Streptococcus pneumoniae infection: Difference between revisions

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{{CMG}}; {{AE}} {{USAMA}}
{{CMG}}; {{AE}} {{USAMA}}
{{SK}} Strep pnumoniae; Strep pneumoniae infection


==Overview==
==Overview==
'''''Streptococcus pneumoniae''''', or '''pneumococcus''', is a [[Gram-positive]], [[Hemolysis (microbiology)|alpha-hemolytic]] diplococcus [[bacterium]] and a member of the [[genus]] ''[[Streptococcus]]''.<ref name=Sherris>{{cite book | author = Ryan KJ; Ray CG (editors) | title = Sherris Medical Microbiology | edition = 4th ed. | publisher = McGraw Hill | year = 2004 | id = ISBN 0-8385-8529-9 }}</ref> A significant human [[pathogen]], ''S. pneumoniae'' was recognized as a major cause of [[pneumonia]] in the late 19th century and is the subject of many [[humoral immunity]] studies.
'''''Streptococcus pneumoniae''''', or '''pneumococcus''', is a [[Gram-positive]] bacterium. It is a diplococcus, [[Hemolysis (microbiology)|alpha-hemolytic]] member of the ''[[Streptococcus]]'' [[genus]].<ref name="Sherris">{{cite book | author = Ryan KJ; Ray CG (editors) | title = Sherris Medical Microbiology | edition = 4th ed. | publisher = McGraw Hill | year = 2004 | id = ISBN 0-8385-8529-9 }}</ref> During the 19th century pneumonia was heavily associated with this pathogen. ''[[S. pneumoniae]]'' is known to be the cause of various different infections apart from [[pneumonia]] including  [[endocarditis]], [[meningitis]], [[pericarditis]], [[brain abscess]], [[otitis media]], [[osteomyelitis]], [[acute sinusitis]], [[septic arthritis]], [[peritonitis]], and [[cellulitis]]. In children as well as adults, ''[[Streptococcus pneumoniae|S. pneumoniae]]'' is the most common cause of [[otitis media]] as well as [[Bacterial meningitis|bacterial meningiti]]<nowiki/>s.<ref>{{cite journal |author=Dagan R |title=Treatment of acute otitis media - challenges in the era of antibiotic resistance |journal=Vaccine |volume=19 Suppl 1 |issue= |pages=S9-S16 |year= |pmid=11163457}}</ref> [[Pneumonia]] caused by ''[[S. pneumoniae]]'' is usually found at the extremes of the age (in old or very young individuals). ''[[Streptococcus viridans]]'' also belongs to the family of alpha hemolytic bacteria but can e distinguished from ''[[Streptococcus pneumoniae|S. pneumoniae]]'' by an [[optochin]] test. ''[[Streptococcus viridans]]'' are found to be insensitive to [[optochin]] where as ''[[S. pneumoniae]]'' are found to be [[Optochin|optochin sensitive]]. The most potent [[virulence factor]] of ''[[Streptococcus pneumoniae|S. pneumoniae]]''  is its [[Polysaccharide encapsulated bacteria|polysaccharide capsule]]. Up to 91 various types of capsules have been discovered; each of these differ in [[virulence]], drug resistance, [[prevalence|prevalence,]] and distribution.
 
Despite the name, the organism causes many types of infection other than [[pneumonia]], including [[acute sinusitis]], [[otitis media]], [[meningitis]], [[osteomyelitis]], [[septic arthritis]], [[endocarditis]], [[peritonitis]], [[pericarditis]], [[cellulitis]], and [[brain abscess]].
 
''S. pneumoniae'' is the most common cause of bacterial meningitis in adults and children, and is one of the top two isolates found in otitis media.<ref>{{cite journal |author=Dagan R |title=Treatment of acute otitis media - challenges in the era of antibiotic resistance |journal=Vaccine |volume=19 Suppl 1 |issue= |pages=S9-S16 |year= |pmid=11163457}}</ref> Pneumococcal pneumonia is more common in the very young and the very old.
 
