This supplementary information is presented as submitted by the corresponding author. It has not been copy-edited by NTvG.

Following the introduction of a heptavalent pneumococcalconjugate vaccine (PCV7) in the Netherlands in 2006, the incidence of invasive pneumococcal disease (IPD) declined significantly. In the 2 years after introduction of the vaccine, the incidence of IPD in children <2 years decreased from 34 to 19,2/100.000 (44%). This is the net result of a significant reduction in vaccine-serotype IPD from 24,2 to 2,4/100.000 (90%) and an increase in non-vaccine-serotype IPD from 9,8 to 16.8/100.00 (71%). This is the same pattern that has been noted in the United States in the 5 years after introduction of this vaccine; after an initial reduction, the total net effect levelled off due to a gradual increase of non-vaccine-serotype IPD, particularly serotype 19A.

We present the case of multidrug resistant non-vaccine serotype 19A pneumococcal meningitis in a 5-month-old boy. His previous history was unremarkable, except for a recent visit to Curaçao (Dutch Antilles). He was admitted to our Pediatric Intensive Care Unit (PICU) with seizures and septic shock. Inotropic support combined with fluid challenges combated shock and seizures were controlled with diazepam bolus and intravenous midazolam. On the third day he started having seizures again. On MRI no focal lesions were seen. A barbiturate-induced coma was required to control the seizures. Blood and CSF were positive with a multidrug resistant S. pneumoniae serotype 19A. He received a six-week treatment with ceftriaxone and vancomycin. At follow-up, one year after discharge, he had unilateral deafness and minor developmental delay.

Worldwide serotype 19A is now the most common cause of IPD in children, with an increasing incidence of multidrug resistant strains. In the Netherlands, surveillance numbers do not show this global trend. Non-vaccin serotypes causing IPD in children <2 years in the Netherlands are: 7F,1, 10A,33F,19A and 22F, in decreasing order. Ninety-nine percent of the pneumococci is sensitive to penicillin. This is possibly due to restricted use of antibiotics with less selection of multidrug resistant serotypes. We suggest that our patient has become colonised with this multidrug resistant serotype 19A during his visit to Curaçao.