eMedicine Specialties > Infectious Diseases > Lower Respiratory Tract Infections
Pneumococcal Infections: Treatment & Medication
Updated: May 16, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
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Treatment
Medical Care
Conjunctivitis, otitis media, sinusitis, bronchitis, and tracheobronchitis
Most patients with conjunctivitis, otitis media, sinusitis, bronchitis, and tracheobronchitis due to S pneumoniae infection can be treated on an outpatient basis with appropriate antibiotics, compliance, and follow-up.
Infants and elderly patients, as well as those with immunodeficiencies, underlying disease, or signs of severe disease, should be treated more aggressively and hospitalized when indicated.
Pneumonia
Presenting signs and symptoms widely vary in patients with pneumococcal pneumonia, from mildly ill presentations to febrile pneumonia to respiratory distress requiring ICU-level care. Factors such as age, types of symptoms, duration of symptoms, underlying and/or chronic illness, compliance with treatment, appropriate home care and potential for worsening disease must be considered in deciding the need for and level of hospitalization.
Hospitalized patients should usually be treated with parenteral antibiotics in addition to medications for pulmonary symptoms, pain medications, intravenous fluids, and/or parenteral or enteral nutrition, oxygen, and other indicated medications, as needed.
Meningitis
Patients with S pneumoniae meningitis should be admitted to the hospital and treated with parenteral antibiotics.
The use of steroids in adult patients with bacterial meningitis is usually recommended with caution, as they may decrease CSF antibiotic concentration; patients with meningitis treated with steroids should be monitored closely.13
Steroids should be considered prior to antibiotic therapy in children aged 6 weeks and older with possible pneumococcal meningitis.14
Intravenous fluids, parenteral/enteral nutrition, and other medications should be used as indicated in certain patients.
Bacteremia and sepsis
Patients with pneumococcal bacteremia should be treated with appropriate antibiotics.
Children who undergo a workup to rule out sepsis (or serious bacterial illness) but who are not treated initially with antibiotics and whose cultures subsequently grow S pneumoniae are often asymptomatic and have negative repeat blood culture findings at follow-up.
Repeat blood cultures should always be obtained in patients with S pneumoniae bacteremia.
Patients with signs or symptoms of sepsis should be admitted to the hospital and treated aggressively with antibiotics and other medical therapies, as indicated.
Other infections
Patients with cardiac, skin/soft-tissue, bone, and/or joint infections with S pneumoniae should usually be admitted to the hospital for observation, intravenous antibiotic therapy, and expedition of further workup and evaluation for location and extent of disease.
Surgical Care
- Patients with complicated pneumonia may require a chest tube for drainage of pleural fluid; VATS or decortication may be required in more severe cases.
- In patients with suspected septic arthritis or osteomyelitis, appropriate specimens should be obtained for Gram stain, cell count, histology, and/or culture.
- Patients with recurrent or chronic otitis media, periorbital or orbital cellulitis, or facial cellulitis may require surgical intervention.
Consultations
- An infectious disease specialist should be consulted in all cases of sepsis, meningitis, complicated pneumonia, spontaneous bacterial peritonitis, osteomyelitis, septic arthritis, and infection with resistant isolates.
- A surgeon should be consulted in cases of complicated pneumonia or complicated soft-tissue infections.
- An orthopedic specialist should be consulted in cases of septic arthritis or osteomyelitis.
- A neurosurgeon should be consulted in cases of recurrent meningitis.
- A pulmonologist should be consulted in cases of complicated pneumonia.
- Consultation with an otolaryngologist may be needed in cases of recurrent otitis media.
- An otolaryngologist and/or an ophthalmologist should be consulted in cases of periorbital and/or orbital cellulitis.
- A cardiologist should be consulted in all cases of endocarditis or pericarditis.
Medication
Antibiotics are the mainstay of treatment in S pneumoniae infections. Until the 1970s, essentially all pneumococcal isolates were sensitive to easily achievable levels of most commonly used antibiotics, including penicillins, macrolides, clindamycin, cephalosporins, rifampin, vancomycin, and trimethoprim-sulfamethoxazole. Beginning in the 1990s, many pneumococcal isolates in the United States showed decreased susceptibility to penicillin and other commonly used antibiotics. Continued increases in these isolates have led to the need for re-establishment of susceptibility standards.
