Pediatric Pneumococcal Infections 

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

Overview

Practice Essentials

Streptococcus pneumoniae colonizes the upper respiratory tract of healthy individuals and is one of the most frequent causes of bacterial infection in children. Pediatric infections caused by this pathogen include otitis media (OM), sinusitis, occult bacteremia, pneumonia, meningitis, osteomyelitis, septic arthritis, pericarditis, and peritonitis. See the image below.

Sputum Gram stain from a patient with a pneumococc 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.

Signs and symptoms

Children with pneumococcal infections usually have a temperature higher than 102°F, along with symptoms of specific infections, as follows:

  • OM – Otalgia, upper respiratory symptoms, vomiting

  • Sinusitis – Headache, facial tenderness (much less frequent than in adults), symptoms of upper respiratory tract infection lasting for 10 days or longer

  • Occult bacteremia – Fever without a localizing source in children aged 2-24 months

  • Pneumonia – Cough; chest pain, shortness of breath, or respiratory difficulty; malaise and poor appetite

  • Meningitis – Stiff neck, vomiting, headache (older children); high fever (>103°F), lethargy, irritability, poor feeding, inconsolable crying[1]

Physical findings include the following:

  • OM – Bulging, erythematous, or yellow tympanic membrane with poor mobility and purulent fluid seen behind the membrane

  • Sinusitis – Tenderness to palpation over maxillary or frontal sinuses, nasal discharge of any color, swollen nasal turbinates

  • Bacteremia – None, besides fever (≥102°F) and tachycardia associated with the fever

  • Pneumonia – Crackles or decreased breath sounds in the area of lobar consolidation on chest auscultation, with egophony in patients with severe consolidation and dullness to percussion; retractions, tachypnea, or both

  • Meningitis or other central nervous system (CNS) infection – Ill appearance; nuchal rigidity (may not be present before age 4 months); altered mental status with poor responsiveness (patient may present in comatose state); other neurologic abnormalities possible (eg, cranial nerve deficits, ataxia, weakness); poor perfusion and signs of shock in patients with concurrent pneumococcal sepsis

See Presentation for more detail.

Diagnosis

The following laboratory studies are indicated in patients with pneumococcal infections:

  • White blood cell (WBC) count and differential

  • Antigen tests (cerebrospinal fluid [CSF], urine)

  • Gram stain (CSF, synovial fluid, pleural fluid)

  • Culture (blood, CSF, pleural fluid, middle ear effusion, synovial fluid)

Specific testing recommendations for particular clinical syndromes are as follows:

  • OM or sinusitis – Tympanocentesis and bacterial cultures of middle ear fluid if chronic OM is refractory to antibiotics

  • Sinusitis – Culture of sinus fluid if sinusitis is refractory to antibiotics

  • Occult bacteremia – Culture of blood (≥2 mL)

  • Pneumonia – Blood culture; sputum cultures are difficult to obtain from children, and results may be falsely positive

  • Meningitis (suspected) – Lumbar puncture with CSF analysis (cell count, protein levels, glucose levels, Gram stain, culture; antigen tests are needed only in cases of antibiotic pretreatment); blood culture

  • Osteomyelitis or septic arthritis – Surgical biopsy or joint aspiration; culture of fluid or bone; blood culture

Imaging studies that may be helpful include the following:

See the list below:

  • Chest radiography

  • Computed tomography (CT) of the head (often unnecessary)

  • Magnetic resonance imaging (MRI) of the head

See Workup for more detail.

Management

Antibiotic therapy and supportive care are indicated. The key to successful antibiotic therapy is achieving drug concentrations in the affected area of the body that are several times higher than the minimal inhibitory concentration (MIC) for S pneumoniae.

Recommendations for particular clinical situations include the following:

  • OM or sinusitis (initial treatment) – Amoxicillin for 5-10 days (otitis media) or 10-21 days (sinusitis)

  • OM or sinusitis that does not improve with standard-dose amoxicillin – High-dose amoxicillin, amoxicillin-clavulanate, cefuroxime, or ceftriaxone (IM)

  • Pneumonia (outpatient) – Amoxicillin for 10 days

  • Pneumonia (inpatient) – IV ceftriaxone until clinical improvement, then 10 days of outpatient treatment; in critical illness, addition of vancomycin should be considered

  • Other invasive pneumococcal diseases – A third- or fourth-generation parenteral cephalosporin (ceftriaxone, cefotaxime, cefepime); in critical illness or the absence of clinical improvement, addition of vancomycin should be considered

  • Meningitis – Ceftriaxone or cefotaxime; meropenem may be an alternative in cases of ceftriaxone resistance; vancomycin is always added until susceptibilities are known; rifampin may be added after 24-48 hours of improvement is not noted or the relevant MIC is high

  • Penicillin allergy (OM, sinusitis, outpatient treatment of pneumonia) – Azithromycin (or other macrolide), clindamycin, cefuroxime (if there is no cephalosporin allergy), or cefprozil

  • Penicillin allergy (inpatient treatment of pneumonia or other invasive infections) – IV ceftriaxone (if there is no cephalosporin allergy); alternatively, IV clindamycin or meropenem; vancomycin may be considered if the patient is severely ill and microbial susceptibility is unknown

See Treatment and Medication for more detail.

