Pneumococcal Infections Workup

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

Laboratory Studies

If a pneumococcal infection is suspected or considered, Gram stain and culture of appropriate specimens should be obtained, when possible. Potential specimen sites may include one or more of the following:

  • Blood
  • Cerebrospinal fluid (CSF)
  • Sputum
  • Pleural fluid or lung aspirate
  • Joint fluid
  • Bone
  • Other abscess or tissue specimens

Specimens should be obtained prior to the initiation of antibiotic therapy and inoculated directly into blood-culture bottles, when possible.

Antibiotic susceptibilities should be obtained routinely on all cultures with growth of S pneumoniae.

Other laboratory values that may be helpful in diagnosis and treatment include a complete blood cell (CBC) count and differential, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP).

In children (who do not produce sputum and in adults with a nonproductive cough, the diagnosis may be made by urine antigen testing for S pneumoniae. As with urinary antigen testing for Legionella, antigenuria may not be present early in infection but persists after clinical resolution of infection.

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Noninvasive Infections

Conjunctivitis, otitis media, sinusitis

Laboratory work is not usually obtained in patients with conjunctivitis, otitis media, or sinusitis unless they have unusually high fevers or have an extremely ill appearance. If specimens are obtained, they should be sent for Gram stain and culture and susceptibility. In these cases, isolation of S pneumoniae should be considered a strong indication for pathogenicity and treatment.[39]

Pneumonia

Many patients with pneumonia are treated presumptively. Antibiotics used in these cases should include those that cover S pneumoniae. In severe, unusual, or complicated cases or those that require hospitalization, an attempt to obtain sputum cultures should be made.[40]

An acceptable sputum sample is indicated by the presence of few epithelial cells and many polymorphonuclear neutrophils (a ratio of 1:10-20).The presence of many gram-positive cocci in pairs and chains on Gram stain provides good evidence for pneumococcus.

When large effusions/empyema is present, attempts should be made to obtain pleural fluid for Gram stain and culture.

Blood cultures should be obtained in hospitalized patients with pneumonia; in pneumococcal pneumonia, blood cultures are positive in an estimated 10% of children and up to 25% of adults.

Most patients with pneumococcal pneumonia have significant leukocytosis (>12,000 cells/μL), and up to one fourth have a hemoglobin level of 10 mg/dL or less.

Howell-Jolly bodies in the peripheral smear indicate splenic dysfunction.

Neutrophil levels, CRP levels, and ESR are often elevated.

A small study by Casado Flores et al evaluated a rapid immunochromatographic test for detection of the pneumococcal antigen, C polysaccharide antigen, in children with pleural effusion.[41] The positive predictive value was 96%, and the sensitivity and specificity were high. In this study, the immunochromatographic test made identification of the pneumococcal origin of effusion easy.

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Invasive Infections

In most patients with invasive pneumococcal infections, the WBC count is elevated (>12,000 cells/μL) and there is a predominance of neutrophils. However, the WBC count may be normal, especially early in the disease process. An abnormally low WBC count may indicate severe disease and a poor prognosis.

The ESR and CRP level are typically elevated in patients with invasive pneumococcal disease.

The development of polymerase chain reaction (PCR) assays for S pneumoniae with sufficient sensitivity and specificity is being widely investigated. Successful commercial assays may prove to be clinically useful.

Meningitis

CSF findings are typical of those found in bacterial meningitis and usually include the following:

  • Elevated opening pressure
  • Elevated WBC count (1000-5000 cells/μL) and elevated neutrophil level (>80%)
  • Elevated protein level (>100 mg/dL)
  • Decreased glucose level (< 40 mg/dL; < 50% of simultaneous blood glucose)
  • Highly elevated lactic acid levels (>6 mmol/L)

Most patients with pneumococcal meningitis who do not receive antibiotics in the 4-6 hours prior to lumbar puncture will have positive results on Gram stain and culture.

Rapid antigen tests (latex agglutination or enzyme immunosorbent assays) can be performed on CSF (as well as sputum and urine) but rarely provide information beyond what is obtained with Gram stain and culture. CSF obtained from patients pretreated with antibiotics may be an exception.

Blood culture results are positive in up to 90% of patients.

Bacteremia

The WBC count may be elevated and blood cultures are positive for growth of S pneumoniae.

Other invasive infections

The WBC count, neutrophil level, CRP level, and ESR are often elevated in patients with bone, joint, soft tissue, cardiac, and other invasive infections.

