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Pneumococcal Infections Workup

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

Laboratory Studies

If a pneumococcal infection is suspected or considered, Gram stain and culture of appropriate specimens should be obtained, when possible. Potential specimens 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. Note that MIC breakpoints are different depending on the specimen type.

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 based on urine antigen testing for S pneumoniae. As with urinary antigen testing for Legionella, antigenuria may not be present in early infection or in patients without bacteremia, but, if present, may persist after clinical resolution of infection. The pneumococcal urinary antigen assay may augment the standard diagnostic methods of blood culture and sputum culture, as it provides rapid results.[3] It is unable to provide antimicrobial susceptibility data, so it does not supplant traditional culture methods.

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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.[51]

Pneumonia

Many patients with pneumonia are treated empirically. 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.[52] 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 of sputum provides good evidence for pneumococcus. When large effusions/empyema is present, pleural fluid should be obtained for Gram stain and culture.

The yield of blood cultures in pneumonia is relatively low. The most common bacteria isolated is S pneumoniae. Blood cultures are not indicated in all hospitalized patients with CAP, but they should be obtained in patients with severe pneumonia, immunocompromise (alcohol abuse, leukopenic, liver disease, asplenia, HIV infection), and in outpatient therapy failure.[3]

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.

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.[53] 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. Conversely, leukopenia may indicate severe disease and is a poor prognostic sign. The ESR and CRP level are typically elevated.

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 but are not yet commercially available.

Meningitis

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

  • Elevated opening pressure (>20 cm H 2O)
  • Elevated WBC count (1000-5000 cells/μL) with neutrophilic predominance (>80%)
  • Elevated protein level (>100 mg/dL)
  • Decreased glucose level (< 40 mg/dL; <60% 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/or culture.

Rapid antigen tests (eg, 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 unless antibiotics were administered to the patient prior to performing the lumbar puncture.

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 either 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 also be tested for susceptibility to rifampin.

Microbiology 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 (eg, broth microdilution, antibiotic gradient strips).

The Clinical and Laboratory Institute (CLSI) (2010) has defined S pneumoniae susceptibility as follows[1, 2] :

  • Pneumonia: For penicillin-sensitive S pneumoniae (MIC <2 μg/mL), penicillin G or amoxicillin is considered first-line therapy. For penicillin-resistant S pneumoniae (MIC ≥2 μg/mL), the choice of antimicrobial agent should be directed by susceptibility testing.
  • Cefotaxime or ceftriaxone considerations are as follows:
    • Susceptible (non-CNS/CNS): MIC is ≤1/0.5 µg/mL, respectively.
    • Intermediate (non-CNS/CNS): MIC is 2/1 µg/mL, respectively.
    • Resistant (non-CNS/CNS): MIC is ≥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. P Lobar consolidation with pneumococcal pneumonia. Posteroanterior film. Courtesy of R. Duperval, MD.
Lobar consolidation with pneumococcal pneumonia. L Lobar consolidation with pneumococcal pneumonia. Lateral film. Courtesy of R. Duperval, MD.
Empyema caused by Streptococcus pneumoniae. Antero Empyema 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. Studies investigating the diagnostic utility of lung ultrasonography to diagnose pneumonia have also been promising.[54]

Sinus CT scanning may provide information about the presence and extent of sinus disease. Positive findings include opacification 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 evaluate 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 but is not required by Infectious Disease Society of America (IDSA) guidelines.

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Other Tests

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

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Procedures

See the list below:

  • Middle ear fluid aspiration
  • Pleural fluid aspiration
  • Chest tube thoracostomy or catheter placement
  • Video-assisted thoracoscopy (VATS) or pleural decortication
  • Lumbar puncture
  • 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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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.

References
  1. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing: 18th Informational Supplement. 2008.

  2. Centers for Disease Control and Prevention. Effects of new penicillin susceptibility breakpoints for Streptococcus pneumoniae- United States, 2006-2007. 2008. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5750a2.htm.