As of 2007, isolates of drug-resistant S pneumoniae have become increasingly common worldwide. The Centers for Disease Control and Prevention (CDC), as well as many state health departments, maintain a population-based surveillance system (called the Active Bacterial Core Surveillance system) that investigates the epidemiology and susceptibility patterns of invasive pneumococcal infections in the United States. In 2004, 21.4% of all isolates obtained showed intermediate or resistant susceptibility patterns to penicillin (up from 20% in 2003).15 The prevalence of resistance varies greatly among countries, states, counties, and within populations in particular cities and may be as high as 30-40% in some locations.16,17 Resistance rates are generally higher in most European countries, as well as in Hong Kong and Thailand.18
Unlike many common bacterial organisms, the method of resistance of pneumococcus to penicillin and cephalosporins is through alteration in the cell wall penicillin-binding proteins (PBPs). By altering these sites (where the antibiotics bind), the antibiotic affinity is decreased, subsequently decreasing the susceptibilities. This type of resistance can be overcome if the serum or site levels of the antibiotic exceed the minimum inhibitory concentration (MIC) of the organism for 40-50% of the dosing interval.
Penicillin-resistant pneumococci are often also resistant to multiple other classes of antibiotics, including other penicillins, cephalosporins, sulfonamides, trimethoprim-sulfamethoxazole (through amino acid changes), macrolides (through methylation or via an efflux pump), quinolones (through decreased permeability, efflux pumps, and alteration of enzymes), and chloramphenicol (through inactivating enzymes). Resistance is obtained as part of a cassette of genetic information, or transposon, that encodes resistance to multiple antibiotics.
Resistance rates of pneumococcal isolates in the United States to trimethoprim-sulfamethoxazole, doxycycline, and the macrolides are relatively high. Some isolates (<10% in the United States) that are resistant to macrolides are also resistant to clindamycin.
No vancomycin-resistant pneumococcal isolates have been reported to date. The phenomenon of tolerance (survival but not growth in the presence of a given antibiotic) has been observed, but its clinical relevance is unknown.
In the United States, most pneumococcal isolates remain susceptible to fluoroquinolones. In certain countries and specific populations in whom the use of fluoroquinolones is more prevalent (eg, nursing homes), an increase in resistance has been seen.2,3,11
Treatment of Specific Infections
Otitis mediaThe guideline produced by the American Academies of Pediatrics and Family Practitioners for the treatment of otitis media recommends first-line treatment of most patients with amoxicillin 80-90 mg/kg/day.
Patients who do not improve within 48-72 hours should be re-evaluated and their antibiotics switched to amoxicillin-clavulanate or a second- or third-generation oral cephalosporin, although highly resistant pneumococci may require treatment with parenteral ceftriaxone in order to achieve adequate serum levels of antibiotics.
Sinusitis
The typical pathogens that cause sinusitis mimic those of otitis media; therefore, initial therapeutic recommendations are similar. In adult allergic patients and in adults who do not respond to initial therapy, fluoroquinolones provide appropriate coverage. In this clinical situation, this class of antibiotics is not approved for children.
Pneumonia
Most patients treated for community-acquired pneumonia (CAP) are treated as outpatients, and the etiological agent is rarely identified. Clinical studies have shown that, when etiological agents are sought, S pneumoniae is the predominating agent found when a bacterial organism is obtained.
- Children
- In children with CAP treated as outpatients, amoxicillin or amoxicillin-clavulanate at dosages used for the treatment of otitis media are recommended. In school-aged children (>5 y), the addition of a macrolide for coverage of atypical organisms is advised.
- In children ill enough to warrant hospitalization, the use of penicillin, ampicillin-sulbactam, or ceftriaxone is usually appropriate, and decisions for therapy should account for local resistance patterns.
- In critically ill or immunocompromised children in whom pneumococcal pneumonia is suspected or possible, vancomycin and a broad-spectrum cephalosporin should be used until or unless organism susceptibilities are available.11
- Adults
- The Infectious Disease Society of America (IDSA) guidelines recommend the initial use of a macrolide (or doxycycline) for outpatient therapy of previously healthy adults with no specific risk factors for resistant S pneumoniae infection.
