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Pneumococcal Pneumonia

Pneumococcal Pneumonias

Pneumonia may be caused by a variety of microorganisms, including bacteria and viruses, however, one of the primary causes of severe pneumonia is Streptococcus pneumoniae (S. pneumoniae or pneumococcus).


Presentation

The most common and serious form of pneumococcal disease is the lung infection, pneumococcal pneumonia. Common symptoms of pneumococcal pneumonia include fever and chills, cough, hyperventilation, difficulty breathing and chest pain [1] [5].

Classic symptoms of pneumococcal pneumonia are typically observed in older children and adults, while young children and the elderly will present differently (discussed later) [1]. Infected patients typically have an ill or anxious appearance [1]. Initially a viral illness is followed by an acute onset of high fever, rigors, productive cough, chest pain, dyspnea, tachypnea, tachycardia, excess perspiration, general discomfort and fatigue [1] [5]. A detailed physical exam will identify rales in most patients, dullness on percussion (along with other signs of empyema) and splinting due to pain in about half of patients. Decreased diaphragmatic motion from what is expected (considering tachypnea) may be observed [1].

Symptoms of pneumococcal pneumonia in younger children are generally much broader and non-specific compared to older children and adults [1] [5] [8] [9]. These symptoms may include mild respiratory symptoms, initial presentation of cough, tachypnea, dyspnea, splinting, high fever, abdominal pain and distention and/or anorexia [1] [9]. Young patients may also present emesis which suggests primary gastrointestinal disease, meningeal signs due to meningeal irritation (in right upper lobe pneumonias), and/or chest pain due to pleural irritation [1] [9]. The primary presenting symptom of pneumococcal pneumonia in elderly patients may be tachypnea and often elevated temperatures are absent or mild in this patient population [1] [8] [9]. The most common cause of CAP in human immunodeficiency virus (HIV) patients is pneumococcus infection [1].

Pleural effusion is the most common complication from pneumococcal pneumonia occurring in 40% of patients [1]. Only 10% of patients have enough fluid in their pleural cavity to aspirate and only 2% of these patients meet the criteria for true empyema [1] [5]. Nonetheless, pneumococcal infection is one of the most common causes of pediatric empyema [1] [8] [9].