  3. [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. 2007 Mar 1. 44 Suppl 2:S27-72. [Medline].

  4. Jain S, Self WH, Wunderink RG, Fakhran S, Balk R, Bramley AM. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. N Engl J Med. 2015 Jul 30. 373 (5):415-27. [Medline].

  5. O'Brien KL, Wolfson LJ, Watt JP, et al. Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates. Lancet. 2009 Sep 12. 374(9693):893-902. [Medline].

  6. Active Bacterial Core Surveillance (ABCs) Report; Emerging Infections Program Network; Streptococcus pneumoniae. 2010;

  7. Committee on Infectious Diseases; American Academy of Pediatrics. Pneumococcal Infections. 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.

  8. 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. 2008 Feb 15. 57(6):144-8. [Medline]. [Full Text].

  9. Hsu KK, Shea KM, Stevenson AE, Pelton SI,. Changing Serotypes Causing Childhood Invasive Pneumococcal Disease: Massachusetts, 2001-2007. Pediatr Infect Dis J. 2009 Nov 21. [Medline].

  10. 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. 2007 Apr 25. 297(16):1784-92. [Medline].

  11. 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. 2008 Jul. 122(1):34-9. [Medline]. [Full Text].

  12. Eiland LS. Increasing Prevalence of Pneumococcal Serotype 19A Among US Children. Journal of Pharmacy Practice. 2008. 21(5):356-62.

  13. 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. 2007 Apr 25. 297(16):1784-92. [Medline].

  14. 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. 2009 Sep. 28(9):766-8. [Medline].

  15. 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].

  16. 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. 2010 Mar 12. 59(9):253-7. [Medline]. [Full Text].

  17. 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. 2010 Mar 12. 59(9):258-61. [Medline]. [Full Text].

  18. 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. July 1, 2010. 126:186 -190. [Full Text].

  19. Burgos J, Falcó V, Borrego A, Sordé R, et al. Impact of the emergence of non-vaccine pneumococcal serotypes on the clinical presentation and outcome of adults with invasive pneumococcal pneumonia. Clin Microbiol Infect. 2012 Apr 16. [Medline].

  20. Gubbins PO, Li C. The Influence of Influenza and Pneumococcal Vaccines on Community-Acquired Pneumonia (CAP) Outcomes Among Elderly Patients. Curr Infect Dis Rep. 2015 Dec. 17 (12):49. [Medline].

  21. Hede K. FDA extends pneumococcal vaccine use to older children. Medscape Medical News. January 29, 2013. Available at http://www.medscape.com/viewarticle/778454. Accessed: February 11, 2013.

  22. Tucker ME. CDC Panel Endorses PCV13 Use in Immunocompromised Children. Available at http://www.medscape.com/viewarticle/779664. Accessed: February 28, 2013.

  23. 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. 2005 Jun 15. 40(12):1738-44. [Medline]. [Full Text].

  24. 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. 2007 Apr. 119(4):707-15. [Medline].

  25. 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. 2004 Sep. 114(3):755-61. [Medline].

  26. Henriques-Normark B, Tuomanen EI. The pneumococcus: epidemiology, microbiology, and pathogenesis. Cold Spring Harb Perspect Med. 2013 Jul 1. 3 (7):[Medline].

  27. Kadioglu A, Weiser JN, Paton JC, Andrew PW. The role of Streptococcus pneumoniae virulence factors in host respiratory colonization and disease. Nat Rev Microbiol. 2008 Apr. 6 (4):288-301. [Medline].

  28. Rubins JB, Charboneau D, Paton JC, Mitchell TJ, Andrew PW, Janoff EN. Dual function of pneumolysin in the early pathogenesis of murine pneumococcal pneumonia. J Clin Invest. 1995 Jan. 95 (1):142-50. [Medline]. [Full Text].

