Pneumococcal Infections Follow-up

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

Further Inpatient Care

Pneumonia

Patients with pneumococcal pneumonia who do not respond or respond slower than usual to initial treatment should undergo follow-up chest radiography. Worsening or developing disease may indicate the need for consultation with a pulmonologist, an infectious disease specialist, and/or a surgeon and further intervention.

Repeat chest radiography should be performed after therapy is completed to ensure resolution of disease and to document pulmonary findings. Chest radiography findings may remain abnormal for weeks to months, particularly following severe disease or complicated pneumonias.

Oral therapy can be initiated when patients are clinically improved and afebrile.

Bacteremia

In hospitalized patients with pneumococcal bacteremia, follow-up blood cultures should be obtained until culture results are negative.

Meningitis

A repeat lumbar puncture should be considered after 48 hours of therapy in the following circumstances:

  • Patients whose isolates are not susceptible to penicillin based on oxacillin disk or MIC testing in whom results of cefotaxime and/or ceftriaxone susceptibilities are not yet available
  • Patients whose condition has worsened or has not improved
  • Patients who received steroid therapy (which could alter the ability to observe clinical improvement/worsening)

Patients with pneumococcal meningitis should receive the entire course of antibiotic therapy parenterally.

Other invasive infections

Purulent pneumococcal pericarditis and endocarditis are serious diseases and should be treated aggressively with appropriate courses of parenteral antibiotics.

Blood cultures should be obtained until multiple negative sets are documented.

Repeat chest radiography, echocardiography, and other imaging tests may be repeated as recommended to monitor disease resolution.

Patients with osteomyelitis and joint infections caused by S pneumoniae infection should be monitored closely for a decrease in pain and inflammatory markers and improved use of the affected limb or joint. Failure to improve should prompt re-evaluation of the area via aspiration, washout, biopsy, or repeat imaging.

Next

Deterrence/Prevention

Behavior modification and risk factors

Cigarette smoking and passive cigarette smoke exposure have been linked to an increased risk for invasive pneumococcal disease in healthy adults; thus, smoking cessation should be encouraged.

Optimal nutrition and living conditions may decrease the risk for pneumococcal disease. Breastfeeding should also be encouraged, when possible.

Daycare attendance is associated with acquisition, carriage (of susceptible and drug-resistant strains), infection, and outbreaks of pneumococcal disease in proportion to the number of attendees.

Medical therapy

Antimicrobial prophylaxis may be used in selected patients with recurrent otitis media.

Daily antimicrobial prophylaxis with penicillin, in addition to routine vaccination, is recommended in children with true anatomical or functional asplenia to prevent pneumococcal disease. Resistant pneumococcal strains and pneumococcal carriage in these patients have increased, and the optimal duration of prophylaxis in these children is uncertain.

Patients with hypogammaglobulinemia due to congenital or acquired immune disorders (including patients with HIV/AIDS and recurrent pneumococcal infections) can be treated with monthly intravenous immunoglobulin in an attempt to maintain immunoglobulin levels above 400 mg/dL.

Immunization

Until February 2010, two pneumococcal vaccines were available for use in the prevention of pneumococcal disease. On February 24, 2010, the FDA approved the use of PCV13 vaccine for use in children aged 2-71 months and its use replaces PCV7.[12, 64, 65, 66, 67, 68, 69, 70]

The capsular polysaccharide vaccine was licensed in 1977 and contains capsular antigens from the 23 serotypes of S pneumoniae that cause most of the infections in the United States. After vaccination with the polysaccharide vaccine, persons aged 5 years and older develop type-specific protective antibodies. Bacterial polysaccharide vaccines produce antibodies primarily through T-cell–independent methods. Because these systems are not fully developed in young children, children younger than 2 years have a poor response to these types of vaccines.[55] In some elderly persons and persons of all ages with immunosuppressive conditions, immunogenicity of the polysaccharide vaccine is poor. No anamnestic response occurs with revaccination, and the duration of immunity with the polysaccharide vaccine is unknown. Neither a decrease in pneumococcal carriage rates or protection of unimmunized persons due to herd immunity has been documented after immunization using the polysaccharide vaccine.

