We defined IPD patients as those from whom S. pneumoniae was isolated from a normally sterile body site such as cerebrospinal fluid (CSF), blood, or pleural fluid. Within 24 hours after admission, the hospital collects CSF specimens from patients with suspected meningitis, defined as acute onset of fever with change in mental status, meningeal signs (e.g., neck stiffness, headache), or both; blood cultures from patients with a temperature of >39.0°C; and pleural fluid from patients with suspected effusion detected in chest radiography or computed tomography scan. The specimens were sent to the laboratory at SCH for bacterial culture <2 hours after collection according to the standard methods of collection, transport, and culturing (7). Laboratory physicians identified isolates as S. pneumoniae by morphologic features, α-hemolysis, Gram staining, and bile solubility or optochin susceptibility using Oxoid Optochin Discs (Thermo Fisher Scientific, https://www.thermofisher.com).

We collected the S. pneumoniae–positive isolates from SCH and sent them to the Key Laboratory of Public Health Safety at Fudan University, Shanghai, for serotyping. We identified the serotypes of pneumococcal isolates using the Quellung reaction with antisera (Statens Serum Institute, https://en.ssi.dk), a multiplex PCR described previously (15), or both.

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