Fever
  • With adequate antipneumococcal therapy and/or chest tube drainage, all of the patients recovered completely; however, clinical improvement was prolonged: fever lasted 9 to 20 days, and length of hospitalization was 12 to 26 days.[ncbi.nlm.nih.gov]
  • A previously healthy 4-month-old boy presented at our emergency department with a 10-day history of fever and non-productive cough. No signs of heart failure or cardiac friction rub were evidenced.[ncbi.nlm.nih.gov]
  • Common symptoms of pneumococcal pneumonia include fever and chills, cough, hyperventilation, difficulty breathing and chest pain.[symptoma.com]
  • Other side effects include: fatigue muscle pain joint pain chills headache vomiting decreased appetite rash fever PREVNAR 13 should not be given to anyone with a severe allergic reaction to any component of PREVNAR 13 or any diphtheria toxoid–containing[adult.prevnar13.com]
  • Key terms Acetaminophen — A drug used for pain relief as well as to decrease fever. A common trade name for the drug is Tylenol. Aspirin — A commonly used drug for pain relief and to decrease fever.[medical-dictionary.thefreedictionary.com]
Chills
  • Other side effects include: fatigue muscle pain joint pain chills headache vomiting decreased appetite rash fever PREVNAR 13 should not be given to anyone with a severe allergic reaction to any component of PREVNAR 13 or any diphtheria toxoid–containing[adult.prevnar13.com]
  • […] number of Americans with pneumococcal pneumonia is 900,000 annually, with almost 400,000 cases hospitalized and fatalities accounting for 5-7% of these cases.The symptoms of pneumococcal pneumonia can occur suddenly, typically presenting as a severe chill[en.wikipedia.org]
  • Common symptoms of pneumococcal pneumonia include fever and chills, cough, hyperventilation, difficulty breathing and chest pain.[symptoma.com]
  • Symptoms Fevers, body-shaking chills, productive cough, pleurisy, prostration, and sweating.[medical-dictionary.thefreedictionary.com]
  • The disease may begin quickly, with: Fever and chills Cough Chest Pain Rapid breathing or difficulty breathing Older adults with pneumococcal pneumonia may experience confusion or low alertness, rather than the more common symptoms listed above.[oakgov.com]
High Fever
  • Common symptoms of pneumococcal pneumonia include high fever, excessive sweating, shaking chills, coughing, difficulty breathing, shortness of breath and chest pain.[lung.org]
  • Her history is of rapid onset (over a few hours) of shortness of breath, high fevers and rigors.[lifeinthefastlane.com]
  • These symptoms may include mild respiratory symptoms, initial presentation of cough, tachypnea, dyspnea, splinting, high fever, abdominal pain and distention and/or anorexia.[symptoma.com]
  • Symptoms include: High fever Cough Shortness of breath Headache Nasal congestion or discharge Ear pain Slow, unclear thinking The pneumococcal vaccine can lessen the chance of getting pneumococcal pneumonia; however, it is not a substitute for the influenza[nationaljewish.org]
Anemia
  • All of them were acutely ill on presentation with arterial desaturation, and they developed anemia and thrombocytosis. Two patients had pleural effusion requiring drainage.[ncbi.nlm.nih.gov]
  • It usually strikes smokers, people with underlying lung diseases, those recently infected with influenza or those with sickle-cell anemia, chronic or heavy alcohol use, or cirrhosis.[medical-dictionary.thefreedictionary.com]
  • Anyone age 65 and older Higher-risk adults aged 19-64 who meet one or more of these criteria: Serious long-term health condition Heart disease Sickle cell anemia Alcoholism Chronic lung disease ( COPD , emphysema , asthma ) Diabetes Liver cirrhosis Smokers[nationaljewish.org]
  • In addition, people with certain medical conditions, such as chronic heart, lung, or liver diseases, or sickle cell anemia are also at increased risk for getting pneumococcal pneumonia.[medicinenet.com]
Rigor
  • Her history is of rapid onset (over a few hours) of shortness of breath, high fevers and rigors.[lifeinthefastlane.com]
  • We apply rigorous science to build knowledge and support for the value of vaccines.[jhsph.edu]
  • Symptoms generally include an abrupt onset of fever and chills or rigors. Typically, there is a single rigor, and repeated shaking chills are uncommon.[cdc.gov]
Cough
  • Sharp stabbing chest pains on one side, which are worsened by deep breathing and cough, often occur.[symptoma.com]
  • This report involves a 4½-year-old girl who presented to our emergency department with productive cough, shortness of breath, and left-sided chest pain with a diagnosis of pneumococcal pneumonia.[ncbi.nlm.nih.gov]
  • A previously healthy 4-month-old boy presented at our emergency department with a 10-day history of fever and non-productive cough. No signs of heart failure or cardiac friction rub were evidenced.[ncbi.nlm.nih.gov]
  • Sometimes the coughing can produce rusty or blood-streaked sputum. In 25% of cases, a parapneumonic effusion may occur.[en.wikipedia.org]
  • Remember to cover your cough and wash your hands often.[oakgov.com]
Pleural Effusion
