eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Pneumococcal Infections: Treatment & Medication
Updated: Aug 18, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Antibiotic therapy (see Medication)
- Supportive care
Consultations
- Surgeon: Children with septic arthritis, osteomyelitis, subdural effusion with meningitis, mastoiditis, or other unusual invasive infections require appropriate surgical consultation.
- Infectious disease specialist: A specialist in pediatric infectious diseases should be consulted when treating children with complicated pneumococcal infections or invasive pneumococcal disease caused by drug-resistant S pneumoniae.
Medication
Many pneumococcal strains are resistant to penicillin (8-40%, depending on geographic location), and resistance to ceftriaxone is also increasing. Therapy must be altered accordingly. Nonsusceptibility to penicillin and trimethoprim/sulfamethoxazole has increased from 25% and 18%, respectively, in the prepneumococcal vaccine era (ie, prior to availability of pneumococcal vaccine 7 [PCV7]) to 39% and 29%, respectively, in the postvaccination period.
When a strain is resistant to penicillin and cephalosporins, it is often also resistant to erythromycin, trimethoprim-sulfamethoxazole, and tetracyclines. Resistance is seen most often in serotypes 6, 9, 14, 19, and 23.
Penicillin-resistant strains are defined as intermediately resistant (minimum inhibitory concentration [MIC] >0.1-1 mcg/mL) or highly resistant (MIC >2 mcg/mL). The susceptibility to cefotaxime or ceftriaxone is based on location of isolation of the organism.
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Table
| Drug | Sensitive, MIC mcg/mL | Resistant isolate, MIC mcg/mL | |
| Intermediate resistance | Resistant | ||
| Penicillin/amoxicillin | ≤0.06 | 0.1-1 | ≥2 |
| Cefotaxime or ceftriaxone | Nonmeningeal ≤1, meningeal ≤0.5 | Nonmeningeal 2, meningeal 1 | Nonmeningeal ≥4, meningeal ≥2 |
| Drug | Sensitive, MIC mcg/mL | Resistant isolate, MIC mcg/mL | |
| Intermediate resistance | Resistant | ||
| Penicillin/amoxicillin | ≤0.06 | 0.1-1 | ≥2 |
| Cefotaxime or ceftriaxone | Nonmeningeal ≤1, meningeal ≤0.5 | Nonmeningeal 2, meningeal 1 | Nonmeningeal ≥4, meningeal ≥2 |
The key to successful antibiotic therapy of pneumococcal disease is achieving drug concentrations in the affected area of the body that are several times higher than the MIC of the organism.
Beta-lactam antibiotics (eg, amoxicillin, cefuroxime) achieve high levels in middle ear fluid and in the respiratory tract. For this reason, they remain the drugs of choice for otitis media and sinusitis, even when these infections are caused by penicillin-resistant pneumococci. Amoxicillin is the drug of choice for susceptible strains causing most noninvasive disease (eg, otitis media, sinusitis) and for outpatient treatment of pneumonia. High-dose amoxicillin (80-90 mg/kg/d) can also be used for otitis media, sinusitis, and pneumonia caused by penicillin-resistant pneumococci with intermediate resistance. If otitis media fails to respond after high-dose amoxicillin, the next options include amoxacillin/clavulanate (Augmentin), cefdinir, cefpodoxime, or intramuscular ceftriaxone. If the patients fail with these regimens myringotomy may be required.
Eradication of meningitis requires a drug concentration of 8-fold to 15-fold higher than the minimum bactericidal concentration (MBC) in the CNS. Initial empiric therapy should include cefotaxime (225-300 mg/kg/d divided every 8 h) or ceftriaxone (100 mg/kg/d divided every 12-24 h) along with vancomycin (60 mg/kg/d divided every 6 h). Vancomycin should be discontinued if the organism is susceptible to ceftriaxone. Ceftriaxone is the drug of choice for meningitis caused by ceftriaxone-susceptible pneumococci (MIC <0.5 mcg/mL).
