Pediatric Pneumococcal Infections Follow-up

ICU admission is initially recommended for all patients with bacterial meningitis.

Consider a second lumbar puncture at 24-48 hours to evaluate therapy if patient is not improving. A repeat lumbar puncture should be performed in all patients with penicillin-resistant pneumococcal meningitis.

If the pneumococcal isolate is found to be susceptible to ceftriaxone (MIC < 0.5), discontinue vancomycin. If the isolate is resistant to ceftriaxone, continue vancomycin and ceftriaxone.

Daily fluid intake and output should be recorded in children with meningitis, and daily electrolyte levels tested during the acute phase of the illness, since children are at risk for syndrome of inappropriate antidiuretic hormone secretion and resultant hyponatremia. Most experts now agree that children with meningitis should receive regular maintenance intravenous or oral fluids rather than fluid restriction, but fluid intake and output still should be recorded carefully.

Children with meningitis should be observed for signs of hydrocephalus. In the young child with an open fontanelle, daily head circumference measurements and palpation of the fontanelle should be performed. Older children should be observed for signs and symptoms of hydrocephalus.

All children with meningitis should undergo hearing tests.

Dexamethasone therapy started prior to antibiotics and administered for 4 days decreased the frequency of hearing loss in children with meningitis caused by Haemophilus influenzae.^[5] Smaller studies have documented a decreased frequency of hearing loss in children and adults with pneumococcal meningitis who were treated with dexamethasone. If dexamethasone is given, it should be done prior to the first dose of antibiotics. Dexamethasone dosing is 0.6 mg/kg/d divided every 6 hours for 4 days. However, dexamethasone may decrease CSF concentrations of vancomycin; therefore, use of dexamethasone in regions with a high prevalence of penicillin-resistant pneumococci is controversial.

Discharged patients treated for invasive disease should have outpatient follow-up care at 24-48 hours.

Initial treatment of otitis media or sinusitis

Administer amoxicillin for 5-10 days (otitis media) or 10-21 days (sinusitis).

Treatment of otitis media or sinusitis that has failed to improve clinically using standard-dose amoxicillin treatment

Administer high-dose amoxicillin, amoxicillin-clavulanic acid (Augmentin), cefuroxime, or ceftriaxone (intramuscularly).

Occult bacteremia (with positive culture results)

See Pneumococcal Bacteremia.

Outpatient pneumonia

Administer amoxicillin for 10 days.

Inpatient pneumonia

Administer intravenous ceftriaxone until the child has improved clinically, with a subsequent outpatient regimen for a total of 10 days of treatment.

For critically ill patients, the addition of vancomycin should be considered, but most pneumococci causing non-CNS disease, even penicillin-resistant strains, should respond to high-dose ceftriaxone.

Other invasive pneumococcal diseases

Administer third-generation or fourth-generation parenteral cephalosporins (ceftriaxone, cefotaxime, cefepime).

If a patient is critically ill at presentation or not clinically improving, consider adding vancomycin until susceptibilities are known.

Meningitis in children older than 1 month

Ceftriaxone or cefotaxime are the drugs of choice because they have the best CSF penetration.

For meningitis, always add vancomycin until susceptibilities are known.

After 24-48 hours of therapy, adding rifampin to vancomycin therapy may be considered if (1) clinical worsening is noted, (2) the follow-up CSF does not show eradication of organism or decrease in bacterial load, or (3) minimum inhibitory concentration (MIC) of pneumococci to cefotaxime is 4 or higher.

Patients allergic to penicillin

Otitis media, sinusitis, outpatient treatment of pneumonia: Administer azithromycin (or other macrolide), clindamycin (if not allergic to cephalosporins), cefuroxime, or cefprozil.

Inpatient treatment of pneumonia or other invasive infections: Administer intravenous ceftriaxone if the patient is not allergic to cephalosporins. If the patient is allergic to cephalosporins, administer intravenous clindamycin or meropenem. Meropenem has 5-10% cross-reactivity with beta-lactams; therefore, hypersensitivity testing may need to be performed if the allergy is severe. Consider adding vancomycin if the patient is severely ill and organism susceptibility is not known.

Meningitis

Administer vancomycin plus rifampin or meropenem (patients age >3 mo).

In hospitals without a pediatric ICU, consider transfer of patients with meningitis or critically ill patients with other invasive disease.

Also consider transfer if subspecialty surgical consultation may be needed (osteomyelitis, septic arthritis, mastoiditis, other unusual invasive disease).