Background

Streptococcus pneumoniae colonizes the upper respiratory tract of healthy individuals and is one of the most frequent causes of bacterial infection in children. Common infections caused by this pathogen include otitis media (OM), sinusitis, occult bacteremia, pneumonia, and meningitis. Pneumococci may also cause osteomyelitis, septic arthritis, pericarditis, and peritonitis. See the image below.

Sputum Gram stain from a patient with a pneumococc 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.

Pathophysiology

Pneumococci are encapsulated, lancet-shaped, gram-positive diplococci. The bacteria are transmitted person to person via respiratory droplet contact. Pneumococci can cause disease either by direct spread from colonized mucosal surfaces (eg, otitis media) or by hematogenous spread (eg, meningitis following bacteremia). Mucosal irritation resulting from factors such as viral infection or smoke often is a predisposing factor for pneumococcal infection. Ninety serotypes have been identified, with varying degrees of pathogenicity. Serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F cause most invasive disease, and pneumococci with these serotypes are often resistant to penicillin.

Frequency

Overall Frequency

Invasive disease is most frequent in children younger than 2 years and in adults older than 65 years. Overall annual incidence of invasive disease in the United States is 15 cases per 100,000 individuals but widely varies by age, from 166 cases per 100,000 children younger than 2 years to 5 cases per 100,000 young adults. After the introduction of heptavalent conjugated pneumococcal vaccine, the rate of invasive pneumococcal disease (IPD) has trended down.[2, 3] In an active laboratory surveillance from 1997-2004, the IPD decreased by 40% from 11.8 cases to 7.2 cases per 100,000 live births. Among black infants, a marked decrease was noted in incidence of IPD from 17.1 cases to 5.3 cases per 100,000 live births compared with white infants with a decrease from 9.6 cases to 6.8 cases per 100,000 live births.

From 1999-2007, a 92% reduction in vaccine serotypes has been observed among both invasive and noninvasive isolates; during the same period, a 200% increase has been observed in vaccine-related or nonvaccine serotypes. Among these, serotypes 19A, 6C, 15, and 22F were predominantly noted.[4] The amoxicillin susceptibility was about 70% compared with 50% in macrolides. Serotype 6C is considered to be emerging as well.[5]

An increased frequency of disease and increased morbidity and mortality rates are seen in children younger than 2 years and in children with humoral immunodeficiency (eg, HIV infection, agammaglobulinemia, complement deficiency), absent or deficient splenic function (eg, splenectomy, sickle cell anemia), nephrotic syndrome, chronic renal failure, organ transplantation, immunosuppressive therapy, chronic pulmonary disease, cerebral spinal fluid (CSF) leak after skull fracture, cochlear implant, diabetes mellitus, and malignancy. Parental smoking invariably increases acute otitis media by about 64% compared to no history of parental smoking (56%).

Specific Infections

See the list below:

  • Otitis media: Approximately 30% of children have at least one episode of pneumococcal otitis media by age 3 years. Pneumococci cause approximately 40% of otitis media cases. After the pneumococcal vaccination, nonvaccine serotype is encountered more frequently as a cause of otitis compared with vaccine serotypes.

  • Bacteremia: Pneumococci are responsible for as many as 85% of occult cases of bacteremia in children. Bacteremia is seen in 3-5% of children aged 3-36 months with fever higher than 102.5°F without another source. In the postvaccine licensure period, the annual episodes of pneumococcal bacteremia decreased from 7.2 episodes to 2.3 episodes per 100,000 emergency department visits in 1999. However, it increased to 2.8 episodes in 2004 and to 3.64 episodes per 100,000 emergency department visits in 2005. The rate of invasive disease due to serotype 19F in the conjugate vaccine has increased.

  • Pneumonia: S pneumoniae is the most common bacterial cause of childhood pneumonia, especially in children younger than 5 years.

  • Meningitis/CNS infections: S pneumoniae is the most common cause of bacterial meningitis in children. Yearly incidence in all age groups is 1-2 cases per 100,000 population.

