Medical Care
Conjunctivitis, otitis media, sinusitis, bronchitis, and tracheobronchitis
Most patients with conjunctivitis, otitis media, sinusitis, bronchitis, and tracheobronchitis due to S pneumoniae infection can be treated on an outpatient basis with appropriate antibiotics. Compliance and follow-up should be ensured.
Infants and elderly patients, as well as those with immunodeficiencies, underlying disease, or signs of severe disease, should be treated more aggressively and hospitalized when indicated.
Pneumonia
Presenting signs and symptoms widely vary in patients with pneumococcal pneumonia, from mild illness to severe pneumonia to respiratory distress requiring ICU-level care. Factors such as age, type of symptoms, duration of symptoms, underlying and/or chronic illness, compliance with treatment, appropriate home care and potential for worsening disease must be considered in determining the need for and level of hospitalization. There are several scoring systems to appropriately triage patients with pneumonia and decide level of care. [68, 69, 70, 71, 72, 73, 74]
Most hospitalized patients should be treated with parenteral antibiotics in addition to medications for pulmonary symptoms, pain medications, intravenous fluids and/or parenteral or enteral nutrition, oxygen, and additional medications, as indicated on an individual basis. [75, 76, 77, 78, 79]
Diabetes appears to be the only underlying condition that by itself worsened mortality in ICU patients with invasive pneumococcal disease. [80]
Meningitis
Patients with S pneumoniae meningitis should be admitted to the hospital and treated with parenteral antibiotics.
The use of systemic steroids within 15 minutes of initiating infusion of antibiotics in adult patients with bacterial meningitis is usually recommended with caution, as they may decrease CSF antibiotic concentration; patients with meningitis treated with steroids should be monitored closely. [81]
Steroids can be considered prior to antibiotic therapy in children aged 6 weeks and older with possible pneumococcal meningitis. If used, they should be given before or at the time of the first dose of antibiotics. [7]
Intravenous fluids, parenteral/enteral nutrition, and other medications should be used as indicated in appropriate clinical instances.
Bacteremia and sepsis
Patients with pneumococcal bacteremia should be treated with appropriate antibiotics and supportive care.
Repeat blood cultures should always be obtained in patients with S pneumoniae bacteremia.
Patients with signs or symptoms of sepsis should be admitted to the hospital and treated aggressively with antibiotics and other medical therapies, as indicated.
Surgical Care
Patients with complicated pneumonia may require a chest tube for drainage of pleural fluid; VATS or decortication may be required in more severe cases or in those with empyema.
In patients with suspected septic arthritis or osteomyelitis, synovial fluid or bone tissue should be obtained for Gram stain, cell count, histology, and culture.
Patients with recurrent or chronic otitis media, periorbital or orbital cellulitis, or facial cellulitis may require surgical intervention.
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, 2 pneumococcal vaccines (ie, PPSV23, PCV7) 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, 82, 83, 84, 85, 86, 87]
The FDA approved 2 additional pneumococcal conjugate vaccines (ie, PCV15, PCV20) in 2021 to expand protection against vaccine-preventable pneumococcal disease. Antibody responses to 2 additional serotypes (ie, 22F and 33F) included in PCV15 were compared to corresponding responses after PCV13 vaccination, and antibody responses to 7 additional serotypes (ie, 8, 10A, 11A, 12F, 15B, 22F, and 33F) included in PCV20 were compared with those to the 23-valent pneumococcal polysaccharide vaccine (PPSV23). [88]
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. [79] 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 [86, 89, 90] (Open Table in a new window)
Population |
Vaccine |
|
Children aged 6 weeks through 5 years: 0.5 mL IM |
Pneumococcal conjugate vaccine 13-valent (Prevnar 13) or 15-valent (Vaxneuvance) Series of 4 doses at ages 2, 4, 6, and 12-15 months (catch-up schedule through age 5 y) |
|
Adults aged 65 years and older*†: 0.5 mL IM |
Adults who have not previously received a pneumococcal conjugate vaccine or whose previous immunization history is unknown should receive either PCV20 or PCV15 If PCV15 is used, follow with a dose of pneumococcal polyvalent vaccine 23-valent (PPSV23) after 1 year (or at least 8 weeks if immunocompromised) |
|
†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 or PCV15 before PPSV23 is given).
