Pneumococcal Infections Differential Diagnoses

  • Author: Dawn F Muench, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Nov 3, 2010
 
 

Differential Diagnoses

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Contributor Information and Disclosures
Author

Dawn F Muench, MD  Assistant Professor of Pediatrics, F Edward Herbert School of Medicine, Uniformed Services University of the Health Sciences; Clinical Assistant Professor of Pediatrics, University of Washington School of Medicine, Seattle, WA; Pediatric Infectious Disease Physician, Department of Pediatrics, Madigan Army Medical Center

Dawn F Muench, MD is a member of the following medical societies: American Academy of Pediatrics, Armed Forces Infectious Diseases Society, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Coauthor(s)

Michael Rajnik, MD  Associate Professor, Department of Pediatrics, Program Director, Pediatric Infectious Disease Fellowship Program, Uniformed Services University of the Health Sciences

Michael Rajnik, MD is a member of the following medical societies: American Academy of Pediatrics, Armed Forces Infectious Diseases Society, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Thomas E Herchline, MD  Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Director, Public Health, Dayton and Montgomery County, Ohio

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, and Infectious Diseases Society of Ohio

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Aaron Glatt, MD  Professor of Clinical Medicine, New York Medical College; President and CEO, Former Chief Medical Officer, Departments of Medicine and Infectious Diseases, St Joseph Hospital (formerly New Island Hospital)

Aaron Glatt, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Infectious Diseases Society of America, International AIDS Society, and Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

References

  1. Active Bacterial Core Surveillance (ABCs) Report; Emerging Infections Program Network; Streptococcus pneumoniae [database online]. CDC website: CDC; September 2009. Updated 2009.

  2. Committee on Infectious Diseases; American Academy of Pediatrics. Pneumococcal Infections. In: Pickering LK, Baker CJ, Long SS, McMillan JA. Red Book 2009 Report of the Committee on Infectious Diseases. 28th. American Academy of Pediatrics; 2009:525-335.

  3. Centers for Disease Control and Prevention (CDC). Invasive pneumococcal disease in children 5 years after conjugate vaccine introduction--eight states, 1998-2005. MMWR Morb Mortal Wkly Rep. Feb 15 2008;57(6):144-8. [Medline]. [Full Text].

  4. Hsu KK, Shea KM, Stevenson AE, Pelton SI,. Changing Serotypes Causing Childhood Invasive Pneumococcal Disease: Massachusetts, 2001-2007. Pediatr Infect Dis J. Nov 21 2009;[Medline].

  5. Singleton RJ, Hennessy TW, Bulkow LR, Hammitt LL, Zulz T, Hurlburt DA. Invasive pneumococcal disease caused by nonvaccine serotypes among alaska native children with high levels of 7-valent pneumococcal conjugate vaccine coverage. JAMA. Apr 25 2007;297(16):1784-92. [Medline].

  6. Ongkasuwan J, Valdez TA, Hulten KG, Mason EO Jr, Kaplan SL. Pneumococcal mastoiditis in children and the emergence of multidrug-resistant serotype 19A isolates. Pediatrics. Jul 2008;122(1):34-9. [Medline]. [Full Text].

  7. Eiland LS. Increasing Prevalence of Pneumococcal Serotype 19A Among US Children. Journal of Pharmacy Practice. 2008;21(5):356-62.

  8. Singleton RJ, Hennessy TW, Bulkow LR, Hammitt LL, Zulz T, Hurlburt DA, et al. Invasive pneumococcal disease caused by nonvaccine serotypes among alaska native children with high levels of 7-valent pneumococcal conjugate vaccine coverage. JAMA. Apr 25 2007;297(16):1784-92. [Medline].

  9. McNeil JC, Hulten KG, Mason EO Jr, Kaplan SL. Serotype 19A is the Most Common Streptococcus pneumoniae Isolate in Children With Chronic Sinusitis. Pediatr Infect Dis J. Sep 2009;28(9):766-8. [Medline].

  10. Pilishvili T, Lexau C, Farley MM, Hadler J, Harrison LH, Bennett NM, et al. Sustained reductions in invasive pneumococcal disease in the era of conjugate vaccine. J Infect Dis. 201(1);2010 Jan 1:32-41. [Medline].

  11. Centers for Disease Control and Prevention (CDC). Invasive pneumococcal disease in young children before licensure of 13-valent pneumococcal conjugate vaccine - United States, 2007. MMWR Morb Mortal Wkly Rep. Mar 12 2010;59(9):253-7. [Medline]. [Full Text].

