www.mkldiagnostics.com).

We enrolled in the study all patients <24 months of age who received a diagnosis of conjunctivitis from pediatricians at SUMC or at the primary clinical service in southern Israel and whose conjunctival swabs were cultured at SUMC’s clinical microbiology laboratory and grew S. pneumoniae. Swabbing methods were described previously (15). Specimen swabs were placed in transport medium and were processed in a similar manner to the nasopharyngeal swabs.

Specimen swabs were sent in transport medium. They were processed in a similar manner to the nasopharyngeal and conjunctival swabs.

Pneumococcal isolates from blood and CSF were initially identified by each center using local standard procedures as described previously (14,16).

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