  • High C-reactive protein (CRP) ( 20 mg·dL(-1)) (odds ratio (OR) 2.36, 95% CI 1.45-3.85), pleural effusion (OR 2.03, 95% CI 1.13-3.65) and multilobar involvement (OR 1.69, 95% CI 1.02-2.79) were independently associated with bacteraemic CAP, while nursing[ncbi.nlm.nih.gov]
  • Lobar consolidation and pleural effusions appeared initially, followed within several days by the appearance of multiple small lucencies in the area of consolidation. In one case, necrosis progressed to a large abscess cavity.[ncbi.nlm.nih.gov]
  • Two patients had pleural effusion requiring drainage. A chest CT scan revealed segmental or lobar pulmonary liquification, which led to the diagnosis of necrotizing pneumonia. This finding could be demonstrated early in the course of the disease.[ncbi.nlm.nih.gov]
  • Chest radiography showed lobar pneumonia, right pleural effusion and cardiomegaly. Echocardiography revealed a massive pericardial effusion, and an emergency drainage was performed.[ncbi.nlm.nih.gov]
  • Nonsteroidal antiinflammatory drug-exposed patients were younger (43.3 vs 62.2 years; P .0001), had less frequently at least one chronic comorbid condition (40% vs 75%; P .003), had more often complicated pleural effusions (20% vs 2.3%; P .01), and more[ncbi.nlm.nih.gov]
Productive Cough
  • This report involves a 4½-year-old girl who presented to our emergency department with productive cough, shortness of breath, and left-sided chest pain with a diagnosis of pneumococcal pneumonia.[ncbi.nlm.nih.gov]
  • A previously healthy 4-month-old boy presented at our emergency department with a 10-day history of fever and non-productive cough. No signs of heart failure or cardiac friction rub were evidenced.[ncbi.nlm.nih.gov]
  • Symptoms Fevers, body-shaking chills, productive cough, pleurisy, prostration, and sweating.[medical-dictionary.thefreedictionary.com]
  • Initially a viral illness is followed by an acute onset of high fever, rigors, productive cough, chest pain, dyspnea, tachypnea, tachycardia, excess perspiration, general discomfort and fatigue.[symptoma.com]
  • In adults, symptoms of pneumonia include sudden onset of illness characterized by shaking chills, fever, shortness of breath or rapid breathing, chest pain that is worsened by breathing deeply and a productive cough.[nfid.org]
Dyspnea
  • A 36-year-old pregnant woman was visiting the emergency department for dyspnea and flu-like syndrom that had been going on for a week.[ncbi.nlm.nih.gov]
  • CASE PRESENTATION: A 72-year-old patient with long history of chronic obstructive pulmonary disease and multiple fluoroquinolone treatments for recurrent lower respiratory tract infections developed fever, increased sputum production, and dyspnea.[ncbi.nlm.nih.gov]
  • Pneumonia is diagnosed by clinical symptoms, including cough, dyspnea and tachypnea, and radiologic evidence.[symptoma.com]
  • Before antibiotic therapy the clinical course was characterized by severe fever, dyspnea, debility, and even loss of consciousness. The satisfactory resolution of a crisis was the result of a good immune response to the infection.[histopathology-india.net]
  • Other common symptoms include Pleuritic chest pain Cough productive of mucopurulent Rusty sputum Dyspnea Tachypnea or tachycardia Hypoxia Malaise or weakness Nausea, vomiting, and headaches occur less frequently.[cdc.gov]
Painful Cough
  • Other common symptoms include Pleuritic chest pain Cough productive of mucopurulent Rusty sputum Dyspnea Tachypnea or tachycardia Hypoxia Malaise or weakness Nausea, vomiting, and headaches occur less frequently.[cdc.gov]
  • Pneumococcal pneumonia symptoms include fever, chest pain, cough, and shortness of breath. When pneumococci infect normally sterile locations, so-called invasive pneumococcal disease may result.[historyofvaccines.org]
Vomiting
  • Other side effects include: fatigue muscle pain joint pain chills headache vomiting decreased appetite rash fever PREVNAR 13 should not be given to anyone with a severe allergic reaction to any component of PREVNAR 13 or any diphtheria toxoid–containing[adult.prevnar13.com]
  • Other symptoms like nausea, vomiting, headache, fatigue, and muscle aches could also accompany the original symptoms. Sometimes the coughing can produce rusty or blood-streaked sputum. In 25% of cases, a parapneumonic effusion may occur.[en.wikipedia.org]
  • You may first have a severe shaking chill which is usually followed by: High fever Cough Shortness of breath Rapid breathing Chest pains Other symptoms may include: Nausea Vomiting Headache Tiredness Muscle aches Diagnosis Your healthcare provider can[medicinenet.com]
Nausea
  • Other symptoms like nausea, vomiting, headache, fatigue, and muscle aches could also accompany the original symptoms. Sometimes the coughing can produce rusty or blood-streaked sputum. In 25% of cases, a parapneumonic effusion may occur.[en.wikipedia.org]
  • You may first have a severe shaking chill which is usually followed by: High fever Cough Shortness of breath Rapid breathing Chest pains Other symptoms may include: Nausea Vomiting Headache Tiredness Muscle aches Diagnosis Your healthcare provider can[medicinenet.com]