  12. Centers for Disease Control and Prevention (CDC). Licensure of a 13-valent pneumococcal conjugate vaccine (PCV13) and recommendations for use among children - Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep. Mar 12 2010;59(9):258-61. [Medline]. [Full Text].

  13. McEllistrem MC, Adams JM, Patel K, Mendelsohn AB, Kaplan SL, Bradley JS, et al. Acute otitis media due to penicillin-nonsusceptible Streptococcus pneumoniae before and after the introduction of the pneumococcal conjugate vaccine. Clin Infect Dis. Jun 15 2005;40(12):1738-44. [Medline]. [Full Text].

  14. Poehling KA, Szilagyi PG, Grijalva CG, Martin SW, LaFleur B, Mitchel E, et al. Reduction of frequent otitis media and pressure-equalizing tube insertions in children after introduction of pneumococcal conjugate vaccine. Pediatrics. Apr 2007;119(4):707-15. [Medline].

  15. Poehling KA, Lafleur BJ, Szilagyi PG, Edwards KM, Mitchel E, Barth R, et al. Population-based impact of pneumococcal conjugate vaccine in young children. Pediatrics. Sep 2004;114(3):755-61. [Medline].

  16. Mitchell AM, Mitchell TJ. Streptococcus pneumoniae: virulence factors and variation. Clin Microbiol Infect. May 2010;16(5):411-8. [Medline].

  17. Ghaffar F, Friedland IR, McCracken GH Jr. Dynamics of nasopharyngeal colonization by Streptococcus pneumoniae. Pediatr Infect Dis J. Jul 1999;18(7):638-46. [Medline].

  18. Dagan R, Greenberg D, Jacobs MR. Pneumococcal Infections. In: Feigin RD, Cherry JD, Demmler GJ, Kaplan SL. Textbook of Pediatric Infectious Diseases. 1. 5th. Philadelphia, Pennsylvania: Saunders (Elsevier Science); 2004:1204-1258/90.

  19. Musher DM. Streptococcus pneumoniae. In: Mandell GL, Bennett JE, Dolin R. Principles and Practice of Infectious Diseases. 2. 6th. Philadelphia, Pennsylvania: Elsevier, Churchill Livingstone; 2005:197.

  20. Lynch JP 3rd, Zhanel GG. Streptococcus pneumoniae: epidemiology and risk factors, evolution of antimicrobial resistance, and impact of vaccines. Curr Opin Pulm Med. May 2010;16(3):217-25. [Medline].

  21. CDC. Streptococcus pneumoniae Disease. CDC.gov. Available at http://www.cdc.gov/ncidod/dbmd/diseaseinfo/streppneum_t.htm. Accessed December 5, 2009.

  22. CDC. 2009 H1N1 Pandemic Update: Pneumococcal Vaccination Recommended to Help Prevent Secondary Infections. CDC website: CDC; November 16, 2009. [Full Text].

  23. Centers for Disease Control and Prevention (CDC). Bacterial coinfections in lung tissue specimens from fatal cases of 2009 pandemic influenza A (H1N1) - United States, May-August 2009. MMWR Morb Mortal Wkly Rep. Oct 2 2009;58(38):1071-4. [Medline]. [Full Text].

  24. WHO Initiative for Vaccine Research Division. Acute Respiratory Infections, Streptococcus pneumoniae. World Health Organization (WHO). Available at http://www.who.int/vaccine_research/diseases/ari/en/index5.html#vaccine.

  25. National Center for Immunization and Respiratory Diseases / Division of Bacterial Diseases. ABCs Report: Streptococcus pneumoniae, PROVISIONAL 2008Active Bacterial Core Surveillance (ABCs): Emerging Infections Program Network. CDC.gov: CDC; 1 September 2009. [Full Text].

  26. Goetghebuer T, West TE, Wermenbol V, Cadbury AL, Milligan P, Lloyd-Evans N, et al. Outcome of meningitis caused by Streptococcus pneumoniae and Haemophilus influenzae type b in children in The Gambia. Trop Med Int Health. Mar 2000;5(3):207-13. [Medline]. [Full Text].

  27. Eskola J, Black S, Shinefield H. Pneumococcal conjugate vaccines. In: Plotkin SA, Orenstein WA, eds. Vaccines. 4th ed. Philadelphia, PA: Elsevier Inc; 2004:23.

  28. Scott JA. The preventable burden of pneumococcal disease in the developing world. Vaccine. Mar 22 2007;25(13):2398-405. [Medline].

  29. Fedson DS, Scott JA. The burden of pneumococcal disease among adults in developed and developing countries: what is and is not known. Vaccine. Jul 30 1999;17 Suppl 1:S11-8. [Medline].

