eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Pneumococcal Bacteremia: Treatment & Medication
Updated: May 5, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- All patients with blood culture results positive for pneumococcus need prompt reevaluation and treatment with antibiotics.
- For patients with focal infection and pneumococcal bacteremia, treatment of the focal infection and monitoring for improvement is standard.
- For outpatients with proven pneumococcal bacteremia, urgent reevaluations are indicated for their conditions and to identify any new focus of infection.
- Based on the age, initial antibiotic therapy, condition of patient, and persistence of fever, appropriate treatment can be determined (see Media file 1).
Algorithm for the reevaluation of outpatients with Streptococcus pneumoniae bacteremia.
- Most patients can be treated as outpatients, but all patients need close follow-up care.
- Reviewing sensitivities of the isolate in order to tailor subsequent therapy is essential because of the increasing rates of resistant pneumococcus.2,3
- Based on the age, initial antibiotic therapy, condition of patient, and persistence of fever, appropriate treatment can be determined (see Media file 1).
Medication
For patients at risk for occult pneumococcal bacteremia as determined by age, height of fever, and an elevated WBC count, empiric antibiotics are recommended. Ceftriaxone 50 mg/kg administered parenterally is the antibiotic of choice.
Patients with proven pneumococcal bacteremia can be treated with penicillins or cephalosporins unless the isolate has specific antibiotic resistance. All life-threatening infections should be treated with vancomycin (60 mg/kg/d divided q6h) pending result of the antibiotic susceptibilities.
For outpatients with a positive blood culture for pneumococcus, appropriate therapy can be determined at the reevaluation visit. Patients who return afebrile, well appearing, and without evidence of new focal infection can be treated successfully with outpatient oral antibiotics, such as amoxicillin (40-80 mg/kg/d divided tid).
Antibiotics
Antibiotics can be used in patients at risk for pneumococcal bacteremia to decrease secondary complications (eg, sepsis, meningitis, pneumonia, arthritis, osteomyelitis), and they should be used in all patients with proven pneumococcal bacteremia. The choice of antibiotics depends on antibiotic-susceptibility profiles for a particular geographic region.
Penicillin (Pfizerpen, Pen.Vee K, Beepen-VK)
Penicillin and amoxicillin are the drugs of choice for outpatients without signs of serious bacterial infection. IV penicillin or ampicillin can be administered parenterally for more serious infections requiring hospitalization.
Adult
500 mg (800,000 U) PO qid
10-30 million U/d IV divided q4-6h
Pediatric
40,000-80,000 U/kg/d PO divided qid or 25-50 mg/kg/d divided qid (250 mg=400,000 U)
100,000-400,000 U/kg/d IV divided q4-6h
Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function
Amoxicillin (Amoxil, Biomox, Trimox)
Can be used when oral outpatient therapy is appropriate.
Adult
1.5-3 g/d PO divided tid
Pediatric
40-60 mg/kg/d PO divided tid
High-dose therapy: 60-80 mg/kg/d PO divided tid
Reduces the efficacy of PO 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
Ampicillin (Marcillin, Omnipen, Polycillin, Principen, Totacillin)
Can be used when parenteral treatment is required and penicillin resistance is not suggested.
Adult
500-3000 mg IV/IM q4-6h; not to exceed 12 g/d
Pediatric
100-400 mg/kg/d IV/IM divided q6h
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of PO 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
Ceftriaxone (Rocephin)
Can be used in patients with suggested but not proven pneumococcal bacteremia to prevent complications of bacteremia. Long half-life affords antibiotic coverage for outpatients while blood culture is pending. Ceftriaxone can also be used for parenteral treatment of bacteremia.
Adult
1-4 g/d IV/IM divided q12h or qd
Pediatric
50-100 mg/kg/d IV/IM divided q12h or qd
Probenecid may increase ceftriaxone 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 breastfeeding women and allergy to penicillin
Vancomycin (Lyphocin, Vancocin, Vancoled)
Should be used in all cases of life-threatening infection caused by S pneumoniae pending results of culture and antibiotic sensitivities.
Adult
2 g/d IV divided q6-12h
Pediatric
60 mg/kg/d IV divided q6h
Erythema, histaminelike flushing, and 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
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 renal failure and neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given as 2-h administration or as PO or IP administration; red man syndrome is not an allergic reaction; monitor serum levels to assure adequate therapeutic effect
More on Pneumococcal Bacteremia |
| Overview: Pneumococcal Bacteremia |
| Differential Diagnoses & Workup: Pneumococcal Bacteremia |
 Treatment & Medication: Pneumococcal Bacteremia |
| Follow-up: Pneumococcal Bacteremia |
| Multimedia: Pneumococcal Bacteremia |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
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Picazo JJ. Management of antibiotic-resistant Streptococcus pneumoniae infections and the use of pneumococcal conjugate vaccines. Clin Microbiol Infect. Apr 2009;15 Suppl 3:4-6. [Medline].
Feldman C, Anderson R. Therapy for pneumococcal bacteremia: monotherapy or combination therapy?. Curr Opin Infect Dis. Apr 2009;22(2):137-42. [Medline].
Pneumonia hospitalizations among young children before and after introduction of pneumococcal conjugate vaccine--United States, 1997-2006. MMWR Morb Mortal Wkly Rep. Jan 16 2009;58(1):1-4. [Medline].