  • Other common symptoms include Pleuritic chest pain Cough productive of mucopurulent Rusty sputum Dyspnea Tachypnea or tachycardia Hypoxia Malaise or weakness Nausea, vomiting, and headaches occur less frequently.[cdc.gov]
  • Pneumococcal meningitis People with pneumococcal meningitis often have: high fever headache stiff neck nausea and vomiting photophobia (discomfort when looking at light).[sahealth.sa.gov.au]
Loss of Appetite
  • The most common problems reported among children were: About half became drowsy after the shot, had a temporary loss of appetite, or had redness or tenderness where the shot was given. About 1 out of 3 had swelling where the shot was given.[schwietermanpharmacy.com]
  • But some people have mild side effects from the vaccine, including: Swelling, soreness, or redness where you got the shot Mild fever Fussiness or irritability Loss of appetite Sore muscles Fewer than 1% of people who get the pneumonia vaccine have these[webmd.com]
  • […] of appetite sweating Older adults will share all the symptoms with younger adults, but are much more likely to experience confusion and dizziness.[healthline.com]
Abdominal Pain
  • These symptoms may include mild respiratory symptoms, initial presentation of cough, tachypnea, dyspnea, splinting, high fever, abdominal pain and distention and/or anorexia.[symptoma.com]
Chest Pain
  • This report involves a 4½-year-old girl who presented to our emergency department with productive cough, shortness of breath, and left-sided chest pain with a diagnosis of pneumococcal pneumonia.[ncbi.nlm.nih.gov]
  • Sharp stabbing chest pains on one side, which are worsened by deep breathing and cough, often occur.[symptoma.com]
  • The disease may begin quickly, with: Fever and chills Cough Chest Pain Rapid breathing or difficulty breathing Older adults with pneumococcal pneumonia may experience confusion or low alertness, rather than the more common symptoms listed above.[oakgov.com]
Meningism
  • Mortality rates from all-cause pneumonia and meningitis were highest in the oldest age groups. CONCLUSIONS: The burden of all-cause and pneumococcal pneumonia and meningitis remains substantial.[ncbi.nlm.nih.gov]
  • Abstract An extended-spectrum cephalosporin has been considered appropriate therapy for non-meningeal infections caused by drug-resistant Streptococcus pneumoniae.[ncbi.nlm.nih.gov]
  • Bacterial meningitis: Pneumococcal meningitis infections cause more than 50% of all bacterial meningitis cases in the U.S. About 8% of children and 22% of adults with pneumococcal meningitis will die. Middle ear infections.[health.ny.gov]
  • Author information 1 Respiratory and Meningeal Pathogens Research Unit/Medical Research Council, Johannesburg, South Africa Werner.albrich@kssg.ch. 2 Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St.[ncbi.nlm.nih.gov]
  • The new initiative will target pneumococcal disease , a major cause of pneumonia and meningitis that kills 1.6 million people every year. In adults, too, meningococcal meningitis has a lower mortality (3-7%) than pneumococcal disease .[diki.pl]
Headache
  • Other side effects include: fatigue muscle pain joint pain chills headache vomiting decreased appetite rash fever PREVNAR 13 should not be given to anyone with a severe allergic reaction to any component of PREVNAR 13 or any diphtheria toxoid–containing[adult.prevnar13.com]
  • Other symptoms like nausea, vomiting, headache, fatigue, and muscle aches could also accompany the original symptoms. Sometimes the coughing can produce rusty or blood-streaked sputum. In 25% of cases, a parapneumonic effusion may occur.[en.wikipedia.org]
  • Symptoms include: High fever Cough Shortness of breath Headache Nasal congestion or discharge Ear pain Slow, unclear thinking The pneumococcal vaccine can lessen the chance of getting pneumococcal pneumonia; however, it is not a substitute for the influenza[nationaljewish.org]
Confusion
  • The disease may begin quickly, with: Fever and chills Cough Chest Pain Rapid breathing or difficulty breathing Older adults with pneumococcal pneumonia may experience confusion or low alertness, rather than the more common symptoms listed above.[oakgov.com]
  • Symptoms include: Fever and chills Cough Rapid breathing or difficulty breathing Chest pain Older adults with pneumococcal pneumonia may experience confusion or low alertness, rather than the more common symptoms listed above.[cdc.gov]
  • Symptoms may differ somewhat in the elderly, with minimal cough, no sputum and no fever, but rather tiredness and confusion leading to hypothermia and shock.[medical-dictionary.thefreedictionary.com]
  • , especially among older persons loss of appetite sweating Older adults will share all the symptoms with younger adults, but are much more likely to experience confusion and dizziness.[healthline.com]
Agitation
  • A 30-year-old confirmed body packer was brought to our emergency department from jail because of agitation and mydriasis.[ncbi.nlm.nih.gov]
  • […] spleen that does not function Symptoms usually come on quickly, and may include: Fever and chills Mental status changes Nausea and vomiting Sensitivity to light ( photophobia ) Severe headache Stiff neck Other symptoms that can occur with this disease: Agitation[m.medlineplus.gov]

