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Pneumococcal Infections Treatment & Management

  • Author: Claudia Antonieta Nieves Prado, MD; Chief Editor: John L Brusch, MD, FACP  more...
 
Updated: Jan 22, 2016
 

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 should be ensured.

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 mild illness to severe pneumonia to respiratory distress requiring ICU-level care. Factors such as age, type 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 determining the need for and level of hospitalization. There are several scoring systems to appropriately triage patients with pneumonia and decide level of care.[55, 56, 57, 58, 59, 60, 61]

Most hospitalized patients should be treated with parenteral antibiotics in addition to medications for pulmonary symptoms, pain medications, intravenous fluids and/or parenteral or enteral nutrition, oxygen, and additional medications, as indicated on an individual basis.[62, 63, 64, 65, 66]

Meningitis

Patients with S pneumoniae meningitis should be admitted to the hospital and treated with parenteral antibiotics.

The use of systemic steroids within 15 minutes of initiating infusion of antibiotics 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.[67]

Steroids can be considered prior to antibiotic therapy in children aged 6 weeks and older with possible pneumococcal meningitis. If used, they should be given before or at the time of the first dose of antibiotics.[7]

Intravenous fluids, parenteral/enteral nutrition, and other medications should be used as indicated in appropriate clinical instances.

Bacteremia and sepsis

Patients with pneumococcal bacteremia should be treated with appropriate antibiotics and supportive care.

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.

Next

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 or in those with empyema.

In patients with suspected septic arthritis or osteomyelitis, synovial fluid or bone tissue should be obtained for Gram stain, cell count, histology, and culture.

Patients with recurrent or chronic otitis media, periorbital or orbital cellulitis, or facial cellulitis may require surgical intervention.

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Contributor Information and Disclosures
Author

Claudia Antonieta Nieves Prado, MD Resident Physician, Department of Internal Medicine, Albert Einstein Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Sarah Perloff, DO, FACP Director, Antibiotic Stewardship Program, Associate Program Director, Internal Medicine Residency, Program Director, Infectious Diseases Fellowship, Einstein Medical Center

Sarah Perloff, DO, FACP is a member of the following medical societies: American College of Physicians, American Osteopathic Association, Infectious Diseases Society of America, HIV Medicine Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Aaron Glatt, MD Chief Administrative Officer, Executive Vice President, Mercy Medical Center, Catholic Health Services of Long Island

Aaron Glatt, MD is a member of the following medical societies: American College of Chest Physicians, American Association for Physician Leadership, 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, Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.

Chief Editor

John L Brusch, MD, FACP Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

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 Ohio, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Armed Forces Infectious Diseases Society

Disclosure: Nothing to disclose.

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, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Armed Forces Infectious Diseases Society

Disclosure: Nothing to disclose.

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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. Routine Vaccination With Pneumococcal Vaccines [84, 85, 82]
Population Vaccine
Children aged 6 weeks through 5 years: 0.5 mL IM; series of 4 doses at ages 2, 4, 6, and 12-15 months (catch-up schedule through age 5 y) Pneumococcal conjugate vaccine 13-valent (Prevnar 13)
Adults ≥50 years*: 0.5 mL IM as a single dose Pneumococcal conjugate vaccine 13-valent (Prevnar 13, PCV13)
Adults >65 years*†: 0.5 mL IM Pneumococcal polyvalent vaccine 23-valent (PPSV23); 6-12 mo after PCV13
*Although PCV13 is licensed by the FDA for individuals aged ≥50 y, ACIP recommends routine vaccination with both PCV13 plus PPSV23 for individuals aged ≥65 y.



†Those who received PPSV23 before age 65 years for any indication should receive another dose of the vaccine at age 65 years or later if at least 5 years have passed since their previous dose.



Table 2. Vaccination of High-Risk Children Aged 2-18 Years With Pneumococcal Polyvalent Vaccine 23-Valent [86]
Pediatric Risk Group Condition
Immunocompetent Chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure)



Chronic lung disease (including asthma if treated with high-dose corticosteroids)



Diabetes mellitus



Cerebrospinal fluid leaks



Cochlear implant



Functional or anatomic asplenia Sickle cell disease and other hemoglobinopathies



Congenital or acquired asplenia or splenic dysfunction



Immunocompromising conditions HIV infection



Chronic renal failure and nephrotic syndrome



Immunosuppressive drugs or radiation therapy, malignant neoplasms, leukemias, lymphomas, Hodgkin disease, solid organ transplantation



Congenital immunodeficiency



Table 3. Vaccination of High-Risk Adults Aged 19 Years or Older With Pneumococcal Vaccines [87]
Risk Group Condition PCV13 PPSV23 Revaccinate With PPSV23 5 Years After First Dose
Immunocompetent individuals Chronic heart disease*      
Chronic lung disease†      
Diabetes mellitus      
Cerebrospinal fluid leaks x x  
Cochlear implant x x  
Alcoholism   x  
Chronic liver disease, cirrhosis   x  
Functional or anatomic asplenia Sickle cell disease and other hemoglobinopathies x x x
Congenital or acquired asplenia x x x
Immunocompromised individuals Congenital or acquired immunodeficiency x x x
HIV infection x x x
Chronic renal failure x x x
Nephrotic syndrome x x x
Leukemia x x x
Lymphoma x x x
Hodgkin disease x x x
Generalized malignancy x x x
Iatrogenic immunosuppression‡ x x x
Solid organ transplant x x x
Multiple myeloma x x x
*Congestive heart failure and cardiomyopathies, excluding hypertension.



†Including chronic obstructive pulmonary disease, emphysema, and asthma.



‡Diseases requiring treatment with immunosuppressive drugs, including long-term systemic corticosteroids and radiation therapy.



Table 4. Recommended Schedule for Doses of PCV13, Including Catch-up Immunizations in Previously Unimmunized and Partially Immunized Children [7]
Age at Examination (mo) Immunization History Recommended Regimen*
2-6 0 doses 3 doses, 2 mo apart; fourth dose at age 12-15 mo
  1 dose 2 doses, 2 mo apart; fourth dose at age 12-15 mo
  2 doses 1 dose, 2 mo after the most recent dose; fourth dose at age 12-15 mo
7-11 0 doses 2 doses, 2 mo apart; third dose at age 12 mo
  1 or 2 doses before age 7 mo 1 dose at age 7-11 mo, with another dose at age 12-15 mo (≥2 mo later)
12-23 0 doses 2 doses, ≥2 mo apart
  1 dose at < 12 mo 2 doses, ≥2 mo apart
  1 dose at ≥12 mo 1 dose, ≥2 mo after the most recent dose
  2 or 3 doses at < 12 mo 1 dose, ≥2 mo after the most recent dose
24-71[79]    
Healthy children



(24-59mo)



Any incomplete schedule 1 dose, ≥2 mo after the most recent dose†
Children at high



risk‡ (24-71 mo)



Any incomplete schedule of < 3 doses 2 doses, one ≥2 mo after the most recent dose and another dose ≥2 mo later
  Any incomplete schedule of 3 doses 1 dose, ≥2 mo after the most recent dose
*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.



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



‡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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