  30. World Health Organization. Weekly Epidemiological Record. March/2007. [Full Text].

  31. WHO.INT; Immunization, Vaccines and Biologicals Division. Pneumococcal Vaccines. WHO.INT. Available at http://www.who.int/vaccines/en/pneumococcus.shtml. Accessed April 2003.

  32. Rudan I, Campbell H. The deadly toll of S pneumoniae and H influenzae type b. Lancet. Sep 12 2009;374(9693):854-6. [Medline].

  33. [Guideline] Brunton S, Carmichael BP, Colgan R, Feeney AS, Fendrick AM, Quintiliani R, et al. Acute exacerbation of chronic bronchitis: a primary care consensus guideline. Am J Manag Care. Oct 2004;10(10):689-96. [Medline].

  34. Peter G, Klein JO. Streptococcus pneumoniae. In: Long SS, Pickering LK, Prober CG, eds. Principles and Practices of Pediatric Infectious Diseases. 2nd ed. Philadelphia, PA: Churchill Livingstone (Elsevier); 2002:739-746/131.

  35. Worsoe L, Caye-Thomasen P, Brandt CT, Thomsen J, Ostergaard C. Factors associated with the occurrence of hearing loss after pneumococcal meningitis. Clin Infect Dis. Oct 15 2010;51(8):917-24. [Medline].

  36. Waddle E, Jhaveri R. Outcomes of febrile children without localising signs after pneumococcal conjugate vaccine. Arch Dis Child. Feb 2009;94(2):144-7. [Medline]. [Full Text].

  37. Stoll ML, Rubin LG. Incidence of occult bacteremia among highly febrile young children in the era of the pneumococcal conjugate vaccine: a study from a Children's Hospital Emergency Department and Urgent Care Center. Arch Pediatr Adolesc Med. Jul 2004;158(7):671-5. [Medline]. [Full Text].

  38. Bradley JS, Kaplan SL, Tan TQ, Barson WJ, Arditi M, Schutze GE, et al. Pediatric pneumococcal bone and joint infections. The Pediatric Multicenter Pneumococcal Surveillance Study Group (PMPSSG). Pediatrics. Dec 1998;102(6):1376-82. [Medline].

  39. American Academy of Pediatrics/American Academy of Family Physicians. Clinical Practice Guideline: Diagnosis and Management of Acute Otitis Media. www.aafp.org. Available at http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/clin_recs/otitismedia.Par.0001.File.dat/final_aom.pdf. Accessed March 2004.

  40. Anevlavis S, Petroglou N, Tzavaras A, Maltezos E, Pneumatikos I, Froudarakis M, et al. A prospective study of the diagnostic utility of sputum Gram stain in pneumonia. J Infect. Aug 2009;59(2):83-9. [Medline].

  41. Casado Flores J, Nieto Moro M, Berrón S, Jiménez R, Casal J. Usefulness of pneumococcal antigen detection in pleural effusion for the rapid diagnosis of infection by Streptococcus pneumoniae. Eur J Pediatr. May 2010;169(5):581-4. [Medline].

  42. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing: 18th Informational Supplement. Wayne, PA: Clinical and Laboratory Standards Institute; 2008.

  43. Centers for Disease Control and Prevention. Effects of new penicillin susceptibility breakpoints for Streptococcus pneumoniae- United States, 2006-2007. MMWR Morb Mortal Wkly Rep.: CDC; 2008. [Full Text].

  44. Cunha BA. Pneumonia Essentials. 2nd ed. Sudbury, MA: Jones & Bartlett, Publishers; 2010.

  45. Fung HB, Monteagudo-Chu MO. Community-acquired pneumonia in the elderly. Am J Geriatr Pharmacother. Feb 2010;8(1):47-62. [Medline].

  46. Johnstone J. Review: pneumococcal vaccination is not effective for preventing pneumonia, bacteraemia, bronchitis, or mortality. Evid Based Med. Aug 2009;14(4):109. [Medline].

  47. Johnstone J, Eurich DT, Minhas JK, Marrie TJ, Majumdar SR. Impact of the pneumococcal vaccine on long-term morbidity and mortality of adults at high risk for pneumonia. Clin Infect Dis. Jul 1 2010;51(1):15-22. [Medline].

  48. Luján M, Gallego M, Belmonte Y, Fontanals D, Vallès J, Lisboa T, et al. Influence of pneumococcal serotype group on outcome in adults with bacteremic pneumonia. Eur Respir J. Feb 11 2010;[Medline].