Table 2. Vaccination of High-Risk Children Aged 2-18 Years With Pneumococcal Polyvalent Vaccine 23-Valent [91] (Open Table in a new window)
Pediatric Risk Group |
High-Risk Condition |
Chronic medical conditions |
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 Sickle cell disease and other hemoglobinopathies Anatomic or functional asplenia |
Hepatic disease |
Chronic liver disease, alcoholism |
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 or acquired immunodeficiency |
On October 20, 2021, the Advisory Committee on Immunization Practices (ACIP) recommended use of either PCV20 alone or PCV15 in series with PPSV23 for all adults aged 65 years and older, and for adults aged 19-64 years with certain underlying medical conditions or other risk factors who have not previously received a PCV or whose previous vaccination history is unknown. Regimens are as follows: [89, 88]
Aged 65 years and older
-
No prior vaccine: Administer 1 dose of PCV20 or 1 dose of PCV15 followed by a dose of PPSV23 at least 1 year later
-
Received PCV13 or PPSV23 only at any age, or received PCV13 and PPSV23 at < 65 years: After at least 5 years, administer 1 dose of PCV20 or 1 dose of PCV15 followed by a dose of PPSV23 at least 1 year later
Aged 19-64 years with underlying conditions
-
Administer 1 dose of PCV20 or 1 dose of PCV15 followed by a dose of PPSV23 at least 1 year later
-
Those with immunocompromising conditions, cochlear implant, or CSF leak might benefit from shorter intervals such as least 8 weeks
-
Received PCV13 at any age and PPSV23 at < 65 years: After at least 5 years, administer 1 dose of PCV20 or 1 dose of PCV15 followed by a dose of PPSV23 at least 1 year later
Table 3. Vaccination of High-Risk Adults Aged 19 Years and Older With Pneumococcal Vaccines [89, 88] (Open Table in a new window)
Risk Group |
Condition |
Immunocompetent individuals |
Chronic heart disease* |
Chronic lung disease† |
|
Diabetes mellitus |
|
Cerebrospinal fluid leaks |
|
Cochlear implant |
|
Alcoholism |
|
Chronic liver disease, cirrhosis |
|
Functional or anatomic asplenia |
Sickle cell disease and other hemoglobinopathies |
Congenital or acquired asplenia |
|
Immunocompromised individuals |
Congenital or acquired immunodeficiency |
HIV infection |
|
Chronic renal failure |
|
Nephrotic syndrome |
|
Leukemia |
|
Lymphoma |
|
Hodgkin disease |
|
Generalized malignancy |
|
Iatrogenic immunosuppression‡ |
|
Solid organ transplant |
|
Multiple myeloma |
|
*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. [92] 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 or PCV15 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 [82] :
-
A 4-shot series should be given at ages 2, 4, 6, and 12-15 months.
-
Immunization with PCV13 or PCV15 have replaced PCV7. Children who have received one of more doses of PCV7 should have those doses counted, but complete the series with PCV13 or PCV15.
-
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 or PCV15.
-
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.
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 or PCV15, Including Catch-up Immunizations in Previously Unimmunized and Partially Immunized Children [90] (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 |
|
|
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. [93, 94]
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.
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.
-
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.
Tables
- Table 1. Routine Vaccination With Pneumococcal Vaccines [86, 89, 90]
- Table 2. Vaccination of High-Risk Children Aged 2-18 Years With Pneumococcal Polyvalent Vaccine 23-Valent [91]
- Table 3. Vaccination of High-Risk Adults Aged 19 Years and Older With Pneumococcal Vaccines [89, 88]
- Table 4. Recommended Schedule for Doses of PCV13 or PCV15, Including Catch-up Immunizations in Previously Unimmunized and Partially Immunized Children [90]
Population |
Vaccine |
|
Children aged 6 weeks through 5 years: 0.5 mL IM |
Pneumococcal conjugate vaccine 13-valent (Prevnar 13) or 15-valent (Vaxneuvance) Series of 4 doses at ages 2, 4, 6, and 12-15 months (catch-up schedule through age 5 y) |
|
Adults aged 65 years and older*†: 0.5 mL IM |
Adults who have not previously received a pneumococcal conjugate vaccine or whose previous immunization history is unknown should receive either PCV20 or PCV15 If PCV15 is used, follow with a dose of pneumococcal polyvalent vaccine 23-valent (PPSV23) after 1 year (or at least 8 weeks if immunocompromised) |
|
†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. |
||
Pediatric Risk Group |
High-Risk Condition |
Chronic medical conditions |
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 Sickle cell disease and other hemoglobinopathies Anatomic or functional asplenia |
Hepatic disease |
Chronic liver disease, alcoholism |
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 or acquired immunodeficiency |
Risk Group |
Condition |
Immunocompetent individuals |
Chronic heart disease* |
Chronic lung disease† |
|
Diabetes mellitus |
|
Cerebrospinal fluid leaks |
|
Cochlear implant |
|
Alcoholism |
|
Chronic liver disease, cirrhosis |
|
Functional or anatomic asplenia |
Sickle cell disease and other hemoglobinopathies |
Congenital or acquired asplenia |
|
Immunocompromised individuals |
Congenital or acquired immunodeficiency |
HIV infection |
|
Chronic renal failure |
|
Nephrotic syndrome |
|
Leukemia |
|
Lymphoma |
|
Hodgkin disease |
|
Generalized malignancy |
|
Iatrogenic immunosuppression‡ |
|
Solid organ transplant |
|
Multiple myeloma |
|
*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. |
|
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 |
|
|
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). |
||