In March 2000, the US Food and Drug Administration approved a heptavalent protein-conjugate vaccine (PVC7) safe for use in children as young as 6 weeks. The new heptavalent conjugate vaccine has been recommended by the American Academy of Pediatrics Advisory Committee on Immunization Practices for all children younger than 2 years and for high-risk children (see Frequency) aged 2-5 years. The vaccine has been shown in several large-scale trials to markedly reduce the number of cases of meningitis and bacteremic pneumonia. The vaccine was less efficacious in reducing OM. Children should receive the pneumococcal vaccine at age 2, 4, 6, and 12-15 months.

Since the initiation of the heptavalent pneumococcal vaccine in 2000, researchers have found that nearly two thirds of invasive pneumococcal disease cases in young children have been caused by 6 serotypes not included in that vaccine. Those serotypes, along with the original 7, have been incorporated into the pneumococcal vaccine valent-13 (Prevnar 13), which was approved in February 2010.^[6]

The older 23-valent pneumococcal polysaccharide vaccine is effective and safe in children older than 2 years. It can be used in children at high risk for invasive pneumococcal disease who have not received the conjugate vaccine. Children older than 24 months who are at high risk of pneumococcal infection should have received 4 doses of PCV7; recommendations suggest administration of Pneumovax (PPV23), which is a 23-valent vaccine, followed by another dose after 3-5 years to give additional protection. Further study is required to determine whether revaccination is necessary in later years and which vaccine should be administered if revaccination is necessary.

Pneumococcal vaccination with PCV7 and/or PPV 23 is recommended 2 weeks prior to splenectomy, cochlear implant, or immunosuppressive therapy. Children who are diagnosed with invasive pneumococcal disease should still complete their pneumococcal vaccine series.

Although the World Health Organization (WHO) recommends global implementation of PCV7, only a few countries have introduced PCV7 because of difficulty with completion of the 3 + 1 dose schedule (ie, doses at 2 mo, 4 mo, 6 mo, and 12-15 mo).

van Gils et al conducted a study to examine reduced pneumococcal carriage with vaccination schedules of 2 doses (administered at age 2 mo and 4 mo) or 2 + 1 dose (administered at age 2 mo, 4 mo, and 11 mo).^[7] Vaccine serotype pneumococcal carriage rates were measured during the second year of life. Vaccine serotype pneumococcal carriage was significantly decreased after both PCV7 schedules at age 12 months; 25% in the 2-dose schedule and 20% in the 2 + 1-dose schedule, compared with 38% in the control group who did not receive the vaccine (both P < 0.001).

At 18 months, the 2 + 1–dose schedule group had further decreased to 16% and, at 24 months, decreased to 14% (both P < 0.001).

The 2-dose schedule group remained stable at 18 months (24%), but at 24 months had further decreased to 15% (both P < 0.001).

In the control group, vaccine serotype pneumococcal carriage remained around 36-38% until 24 months.

Results showed that significant reductions of vaccine serotype pneumococcal carriage occurred in the second year of life for those on the 2 + 1–dose or 2-dose schedule for PCV7 vaccination compared with those who did not receive pneumococcal vaccination.

The results of one study of 300 infants noted that newborn immunization with pneumococcal conjugate vaccines was safe and immunogenic, priming the patient for immunological memory, with no evidence of immune tolerance. While not an official recommendation, these preliminary results suggest that vaccination beginning at birth may offer an alternative to infants at high risk of invasive pneumococcal disease (IPD), such as those in developing countries.^[8]

Further recommendations for prevention include restricting antibiotic use to reduce the resistance, adding more antigen to the pneumococcal vaccine, and improving the vaccination coverage.

• Meningitis - Subdural empyema, hydrocephalus, hearing loss, developmental delay, spasticity, mental retardation, and neurologic weakness
• Otitis media - Mastoiditis and cavernous sinus thrombosis
• Sinusitis - Intracranial abscess, periorbital/orbital cellulitis, subperiosteal abscess, cavernous sinus or sagittal sinus thrombosis, and meningitis
• Bacteremia - Osteomyelitis, endocarditis, and meningitis

In a population-based case study conducted in 2 regions in the United Kingdom, the authors analyzed 100 patients aged 3-20 years who were diagnosed with pneumococcal meningitis before age 14 years. Children who were diagnosed with pneumococcal meningitis had been noted to have statistically significant impairment in several areas of cognitive, functional, social, and psychological development, including hearing loss, compared with the control group. Overall, the intelligence quotient (IQ) and several areas of quality of life were reportedly lower among those who had pneumococcal meningitis.^[9]

See Mortality/Morbidity.