The Advisory Committee on Immunization Practices (ACIP) recommends that the pneumococcal polysaccharide vaccine (PPSV23) be given to the following groups (children aged 2-6 years should complete the recommended doses of PCV13 before PPSV23 is given)[69] :

  • Persons aged 65 years or older
  • Immunocompetent persons aged 2-64 years with underlying medical conditions, including the following:
    • Chronic heart disease (excluding hypertension)
    • Chronic lung disease (including chronic obstructive pulmonary disease, emphysema, and asthma)
    • Chronic liver disease
    • Cochlear implant
    • CSF leaks
    • Alcoholism
    • Cigarette smoking
  • Persons aged 2-64 years with functional or anatomic asplenia
  • Persons aged 2-64 years who are immunocompromised due to the following:
    • Congenital or acquired immunodeficiencies
    • HIV infection
    • Leukemia
    • Lymphoma or Hodgkin disease
    • Multiple myeloma
    • Disseminated malignancy
    • Chronic renal failure or nephrotic syndrome
    • Persons receiving corticosteroids or other immunosuppressive therapies
    • Bone marrow or organ-transplant recipients
  • Persons aged 50-64 years living in high-risk environments (eg, Alaskan natives, certain American Indian populations)

The duration of protection is probably 5-10 years but may vary widely. Revaccination is recommended in certain populations, including the following:

  • Five years after initial immunization in children aged 2 years or older at high risk for pneumococcal infection or in whom antibody titers are highly likely to rapidly decline, including those with functional or anatomic asplenia, sickle cell disease, or immunosuppression. All other children with underlying medical conditions should receive 1 dose of PPSV23.
  • Persons aged 65 years or older who are at high risk for disease or rapid antibody decline, including those with asplenia, HIV, leukemia, lymphoma, Hodgkin disease, multiple myeloma, malignancy, renal disease, or organ/marrow transplant or those on immunosuppressive therapies

A study showed that in elderly patients with chronic illness, dual vaccination with pneumococcal polysaccharide vaccine and influenza vaccine led to decreased complications related to respiratory, cardiovascular, and cerebrovascular diseases.[71] A reduction in hospitalizations, coronary and intensive care admissions, and death was also noted in these patients.

A 13-valent pneumococcal conjugate vaccine (PVC13) was licensed for use in 2010 and includes antigens from the capsules of 13 pneumococcal serotypes (1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F). When this vaccine was introduced and replaced PCV7 in 2010, these additional 6 serotypes accounted for the majority of pneumococcal isolates that caused invasive disease since the introduction of PCV7 in 2000.[11]

Pneumococcal conjugate vaccines link capsular polysaccharides to a conjugate (diphtheroid) carrier protein. Responses to these antigens are developed using T-cell–dependent mechanisms. These antibodies induce immunologic memory, reduce carriage rates of pneumococcal vaccine-serotype isolates, and provide indirect protection to unimmunized persons via herd immunity.

Recommendations for universal vaccination in all children aged 59 months and younger in the United States are now in place. PCV13 immunization follows the same recommendations as that for PCV7 and replaces its use. In addition, PCV13 use is recommended in children aged 60-71 months with underlying medical conditions placing them at increased risk of pneumococcal disease and its complications. Health care providers considering vaccination should refer to the ACIP guidelines and the American Academy of Pediatrics policy statement on recommendations for immunization of children against pneumococcal disease, outlined as follows[64] :

  • A 4-shot series should be given at ages 2, 4, 6, and 12-15 months.
  • Immunization with PCV13 should replace that of PCV7 as soon as it is available. Children who have received one of more doses of PCV7 should have those doses counted, but complete the series with PCV13.
  • Catch-up immunization should be pursued in all children aged 59 months or younger who are incompletely immunized for age using current recommendations by the American Academy of Pediatrics and ACIP. PCV13 replaces the use and previous recommendations for PCV7.[2, 65]
  • Healthy children aged 24-59 months who have an incomplete schedule of immunization with PCV7/PCV13 should receive a single dose of PCV13.
  • Children aged 24-71 months who are at high risk for pneumococcal disease with an incomplete schedule of fewer than 3 doses should receive 2 doses of conjugate vaccine 2 months apart, followed at least 2 months later by 1 dose of polysaccharide vaccine. Children with an incomplete schedule of 3 doses should receive 1 additional dose.