Workup

Diagnosing pneumococcal pneumonia most often starts by establishing the presence of pneumonia [1]. Pneumonia is diagnosed by clinical symptoms, including cough, dyspnea and tachypnea, and radiologic evidence [1] [5]. Representative chest radiographs in older children and adults with pneumococcal pneumonia show lobar consolidation while younger children and infants more often display patterns of scattered parenchymal consolidation [1] [5] [9]. Sputum Gram staining and culture are also primary steps for diagnosing pneumonia [1] [3] [5].

The gold standard to determine pneumococcal pneumonia is by identifying S. pneumoniae in a normally sterile body fluid [3] [5]. In suspected pneumonia cases that require hospitalization, sputum cultures should be attempted [1]. Suitable sputum samples should have a few epithelial cells (<10 at 100X) and many polymorphonuclear neutrophils (>25 at 100X) with a ratio between 1:10 and 1:20 [3] [5]. The presence of pneumococcus is likely if Gram staining of sputum reveals numerous pairs of Gram-positive cocci organized in chains (characteristic of S. pneumoniae) [3] [4] [5]. Blood cultures should be obtained from patients with pneumonia, which will stain positive for S. pneumoniae in 10% of children and up to 25% of adults with pneumococcal pneumonia [1] [3] [5]. Chest ultrasonography or computerized tomography may be performed to determine the presence and extent of pleural effusion [1]. In extreme cases of pleural effusion/empyema, attempts should be made to aspirate pleural fluid for Gram staining and culture of S. pneumoniae [1] [3] [5].

The majority of patients with pneumococcal pneumonia present leukocytosis (>12,000 cells/µL) and one out of four patients have low hemoglobin levels (<10 mg/dL) [1] [5]. If Howell-Jolly bodies are observed in peripheral smears this indicates splenic dysfunction [1]. Additionally, pneumococcal pneumonia patients may display elevated neutrophil levels, C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR) [1] [5].

Pulmonary Infiltrate
  • This may be the first report of the association of these two disorders, and may influence the choice of antibiotic selection in patients with rhabdomyolysis and a pulmonary infiltrate.[ncbi.nlm.nih.gov]
  • Abdominal and thoracic computed tomography scans showed pulmonary infiltrates as a possible focus of infection; signs of bowel obstruction or perforation were absent.[ncbi.nlm.nih.gov]
  • Definitions IPP was diagnosed when a patient had consistent clinical findings plus a new pulmonary infiltrate on chest radiography and isolation of S. pneumoniae in blood and/or pleural fluid cultures [ 10 ].[erj.ersjournals.com]
Air Bronchogram
  • bronchograms (DDX: Staph has no air bronchogram) Organism is aspirated into the lungs from the upper airways so it shows a predilection for lower lobes Does not respect segmental boundaries Resolution begins promptly with antibiotics – frequently within[learningradiology.com]
Alveolar Consolidation
  • High blood pneumococcal load was associated with alveolar consolidation on chest radiograph in nonconfirmed cases, and with high ( 6.9 log10 copies/mL) nasopharyngeal/oropharyngeal load and C-reactive protein 40 mg/L (both P .01) in nonconfirmed cases[ncbi.nlm.nih.gov]
  • Among the 4035 non-MCPP cases, 500 (12%) had pneumococcal colonization density 6.9 log10 copies/mL; above this cutoff was associated with alveolar consolidation at chest radiography, very severe pneumonia, oxygen saturation Conclusions.: Pneumococcal[ncbi.nlm.nih.gov]
Streptococcus Pneumoniae
  • A case of pneumonia caused by Streptococcus pneumoniae occurring in a patient receiving pristinamycin is reported. Despite empirical treatment with pristinamycin, 2 g/day for five days, the patient's condition worsened.[ncbi.nlm.nih.gov]
  • (disorder) Pneumococcal pneumonia (disorder) Pneumococcal pneumonia (disorder) [Ambiguous] Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia] Streptococcus pneumoniae pneumonia Streptococcus pneumonia Statements Identifiers Sitelinks Wikibooks[wikidata.org]
  • Patients with AIDS and LIP are at high risk for bacterial pneumonia caused by Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus.[ncbi.nlm.nih.gov]
  • Generally, Streptococcus pneumoniae is the most common pathogen in adult community-acquired pneumonia. Therefore, it is critical to recognize HSV as one of the important complications after bacterial infection, especially Streptococcus pneumoniae.[ncbi.nlm.nih.gov]
  • BACKGROUND: Mucosal immune mechanisms in the upper and lower respiratory tracts may serve a critical role in preventing pneumonia due to Streptococcus pneumoniae.[ncbi.nlm.nih.gov]
Blood Culture Positive
  • We define severe pneumonia according to American Thoracic Society/Infectious Diseases Society of America guidelines.Of a total of 917 patients with pneumococcal CAP, 362 had blood-culture-positive pneumococcal pneumonia (BCPPP; 39%).[ncbi.nlm.nih.gov]
  • AIM: The occurrence of blood culture-positive pneumococcal bacteraemia and bacteraemic pneumonia decreased after large-scale pneumococcal vaccinations were introduced.[ncbi.nlm.nih.gov]
Gram-Positive Coccus
  • Streptococcus pneumoniae is a Gram-positive coccus that may be found in pairs or in short chains. Lobar Pneumonia involves large portion of a lobe or an entire lobe of the lung.[histopathology-india.net]
  • Gram positive coccus (usually seen as diplococci with a distinctive “lancet shape”. Belongs to the alpha hemolytic "viridans” streptococci. b.[web.biosci.utexas.edu]
Pleural Effusion
  • High C-reactive protein (CRP) ( 20 mg·dL(-1)) (odds ratio (OR) 2.36, 95% CI 1.45-3.85), pleural effusion (OR 2.03, 95% CI 1.13-3.65) and multilobar involvement (OR 1.69, 95% CI 1.02-2.79) were independently associated with bacteraemic CAP, while nursing[ncbi.nlm.nih.gov]
  • Lobar consolidation and pleural effusions appeared initially, followed within several days by the appearance of multiple small lucencies in the area of consolidation. In one case, necrosis progressed to a large abscess cavity.[ncbi.nlm.nih.gov]
  • Two patients had pleural effusion requiring drainage. A chest CT scan revealed segmental or lobar pulmonary liquification, which led to the diagnosis of necrotizing pneumonia. This finding could be demonstrated early in the course of the disease.[ncbi.nlm.nih.gov]
  • Chest radiography showed lobar pneumonia, right pleural effusion and cardiomegaly. Echocardiography revealed a massive pericardial effusion, and an emergency drainage was performed.[ncbi.nlm.nih.gov]
  • Nonsteroidal antiinflammatory drug-exposed patients were younger (43.3 vs 62.2 years; P .0001), had less frequently at least one chronic comorbid condition (40% vs 75%; P .003), had more often complicated pleural effusions (20% vs 2.3%; P .01), and more[ncbi.nlm.nih.gov]
Pleural Exudate
  • (ii) In outer surface pleural exudates is thicker. (iii) Cut surface is moist & brownish-gray colour (bronchial lymphnodes may be enlarged).[histopathology-india.net]