''S. pneumoniae'' can be differentiated from ''[[Streptococcus viridans]]'', which is also alpha hemolytic, using an [[optochin]] test, as ''S. pneumoniae'' is optochin sensitive. The encapsulated, gram-positive coccoid bacteria have a distinctive morphology on gram stain, the so-called, "lancet shape." It has a polysaccharide capsule that acts as a virulence factor for the organism; 91 different capsular types are known, and these types differ in virulence, prevalence, and extent of drug resistance.


==Classification==
==Classification==
Streptococcus pneumoniae infections can be classified as:
Streptococcus pneumoniae infections may be classified as follows:


*[[Community-acquired pneumonia|Community Acquired Pneumonia]]
*[[Community-acquired pneumonia|Community Acquired Pneumonia]]
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==Laboratory Findings==  
==Laboratory Findings==  
Depending on the nature of infection, an appropriate sample is collected for laboratory identification. Pneumococci are typically gram positive, cocci, seen in pairs or chains. When cultured on [[blood agar]] plates with added [[optochin]] antibiotic disk, they show [[hemolysis (microbiology)|alpha-hemolytic]] colonies and a clear zone of inhibition around the disk meaning they're sensitive to the antibiotic. Pneumococci are also bile soluble. Just like other [[streptococci]], it's [[catalase]] negative. [[Quellung]] test to identify specific capsular polysaccharides may also be done.
Depending on the nature of infection, an appropriate sample is collected from the infected area for laboratory identification. Commonly found
* [[Pneumococci]] are gram positive, cocci, seen in pairs or chains.  
*When cultured on [[blood agar]] plates with added [[optochin]] antibiotic disk, [[pneumococci]] show [[hemolysis (microbiology)|alpha-hemolytic]] colonies and a clear zone of inhibition around the disk meaning [[pneumococci]] are sensitive to the [[antibiotic]].  
*[[Pneumococci]] are also [[bile]] soluble.  
*Similar to other [[streptococci]], [[pneumococci]] are [[catalase]] negative.  
*[[Quellung]] test to identify specific capsular [[polysaccharides]] may also be done.


===Laboratory Diagnosis===
===Laboratory Diagnosis===
[[Medical diagnosis|Diagnosis]] is generally made based on clinical suspicion along with a positive culture from a sample from virtually any place in the body. An ASO Titre of >200 units is significant.<ref name="Siemieniuk 2011">{{cite journal|last=Siemieniuk|first=Reed A.C.|coauthors= Gregson, Dan B.; Gill, M. John |title=The persisting burden of invasive pneumococcal disease in HIV patients: an observational cohort study|journal=BMC Infectious Diseases|date=Nov 2011|volume=11|doi=10.1186/1471-2334-11-314|pmid=22078162|url=http://www.biomedcentral.com/content/pdf/1471-2334-11-314.pdf|pages=314|pmc=3226630}}</ref>  ''S. pneumoniae'' is, in general, [[optochin]] sensitive, although optochin resistance has been observed.<ref>{{Cite journal |title=Optochin resistance in ''Streptococcus pneumoniae'': mechanism, significance, and clinical implications |journal=Journal of Infectious Diseases |url=http://www.journals.uchicago.edu/doi/pdf/10.1086/322803?cookieSet=1 |volume=184 |issue=5 |pages=582–590 |year=2001 |pmid=11474432 |doi=10.1086/322803 |author8=Pikis A, Campos JM, Rodriguez WJ, Keith JM |last1=Pikis |first1=A |last2=Campos |first2=JM |last3=Rodriguez |first3=WJ |last4=Keith |first4=JM}}</ref>
[[Medical diagnosis|Diagnosis]] of [[streptococcus pneumoniae]] infection is generally made based on clinical suspicion along with a positive culture from a sample from virtually any place in the body.  
 