  • Osteomyelitis/septic arthritis: Pneumococci are responsible for fewer than 10% of all cases of osteomyelitis and septic arthritis.

Other unusual infections caused by pneumococci are sporadic.

Vaccination

The recent inclusion of the pneumococcal conjugate vaccine in the routine pediatric immunization schedule has markedly decreased the incidence of invasive pneumococcal disease. The vaccine is about 50-60% efficacious in reducing otitis media caused by the vaccine strains of S pneumoniae compared with 80-100% in preventing invasive disease. In children younger than 5 years, IPD has decreased from 98.7 cases per 100,000 population in 1998-99 to 23.4 cases per 100,000 population in 2005, with 77% reduction.[6, 7] An increase in serotype 19A from 2.6 cases in 98-99 to 9.3 cases in 2005 has been reported in this age group.

A study by Greenhow et al that retrospectively reviewed 57,733 blood cultures from children 3 to 36 months old reported that the incidence of Streptococcus pneumoniae bacteremia decreased from 74.5 per 100,000 children to 3.5 per 100,000 in the post-PCV-13 period, a 95.3% reduction.[8]  

A study that compared the pneumococcal prevaccination period of 2005-2008 to 2014 reported that incidence of otitis media decreased from 41.5% in children < 5 and 20.9% in children >5. The study also reported significant reductions in sinusitis and other upper respiratory tract infections and a decreased incidence of pneumonia by 28.6% in children < 5.[48]

International

Pneumococcal pneumonia is estimated to cause 1.2 million deaths per year worldwide in children younger than 5 years.

Mortality/Morbidity

Death resulting from complications of pneumococcal otitis, sinusitis, bacteremia, and pneumonia is rare in otherwise healthy children. As a complication of pneumonia, pneumococcal empyema is not infrequent, even in developed countries, and it remains a significant problem in developing nations.

The case-fatality rate for pneumococcal meningitis is 5-10%. Between 25-35% of children with pneumococcal meningitis develop permanent neurologic sequelae (eg, hearing deficits, paralysis, hydrocephalus). The risk of fulminant pneumococcal infection and death in the high-risk patient population outlined above (eg, children with humoral immunodeficiency, functional asplenia, nephrotic syndrome) is much higher than the risk in otherwise healthy children.

A study that described the epidemiology, serotype distribution, clinical presentations, and outcomes of invasive pneumococcal diseases (IPD) in children with and without comorbidity reported that in children with comorbidity, IPD results in higher mortality, and a large proportion of disease is due to serotypes not included in current conjugate vaccines.[9, 10]

Race

An increased incidence of invasive pneumococcal disease has been documented in blacks, American Indians (white Mountain Apache, Navajo), and Alaskan Eskimos.

Sex

Pneumococcal disease is slightly more frequent in males than in females, with a male-to-female ratio of 3:2 for pneumococcal bacteremia.

Age

Pneumococcal infections are most common in children aged 1-24 months.

  • Otitis media and bacteremia are most common in children aged 6 months to 2 years.

  • Sinusitis is most common in children 2 years and older.

  • Pneumonia and meningitis are most common in children younger than 5 years.

 

Presentation

History

Children with pneumococcal infections usually have a temperature higher than 102°F. Children with invasive infections also demonstrate signs and symptoms related to the site of infection. Symptoms of specific infections in addition to fever are as follows:

Otitis media symptoms include the following:

  • Otalgia (irritability and ear pulling in younger children)

  • Upper respiratory symptoms

  • Vomiting

Sinusitis symptoms include the following:

  • Headache

  • Facial tenderness (much less frequent than in adults)

  • Symptoms of upper respiratory infection (cough, nasal drainage, congestion) lasting for 10 days or longer

Occult bacteremia may present with fever without a localizing source in children aged 2-24 months.

Pneumonia may present with the following:

  • Cough

  • Chest pain, shortness of breath, or respiratory difficulty

  • Malaise and poor appetite

Meningitis may present with the following:

  • Stiff neck

  • Vomiting

  • Headache (older children)

  • High fever (temperature >103°F)

  • Lethargy

  • Irritability

  • Poor feeding

  • Inconsolable crying

Physical

Otitis media findings include bulging, erythematous, or yellow tympanic membrane with poor mobility and purulent fluid seen behind the tympanic membrane.

Sinusitis findings include the following:

  • Tenderness to palpation over maxillary or frontal sinuses

  • Nasal discharge of any color

  • Swollen nasal turbinates

Bacteremia has no physical findings except fever (temperature of 102°F or higher) and tachycardia associated with the fever.