Meropenem may be an alternative to ceftriaxone for ceftriaxone-resistant pneumococcal meningitis. If the MIC to meropenem is more than 0.12 mcg/mL, vancomycin should be used in addition to meropenem.
For nonmeningeal invasive pneumococcal disease including disease caused by penicillin- and ceftriaxone-resistant pneumococci, ceftriaxone is the drug of choice if the organism's MIC to ceftriaxone is less than 4 mcg/mL. For organisms with an MIC of 4 mcg/mL or higher, vancomycin probably should be used in addition to ceftriaxone.
Antibiotic agents
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Amoxicillin (Trimox, Amoxil, Biomox)
DOC for OM, sinusitis, and outpatient treatment of pneumonia. Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria.
Adult
250-500 mg/dose PO tid
Pediatric
Standard dose: 20-50 mg/kg/d PO divided tid
High dose: 80-90 mg/kg/d PO divided tid for unresponsive OM and sinusitis; not to exceed 2-3 g/d
Note: May need to start with high-dose treatment in areas with high prevalence (>30%) of penicillin-resistant pneumococci
Reduces efficacy of PO contraceptives
Documented hypersensitivity; Epstein-Barr virus infection
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Dose adjustment needed in renal failure; diarrhea may occur
Ceftriaxone (Rocephin)
Third-generation cephalosporin. DOC for meningitis (age >1 mo), inpatient treatment of pneumonia, occult bacteremia, and other invasive infections. Alternative for outpatient treatment of occult bacteremia and OM unresponsive to standard antibiotics.
Adult
1-4 g/d IV/IM divided q12-24h; not to exceed 4 g/24 h
Pediatric
50-75 mg/kg/d IM/IV divided q12-24h
Meningitis (including penicillin-resistant strains): 100 mg/kg/d IV divided q12h administered with vancomycin
Non-CNS infections caused by penicillin-resistant strains: 80-100 mg/kg/d IV divided q12-24h
Acute OM: 50 mg/kg IM as single dose
Acute OM refractory to prior antibiotic treatment: 50 mg/kg/d IM for 3 d
Occult bacteremia: 50 mg/kg/d IM
Note: Not to exceed 1 g/dose
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 in renal impairment; caution in infants <4 wk because of risk of hyperbilirubinemia (consider alternative cephalosporin, eg, cefotaxime)
Cefotaxime (Claforan)
Third-generation cephalosporin. DOC for meningitis (all ages), inpatient treatment of pneumonia, bacteremia, and other invasive infections.
Adult
Standard dose: 1-2 g/dose IV/IM q6-8h
Meningitis or other severe infection: 2 g/dose IV/IM q4-6h
Note: Not to exceed 12 g/d
Pediatric
Neonates (dose based on postnatal age and weight):
<7 days and <2000 g: 100 mg/kg/d IV/IM divided q12h
<7 days and >2000 g: 100-150 mg/kg/d IV/IM divided q8-12h
7-28 days and <1200 g: 100 mg/kg/d IV/IM divided q12h
7-28 days and >1200 g: 150 mg/kg/d IV/IM divided q8h
Infants age >4 weeks and children:
100-200 mg/kg/d IV/IM divided q8h
Meningitis: 200 mg/kg/d IV/IM divided q6h
Non-CNS penicillin-resistant infections: 150-225 mg/kg/d
IV/IM divided q6-8h
Penicillin-resistant CNS/meningitis: 225-300 mg/kg/d IV/IM divded q6-8h administered with vancomycin
Probenecid may increase cefotaxime levels; coadministration with 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
Possible neutropenia, thrombocytopenia, eosinophilia, positive Coombs test result, elevated BUN level, creatinine level, and liver enzyme level; dose adjustment needed in renal failure
Vancomycin (Vancocin)
DOC for initial treatment of all meningitis (with cefotaxime or ceftriaxone) until susceptibilities are known. Continue in addition to ceftriaxone if the organism's ceftriaxone MIC is >0.25 mcg/mL. Also consider adding for non-CNS invasive infections if not responding to standard treatment because the infection may be caused by highly penicillin-resistant strains. DOC for patients allergic to penicillin with meningitis (with rifampin) or other invasive infections (alone).