*An [[Antistreptolysin O titer|ASO titre]] of >200 units is significant.<ref name="Siemieniuk 2011">{{cite journal|last=Siemieniuk|first=Reed A.C.|coauthors= Gregson, Dan B.; Gill, M. John |title=The persisting burden of invasive pneumococcal disease in HIV patients: an observational cohort study|journal=BMC Infectious Diseases|date=Nov 2011|volume=11|doi=10.1186/1471-2334-11-314|pmid=22078162|url=http://www.biomedcentral.com/content/pdf/1471-2334-11-314.pdf|pages=314|pmc=3226630}}</ref>   
[[Atromentin]] and [[leucomelone]] possess antibacterial activity, inhibiting the [[enzyme]] [[enoyl-acyl carrier protein reductase]], (essential for the [[fatty acid metabolism#Synthesis|biosynthesis]] of [[fatty acid]]s) in ''S. pneumoniae''.<ref name=Zheng2006>{{cite journal |author=Zheng CJ, Sohn MJ, Kim WG. |year=2006 |title=Atromentin and [[leucomelone]], the first inhibitors specific to enoyl-ACP reductase (FabK) of ''Streptococcus pneumoniae'' |journal=Journal of Antibiotics |volume=59 |issue=12 |pages=808–12 |doi=10.1038/ja.2006.108 |pmid=17323650}}</ref>
*''[[S. pneumoniae]]'' is, in general, [[optochin]] sensitive, although [[optochin]] resistance has been observed.<ref>{{Cite journal |title=Optochin resistance in ''Streptococcus pneumoniae'': mechanism, significance, and clinical implications |journal=Journal of Infectious Diseases |url=http://www.journals.uchicago.edu/doi/pdf/10.1086/322803?cookieSet=1 |volume=184 |issue=5 |pages=582–590 |year=2001 |pmid=11474432 |doi=10.1086/322803 |author8=Pikis A, Campos JM, Rodriguez WJ, Keith JM |last1=Pikis |first1=A |last2=Campos |first2=JM |last3=Rodriguez |first3=WJ |last4=Keith |first4=JM}}</ref>
*Atromentin and leucomelone possess antibacterial activity, inhibiting the [[enzyme]] [[enoyl-acyl carrier protein reductase]], (essential for the [[fatty acid metabolism#Synthesis|biosynthesis]] of [[fatty acid]]s) in ''[[S. pneumoniae]]''.<ref name="Zheng2006">{{cite journal |author=Zheng CJ, Sohn MJ, Kim WG. |year=2006 |title=Atromentin and [[leucomelone]], the first inhibitors specific to enoyl-ACP reductase (FabK) of ''Streptococcus pneumoniae'' |journal=Journal of Antibiotics |volume=59 |issue=12 |pages=808–12 |doi=10.1038/ja.2006.108 |pmid=17323650}}</ref>