Treatment

Severity and presentation of symptoms among patients with pneumococcal pneumonia vary widely, from mild illness to respiratory distress requiring intensive care [1] [5]. Hospitalized patients should be administered parenteral antibiotics along with medications to manage nutrition and symptoms, including pulmonary symptoms, pain medications, intravenous (IV) fluids and nutrition, and other medications administered on a case by case basis [1] [5] [13] [14] [15]. Severe and/or complicated cases may require a chest tube to drain pleural fluid, video-assisted thoracoscopic surgery (VATS) or decortication [13] [14] [15]. New Clinical Practice Guidelines (CPG) for infants and children were released by the Infectious Disease Society of America (IDSA) in 2011 [14]. Briefly, these guidelines recommend IV administration of amoxicillin (90 mg/kg/day or 45 mg/kg/day in 2 or 3 doses, respectively) as the first-line therapy for previously healthy and immunized patients from the infant to adolescent ages with mild to moderate pneumococcal pneumonia [14]. Additionally, children greater than 5 years of age should be administered macrolide if clinical symptoms are compatible with atypical organism infection [14]. Children who are incompletely immunized, live in areas with prevalent penicillin resistance or who have life threatening conditions (including empyema) should be given third-generation parenteral cephalosporin (ceftriaxone or cefotaxime) [14]. If there is a suspicion of S. aureus infection non-beta-lactam agents, such as vancomycin, should also be administered [14].

Prognosis

Worldwide, pneumococcal disease caused an estimated 1.6 million deaths in 2005, with the majority of these deaths (40-60%) occurring in young children (less than 5 years of age) [5] [6] [7]. The mortality rate associated with pneumococcal pneumonia is 10-20% in adults, even in developed countries, and can be much higher in individuals with risk factors for this disease, such as compromised immune system, smoking and drug use [5] [7].

Etiology

S. pneumoniae is an encapsulated, Gram-positive, catalase-negative, facultative anaerobe that displays characteristic chains of lancet-shaped diplococcic on Gram stains [1] [2] [3]. Along with Gram staining, pneumococcus can be detected on blood or chocolate agar plates where they form a green zone around colonies due to the production of pneumolysin (making them hemolytic) [2] [3] [4] [5]. These organisms can be distinguished from other alpha-hemolytic streptococci based on their optochin-sensitivity and bile solubility [5].

Epidemiology

S. pneumoniae, which is the leading cause of CAP, is responsible for approximately two million deaths worldwide and costs hundreds of billions of dollars annually [5]. Worldwide, children under the age of two are the most common individuals to contract pneumococcal disease, followed by adults older than 55 years of age [5] [6] [7]. Disease prevalence in developing countries is higher in children under 6 months of age, whereas, developed countries have higher incidence in children between 6 months and 1 year or age [5] [6] [7]. Most studies indicate males have a higher prevalence of pneumococcal infection compared to females [5]. Certain ethnic groups in the United States have higher incidence of invasive pneumococcal disease including, native Alaskans, Navajo and Apache Indians, and African Americans [5] [6] [7]. The reasons for these discrepancies remain unclear. Individuals with suppressed immune systems have a higher risk for contracting pneumococcal disease [5] [6] [7].