Specimens of appropriate material may yield positive Gram stain findings and/or culture growth.

Blood cultures are frequently positive and should be obtained when possible.

In females with peritonitis, vaginal swab cultures should be obtained in addition to blood and peritoneal cultures.

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Culture and Susceptibility

Antimicrobial susceptibility testing should be performed on all isolates of S pneumoniae, regardless of the isolation site, because of the increasing prevalence of intermediately susceptible and resistant isolates. All isolates should be tested for susceptibility to penicillin and cefotaxime or ceftriaxone. In addition, CSF isolates should be tested for susceptibility to vancomycin and meropenem. CSF isolates that are found to be nonsusceptible to penicillin should be tested for susceptibility to rifampin.

Microbiological laboratories should follow established guidelines regarding inoculum size and media (Mueller-Hinton agar with sheep, horse, or lysed horse red blood cells).

Isolates from patients with invasive disease should undergo testing with quantitative minimal inhibitory concentration (MIC) techniques (broth microdilution, antibiotic gradient strips).

The Clinical and Laboratory Institute (CLSI) (2010) has defined S pneumoniae susceptibility as follows[42, 43] :

  • Penicillin (nonmeningeal infections)
  • Penicillin (non-CNS/CNS infections)
    • Susceptible (non-CNS/CNS): MIC is less than or equal to 2/0.06 µg/mL, respectively.
    • Intermediate (non-CNS/CNS): MIC is 4/CNS isolates treated with intravenous penicillin are considered either susceptible or resistant.
    • Resistant (non-CNS/CNS): MIC is greater than or equal to 8/0.12 µg/mL, respectively.
  • Cefotaxime or ceftriaxone
    • Susceptible (non-CNS/CNS): MIC is less than or equal to 1/0.5 µg/mL, respectively.
    • Intermediate (non-CNS/CNS): MIC is 2/1 µg/mL, respectively.
    • Resistant (non-CNS/CNS): MIC is greater than or equal to 4/2 µg/mL, respectively.

Strains with intermediate or resistant susceptibility patterns should be considered nonsusceptible and alternate therapy used.

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Imaging Studies

Chest radiography

Chest radiography should be performed in most patients with evidence of invasive pneumococcal infection and in those with pneumococcal pneumonia.

The typical chest radiography finding in adolescents and adults with pneumococcal pneumonia is lobar consolidation.

Infants and young children with pneumococcal pneumonia more often have a pattern of scattered parenchymal consolidation and bronchopneumonia.

Other chest radiography findings may include air bronchograms, pleural effusions/empyema, pneumatoceles, and, rarely, abscesses.

Cavitation is not a feature of S pneumoniae pneumonia and, if present, should prompt investigation for other pathogens.

Lobar consolidation with pneumococcal pneumonia. PLobar consolidation with pneumococcal pneumonia. Posteroanterior film. Courtesy of R. Duperval, MD. Lobar consolidation with pneumococcal pneumonia. LLobar consolidation with pneumococcal pneumonia. Lateral film. Courtesy of R. Duperval, MD. Empyema caused by Streptococcus pneumoniae. AnteroEmpyema caused by Streptococcus pneumoniae. Anteroposterior film. Courtesy of R. Duperval, MD.

Ultrasonography/CT scanning

Chest ultrasonography or chest CT scanning may be obtained to provide information on the presence and/or extent of pleural effusion/empyema and parenchymal disease.

Sinus CT scanning may provide information about the presence and extent of sinus disease. Positive findings include opacification and/or air-fluid levels.

Facial CT scanning should be obtained in patients with periorbital or orbital cellulitis to look for evidence of soft tissue swelling, bony involvement, cranial nerve impingement, or proptosis.

MRI/CT scanning

MRI or CT scanning of affected bones or joints should be obtained to observe for evidence of joint destruction, periosteal elevation, or a mass.

An MRI of the brain may be obtained in patients with meningitis to determine the location and extent of involvement.

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Other Tests

Echocardiography should be performed in patients in whom endocarditis is suspected.

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Procedures

  • Middle ear fluid aspiration
  • Pleural fluid aspiration
  • Chest tube thoracostomy or catheter placement
  • Video-assisted thoracoscopy (VATS) or pleural decortication
  • Joint fluid aspiration and/or wash-out of joint space
  • Bone biopsy
  • Soft tissue/muscle biopsy
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Histologic Findings

See Causes.

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Proceed to Treatment & Management
 
 
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.

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



(24-59mo)



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



riskc (24-71 mo)



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



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



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



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