Adult
2 g/d IV divided q6-12h
Pediatric
Neonates (dose based on postnatal age and weight):
<7 days and <1200 g: 15 mg/kg/dose/d IV
<7 days and 1200-2000 g: 10-15 mg/kg/dose IV q12-18h
<7 days and >2000 g: 10-15 mg/kg/dose IV q8-12h
7-28 days and <1200 g: 15 mg/kg/dose/d IV
7-28 days and 1200-2000 g: 10-15 mg/kg/dose IV q8-12h
7-28 days and >2000 g: 15-20 mg/kg/dose IV q8h
Infants age >4 weeks and children: 40 mg/kg/d IV divided q6-8h
CNS infections: 60 mg/kg/d IV divided q6-8h
Note: Not to exceed 2 g/24 h
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above risk 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
Possibility of ototoxicity and nephrotoxicity; possible exacerbation by concurrent aminoglycosides; dose adjustment needed in renal failure; possible red man syndrome with rapid IV infusion; infuse over 60-120 min for safety; monitor serum levels to avoid toxicity and ensure therapeutic levels (obtain trough level 30 min prior to dose 3, obtain peak level 60 min after dose 5); desired peak level is 25-40 mg/L and desired trough level is <10 mg/L; for meningitis, desired peak level is a minimum of 30 mg/L; when coadministered with aminoglycosides, monitor serum levels of both drugs and creatinine daily
Azithromycin (Zithromax)
Alternative for patients allergic to penicillin with OM, sinusitis, or outpatient treatment of pneumonia.
Adult
500 mg PO on day 1, then 250 mg/d PO on days 2-5
Pediatric
10 mg/kg/dose PO day 1, then 5 mg/kg/d PO on days 2-5; not to exceed 250 mg/d
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Clindamycin (Cleocin)
Alternative treatment for OM or sinusitis unresponsive to standard treatment. Alternative also for OM, sinusitis, and inpatient or outpatient treatment of pneumonia and treatment of invasive infections other than CNS infections in patients who are allergic to penicillin.
Adult
150-450 mg/dose PO q6-8h; not to exceed 1.8 g/d
1200-1800 mg/d IM/IV divided q6-12h; not to exceed 4.8 g/d
Pediatric
Neonates: 5 mg/kg/dose q6-12h (longer interval if weight <2 kg)
Infants age >4 weeks and children:
30 mg/kg/d PO divided q6-8h
40 mg/kg/d IV/IM divided q6-8h
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; hepatic impairment; antibiotic-associated colitis; CNS infections
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Possibility of pseudomembranous colitis up to several weeks after cessation of therapy; possible diarrhea, rash, Stevens-Johnson syndrome, granulocytopenia, thrombocytopenia, or sterile abscess at injection site; not to exceed infusion rate of 30 mg/min; possible hypotension or cardiac arrest; do not use in CNS infections (poor CNS penetration)
Meropenem (Merrem IV)
A carbapenem antibiotic alternative for patients allergic to penicillin with meningitis or other severe invasive infections (good CSF penetration). Has been used successfully in patients with meningitis caused by penicillin-resistant pneumococci.
Adult
1.5-3 g/d IV divided q8h
Meningitis and severe infections: 6 g/d IV divided q8h
Pediatric
<3 months: Not established
>3 months and children: 60 mg/kg/d IV divided q8h; not to exceed 3 g/d
Meningitis: 120 mg/kg/d IV divided q8h; not to exceed 6 g/d
Probenecid may inhibit renal excretion of meropenem, increasing meropenem levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Possible diarrhea, rash, vomiting, PO moniliasis, glossitis, pain and irritation at IV injection site, and headache; possible hepatic enzyme elevation, bilirubin elevation, leukopenia, and neutropenia; dose adjustment needed in renal impairment; use in meningitis only if organism is susceptible to meropenem (MIC <0.12 mcg/mL)
Rifampin (Rifadin)
Used in conjunction with vancomycin for patients allergic to penicillin with meningitis.