Wilkinson M, Bulloch B, Smith M. Prevalence of occult bacteremia in children aged 3 to 36 months presenting to the emergency department with fever in the postpneumococcal conjugate vaccine era. Acad Emerg Med. Mar 2009;16(3):220-5. [Medline].
[Best Evidence] Jansen AG, Sanders EA, Hoes AW, van Loon AM, Hak E. Effects of influenza plus pneumococcal conjugate vaccination versus influenza vaccination alone in preventing respiratory tract infections in children: a randomized, double-blind, placebo-controlled trial. J Pediatr. Dec 2008;153(6):764-70. [Medline].
Alpern ER, Alessandrini EA, Bell LM, et al. Occult bacteremia from a pediatric emergency department: current prevalence,time to detection, and outcome. Pediatrics. Sep 2000;106(3):505-11. [Medline].
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Bachur R, Perry H, Harper MB. Occult pneumonias: empiric chest radiographs in febrile children with leukocytosis. Ann Emerg Med. Feb 1999;33(2):166-73. [Medline].
Baraff LJ, Oslund S, Prather M. Effect of antibiotic therapy and etiologic microorganism on the risk of bacterial meningitis in children with occult bacteremia. Pediatrics. Jul 1993;92(1):140-3. [Medline].
Black SB, Shinefield HR, Hansen J, et al. Postlicensure evaluation of the effectiveness of seven valent pneumococcalconjugate vaccine. Pediatr Infect Dis J. Dec 2001;20(12):1105-7. [Medline].
Fireman B, Black SB, Shinefield HR, et al. Impact of the pneumococcal conjugate vaccine on otitis media. Pediatr Infect Dis J. Jan 2003;22(1):10-6. [Medline].
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Harper MB, Bachur R, Fleisher GR. Effect of antibiotic therapy on the outcome of outpatients with unsuspected bacteremia. Pediatr Infect Dis J. Sep 1995;14(9):760-7. [Medline].
Harper MB, Fleisher GR. Occult bacteremia in the 3-month-old to 3-year-old age group. Pediatr Ann. Aug 1993;22(8):484, 487-93. [Medline].
Isaacman DJ, Shults J, Gross TK, et al. Predictors of bacteremia in febrile children 3 to 36 months of age. Pediatrics. Nov 2000;106(5):977-82. [Medline].
Kuppermann N. Occult bacteremia in young febrile children. Pediatr Clin North Am. Dec 1999;46(6):1073-109. [Medline].
Kuppermann N, Bank DE, Walton EA, et al. Risks for bacteremia and urinary tract infections in young febrile children with bronchiolitis. Arch Pediatr Adolesc Med. Dec 1997;151(12):1207-14. [Medline].
Lee GM, Fleisher GR, Harper MB. Management of febrile children in the age of the conjugate pneumococcal vaccine:a cost-effectiveness analysis. Pediatrics. Oct 2001;108(4):835-44. [Medline].
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Levine DA, Platt SL, Dayan PS, et al. Risk of serious bacterial infection in young febrile infants with respiratorysyncytial virus infections. Pediatrics. Jun 2004;113(6):1728-34. [Medline].
Lieu T, Ray GT, Black S. Cost-effectiveness of pneumococcal vaccine. JAMA. Jul 26 2000;284(4):440-1. [Medline].
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Sniadack DH, Schwartz B, Lipman H, et al. Potential interventions for the prevention of childhood pneumonia: geographic and temporal differences in serotype and serogroup distribution of sterile site pneumococcal isolates from children-- implications for vaccine strategies. Pediatr Infect Dis J. Jun 1995;14(6):503-10. [Medline].
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Further Reading
- Relevant clinical guidelines include the following:
- (1) Preventing pneumococcal disease among infants and young children. Recommendations of the Advisory Committee on Immunization Practices (ACIP). (2) Updated recommendation from the ACIP for use of 7-valent pneumococcal conjugate vaccine (PCV7) in children aged 24-59 months who are not completely vaccinated
- Immunizations. Institute for Clinical Systems Improvement.
- Routine preventive services for infants and children (birth - 24 months). Michigan Quality Improvement Consortium.
- Preventive services for children and adolescents. Institute for Clinical Systems Improvement.
- Relevant clinical trials include the following:
- Coadministration of Pneumococcal Conjugate Vaccine With DTPa-IPV-Hib Versus Coadministration with DTPa-HBV-IPV/Hib
- Vaccination Course in Primed Children and Age-Matched Unprimed Children With Pneumococcal Vaccine GSK1024850A.
- Disease Burden Of Pneumonia, Meningitis and Bacteremia Among Children in Japan: Pneumonet Japan
- Related eMedicine topics include the following:
- Bacteremia
- Fever in the Infant and Toddler
- Pneumococcal Infections (Infection Diseases)
- Pneumococcal Infections (Pediatrics: General Medicine)
- Pneumonia, Bacterial
Keywords
pneumococcal bacteremia, Streptococcus pneumoniae bacteremia, Streptococcus pneumoniae, S pneumoniae, pneumococcus, gram-positive sepsis, occult bacteremia, OB, meningitis, bacteremia, pneumonia, upper respiratory infection, URI, septic arthritis, osteomyelitis, cellulitis, sickle cell disease, HIV, stomatitis, croup, bronchiolitis, varicella, mononucleosis, treatment, diagnosis