==Treatment==
==Treatment==
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:::* 1.1 '''[[Penicillin]] sensitive (minimum inhibitory concentration < 2 mcg/ml)'''
:::* 1.1 '''[[Penicillin]] sensitive (minimum inhibitory concentration < 2 mcg/ml)'''
::::* Preferred regimen: [[Penicillin G]] 5-24 MU IV in equally divided doses q4-6h, [[Amoxicillin]] 1 g PO tid (+/- macrolide)
::::* Preferred regimen: [[Penicillin G]] 5-24 MU IV in equally divided doses q4-6h, [[Amoxicillin]] 1 g PO tid (+/- macrolide)
::::* Alternative regimen:  Macrolides ([[Azithromycin]] (IV) 500 mg IV qd for at least 2 days followed by 500 mg PO qd 7-10 days or [[Clarithromycin]] extended-release tablets 1000 mg PO qd for 7 days) and oral Cephalosporins-[[Cefpodoxime]] 200 mg PO bd, ([[Cefprozil]] 500 mg PO bd, [[Cefditoren]] 400 mg PO bd, [[Cefdinir]] 300 mg PO bd), {{or}} parenteral Cephalosporins-[[Ceftriaxone]] 2 g IV q24h (or [[Cefotaxime]] 1-2 g IV q6-8h), [[Clindamycin]] 600-1200 mg IV/IM q6-12h, do not give single IM doses > 600 mg; IV infusion rates should not exceed 30 mg/min , [[Doxycycline]] 100 mg PO bd, respiratory flouroquniolones.
::::* Alternative regimen:  Macrolides ([[Azithromycin]] (IV) 500 mg IV qd for at least 2 days followed by 500 mg PO qd 7-10 days or [[Clarithromycin]] extended-release tablets 1000 mg PO qd for 7 days) and oral [[Cephalosporins]]-[[Cefpodoxime]] 200 mg PO bd, ([[Cefprozil]] 500 mg PO bd, [[Cefditoren]] 400 mg PO bd, [[Cefdinir]] 300 mg PO bd), {{or}} parenteral Cephalosporins-[[Ceftriaxone]] 2 g IV q24h (or [[Cefotaxime]] 1-2 g IV q6-8h), [[Clindamycin]] 600-1200 mg IV/IM q6-12h, do not give single IM doses > 600 mg; IV infusion rates should not exceed 30 mg/min , [[Doxycycline]] 100 mg PO bd, respiratory [[Quinolones|flouroquniolones]].
:::* 1.2 '''[[Penicillin]]-resistant ([[Penicillin]] minimum inhibitory concentration ≥ 2 mcg/ml)'''
:::* 1.2 '''[[Penicillin]]-resistant ([[Penicillin]] minimum inhibitory concentration ≥ 2 mcg/ml)'''
::::* Preferred regimen: [[Ceftriaxone]] 2 g IV q24h (or [[Cefotaxime]] 1-2 g IV q6-8h), respiratory [[Flouroquniolones]] [[Levofloxacin]] (Levaquin) 500 mg IV/PO q24h for 7-14 days or 750 mg IV/PO q24h for 5 days  (or [[Moxifloxacin]] (Avelox) 400 mg PO/IV over 60 minutes q24h for 7-14 days)  
::::* Preferred regimen: [[Ceftriaxone]] 2 g IV q24h (or [[Cefotaxime]] 1-2 g IV q6-8h), respiratory [[Flouroquniolones]] [[Levofloxacin]] (Levaquin) 500 mg IV/PO q24h for 7-14 days or 750 mg IV/PO q24h for 5 days  (or [[Moxifloxacin]] (Avelox) 400 mg PO/IV over 60 minutes q24h for 7-14 days)  
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::* 2.'''Endocarditis'''<ref name="pmid15956145">{{cite journal| author=Baddour LM, Wilson WR, Bayer AS, Fowler VG, Bolger AF, Levison ME et al.| title=Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. | journal=Circulation | year= 2005 | volume= 111 | issue= 23 | pages= e394-434 | pmid=15956145 | doi=10.1161/CIRCULATIONAHA.105.165564 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15956145 }}</ref>
::* 2.'''Endocarditis'''<ref name="pmid15956145">{{cite journal| author=Baddour LM, Wilson WR, Bayer AS, Fowler VG, Bolger AF, Levison ME et al.| title=Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. | journal=Circulation | year= 2005 | volume= 111 | issue= 23 | pages= e394-434 | pmid=15956145 | doi=10.1161/CIRCULATIONAHA.105.165564 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15956145 }}</ref>
:::* Preferred regimen (1):  Aqueous crystalline [[Penicillin-G]]  6 MU q4-6h IV  for 4 weeks
:::* Preferred regimen (1):  Aqueous crystalline [[Penicillin G|Penicillin-G]]  6 MU q4-6h IV  for 4 weeks
:::* Preferred regimen (2) (who are unable to tolerate beta lactams therapy): [[Vancomycin]] 15 mg/kg IV q12h (target trough concentration, 10-15 mcg/mL); for troughs of 15-20 mcg/mL (MIC, 1 mcg/mL or less), 15-20 mg/kg (actual body weight) IV q8-12h for most patients with normal renal function
:::* Preferred regimen (2) (who are unable to tolerate beta lactams therapy): [[Vancomycin]] 15 mg/kg IV q12h (target trough concentration, 10-15 mcg/mL); for troughs of 15-20 mcg/mL (MIC, 1 mcg/mL or less), 15-20 mg/kg (actual body weight) IV q8-12h for most patients with normal renal function
:::* Preferred regimen (3) (If the isolate is resistant (MIC 2 g/mL) to cefotaxime): [[Cefotaxime]] 1-2 g q8-12h IV/IM (max dose: 12 g/24 hr) {{and}} [[Vancomycin]] 15 mg/kg/day IV q12h {{and}} [[Rifampin]] 300 mg IV/PO q8h for 6 weeks, in combination with appropriate antimicrobial therapy
:::* Preferred regimen (3) (If the isolate is resistant (MIC 2 g/mL) to cefotaxime): [[Cefotaxime]] 1-2 g q8-12h IV/IM (max dose: 12 g/24 hr) {{and}} [[Vancomycin]] 15 mg/kg/day IV q12h {{and}} [[Rifampin]] 300 mg IV/PO q8h for 6 weeks, in combination with appropriate antimicrobial therapy
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::::* Preferred regimen: [[Vancomycin]] 15 mg/kg/day IV q12h {{and}} a third-generation cephalosporin ([[Ceftriaxone]] 2 g IV q12h {{or}} [[Cefotaxime]] 2 g IV q4h or 3 g q6h) {{and}} [[Rifampin]] 600 mg IV qd in combination with [[Vancomycin]]
::::* Preferred regimen: [[Vancomycin]] 15 mg/kg/day IV q12h {{and}} a third-generation cephalosporin ([[Ceftriaxone]] 2 g IV q12h {{or}} [[Cefotaxime]] 2 g IV q4h or 3 g q6h) {{and}} [[Rifampin]] 600 mg IV qd in combination with [[Vancomycin]]
::::* Alternative regimen: [[Meropenem]], fluoroquinolones   
::::* Alternative regimen: [[Meropenem]], fluoroquinolones   
::::: Note: Middle ear infections (otitis media), peritoneum infections (spontaneous bacterial peritonitis), pericardium infections (purulent pericarditis), skin infections (cellulitis) and eye infections (conjunctivitis) caused by Streptococcus pneumonia.
::::: Note: Middle ear infections ([[otitis media]]), peritoneum infections ([[spontaneous bacterial peritonitis]]), pericardium infections (purulent [[pericarditis]]), skin infections ([[cellulitis]]) and eye infections ([[conjunctivitis]]) caused by ''[[Streptococcus pneumonia]]''.