- In adult patients with underlying chronic disease, immunosuppression (including asplenia or that caused by immunosuppressive therapies), recent use of antibiotics (the preceding 3 mo), or other specific risk factors for resistant organisms (eg, residence in an area with high rates of resistant pneumococcus), the IDSA guidelines recommend use of either (1) a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin) or (2) a beta-lactam antibiotic (high-dose amoxicillin, amoxicillin-clavulanate, or, alternatively, a second- or third-generation cephalosporin) plus a macrolide (or doxycycline).
- For inpatient treatment of adult pneumonia on a medical ward, treatment recommendations are as above for outpatient treatment of patients with comorbid conditions.
- For inpatient treatment of adult patients who require ICU care, recommendations are for a beta-lactam antibiotic plus a macrolide or a fluoroquinolone.19
The recommended initial therapy of presumed bacterial meningitis in children is with vancomycin and ceftriaxone or cefotaxime at increased doses. If S pneumoniae is isolated from the blood or CSF and is susceptible to penicillin or ceftriaxone/cefotaxime, vancomycin should be stopped and therapy completed with penicillin G, ceftriaxone, or cefotaxime, as indicated. If the isolate is resistant to penicillin and cephalosporins, the regimen started initially should be continued through the completion of therapy, usually 10 days in uncomplicated cases.
The recommendations for treatment of bacterial meningitis in adults are similar to those in children.
A beta-lactam (penicillin or, more likely, ceftriaxone or cefotaxime [for superior CSF penetration]) is used in conjunction with vancomycin (for more certain susceptibility) until susceptibility patterns are determined. Imipenem can be substituted for severe allergy to penicillin/cephalosporin.
Some have recommended the addition of rifampin to beta-lactam antibiotics in the treatment of pneumococcal meningitis. However, this has not been proven to be helpful in clinical or in in vitro studies.
Bacteremia
Treatment of bacteremia should be guided by isolate susceptibilities.
Other invasive infections
S pneumoniae is not a particularly common cause of other invasive infections, and initial empiric antibiotic coverage may be adequate, although resistant isolates may require a change in antibiotics if pneumococcus is isolated.
Antibiotics
Penicillin and its derivatives are inexpensive effective antibiotics for treating pneumococcal infections when they are used against susceptible isolates. Penicillins can be administered orally or parenterally and work by inhibiting cell wall synthesis. Penicillin G is the parenteral drug of choice for susceptible S pneumoniae infections, and other parenteral beta-lactams do not provide additional or improved coverage (nor do beta-lactamase inhibitor combinations).
Typical doses of penicillin provide more than adequate serum and body fluid concentrations for susceptible organisms (usually even with intermediate-susceptible strains), and many studies have shown similar outcomes in patients with penicillin-resistant versus penicillin-susceptible pneumococcal isolates treated with appropriate doses of beta-lactam antibiotics. Levels of CSF penetration are also therapeutic, although, in most cases, vancomycin should be used in addition to a beta-lactam antibiotic until isolate susceptibilities can be determined given the increasing rate of penicillin-resistant strains of S pneumoniae.
Cephalosporins, which are also beta-lactam antibiotics, inhibit pneumococcus in the same way as penicillins and are resisted in the same manner (alteration in the cell wall PBPs). First-generation cephalosporins provide similar coverage in the treatment of penicillin-susceptible strains, although many of them have higher MICs. Most strains of pneumococcus that are not susceptible to penicillin also have some resistance to third-generation cephalosporins, although some may still be susceptible, depending on the particular PBPs affected.
In most cases, macrolides have activity against penicillin-susceptible strains of S pneumoniae. However, half or more of pneumococcal strains that have intermediate resistance or that are resistant to penicillin are also resistant to macrolides. Most macrolide-resistant isolates of S pneumoniae may derive their resistance through an efflux pump mechanism, which may be overcome with levels of drug that exceed the MIC for sufficient periods. Macrolides have CSF penetration and should not be used to treatment meningitis.
Most pneumococcal isolates in the United States remain susceptible to certain fluoroquinolones, including moxifloxacin (most effective), levofloxacin, gatifloxacin, and gemifloxacin. Ciprofloxacin and ofloxacin have limited activity against pneumococcal infections. Fluoroquinolones provide broad-spectrum treatment for CAP and achieve excellent serum drug levels and tissue penetration. Specific populations in whom the use of fluoroquinolones is traditionally increased (eg, residents of nursing homes) have shown increased levels of pneumococcal resistance to fluoroquinolones, and their empiric use in respiratory infections should also be tempered by the concern for rapid development of resistance to this class by many organisms.