Pneumonia findings include the following:

  • Crackles or decreased breath sounds in the area of lobar consolidation on chest auscultation, with egophony in patients with severe consolidation and dullness to percussion

  • Retractions, tachypnea, or both

Meningitis/CNS infection findings include the following:

  • Ill appearance

  • Nuchal rigidity (may not be present in infants < 4 mo)

  • Altered mental status, poorly responsive (patient may present in comatose state)

  • Other neurologic abnormalities possible, such as cranial nerve deficits, ataxia, and weakness

  • Poor perfusion and signs of shock in patients with concurrent pneumococcal sepsis

 

DDx

 

Workup

Laboratory Studies

Approach Considerations

The following studies are indicated in patients with pneumococcal infections:

WBC count

Elevated WBC count and differential showing a high band count or left shift may suggest bacterial infection.

Young children with a WBC count greater than 15,000 cells/mL and/or an absolute band count greater than 1500/mcL have an increased likelihood of occult bacteremia.

WBC count may be low in children with meningitis and other severe pneumococcal infections.

Antigen tests

The use of CSF and urine antigen tests for pneumococci is limited because of the multitude of S pneumoniae serotypes and the poor sensitivity of the test. At present, these tests should be used only in children in whom blood and CSF cultures were obtained after antibiotic treatment. In these children, antigen test results occasionally are positive when culture results are negative.

A negative result on an antigen test does not exclude pneumococcal infection.

Gram stain

Gram stains of usually sterile body fluids (CSF, synovial fluid, pleural fluid) showing gram-positive diplococci strongly suggest the diagnosis of pneumococcal infection, although alpha-hemolytic streptococci and group B streptococci can look like S pneumoniae.

Results of CSF Gram stains in younger children with meningitis are positive 90-100% of the time, but the CSF Gram stain technique may be slightly less sensitive in older children.

Culture

Culture of S pneumoniae from usually sterile body fluids (eg, blood, CSF, pleural fluid, middle ear effusion, synovial fluid) establishes the diagnosis definitively.

Perform susceptibility testing when an invasive infection is present.

Specific Studies

For each of the following clinical syndromes, specific testing recommendations are as follows:

Otitis media or sinusitis

Tympanocentesis and bacterial cultures of middle ear fluid should be performed in children with chronic otitis media refractory to antibiotic treatment. This requires technical expertise.

Sinus fluid should be obtained and sent for bacterial culture if the sinusitis is refractory to antibiotic treatment.

Upper respiratory tract cultures are not reliable in determining infection because of the high rate of asymptomatic children carrying S pneumoniae.

Occult bacteremia

A blood culture of sufficient volume (minimum of 2 mL) is indicated.

Pneumonia

Sputum cultures are difficult to obtain from children, and results may be falsely positive because of the high rates of upper respiratory colonization in this population.

Blood cultures should be obtained in all patients, although only 25-30% of patients with pneumococcal pneumonia have positive results on blood culture.

Meningitis

When meningitis is suspected, lumbar puncture should be performed. CSF should be sent for cell count, protein levels, glucose levels, Gram stain, and culture. Antigen tests are needed only if the patient was pretreated with antibiotics.

A blood culture also should be obtained to further confirm the diagnosis and the pathogens.

Osteomyelitis/septic arthritis

Procedures include surgical biopsy or joint aspiration; fluid or bone is cultured for the organism.

Perform blood culture because bacteremia is often present as well.

Imaging Studies

Chest radiographs may reveal lobar or segmental consolidation or typical findings of round pneumonia.

In many centers, a head CT scan is performed in older children with meningitis to exclude increased intracranial pressure prior to performing lumbar puncture. No compelling evidence exists that CT findings are better than physical examination at predicting complications from lumbar puncture, and, in most patients, a CT scan causes unnecessary delay of lumbar puncture. In young children with an open fontanelle, a head CT scan is unnecessary unless physical findings suggest complications or a diagnosis other than meningitis. In children with persistent fevers despite appropriate antimicrobial therapy, a head CT scan, or preferably an MRI, should be performed to exclude subdural empyema. MRI is more sensitive than CT in the detection of subdural or epidural empyema.

Procedures

Lumbar puncture may be indicated.

 

Treatment

Medical Care

Antibiotic therapy (see Medication) and supportive care are indicated.

Consultations

Children with septic arthritis, osteomyelitis, subdural effusion with meningitis, mastoiditis, or other unusual invasive infections require appropriate surgical consultation.

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

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.

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

 

Follow-up

Further Outpatient Care

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

Further Inpatient Care

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.[11] 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.

