eMedicine Specialties > Infectious Diseases > Lower Respiratory Tract Infections

Pneumococcal Infections: Follow-up

Author: Dawn F Muench, MD, Assistant Professor of Pediatrics, Uniformed Services University of the Health Sciences; Fellow in Pediatric Infectious Disease, Department of Pediatrics, National Capital Consortium, Walter Reed Army Medical Center
Coauthor(s): Michael Rajnik, MD, Assistant Professor, Department of Pediatrics, Acting Program Director, Pediatric Infectious Disease Fellowship Program, Uniformed Services University of the Health Sciences
Contributor Information and Disclosures

Updated: May 16, 2008

Follow-up

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
  • Repeat lumbar puncture may be indicated in patients who do not respond as expected to initial treatment and in patients in whom disease progresses or new symptoms develop.
  • 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 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.

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.

• 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.

• 23-valent polysaccharide vaccine
  • 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.
  • 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.
  • The Advisory Committee on Immunization Practices (ACIP) recommends that the pneumococcal polysaccharide vaccine be given to the following groups:
    • Persons aged 65 years or older
    • Persons aged 2 years or older with diabetes mellitus and chronic cardiovascular or pulmonary disease
    • Persons aged 2 years or older with alcoholism, chronic liver disease, or CSF leaks
    • Immunocompetent person aged 2 years or older with functional or anatomic asplenia
    • Persons aged 2 years or older living in high-risk environments (eg, Alaskan natives, certain American Indian populations)
    • Immunocompromised persons aged 2 years or older at high risk for infection (including persons with HIV infection, leukemia, lymphoma, Hodgkin disease, multiple myeloma, malignancy, chronic renal failure, or nephrotic syndrome; persons receiving corticosteroids and other immunosuppressive therapies; and bone marrow or organ-transplant recipients)
  • The duration of protection is probably 5-10 years but may vary widely. Revaccination is recommended in certain populations, including the following:
    • 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, renal failure, nephrotic syndrome, or renal transplantation 3 years following the initial vaccination
    • 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
  • Revaccination more than once is not currently recommended but may be reasonable given the short duration of efficacy in certain high-risk patients.²⁰
• 7-valent conjugate vaccine
  • A 7-valent pneumococcal conjugate vaccine was licensed for use in 2000 and includes antigens from the capsules of the 7 pneumococcal serotypes (4, 6B, 9V, 18C, 19F, 23F), which cause most invasive disease in children.
  • Pneumococcal conjugate vaccines link capsular polysaccharides to conjugate carrier proteins. These antigens are responded to using T-cell–dependent mechanisms.
  • A 3- to 4-shot series, given at ages 2, 4, and 6 months, induces good immunogenicity, even in children younger than 2 years. A booster dose is given at age 12-15 months.
  • Recommendations for universal vaccination of all children in the United States are now in place and are outlined as follows:
    • All children younger than 23 months should receive the 4-dose series.
    • Children aged 23-59 months who are at high risk for pneumococcal disease should receive 2 doses of conjugate vaccine 2 months apart, followed at least two months later by one dose of polysaccharide vaccine.
    • High-risk patients include those with sickle cell disease or hemoglobinopathies, asplenia, HIV, immunocompromising conditions, chronic cardiac or pulmonary illness, diabetes mellitus, and/or CSF leaks.
  • Vaccination should be considered in the following groups:
    • All children aged 24-35 months
    • Children aged 24-59 months who are socially or economically disadvantaged, who are homeless or live in crowded housing, or who are exposed to smoke or have a history of severe or recurrent otitis media
    • Children aged 36-59 months who attend out-of-home daycare or who are African American or American Indian^21,14
  • 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.^22,23
  • Nasopharyngeal carriage and invasive disease are still present, and nonvaccine serotypes in these roles have emerged over the past several years.²⁴
  • The development of further vaccines, including additional capsular antigens, is currently underway.

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

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.

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.

Miscellaneous

Medicolegal Pitfalls

Medical personnel should ensure the following:

• Recognize the presence of signs and symptoms of disease potentially caused by S pneumoniae infection and provide appropriate antibiotic coverage.
• Be aware of the potential presence of pneumococcal resistance to traditionally effective antibiotics.
• Recognize potential S pneumoniae disease in populations who may present with subtle, unusual, or atypical findings (neonates, elderly, immunocompromised persons).
• Provide appropriate coverage for potentially resistant isolates of pneumococcus in patients with severe invasive disease.
• Treat presumed or proven pneumococcal meningitis with appropriate antibiotics at appropriate dosages and dosing intervals.
• Recognize patients with recurrent pneumococcal infections and obtain the appropriate workup for conditions that cause immunosuppression (HIV, diabetes mellitus, malignancy, humoral immunity deficiencies).
• Recognize patients with risk factors for severe or invasive pneumococcal disease.

Special Concerns

Overwhelming postsplenectomy sepsis is an entity that may develop in patients with sickle cell disease or in those who have undergone splenectomy (functional or anatomical). The condition is preceded by bacteremia with encapsulated organisms. Initial symptoms may include high fevers, rigors, hypotension, leukocytosis, disseminated intravascular coagulation, and/or purpura, and the bacteremia can rapidly progress to severe sepsis, possibly causing death. S pneumoniae infection accounts for most of these infections, and these patients should receive vaccination to prevent invasive pneumococcal disease.

Patients with HIV infection have defects in multiple arms of the immune system; humoral defects likely play the most important role in susceptibility to pneumococcal infections. With lowering CD4 counts, the ability to produce capsular antigen antibodies likely decreases further. Prior to the widespread use of highly active antiretroviral therapy (HAART) and pneumococcal vaccine, rates of pneumococcal bacteremia in patients with HIV infection were increased. HAART therapy and routine pneumococcal vaccine may decrease pneumococcal disease in persons with HIV infection.²⁵

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