  49. Donowitz GR, Mandell GL. Acute pneumonia. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 5th ed. Philadelphia, Pa: Churchill Livingstone; 2000:717-43.

  50. Madeddu G, Fois AG, Pirina P, Mura MS. Pneumococcal pneumonia: clinical features, diagnosis and management in HIV-infected and HIV noninfected patients. Curr Opin Pulm Med. May 2009;15(3):236-42. [Medline].

  51. Austrian R. Pneumococcal pneumonia. Diagnostic, epidemiologic, therapeutic and prophylactic considerations. 1986. Chest. Nov 2009;136(5 Suppl):e30. [Medline].

  52. Clifford V, Tebruegge M, Vandeleur M, Curtis N. Question 3: can pneumonia caused by penicillin-resistant Streptococcus pneumoniae be treated with penicillin?. Arch Dis Child. Jan 2010;95(1):73-7. [Medline].

  53. Cunha BA. Clinical relevance of penicillin-resistant Streptococcus pneumoniae. Semin Respir Infect. Sep 2002;17(3):204-14. [Medline].

  54. Garnacho-Montero J, García-Cabrera E, Diaz-Martín A, Lepe-Jiménez JA, Iraurgi-Arcarazo P, Jiménez-Alvarez R, et al. Determinants of outcome in patients with bacteraemic pneumococcal pneumonia: importance of early adequate treatment. Scand J Infect Dis. Mar 2010;42(3):185-92. [Medline].

  55. van der Poll T, Opal SM. Pathogenesis, treatment, and prevention of pneumococcal pneumonia. Lancet. Oct 31 2009;374(9700):1543-56. [Medline].

  56. van de Beek D, de Gans J, McIntyre P, Prasad K. Steroids in adults with acute bacterial meningitis: a systematic review. Lancet Infect Dis. Mar 2004;4(3):139-43. [Medline].

  57. Karlowsky JA, Thornsberry C, Jones ME, Evangelista AT, Critchley IA, Sahm DF. Factors associated with relative rates of antimicrobial resistance among Streptococcus pneumoniae in the United States: results from the TRUST Surveillance Program (1998-2002). Clin Infect Dis. Apr 15 2003;36(8):963-70. [Medline].

  58. Whitney CG, Farley MM, Hadler J, Harrison LH, Lexau C, Reingold A, et al. Increasing prevalence of multidrug-resistant Streptococcus pneumoniae in the United States. N Engl J Med. Dec 28 2000;343(26):1917-24. [Medline].

  59. Song JH, Jung SI, Ko KS, Kim NY, Son JS, Chang HH, et al. High prevalence of antimicrobial resistance among clinical Streptococcus pneumoniae isolates in Asia (an ANSORP study). Antimicrob Agents Chemother. Jun 2004;48(6):2101-7. [Medline].

  60. Cunha BA. Effective antibiotic-resistance control strategies. Lancet. Apr 28 2001;357(9265):1307-8. [Medline].

  61. Shea KW, Cunha BA, Ueno Y, Abumustafa F, Qadri SM. Doxycycline activity against Streptococcus pneumoniae. Chest. Dec 1995;108(6):1775-6. [Medline].

  62. [Guideline] Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. Mar 1 2007;44 Suppl 2:S27-72. [Medline].

  63. Hawser SP. Activity of tigecycline against Streptococcus pneumoniae, an important causative pathogen of community-acquired pneumonia (CAP). J Infect. Apr 2010;60(4):306-8. [Medline].

  64. [Guideline] American Academy of Pediatrics Committee on Infectious Diseases. Recommendations for the prevention of Streptococcus pneumoniae infections in infants and children: use of 13-valent pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23). Pediatrics. Jul 2010;126(1):186-90. [Medline].

  65. [Guideline] Advisory Committee on Immunization Practices (ACIP). Preventing pneumococcal disease among infants and young children. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. Oct 6 2000;49:1-35. [Medline]. [Full Text].

  66. [Guideline] Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices (ACIP). Updated recommendation from the Advisory Committee on Immunization Practices (ACIP) for use of 7-valent pneumococcal conjugate vaccine (PCV7) in children aged 24-59 months who are not completely vaccinated. MMWR Morb Mortal Wkly Rep. Apr 4 2008;57(13):343-4. [Medline]. [Full Text].

  67. Domínguez A, Izquierdo C, Salleras L, Ruiz L, Sousa D, Bayas JM, et al. Effectiveness of the pneumococcal polysaccharide vaccine in Preventing Pneumonia in the elderly. Eur Respir J. Jan 14 2010;[Medline].

