Pneumococcal Infections Follow-up

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

Further Inpatient Care

Pneumonia

Patients with pneumococcal pneumonia who do not respond or respond slower than usual to initial treatment should undergo follow-up chest radiography. Worsening disease and/or the presence of a pleural effusion may indicate the need for consultation with a pulmonologist, an infectious disease specialist, and/or a surgeon for further intervention. Oral therapy can be initiated when patients have clinically improved and become afebrile. Repeat chest radiography should be performed 4-8 weeks after therapy is completed to ensure resolution of disease. Chest radiography findings may remain abnormal for weeks to months, particularly following severe disease or complicated pneumonias.

Bacteremia

In hospitalized patients with pneumococcal bacteremia, follow-up blood cultures should be obtained until culture results are negative.

Meningitis

A repeat lumbar puncture should be considered after 48 hours of therapy in the following circumstances:

  • Patients whose isolates are not susceptible to penicillin based on oxacillin disc diffusion testing or MIC testing without pending results of cefotaxime and/or ceftriaxone susceptibilities
  • Patients whose condition has worsened or has not improved
  • Patients who received steroid therapy (which could alter the ability to observe clinical improvement/worsening)

Patients with pneumococcal meningitis should receive the entire course of antibiotic therapy parenterally.

Other invasive infections

Purulent pneumococcal pericarditis and endocarditis are serious diseases and should be treated aggressively with appropriate courses of parenteral antibiotics.

Blood cultures should be obtained until multiple negative sets are documented. Repeat chest radiography, echocardiography, and other imaging tests may be repeated as recommended to monitor disease resolution.

Patients with osteomyelitis and joint infections caused by S pneumoniae infection should be monitored closely for a decrease in pain and inflammatory markers and improved use of the affected limb or joint. Failure to improve should prompt re-evaluation of the area via aspiration, washout, biopsy, or repeat imaging.

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Deterrence/Prevention

Behavior modification and risk factors

Cigarette smoking and passive cigarette smoke exposure have been linked to an increased risk for invasive pneumococcal disease in healthy adults; thus, smoking cessation should be encouraged. Optimal nutrition and living conditions may decrease the risk for pneumococcal disease. Breastfeeding of infants should also be encouraged, as the rates of invasive pneumococcal infection is lower in breastfed infants. Daycare attendance is associated with acquisition, carriage (of susceptible and drug-resistant strains), infection, and outbreaks of pneumococcal disease in proportion to the number of attendees.

Immunization

Until February 2010, two pneumococcal vaccines were available for use in the prevention of pneumococcal disease. On February 24, 2010, the FDA approved the use of PCV13 vaccine for use in children aged 2-71 months, and its use replaces PCV7. [17, 77, 78, 79, 80, 81, 82, 83]

The capsular polysaccharide vaccine (PPSV23), licensed in 1977, contains capsular antigens from the 23 serotypes of S pneumoniae that cause most of the infections in the United States. After vaccination with the polysaccharide vaccine, persons aged 5 years and older develop type-specific protective antibodies. Polysaccharide vaccines produce antibodies primarily through T-cell–independent methods. Because these systems are not fully developed in young children, children younger than 2 years have a poor response to these types of vaccines. [66] In some elderly persons and persons of all ages with immunosuppressive conditions, the immunogenicity is similarly poor. No anamnestic response occurs with revaccination, and the duration of immunity with the polysaccharide vaccine is unknown. Neither a decrease in pneumococcal carriage rates or protection of unimmunized persons due to herd immunity has been documented after immunization using the polysaccharide vaccine.

A 13-valent pneumococcal conjugate vaccine (PVC13) was licensed for use in 2010 and includes antigens from the capsules of 13 pneumococcal serotypes (1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F). When this vaccine was introduced in 2010, it replaced PCV7. The additional 6 serotypes accounted for the majority of pneumococcal isolates that caused invasive disease since the introduction of PCV7 in 2000. [16]

Pneumococcal conjugate vaccines link capsular polysaccharides to a conjugate (diphtheroid) carrier protein. Responses to these antigens are developed using T-cell–dependent mechanisms. These antibodies induce immunologic memory, reduce carriage rates of pneumococcal vaccine-serotype isolates, and provide indirect protection to unimmunized persons via herd immunity.

Table 1. Routine Vaccination With Pneumococcal Vaccines [84, 85, 82] (Open Table in a new window)

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.



The Advisory Committee on Immunization Practices (ACIP) recommends that the pneumococcal vaccine (PPSV23) be given to high-risk children (children aged 2-6 y should complete the recommended doses of PCV13 before PPSV23 is given).

Table 2. Vaccination of High-Risk Children Aged 2-18 Years With Pneumococcal Polyvalent Vaccine 23-Valent [86] (Open Table in a new window)

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



Additionally, in August 2014, the ACIP published updated recommendations for pneumococcal vaccination of high-risk adults. The committee now recommends routine use of PCV13 in sequence with the previously recommended PPSV23. High-risk adults who have not previously received either pneumococcal vaccine should be given 1 dose of PCV13 followed a minimum of 8 weeks later by 1 dose of PPSV23. In patients who have previously received PPSV23, 1 dose of PCV13 should be administered a minimum of 1 year following the last PPSV23 dose. If the last PPSV23 dose was given prior to age 65 years and at least 1 year prior, PCV13 should be administered followed 6-12 months later by another PPSV23 dose. [87]

Table 3. Vaccination of High-Risk Adults Aged 19 Years or Older With Pneumococcal Vaccines [87] (Open Table in a new window)

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.