  29. Ghaffar F, Friedland IR, McCracken GH Jr. Dynamics of nasopharyngeal colonization by Streptococcus pneumoniae. Pediatr Infect Dis J. 1999 Jul. 18(7):638-46. [Medline].

  30. Dagan R, Greenberg D, Jacobs MR. Pneumococcal Infections. Feigin RD, Cherry JD, Demmler GJ, Kaplan SL. Textbook of Pediatric Infectious Diseases. 5th. Philadelphia, Pennsylvania: Saunders (Elsevier Science); 2004. 1: 1204-1258/90.

  31. Musher DM. Streptococcus pneumoniae. Mandell GL, Bennett JE, Dolin R. Principles and Practice of Infectious Diseases. 6th. Philadelphia, Pennsylvania: Elsevier, Churchill Livingstone; 2005. 2: 197.

  32. Lynch JP 3rd, Zhanel GG. Streptococcus pneumoniae: epidemiology and risk factors, evolution of antimicrobial resistance, and impact of vaccines. Curr Opin Pulm Med. 2010 May. 16(3):217-25. [Medline].

  33. CDC. Streptococcus pneumoniae Disease. CDC.gov. Available at http://www.cdc.gov/ncidod/dbmd/diseaseinfo/streppneum_t.htm. Accessed: December 5, 2009.

  34. CDC. 2009 H1N1 Pandemic Update: Pneumococcal Vaccination Recommended to Help Prevent Secondary Infections. CDC. November 16, 2009. Available at http://www.cdc.gov/H1N1flu/HAN/111609.htm.

  35. 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. 2009 Oct 2. 58(38):1071-4. [Medline]. [Full Text].

  36. WHO Initiative for Vaccine Research Division. Acute Respiratory Infections, Streptococcus pneumoniae. World Health Organization (WHO). [Full Text].

  37. 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. 1 September 2009. Available at http://www.cdc.gov/abcs/survreports/spneu08.htm.

  38. 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. 2000 Mar. 5(3):207-13. [Medline]. [Full Text].

  39. Eskola J, Black S, Shinefield H. Pneumococcal conjugate vaccines. Plotkin SA, Orenstein WA, eds. Vaccines. 4th ed. Philadelphia, PA: Elsevier Inc; 2004. 23.

  40. Scott JA. The preventable burden of pneumococcal disease in the developing world. Vaccine. 2007 Mar 22. 25(13):2398-405. [Medline].

  41. Fedson DS, Scott JA. The burden of pneumococcal disease among adults in developed and developing countries: what is and is not known. Vaccine. 1999 Jul 30. 17 Suppl 1:S11-8. [Medline].

  42. World Health Organization. Weekly Epidemiological Record. March/2007. Available at http://www.who.int/wer.

  43. WHO.INT; Immunization, Vaccines and Biologicals Division. Pneumococcal Vaccines. WHO.INT. Available at http://www.who.int/vaccines/en/pneumococcus.shtml. Accessed: April 2003.

  44. Rudan I, Campbell H. The deadly toll of S pneumoniae and H influenzae type b. Lancet. 2009 Sep 12. 374(9693):854-6. [Medline].

  45. [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. 2004 Oct. 10(10):689-96. [Medline].

  46. Peter G, Klein JO. Streptococcus pneumoniae. 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.

  47. 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. 2010 Oct 15. 51(8):917-24. [Medline].

  48. Waddle E, Jhaveri R. Outcomes of febrile children without localising signs after pneumococcal conjugate vaccine. Arch Dis Child. 2009 Feb. 94(2):144-7. [Medline]. [Full Text].

  49. 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. 2004 Jul. 158(7):671-5. [Medline]. [Full Text].

  50. 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. 1998 Dec. 102(6):1376-82. [Medline].

  51. American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Clinical Practice Guideline: Diagnosis and management of acute otitis media. Pediatrics. 2004 May. 113(5):1451-65. [Medline]. [Full Text].

