Pediatric Pneumococcal Infections Medication

Updated: Jan 14, 2019
  • Author: Meera Varman, MD; Chief Editor: Russell W Steele, MD  more...
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Medication

Medication Summary

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.

Table. Drug Comparison (Open Table in a new window)

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 amoxicillin/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.

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Antibiotic Agents

Class Summary

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.

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.

Cefotaxime (Claforan)

Third-generation cephalosporin. DOC for meningitis (all ages), inpatient treatment of pneumonia, bacteremia, and other invasive infections.

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).

Azithromycin (Zithromax)

Alternative for patients allergic to penicillin with OM, sinusitis, or outpatient treatment of pneumonia.

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.

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.

Rifampin (Rifadin)

Used in conjunction with vancomycin for patients allergic to penicillin with meningitis.

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.

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.

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.

Cefuroxime (Zinacef, Ceftin)

Second-generation cephalosporin good for treatment of non-CNS pneumococcal disease

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