==Prevention==
==Prevention==
* '''General principles'''
* '''General principles'''
:::* 1. Pneumovax (23-valent) prevents bacteremia; impact on rates of CAP are modest or nil.
:::* 1. Pneumovax (23-valent) prevents bacteremia; impact on rates of CAP are modest or nil.
:::* 2. Prevnar vaccine for children <2 yrs age prevents invasive pneumococcal infection in adults by herd effect. Impact is impressive with rates of invasive pneumococcal infection down 80% in peds and 20-40% in adults.
:::* 2. [[Prevnar]] vaccine for children <2 yrs age prevents invasive pneumococcal infection in adults by herd effect. Impact is impressive with rates of invasive pneumococcal infection down 80% in peds and 20-40% in adults.
:::* 3. Risk for bacteremia in splenectomy, HIV, smokers, black race, multiple myeloma, asthma.
:::* 3. Risk for [[bacteremia]] in [[splenectomy]], [[Human Immunodeficiency Virus (HIV)|HIV]], smokers, black race, [[multiple myeloma]], [[asthma]].
===Vaccination in the USA===
===Vaccination in the USA===
In the USA, a heptavalent pneumococcal [[conjugate vaccine]] vaccine (PCV 7) (e.g. [[Prevnar]]) is recommended since 2000 for all children aged 2-23 months and for at-risk children aged 24-59 months. The normally 4-doses series is given at 2, 4, 6 &  12 - 14 months of age. Protection is good against deep pneumococcal infections (especially septicemia and meningitis). Similar 9- and 13-valent vaccines are being tested. Yet, if the child is exposed to a serotype of pneumococcus that is not contained in the vaccine, he/she is not afforded any protectionThis limitation, and the ability of capsular-polysaccharide conjugate vaccines to promote the spread of non-covered serotypes, has led to research into vaccines that would provide species-wide protection.
*A heptavalent pneumococcal [[conjugate vaccine]] vaccine (PCV 7) (e.g. [[Prevnar]]) is recommended in the USA since 2000 for all children between 2 to 23 months of age. PCV 7 is also recommended for children between 24 to 59 months of age if they are at risk of getting the infection.  
*The vaccination is generally given as a 4-doses series at 2, 4, 6 &  12 - 14 months of age.  
*The PCV 7 provides a good protection is good against deep pneumococcal infections (especially septicemia and meningitis). Some new vaccines being tested are 9- and 13-valent. No protection is offered if the child is infected by a pneumococcus serotype that is not a component of the current vaccine.  The ability of capsular-polysaccharide conjugate vaccines to promote the spread of non-covered serotypes and the limitation has led to research into vaccines that would provide species-wide protection.


