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Background  Respiratory syncytial virus (RSV) is an important cause of lower respiratory tract infections in infants. A small percentage of the infected infants develops a severe infection, while most of these severely ill patients were previously healthy. It remains unclear why these children develop severe RSV infections. In this study, we investigate whether pneumococcal nasopharyngeal carriage patterns correlate with mucosal inflammation and severity of disease.    Methods  In total, 105 infants hospitalized with RSV infection were included and recovery samples were taken from 42 patients. The presence and density of  Streptococcus pneumoniae  was determined by RT qPCR to study its relation to viral load, inflammation (MMP-9 and IL-6) and severity of RSV disease.    Results  We show that pneumococcal presence or absence in the nasopharynx does not correlate with viral load, inflammation or severity of disease. However, when pneumococcus is present in patients, a higher nasopharyngeal pneumococcal density was correlated with a higher RSV load, higher MMP-9 levels and a less severe course of disease.    Conclusions  Our results show correlations between  S. pneumoniae  density and viral load, inflammation and disease severity, suggesting that pneumococcal density may be an indicator for severity in paediatric RSV disease.    Electronic supplementary material  The online version of this article (doi:10.1186/s12879-016-1454-x) contains supplementary material, which is available to authorized users.

High pneumococcal density correlates with more mucosal inflammation and reduced respiratory syncytial virus disease severity in infants