Vancomycin is the only glycopeptide antibiotic that has demonstrated effectiveness against pneumococcal infections. To date, no clinical or in vitro evidence of pneumococcal resistance to vancomycin has been reported, and it is the drug of choice (with a third-generation cephalosporin) in the treatment of pneumococcal meningitis.
The increased number of pneumococcal isolates resistant to trimethoprim-sulfamethoxazole precludes its use unless susceptibilities are known and beta-lactam use is contraindicated.
Clindamycin may also be used to treat nonmeningeal S pneumoniae infections. Penicillin or macrolide resistance may also be associated with clindamycin resistance in individual isolates.
Carbapenems are also effective against S pneumoniae but should be reserved for specific cases given their broad coverage and the potential for development of resistance by multiple organisms.
Cefotaxime (Claforan)
Third-generation cephalosporin with broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. Arrests bacterial cell wall synthesis by binding to one or more of the PBPs, in turn inhibiting bacterial growth. Safety profile is more favorable than aminoglycosides. DOC for meningitis (all ages), inpatient treatment of pneumonia, bacteremia, and other invasive infections.
Adult
Standard dose: 1-2 g/dose IV/IM q6-8h
Meningitis or other severe infection: 2 g/dose IV/IM q4-6h
Note: Not to exceed 12 g/d
Pediatric
Neonates (dose based on postnatal age and weight):
<7 days and <2000 g: 100 mg/kg/d IV/IM divided q12h
<7 days and >2000 g: 100-150 mg/kg/d IV/IM divided q8-12h
7-28 days and <1200 g: 100 mg/kg/d IV/IM divided q12h
7-28 days and >1200 g: 150 mg/kg/d IV/IM divided q8h
Infants >4 weeks and children:
100-200 mg/kg/d IV/IM divided q8h
Meningitis: 200 mg/kg/d IV/IM divided q6h
Non-CNS penicillin-resistant infections: 150-225 mg/kg/d
IV/IM divided q6-8h
Penicillin-resistant CNS/meningitis: 225-300 mg/kg/d IV/IM q6-8h administered with vancomycin
Probenecid may increase cefotaxime levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy; has been associated with severe colitis
Penicillin G (Pfizerpen)
DOC for severe infections, including meningitis attributed to susceptible strains of S pneumoniae. DOC for severe infections, excluding meningitis attributed to strains of S pneumoniae with intermediate susceptibility to penicillin.
Adult
2-4 million U IV q4h (use 4 million U for meningitis)
Pediatric
<4 weeks: Not established
>4 weeks: 25,000-400,000 U/kg/d IV q4-6h; not to exceed adult dose
Probenecid can increase effects; coadministration of tetracyclines can decrease effects of penicillin
Documented IgE-mediated hypersensitivity or interstitial nephritis; history of rare reactions (eg, serum sickness, Stevens-Johnson syndrome, allergic vasculitis, or major hepatic injury); history of morbilliform eruption if severe and progressing to general desquamation
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Reduce dose with severe renal impairment (CrCl <10 mL/min); monitor for possible CNS toxicity (eg, seizures); perform tests for possible Clostridium difficile colitis in case of persistent diarrhea
Amoxicillin (Trimox, Amoxil)
Has better absorption than penicillin VK and administration is q8h instead of q6h. For minor infections, some authorities advocate administration q12h. Probably most active of the penicillins for non–penicillin-susceptible S pneumoniae.
Adult
1 g PO q8h
Pediatric
6.7-13.3 mg/kg PO q8h
Reduces efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; may enhance chance of candidiasis
Ampicillin (Marcillin, Omnipen)
No advantage over penicillin G in the treatment of pneumococcal infections. Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally.
Adult
1-2 g IV q4h (12 g/d for meningitis)
Pediatric
<4 wk: Not established
>4 wk: 6.25-25 mg/kg IV q6h
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Cefazolin (Ancef, Kefzol, Zolicef)
Alternative choice for parenteral treatment of pneumococcal infection outside CNS. Best beta-lactam for IM administration. Poor capacity to cross blood-brain barrier precludes use for treatment of meningitis.