Sex distribution
Age distribution

Pathophysiology

S. pneumoniae is an extracellular bacterial pathogen that can be found in the nose and throat of 5-10% and 20-40% of healthy adults and children, respectively [1] [3] [5]. Clinical manifestation in patients requires S. pneumoniae to access and colonize the upper and/or lower respiratory tract, which occurs via direct extension, lymphatic spread or hematogenous spread [1]. In healthy individuals under normal conditions, successful clearance mechanisms (anatomic and ciliary) prevent clinical infection/symptoms [1]. Therefore, pathogenicity involves bacterial adhesion proteins and capsule proteins that allow adherence to host cells, escape from clearance and/or phagocytosis and the ability to replicate [1] [5] [7].

Few toxins have been identified from pneumococcal isolates aside from pneumolysin, which is expressed by all serotypes [1] [5]. Pneumolysin is an important virulence factor (classified as a cholesterol-dependent cytolysin), released by S. pneumoniae, that produces pores in host cell membranes leading to cell death [1] [5]. Additionally, pnuemolysin is a potent activator of the complement system and causes the release of inflammatory cytokines, tumor necrosis factor and interleukin-1 [5]. Other important virulence factors may include adhesion proteins, such as surface protein A and surface adhesion A, and enzymes, such as autolysin, hyaluronidase and neuraminidase [1] [5]. The composition and size of the bacterial capsule is another determinant of virulence [5]. Individuals with no previous exposure to S. pneumoniae (or no antibodies to pneumococcal capsule) display a limited immune response, including diminished phagocytosis and activation of the classical complement pathway [1] [5].

Patient symptoms primarily arise from activation of the complement pathway and robust inflammation caused by inflammatory cytokine release [1]. The alternative complement pathway is directly activated by S. pneumoniae cell wall and capsule components, whereas, the classical complement pathway is activated by antibodies to the cell wall of S. pneumoniae [1] [5]. Bacterial cell wall proteins and deoxyribonucleic acid (DNA) along with pnuemolysin and autolysin are the primary causes of inflammatory cytokine production [1].

Prevention

There is an increased risk for invasive pneumococcal disease associated with cigarette smoking, therefore, smoking cessation should be encouraged [5] [10] [15]. A healthy diet and ideal living conditions may decrease disease risk and when applicable breastfeeding should be encouraged [10] [15]. Children who attend daycare have an increased risk for acquisition, carriage and infection with pneumococcal disease which is directly correlated with the number of children that attend a daycare [10]. Doctors may consider antimicrobial prophylaxis for at risk patients with recurrent otitis media [10]. Children with true anatomical or functional asplenia should be administered prophylaxis with penicillin to help prevent pneumococcal disease [5] [10] [15].

Summary

S. pneumoniae is a member of the genus Streptococcus that is characterized by being Gram-positive, catalase-negative, alpha-hemolytic and anaerobic [1]. Along with being the most common cause of community-acquired pneumonia (CAP), S. pneumoniae also causes bacterial meningitis, bacteremia, otitis media, sinusitis, septic arthritis, osteomyelitis, peritonitis and endocarditis [1].

Pneumococcal pneumonia is a serious condition caused by S. pneumoniae, which are easily identified in the sputum of infected individuals by their characteristic organization in Gram-positive diplococci chains. S. pneumoniae release toxins that activate the complement system and induce inflammation leading to a wide range of symptoms, that may include fever and chills, cough, hyperventilation, difficulty breathing and chest pain. An estimated two million deaths per year are caused by pneumococcal pneumonia (mortality rate ~ 10-20%) with the majority of these deaths occurring in children 5 years of age or younger. Antibiotics, such as penicillin, are typically used to treat this disease but with the emergence of resistant strains, cephalosporins, vancomycin or fluoroquinolones may be administered. Presentation of disease varies greatly and the patient’s age should be considered for diagnosis and treatment of pneumococcal pneumonia.

Patient Information

Pneumococcal pneumonia is a serious and sometimes life threatening disease caused by the bacteria S. pneumoniae (also known as pneumococcus) [1] [5]. This bacterium may be spread by water droplets that are released through the air when infected individuals cough or sneeze. Symptoms of pneumococcal pneumonia often arise suddenly and may include fever, chills, malaise (general discomfort), shortness of breath and a cough that produces rust colored sputum [1] [5]. Sharp stabbing chest pains on one side, which are worsened by deep breathing and cough, often occur [5]. A little less than half of patients will develop fluid accumulation in the lining around their lungs (pleural effusion) which also contributes to chest pain and difficulty breathing [5]. Your doctor will perform chest X-rays to look for pneumonia and take sputum samples to look for pathogens [1] [5]. Sputum, blood and pus samples may be sent to a laboratory to identify S. pneumoniae through growth (culture) and staining methods, which easily identify the presence of S. pneumoniae [1] [3] [5]. If bacteria are present, the effectiveness of different antibiotics can be tested through a process known as susceptibility testing [3] [4] [5].

