Improvements to these methods can be made through the absorption of non-specific

reactive antibodies [117] and the use of monoclonal antibodies [124]. In the case of genotype detection, the primary limitations are the sequence diversity of the capsular loci, which can lead to target mismatches, and the inability Pifithrin �� to discriminate between closely related serotypes. The continued production of new sequence data should result in better target selection and primer/probe design that can produce results with similar sensitivity and specificity to the gold standard methods. For pure pneumococcal cultures, many methods are valid, and the most appropriate one will depend on the study setting. As such, we do not recommend a particular method over another, except to note that the particular method’s performance should be rigorously validated against the gold standard Quellung test. Serotyping pneumococci directly from the NP sample is more challenging. As mentioned in Section 11, pneumococci may be present in low numbers (leading to low sensitivity), and/or as a small proportion of the NP cells (i.e. compared with cells from other organisms or the host), leading to low specificity.

Divergent homologues see more of pneumococcal capsular genes also have been found in non-pneumococcal species [126]. Furthermore, the clinical relevance of identifying serotype-specific DNA in a culture-negative sample is not known. Serotyping of pure pneumococcal isolates using Quellung by the wet or dry method is considered the core method. Latex agglutination serotyping may also be used. Many new serotyping methods are being developed, and although some may be valid there is currently insufficient evidence to provide recommendations. Serotyping Sitaxentan directly from the NP specimen is insufficiently developed to recommend as a core

method. Assessment of the assay and clinical performance of new serotyping methods, particularly when testing directly from the NP sample is needed. Carriage of multiple pneumococcal serotypes is relatively common, particularly in areas where the carriage rate and disease burden are high [54], [112], [127] and [128]. Multiple carriage usually involves carriage of a major serotype, together with one or more minor serotype populations. Although it is clear that standard serotyping methods underestimate multiple carriage [49] and [55], the clinical and public health relevance of multiple carriage is less well established. Theoretically, detection of minor serotypes may help to predict the shift in serotype distribution through serotype replacement following pneumococcal vaccination, particularly in high burden settings [129], and allow a better understanding of how epidemic serotypes emerge in some populations.