Adult
1 g IV q8h
Pediatric
<4 wk: Not established
>4 wk: 25-100 mg/kg/d IV/IM divided q6-8h
Probenecid prolongs effect of cefazolin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Ceftriaxone (Rocephin)
May be used to treat pneumococci that have reduced susceptibility to penicillin. Generally not preferred for infections caused by high-level penicillin-resistance pneumococci. For empiric treatment of meningitis, use in conjunction with vancomycin or rifampin.
Adult
1-2 g IV q12-24h
Meningitis: 2 g IV q12h
Pediatric
<4 wk: Not established
>4 wk: 50-100 mg/kg/d IV q12-24h (use maximum for meningitis)
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in the last trimester of pregnancy and in breastfeeding women; pseudobiliary lithiasis
Azithromycin (Zithromax)
Approximately 25% of S pneumoniae strains naturally resistant. Generally better tolerated than erythromycin. Because of long half-life, treatment duration is reduced.
Adult
Day 1: 500 mg PO/IV
Day 2-5: 250 mg PO qd
Pediatric
5-12 mg/kg/d PO
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function or prolonged QT intervals; caution in patients who are hospitalized, geriatric, or debilitated
Gemifloxacin (Factive)
Fluoroquinolone antibiotic with wide range of activity against gram-negative and gram-positive organisms. Acts by inhibiting both DNA gyrase and topoisomerase IV (TOPO IV), which are essential for bacterial growth. Because of this dual mechanism, MIC values remain in the susceptible range for some double mutants (eg, S pneumoniae).
Indicated for mild-to-moderate CAP caused by S pneumoniae (including penicillin-resistant strains; MIC value for penicillin >2 mg/mL), Haemophilus influenzae, Moraxella catarrhalis, Mycoplasma pneumoniae, Chlamydia pneumoniae, or Klebsiella pneumoniae.
Adult
CAP due to known or suspected S pneumoniae, H influenzae, M pneumoniae, or C pneumoniae: 320 mg PO qd for 5 d
CAP due to known or suspected K pneumoniae, M catarrhalis, or multi-drug resistant S pneumoniae: 320 mg PO qd for 7 d
Pediatric
<18 years: Not established
>18 years: Administer as in adults
Coadministration with antacids and divalent or trivalent cations (eg, aluminum, magnesium, iron) significantly reduces absorption (administer 3 h before or 2 h after gemifloxacin); sucralfate decreases absorption and should be administered 2 h following gemifloxacin; may increase QT interval prolongation risk if coadministered with class IA (eg, quinidine, procainamide) or class III antiarrhythmic agents (sotalol, amiodarone), or other drugs known to prolong QT interval (eg, erythromycin, antipsychotics, antidepressants)
Documented hypersensitivity to gemifloxacin or other fluoroquinolones
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Decrease dose by 50% with CrCl <40 mL/min; may prolong QT interval; may cause maculopapular rash
Levofloxacin (Levaquin)
Available in oral and parenteral formulations. DOC (with vancomycin) for parenteral treatment of severe penicillin-resistant pneumococcal infection outside CNS. Has high bioavailability when taken orally. Step-down from parenteral to oral formulation is simple.
Adult
0.5 g PO/IV qd
Pediatric
Not recommended
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2 h before or after; cimetidine may interfere with metabolism of fluoroquinolones; levofloxacin reduces therapeutic effects of phenytoin; probenecid may increase levofloxacin serum concentrations
Documented hypersensitivity; pediatrics, unless benefits outweigh risks (as in cystic fibrosis)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Moxifloxacin (Avelox)
Inhibits the A subunits of DNA gyrase, resulting in inhibition of bacterial DNA replication and transcription.
Adult
400 mg PO qd
Pediatric
Not recommended
Antacids and electrolyte supplements reduce absorption; loop diuretics, probenecid, and cimetidine increase serum levels; NSAIDs enhance CNS-stimulating effect; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity; pediatrics, unless benefits outweigh risks (as in cystic fibrosis)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy; prolonged QT interval on ECG and ventricular arrhythmias may occur
Gatifloxacin (Tequin)
The latest of the respiratory quinolones. Good activity against pneumococci. Available for PO and IV administration.