Inpatient & Outpatient Medications

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).

Transfer

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).

Deterrence/Prevention

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.[12]

A recommendation from the American Association of Pediatrics states that children between the ages of 6 and 18 years with immune deficiency disorders and other high-risk conditions such as HIV, sickle-cell disease, or cerebrospinal fluid leaks should receive a single dose of PCV13. These children should receive the vaccination regardless of prior vaccination status. Also, if these children did not receive PPSV23 previously they should receive a dose of this vaccine no less than 8 weeks after their dose of PCV13. Recommendations for children aged 5 years and younger remain the same.[13]

A study by Moore et al assessed the effectiveness of PCV13 in 772 children aged 2-59 months and 2991 controls and found 86% effectiveness against PCV13 serotypes. The vaccine was most effective for serotypes 19A and 7F (85.6%).[14]

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).[15] 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.[16]

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

Complications

See the list below:

  • 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.[17]

Prognosis

See Mortality/Morbidity.

 

Questions & Answers

Overview

What are pediatric pneumococcal infections?

What are the signs and symptoms of pediatric pneumococcal infections?

Which physical findings are characteristic of pediatric pneumococcal infections?

Which lab tests are performed in the workup of pediatric pneumococcal infections?

Which imaging studies are performed in the workup of pediatric pneumococcal infections?

Which antibiotic regimens are used in the treatment of pediatric pneumococcal infections?

What is Streptococcus pneumoniae?

What is the pathophysiology of pediatric pneumococcal infections?

What is the prevalence of pediatric pneumococcal infections in the US?

What is the prevalence of specific pediatric pneumococcal infections?

What is the role of vaccination in the prevention of pediatric pneumococcal infections?

What is the global prevalence of pediatric pneumococcal infections?

What is the mortality associated with pediatric pneumococcal infections?

What are the racial predilections of pediatric pneumococcal infections?

What are the sexual predilections of pediatric pneumococcal infections?

Which age groups have the highest prevalence of pediatric pneumococcal infections?

Presentation

Which clinical history findings are characteristic of pediatric pneumococcal infections?

Which physical findings are characteristic of pediatric pneumococcal otitis media?

Which physical findings are characteristic of pediatric pneumococcal sinusitis?

Which physical findings are characteristic of pediatric pneumococcal bacteremia?

Which physical findings are characteristic of pediatric pneumococcal pneumonia?

Which physical findings are characteristic of pediatric pneumococcal meningitis?

DDX

What are the differential diagnoses for Pediatric Pneumococcal Infections?

Workup

What is the role of Streptococcus pneumoniae culture in the workup of pediatric pneumococcal infections?

What is the role of a WBC count in the workup of pediatric pneumococcal infections?

What is the role of antigen testing in the workup of pediatric pneumococcal infections?

What is the role of gram staining in the workup of pediatric pneumococcal infections?

Which lab tests are performed in the workup of pediatric pneumococcal otitis media or sinusitis?

Which lab tests are performed in the workup of pediatric pneumococcal occult bacteremia?

Which lab tests are performed in the workup of pediatric pneumococcal pneumonia?

Which lab tests are performed in the workup of pediatric pneumococcal meningitis?

Which lab tests are performed in the workup of pediatric pneumococcal osteomyelitis/septic arthritis?

What is the role of imaging studies in the workup of pediatric pneumococcal infections?

What is the role of lumbar puncture in the workup of pediatric pneumococcal infections?

Treatment

How are pediatric pneumococcal infections treated?

Which specialist consultations are beneficial to patients with pediatric pneumococcal infections?

Medications

What is the role of medications in the treatment of pediatric pneumococcal infections?

Which medications in the drug class Antibiotic Agents are used in the treatment of Pediatric Pneumococcal Infections?

Follow-up

When is follow-up care indicated following treatment of pediatric pneumococcal infections?

What is included in inpatient care of pediatric pneumococcal infections?

What is the initial treatment for pediatric pneumococcal otitis media or sinusitis?

What is the treatment for pediatric pneumococcal otitis media or sinusitis that does not respond to amoxicillin?

What is the outpatient treatment for pediatric pneumococcal pneumonia?

What is the inpatient treatment for pediatric pneumococcal pneumonia?

How are invasive pediatric pneumococcal infections treated?

How is pediatric pneumococcal meningitis treated?

How are pediatric pneumococcal infections treated in patients allergic to penicillin?

How is pediatric pneumococcal meningitis treated in children older than 3 months?

When is patient transfer indicated for the treatment of pediatric pneumococcal infections?

How are pediatric pneumococcal infections prevented?

What are the possible complications of pediatric pneumococcal infections?