The duration of protection is probably 5-10 years but may vary widely. Revaccination is recommended in certain populations, including the following:

  • Five years after initial immunization in children aged 2 years or older at high risk for pneumococcal infection or in whom antibody titers are highly likely to rapidly decline, including those with functional or anatomic asplenia, sickle cell disease, or immunosuppression. All other children with underlying medical conditions should receive 1 dose of PPSV23.
  • Persons aged 65 years or older who are at high risk for disease or rapid antibody decline, including those with asplenia, HIV, leukemia, lymphoma, Hodgkin disease, multiple myeloma, malignancy, renal disease, or organ/marrow transplant or those on immunosuppressive therapies

A study showed that, in elderly patients with chronic illness, dual vaccination with pneumococcal polysaccharide vaccine and influenza vaccine led to decreased complications related to respiratory, cardiovascular, and cerebrovascular diseases. [88] A reduction in hospitalizations, critical illness, and death was also noted in these patients.

Recommendations for universal vaccination in all children aged 59 months and younger in the United States are now in place. In addition, PCV13 use is recommended in children aged 60-71 months with underlying medical conditions placing them at increased risk for pneumococcal disease and its complications. Health care providers considering vaccination should refer to the ACIP guidelines and the American Academy of Pediatrics policy statement on recommendations for immunization of children against pneumococcal disease, outlined as follows [77] :

  • A 4-shot series should be given at ages 2, 4, 6, and 12-15 months.
  • Immunization with PCV13 has replaced PCV7. Children who have received one of more doses of PCV7 should have those doses counted, but complete the series with PCV13.
  • Catch-up immunization should be pursued in all children aged 59 months or younger who are incompletely immunized for age using current recommendations by the American Academy of Pediatrics and ACIP. PCV13 replaces the use and previous recommendations for PCV7. [7, 78]
  • Healthy children aged 24-59 months who have an incomplete schedule of immunization with one of the conjugate vaccines should receive a single dose of PCV13.
  • Children aged 24-71 months who are at high risk for pneumococcal disease with an incomplete schedule of fewer than 3 doses should receive 2 doses of conjugate vaccine 2 months apart, followed at least 2 months later by 1 dose of polysaccharide vaccine. Children with an incomplete schedule of 3 doses should receive 1 additional dose.

A single supplemental dose of PCV13 is recommended for all children in the following groups who were previously fully immunized with PCV7:

  • All healthy children aged 14-59 months old
  • All children aged 14-71 months with underlying medical conditions placing them at increased risk of pneumococcal disease
  • A single dose of PCV13 may be administered to children aged 6-18 years (regardless of previous pneumococcal immunization status) who are at increased risk of IPD because of sickle cell disease, asplenia, HIV/immunocompromise, CSF leaks, or cochlear implants. [77]

High-risk patients include those with sickle cell disease or hemoglobinopathies, asplenia (congenital or functional), HIV infection, cochlear implants, those of Alaskan Native descent (and of some American Indian populations) who are younger than 2 years, immunocompromising conditions (congenital immune deficiencies), chronic cardiac or pulmonary illness, diabetes mellitus, chronic renal insufficiency (including nephrotic syndrome), diseases requiring immunosuppressive or radiation therapy, and/or CSF leaks. [7]

Table 4. Recommended Schedule for Doses of PCV13, Including Catch-up Immunizations in Previously Unimmunized and Partially Immunized Children [7] (Open Table in a new window)

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).



Many clinical investigations have shown the positive impact of the pneumococcal conjugate vaccine on invasive and noninvasive disease in children, as well as the reduction in nasopharyngeal carriage of vaccine serotypes. [89, 90]

The increasing vaccination rates in children and resultant herd immunity coupled with the increased number of serotypes, even with a possible inferior immune response of the polysaccharide vaccine, make this question relevant.

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Prognosis

Pneumococcal conjunctivitis, otitis media, and sinusitis in developed countries where appropriate antibiotics are available usually carry an excellent prognosis; potential complications are listed above (see Complications).

The prognosis of pneumococcal pneumonia depends largely on underlying factors, including age, immunosuppression, availability of antibiotics, and extent of lung involvement. Pneumococcal pneumonia does not tend to cause necrotizing disease, and most healthy patients treated appropriately recover without long-term complications.

The prognosis of pneumococcal meningitis is also related in part to host factors. Most studies have shown that morbidity rates in otherwise healthy US children with meningitis are usually less than 10%; however, neurological sequelae are common.

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Patient Education

All parents should be advised of the recommendations for universal childhood immunization with the pneumococcal conjugate vaccine.

Patients with medical conditions that place them at an increased risk for serious or invasive S pneumoniae disease should be educated about their condition, the potential presenting signs and symptoms of pneumococcal infection, and the need to obtain medical care promptly upon any concern for possible infection. These patients should also be educated about the benefits of the pneumococcal polysaccharide vaccine and should be encouraged to receive it.

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