A single supplemental dose of PCV13 is recommended for all children in the following groups who were previously fully immunized with PCV7:

  • All healthy children aged 14-59 months old
  • All children aged 14-71 months with underlying medical conditions placing them at increased risk of pneumococcal disease
  • A single dose of PCV13 may be administered to children aged 6-18 years (regardless of previous immunization status with PCV7/13/23) who are at increased risk of IPD because of sickle cell disease, asplenia, HIV/immunocompromise, CSF leaks, or cochlear implants.[64]

High-risk patients include those with sickle cell disease or hemoglobinopathies, asplenia (congenital or functional), HIV infection, cochlear implants, those of Alaskan Native descent (and of some American Indian populations) who are younger than 2 years, immunocompromising conditions (congenital immune deficiencies), chronic cardiac or pulmonary illness, diabetes mellitus, chronic renal insufficiency (including nephrotic syndrome), diseases requiring immunosuppressive or radiation therapy, and/or CSF leaks.[2]

Table 1. Recommended Schedule for Doses of PCV13, Including Catch-up Immunizations in Previously Unimmunized and Partially Immunized Children[2] (Open Table in a new window)

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).



Many clinical investigations have shown the positive impact of the pneumococcal conjugate vaccine on invasive and noninvasive disease in children, as well as the reduction in nasopharyngeal carriage of vaccine serotypes.[72, 73]

Nasopharyngeal carriage and invasive disease are still present, and previous nonvaccine serotypes in these roles have emerged over the past several years, particularly serotype 19A (now covered by routine vaccination with PCV13).[8, 4, 5]

Previous
Next

Complications

  • Otitis media - Recurrent or chronic otitis media, mastoiditis, brain abscess, meningitis tympanic membrane perforation
  • Sinusitis - Periorbital/orbital cellulitis, meningitis, cavernous sinus thrombosis, osteomyelitis
  • Pneumonia - Pleural effusion/empyema, abscess
  • Meningitis - Hearing loss, seizure disorder, developmental delay, learning difficulties, cranial nerve palsies, other focal neurological deficits, vasculitis, cerebral infarction, hydrocephalus, cerebral palsy
  • Soft tissue/joint/bone infections - Scarring, disproportionate limb length or size, recurrent infection
Previous
Next

Prognosis

Pneumococcal conjunctivitis, otitis media, and sinusitis in developed countries where appropriate antibiotics are available usually carry an excellent prognosis; potential complications are listed above (see Complications).

The prognosis of pneumococcal pneumonia depends largely on underlying factors, including age, immunosuppression, availability of antibiotics, and extent of lung involvement. Pneumococcal pneumonia does not tend to cause necrotizing disease, and most healthy patients treated appropriately recover without long-term complications.

The prognosis of pneumococcal meningitis is also related in part to host factors. Most studies have shown that morbidity rates in otherwise healthy US children with meningitis are usually less than 10%; however, neurological sequelae are common.

Previous
Next

Patient Education

All parents should be advised of the recommendations for universal childhood immunization with the pneumococcal conjugate vaccine.

Patients with medical conditions that place them at an increased risk for serious or invasive S pneumoniae disease should be educated about their condition, the potential presenting signs and symptoms of pneumococcal infection, and the need to obtain medical care promptly upon any concern for possible infection. These patients should also be educated about the benefits of the pneumococcal polysaccharide vaccine and should be encouraged to receive it.

Previous
 
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].

 
Previous
Next
 
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).



Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.