Currently, there are two types of vaccines for S. pneumoniae available. The PCV13 is a conjugate vaccine that protects against 13 different type of pneumococcus and the PPS23 is a non-conjugate vaccine that protects against 23 different types of pneumococcus [16] [17]. Children under 5 years of age with an absent or dysfunctional spleen are often given recurrent antibiotics that may continue into adulthood [10] [13] [14]. The most common antibiotics administered for pneumococcal infections are penicillin, ampicillin and amoxicillin [5] [10]. Typically, antibiotics are given orally, however, in severe cases intravenous administration may be required [5] [10] [13]. The recent increase in penicillin resistant strains of pneumococcus has led to the use of other antibiotics, such as ceftriaxone, cefotaxime, vancomycin or fluoroquinolones (eg. levofloxacin) [11] [12].

References

Article

  1. Dagan R, Greenberg D, Jacobs MR. Pneumococcal Infections. In: Feigin RD, Cherry JD, Demmler GJ, Kaplan SL, ed. Textbook of Pediatric Infectious Diseases 5th. Philadelphia, PA: Saunders (Elsevier Science); 2004: 1: 1204-1258/90.
  2. Musher DM, Montoya R, Wanahita A. Diagnostic value of microscopic examination of Gram-stained sputum and sputum cultures in patients with bacteremic pneumococcal pneumonia. Clin Infect Dis. 2004;39(2):165-9.
  3. Murray PR, Washington JA. Microscopic and baceriologic analysis of expectorated sputum. Mayo Clin Proc. 1975; 50(6):339-44.
  4. Anevlavis S, Petroglou N, Tzavaras A, et al. A prospective study of the diagnostic utility of sputum Gram stain in pneumonia. J Infect. 2009; 59(2):83-9.
  5. Amsden GW. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 6th Edition, Volumes 1 and 2. Philadelphia, PA: Elsevier Churchill Livingstone; 2005.
  6. World Health Organization Staff. Weekly Epidemiological Record. World Health Organization. http://www.who.int/wer. Published 2007. Accessed 2016.
  7. Rudan I, Campbell H. The deadly toll of S pneumoniae and H influenzae type b. Lancet. 2009; 374(9693):854-6.
  8. Peter G, Klein JO. Streptococcus pneumoniae. In: Long SS, Pickering LK, Prober CG, eds. Principles and Practices of Pediatric Infectious Diseases. 2nd ed. Philadelphia, PA: Elsevier Churchill Livingstone: 2002; 739-746/131.
  9. Cardoso MR, Nascimento-Carvalho CM, Ferrero F, et al. Adding fever to WHO criteria for diagnosing pneumonia enhances the ability to identify pneumonia cases among wheezing children. Arch Dis Child. 2011; 96(1):58-61.
  10. Austrian R. Pneumococcal pneumonia. Diagnostic, epidemiologic, therapeutic and prophylactic considerations. Chest. 2009; 136(5 Suppl):e30.
  11. Azoulay-Dupuis E. Moine, P., & Carbon, C. The Problem of Penicillin-Resistant Streptococcus Pneumoniae. Severe Community Acquired Pneumonia Perspectives on Critical Care Infectious Diseases. 2001; 57-74.
  12. Cunha BA. Clinical relevance of penicillin-resistant Streptococcus pneumoniae. Semin Respir Infect. 2002; 17(3):204-14.
  13. Garnacho-Montero J, García-Cabrera E, Diaz-Martín A, et al. Determinants of outcome in patients with bacteraemic pneumococcal pneumonia: importance of early adequate treatment. Scand J Infect Dis. 2010; 42(3):185-92.
  14. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011; 53(7):e25-76.
  15. van der Poll T, Opal SM. Pathogenesis, treatment, and prevention of pneumococcal pneumonia. Lancet. 2009; 74(9700):1543-56.
  16. World Health Organization Staff. Immunization, Vaccines and Biologicals Division. Pneumococcal Vaccines. World Health Organisation. http://www.who.int/vaccines/en/pneumococcus.shtml. Published 2015. Accessed 2015.
  17. World Health Organization Staff. Pneumococcal Vaccination. World Health Organization. http://www.cdc.gov/pneumococcal/vaccination.html. Published 2015. Accessed 2015.

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Last updated: 2018-06-22 00:45