Adult
600-1200 mg/d IV divided q12h
Pediatric
20 mg/kg/d IV divided q12h
Induces CYP450 microsomal enzymes, which may decrease effects of acetaminophen, PO anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, PO contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations occur in LFTs)
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
Obtain CBC counts and baseline clinical chemistry panels prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur
Amoxicillin-clavulanic acid (Augmentin)
Antibiotic with beta-lactam inhibitor. Alternative for OM or sinusitis unresponsive to standard treatment.
In children >3 mo, base dosage protocol on amoxicillin content. As a result of different amoxicillin–to–clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.
Adult
250-500 mg/dose PO tid or 750 mg/dose PO bid
Pediatric
Based on amoxicillin component:
<3 months: 30 mg/kg/d PO divided bid
>3 months: 20-40 mg/kg/d PO divided tid or 25-45 mg/kg/d PO divided bid
Coadministration with warfarin or heparin increases risk of bleeding
Documented hypersensitivity; sensitivity to phenylketonurics (bid dosage form contains phenylalanine)
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Dose adjustment needed with renal impairment
Cefprozil (Cefzil)
Alternative for OM or sinusitis unresponsive to standard treatment or in patients with penicillin allergy but no cephalosporin allergy. Alternative outpatient treatment for pneumonia.
Adult
500-1000 mg/d PO divided q12h
Pediatric
30 mg/kg/d PO divided q12h; not to exceed 1 g/d
Probenecid increases effect of cefprozil; coadministration with furosemide and aminoglycosides increases nephrotoxic effects of cefprozil
Documented hypersensitivity; caution with penicillin allergy
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Dose adjustment needed with renal failure
Cefepime (Maxipime)
Fourth-generation cephalosporin with good gram-negative coverage. Similar to third-generation cephalosporins but has better gram-positive coverage. Has good pneumococcal coverage and penetrates the CSF well, thus, can be used as alternative to ceftriaxone.
Adult
1-2 g IV q12h for 10 d
Pediatric
50 mg/kg IV q8h; not to exceed 2 g/dose
At high doses, probenecid decreases cefepime clearance; when used concurrently, aminoglycosides increase nephrotoxic potential of cefepime
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 severe renal insufficiency; prolonged use of cefepime may predispose patients to superinfection
Cefuroxime (Zinacef, Ceftin)
Second-generation cephalosporin good for treatment of non-CNS pneumococcal disease
Adult
250-500 mg PO bid
750 mg to 1.5 g IV q8h
Pediatric
30 mg/kg/d PO divided bid; not to exceed 1 g/d
150 mg/kg/d IV divided q8h; not to exceed adult dose
Disulfiramlike reactions may occur when alcohol is consumed within 72 h after taking cefuroxime; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patients receiving potent diuretics, such as loop diuretics; coadministration with aminoglycosides increase nephrotoxic potential
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Administer one-half dose if creatinine clearance is 10-30 mL/min and one-quarter dose if <10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy
More on Pneumococcal Infections |
| Overview: Pneumococcal Infections |
| Differential Diagnoses & Workup: Pneumococcal Infections |
 Treatment & Medication: Pneumococcal Infections |
| Follow-up: Pneumococcal Infections |
| Multimedia: Pneumococcal Infections |
| References |
| « Previous Page | Next Page » |
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Further Reading
Keywords
pneumococcus, Streptococcus pneumoniae, S pneumoniae, pediatric infections, otitis media, osteomyelitis, septic arthritis, pericarditis, peritonitis, pneumococcal disease, pneumococcal pneumonia, pneumococcal infection, invasive pneumococcal disease, IPD, HIV infection, agammaglobulinemia, complement deficiency, splenectomy, sickle cell anemia, nephrotic syndrome, chronic renal failure, organ transplantation, immunosuppressive therapy, chronic pulmonary disease, cerebral spinal fluid leak after skull fracture, cochlear implant, diabetes mellitus, malignancy, otalgia, cough, meningitis