[[Pneumococcal polysaccharide vaccine]] (Pneumovax™ is one brand) gives at least 85% protection in those under 55 years of age for five years or longer. Immunization is suggested for those at highest risk of infection, including those 65 years or older, and generally should be a single lifetime dose (high risk side effects if repeated).  The standard 23-valent vaccines are ineffective for children under two years old.  
*Pneumovax™  which is one trade name for the [[Pneumococcal polysaccharide vaccine]] which approximately provides 85% protection for 5 or more years in individuals younger than age 55.
*Individuals at a high risk of infection such as those who are 65 years or older are recommended to get the vaccine. 
*Generally it is a single once in a lifetime dose as it is associated with high risk of side effects with repitition.  The standard 23-valent vaccines are not effective for children who are less than two years old.  


The current guidelines of the [[American College of Physicians]] call for administration of the immunization between ages 2 and 65 when indicated, or at age 65. If someone received the immunization before age 60, the guidelines call for a one-time revaccination.  
*The [[American College of Physicians]] in its current guidelines recommends immunization administration between 2 to 65 years old in the presence of indications, or at age 65. If someone received the immunization before age 60, the guidelines call for a one-time revaccination.  


''Revaccination'' at periodic intervals is also indicated for those with other conditions such as [[asplenia]] or [[nephrotic syndrome]].
*''Periodic revaccination'' for those who have conditions like [[asplenia]] or [[nephrotic syndrome]] is indicated.