Adult
400 mg PO/IV qd
Pediatric
Not recommended
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2 h before or after; cimetidine may interfere with metabolism of fluoroquinolones; levofloxacin reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations
Documented hypersensitivity; pediatrics, unless benefits outweigh risks (as in cystic fibrosis)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Vancomycin (Vancocin, Lyphocin)
Always active against strains of S pneumoniae. DOC for the treatment of meningitis caused by non–penicillin-susceptible S pneumoniae. Has suboptimal capability to cross blood-brain barrier and should be administered with cefotaxime or ceftriaxone for the treatment of meningitis. In adults, glucocorticoids may decrease penetration of vancomycin in the CNS; avoid this medication unless specific indications exist. Vancomycin is frequently the preferred drug for the treatment of severe penicillin-resistant pneumococcal infections outside the CNS and for patients with an IgE-type allergy to penicillin. Only IV administration is effective.
The maintenance dose can be estimated using the following formula: 150 + 15 times the creatinine clearance in mL/min = mg of vancomycin to be administered daily.
Adult
1 g IV q12h
Meningitis: 15 mg/kg IV q6-8h suggested
Pediatric
<4 wk: Not established
>4 wk: 40 mg/kg/d IV q6-8h
Erythema; histaminelike flushing; anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity; slowing the IV infusion time or q6h administration
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in neutropenia; red man syndrome is caused by too rapid IV infusion (dose administered over a few min) but rarely happens when dose is given over 2 h; red man syndrome is not an allergic reaction nor a contraindication for continuing treatment
Clindamycin (Cleocin)
Lincosamide for treatment of serious skin and soft-tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
600 mg IV q8h
Pediatric
8-20 mg/kg/d PO as hydrochloride or 8-25 mg/kg/d as palmitate divided tid/qid
20-40 mg/kg/d IV/IM divided tid/qid
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of C difficile
Imipenem (Primaxin)
For treatment of multiple-organism infections in which other agents do not have wide-spectrum coverage or are contraindicated because of potential toxicity.
Adult
Base initial dose on severity of infection and administer in equally divided doses; dose may range from 500 mg to 1 g IV for a maximum of 3-4 g/d
Alternatively, 500-750 mg q12h IM or intra-abdominally
Pediatric
<12 years: Not established; 15-25 mg/kg/dose IV q6h suggested for >3 mo
Fully susceptible organisms: Not to exceed 2 g/d
Infections with moderately susceptible organisms: Not to exceed 4 g/d
Coadministration with cyclosporine may increase adverse CNS effects of both agents; coadministration with ganciclovir may result in generalized seizures
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal insufficiency; avoid use in children <12 years
More on Pneumococcal Infections |
| Overview: Pneumococcal Infections |
| Differential Diagnoses & Workup: Pneumococcal Infections |
 Treatment & Medication: Pneumococcal Infections |
| Follow-up: Pneumococcal Infections |
| Multimedia: Pneumococcal Infections |
| References |
| Further Reading |
| « Previous Page | Next Page » |
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Further Reading
For additional information, see Medscape's Pneumonia Resource Center, Otitis Media Resource Center, and Sepsis Resource Center.
Keywords
Streptococcus pneumoniae, S pneumoniae, pneumococcus , pneumococci, upper respiratory tract disease, lower respiratory tract disease, upper respiratory disease, lower respiratory disease, respiratory disease, community-acquired pneumonia, CAP, pneumonia, lung infection, respiratory infection, pneumococcal disease, otitis media, pharyngeal infection, nosocomial pneumonia, hospital-acquired pneumonia, bronchopneumonia, broncho-pneumonia, meningitis, tracheobronchitis, acute sinusitis, sinusitis, pneumococcal sepsis, pneumococcal pneumonia, pneumococcal conjunctivitis, pneumococcal otitis media, pneumococcal sinusitis, acute exacerbations of chronic bronchitis, AECB, pneumococcal meningitis, pneumococcal bacteremia, pneumococcal joint infection, pneumococcal bone infection, pneumococcal soft tissue infection, pneumococcal osteomyelitis, pneumococcal peritonitis, pneumococcal endocarditis, pneumococcal pericarditis, pneumococcal septic arthritis