  52. 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. 2009 Aug. 59(2):83-9. [Medline].

  53. 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. 2010 May. 169(5):581-4. [Medline].

  54. Chavez MA, Shams N, Ellington LE, Naithani N, Gilman RH, Steinhoff MC, et al. Lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis. Respir Res. 2014 Apr 23. 15:50. [Medline]. [Full Text].

  55. Cunha BA. Pneumonia Essentials. 2nd ed. Sudbury, MA: Jones & Bartlett, Publishers; 2010.

  56. Fung HB, Monteagudo-Chu MO. Community-acquired pneumonia in the elderly. Am J Geriatr Pharmacother. 2010 Feb. 8(1):47-62. [Medline].

  57. Johnstone J. Review: pneumococcal vaccination is not effective for preventing pneumonia, bacteraemia, bronchitis, or mortality. Evid Based Med. 2009 Aug. 14(4):109. [Medline].

  58. 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. 2010 Jul 1. 51(1):15-22. [Medline].

  59. 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. 2010 Feb 11. [Medline].

  60. Donowitz GR, Mandell GL. Acute pneumonia. Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 5th ed. Philadelphia, Pa: Churchill Livingstone; 2000. 717-43.

  61. 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. 2009 May. 15(3):236-42. [Medline].

  62. Austrian R. Pneumococcal pneumonia. Diagnostic, epidemiologic, therapeutic and prophylactic considerations. 1986. Chest. 2009 Nov. 136(5 Suppl):e30. [Medline].

  63. 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. 2010 Jan. 95(1):73-7. [Medline].

  64. Cunha BA. Clinical relevance of penicillin-resistant Streptococcus pneumoniae. Semin Respir Infect. 2002 Sep. 17(3):204-14. [Medline].

  65. 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. 2010 Mar. 42(3):185-92. [Medline].

  66. van der Poll T, Opal SM. Pathogenesis, treatment, and prevention of pneumococcal pneumonia. Lancet. 2009 Oct 31. 374(9700):1543-56. [Medline].

  67. van de Beek D, de Gans J, McIntyre P, Prasad K. Steroids in adults with acute bacterial meningitis: a systematic review. Lancet Infect Dis. 2004 Mar. 4(3):139-43. [Medline].

  68. 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. 2003 Apr 15. 36(8):963-70. [Medline].

  69. 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. 2000 Dec 28. 343(26):1917-24. [Medline].

  70. 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. 2004 Jun. 48(6):2101-7. [Medline].

  71. Cunha BA. Effective antibiotic-resistance control strategies. Lancet. 2001 Apr 28. 357(9265):1307-8. [Medline].

  72. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011 Oct. 53(7):e25-76. [Medline].

  73. Shea KW, Cunha BA, Ueno Y, Abumustafa F, Qadri SM. Doxycycline activity against Streptococcus pneumoniae. Chest. 1995 Dec. 108(6):1775-6. [Medline].

  74. Postma DF, van Werkhoven CH, van Elden LJ, Thijsen SF, Hoepelman AI, Kluytmans JA, et al. Antibiotic treatment strategies for community-acquired pneumonia in adults. N Engl J Med. 2015 Apr 2. 372 (14):1312-23. [Medline]. [Full Text].

  75. Jones RN, Sader HS, Mendes RE, Flamm RK. Update on antimicrobial susceptibility trends among Streptococcus pneumoniae in the United States: report of ceftaroline activity from the SENTRY Antimicrobial Surveillance Program (1998-2011). Diagn Microbiol Infect Dis. 2013 Jan. 75 (1):107-9. [Medline].

  76. Jones RN, Jacobs MR, Sader HS. Evolving trends in Streptococcus pneumoniae resistance: implications for therapy of community-acquired bacterial pneumonia. Int J Antimicrob Agents. 2010 Sep. 36 (3):197-204. [Medline].

  77. [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. 2010 Jul. 126(1):186-90. [Medline].