  68. Grijalva CG, Poehling KA, Nuorti JP, Zhu Y, Martin SW, Edwards KM, et al. National impact of universal childhood immunization with pneumococcal conjugate vaccine on outpatient medical care visits in the United States. Pediatrics. Sep 2006;118(3):865-73. [Medline].

  69. Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices. Updated recommendations for prevention of invasive pneumococcal disease among adults using the 23-valent pneumococcal polysaccharide vaccine (PPSV23). MMWR Morb Mortal Wkly Rep. Sep 3 2010;59(34):1102-6. [Medline].

  70. Rinta-Kokko H, Dagan R, Givon-Lavi N, Auranen K. Estimation of vaccine efficacy against acquisition of pneumococcal carriage. Vaccine. Jun 12 2009;27(29):3831-7. [Medline].

  71. Hung IF, Leung AY, Chu DW, Leung D, Cheung T, Chan CK. Prevention of acute myocardial infarction and stroke among elderly persons by dual pneumococcal and influenza vaccination: a prospective cohort study. Clin Infect Dis. Nov 1 2010;51(9):1007-16. [Medline].

  72. Black SB, Shinefield HR, Hansen J, Elvin L, Laufer D, Malinoski F. Postlicensure evaluation of the effectiveness of seven valent pneumococcal conjugate vaccine. Pediatr Infect Dis J. Dec 2001;20(12):1105-7. [Medline].

  73. Kaplan SL, Mason EO Jr, Wald ER, Schutze GE, Bradley JS, Tan TQ, et al. Decrease of invasive pneumococcal infections in children among 8 children's hospitals in the United States after the introduction of the 7-valent pneumococcal conjugate vaccine. Pediatrics. Mar 2004;113(3 Pt 1):443-9. [Medline].

  74. Grau I, Pallares R, Tubau F, Schulze MH, Llopis F, Podzamczer D, et al. Epidemiologic changes in bacteremic pneumococcal disease in patients with human immunodeficiency virus in the era of highly active antiretroviral therapy. Arch Intern Med. Jul 11 2005;165(13):1533-40. [Medline].

 
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Sputum Gram stain from a patient with a pneumococcal pneumonia. Note the numerous polymorphonuclear neutrophils and gram-positive, lancet-shaped diplococci. Courtesy of C. Sinave, MD, personal collection.
Lobar consolidation with pneumococcal pneumonia. Posteroanterior film. Courtesy of R. Duperval, MD.
Lobar consolidation with pneumococcal pneumonia. Lateral film. Courtesy of R. Duperval, MD.
Empyema caused by Streptococcus pneumoniae. Anteroposterior film. Courtesy of R. Duperval, MD.
Purpura due to pneumococcal sepsis in a 39-year-old man who underwent a splenectomy 20 years earlier. Courtesy of Thomas Herchline, MD, Wright State University, Dayton, Ohio.
Table 1. Recommended Schedule for Doses of PCV13, Including Catch-up Immunizations in Previously Unimmunized and Partially Immunized Children[2]
Age at Examination (mo)Immunization HistoryRecommended Regimena
2-60 doses3 doses, 2 mo apart; fourth dose at age 12-15 mo
1 dose2 doses, 2 mo apart; fourth dose at age 12-15 mo
2 doses1 dose, 2 mo after the most recent dose; fourth dose at age 12-15 mo
7-110 doses2 doses, 2 mo apart; third dose at age 12 mo
1 or 2 doses before age 7 mo1 dose at age 7-11 mo, with another dose at age 12-15 mo (≥2 mo later)
12-230 doses2 doses, ≥2 mo apart
1 dose at < 12 mo2 doses, ≥2 mo apart
1 dose at ≥12 mo1 dose, ≥2 mo after the most recent dose
2 or 3 doses at < 12 mo1 dose, ≥2 mo after the most recent dose
24-71[66]
Healthy children



(24-59mo)



Any incomplete schedule1 dose, ≥2 mo after the most recent doseb
Children at high



riskc (24-71 mo)



Any incomplete schedule of < 3 doses2 doses, one ≥2 mo after the most recent dose and another dose ≥2 mo later
Any incomplete schedule of 3 doses1 dose, ≥2 mo after the most recent dose
a In children immunized before age 12 mo, the minimum interval between doses is 4 weeks. Doses administered at age 12 months or later should be administered at least 8 weeks apart.



b Providers should administer a single dose to all healthy children aged 24-59 mo with any incomplete schedule.



c Children with sickle cell disease, asplenia, chronic heart or lung disease, diabetes mellitus, CSF leak, cochlear implant, HIV infection, or another immunocompromising condition. PPV23 is also indicated (see below).



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