  78. [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. 2000 Oct 6. 49:1-35. [Medline]. [Full Text].

  79. [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. 2008 Apr 4. 57(13):343-4. [Medline]. [Full Text].

  80. 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. 2010 Jan 14. [Medline].

  81. 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. 2006 Sep. 118(3):865-73. [Medline].

  82. 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. 2010 Sep 3. 59(34):1102-6. [Medline].

  83. Rinta-Kokko H, Dagan R, Givon-Lavi N, Auranen K. Estimation of vaccine efficacy against acquisition of pneumococcal carriage. Vaccine. 2009 Jun 12. 27(29):3831-7. [Medline].

  84. Centers for Disease Control and Prevention (CDC). Recommended Adult Immunization Schedule – United States, 2012 MMWR 2012 feb 3;61(4):66-72. [Full Text].

  85. Recommended immunization schedules for persons aged 0 through 18 Years — United States, 2012. MMWR Morb Mortal Wkly Rep. 2012 Feb 10. 61(5):1-4. [Medline]. [Full Text].

  86. Nuorti JP, Whitney CG. Prevention of pneumococcal disease among infants and children - use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine - recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010 Dec 10. 59:1-18. [Medline]. [Full Text].

  87. Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine for Adults with Immunocompromising Conditions: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2012 Oct 12. 61:816-9. [Medline]. [Full Text].

  88. 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. 2010 Nov 1. 51(9):1007-16. [Medline].

  89. 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. 2001 Dec. 20(12):1105-7. [Medline].

  90. 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. 2004 Mar. 113(3 Pt 1):443-9. [Medline].

  91. Reuters Health Information. U.S. advisory panel recommends Prevnar 13 vaccine for elderly. Medscape Medical News. August 14, 2014. [Full Text].

  92. Bonten M, Bolkenbaas M, Huijts S, et al. Community Acquired Pneumonia Immunization Trial in Adults (CAPiTA). Abstract no. 0541. Pneumonia 2014;3:95. Available at https://pneumonia.org.au/public/journals/22/PublicFolder/ABSTRACTBOOKMASTERforwebupdated20-3-14.pdf.

  93. Tomczyk S, Bennett NM, Stoecker C, Gierke R, Moore MR, Whitney CG, et al. Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged =65 Years: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2014 Sep 19. 63(37):822-5. [Medline]. [Full Text].

  94. Mitchell AM, Mitchell TJ. Streptococcus pneumoniae: virulence factors and variation. Clin Microbiol Infect. 2010 May. 16(5):411-8. [Medline].

  95. Hawser SP. Activity of tigecycline against Streptococcus pneumoniae, an important causative pathogen of community-acquired pneumonia (CAP). J Infect. 2010 Apr. 60(4):306-8. [Medline].

  96. 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. 2005 Jul 11. 165(13):1533-40. [Medline].

  97. Park SY, Van Beneden CA, Pilishvili T, Martin M, Facklam RR, Whitney CG. Invasive pneumococcal infections among vaccinated children in the United States. J Pediatr. 2010 Mar. 156(3):478-483.e2. [Medline].

  98. Pilishvili T, Lexau C, Farley MM, et al. Sustained reductions in invasive pneumococcal disease in the era of conjugate vaccine. J Infect Dis. 2010 Jan 1. 201(1):32-41. [Medline].

  99. Ray GT, Pelton SI, Klugman KP, Strutton DR, Moore MR. Cost-effectiveness of pneumococcal conjugate vaccine: an update after 7 years of use in the United States. Vaccine. 2009 Nov 5. 27(47):6483-94. [Medline].

  100. Flamm RK, Sader HS, Farrell DJ, Jones RN. Antimicrobial activity of ceftaroline tested against drug-resistant subsets of Streptococcus pneumoniae from U.S. medical centers. Antimicrob Agents Chemother. 2014. 58 (4):2468-71. [Medline]. [Full Text].

 
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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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