===Vaccination in the UK===
===Vaccination in the UK===
It was announced in February 2006 that the UK government would introduce vaccination with the conjugate vaccine in children aged 2, 4 and 13 months.<ref name="BBCVac">[http://news.bbc.co.uk/1/hi/health/4692908.stm "Children to be given new vaccine"] ''BBC News'', [[February 08]], [[2006]], retrieved [[August 25]], [[2006]]</ref><ref name="DoHPress">[http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4128036&chk=PI8e57 "Pneumococcal vaccine added to the childhood immunisation programme"] [[February 08]], [[2006]]</ref> This is expected to start on [[September 4]], [[2006]] and is to include changes to the immunisation programme in general.<ref name="MRF">[http://www.meningitis.org/sect5/subsect12/page1 "Changes to the immunisation programme in the UK"] ''Meningitis Research Foundation'', retrieved [[August 25]], [[2006]]</ref>
*It was announced in February 2006 that the UK government would introduce vaccination with the conjugate vaccine in children aged 2, 4 and 13 months.<ref name="BBCVac">[http://news.bbc.co.uk/1/hi/health/4692908.stm "Children to be given new vaccine"] ''BBC News'', [[February 08]], [[2006]], retrieved [[August 25]], [[2006]]</ref><ref name="DoHPress">[http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4128036&chk=PI8e57 "Pneumococcal vaccine added to the childhood immunisation programme"] [[February 08]], [[2006]]</ref> This is expected to start on [[September 4]], [[2006]] and is to include changes to the immunisation programme in general.<ref name="MRF">[http://www.meningitis.org/sect5/subsect12/page1 "Changes to the immunisation programme in the UK"] ''Meningitis Research Foundation'', retrieved [[August 25]], [[2006]]</ref>


===Vaccination Worldwide===
===Vaccination Worldwide===
[[PneumoADIP|Pneumococcal vaccines Accelerated Development and Introduction Plan (PnemoADIP)]] is a program to accelerate the evaluation and access to new pneumococcal vaccines in the developing world. PneumoADIP is funded by the [[Global Alliance for Vaccines and Immunization|Global Alliance for Vaccines and Immunization (GAVI)]]. Thirty GAVI countries have expressed interest in participating by 2010. PneumoADIP aims to save 5.4 million children by 2030.<ref name="PneumoADIP website">[http://www.pneumoadip.com "PneumoADIP website"]</ref>
*In the developing world a plan to accomplish the accelerated new pneumococcal vaccines evaluation and access is done according to the [[PneumoADIP|Pneumococcal vaccines Accelerated Development and Introduction Plan (PnemoADIP)]]. [[Global Alliance for Vaccines and Immunization|Global Alliance for Vaccines and Immunization (GAVI)]] funds this plan for new pneumococcal vaccines. Almost 30 countries in this list showed interest in participating by 2010. An estimated 5.4 million lives of the children can be saved by PneumoADIP by 2030.<ref name="PneumoADIP website">[http://www.pneumoadip.com "PneumoADIP website"]</ref>


==References==
==References==
{{reflist|2}}
{{reflist|2}}

Latest revision as of 18:41, 5 July 2017

Streptococcus pneumoniae infection Microchapters

Home

Patient Information

Overview

Classification

Community Acquired Pneumonia
Endocarditis
Sinusitis
Bronchitis
Meningitis

Cause

Laboratory Findings

Medical Therapy

Primary Prevention

This page is about clinical aspects of the disease.  For microbiologic aspects of the causative organism(s), see Streptococcus pneumoniae.

For patient information click here.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

Synonyms and keywords: Strep pnumoniae; Strep pneumoniae infection

Overview

Streptococcus pneumoniae, or pneumococcus, is a Gram-positive bacterium. It is a diplococcus, alpha-hemolytic member of the Streptococcus genus.[1] During the 19th century pneumonia was heavily associated with this pathogen. S. pneumoniae is known to be the cause of various different infections apart from pneumonia including endocarditis, meningitis, pericarditis, brain abscess, otitis media, osteomyelitis, acute sinusitis, septic arthritis, peritonitis, and cellulitis. In children as well as adults, S. pneumoniae is the most common cause of otitis media as well as bacterial meningitis.[2] Pneumonia caused by S. pneumoniae is usually found at the extremes of the age (in old or very young individuals). Streptococcus viridans also belongs to the family of alpha hemolytic bacteria but can e distinguished from S. pneumoniae by an optochin test. Streptococcus viridans are found to be insensitive to optochin where as S. pneumoniae are found to be optochin sensitive. The most potent virulence factor of S. pneumoniae is its polysaccharide capsule. Up to 91 various types of capsules have been discovered; each of these differ in virulence, drug resistance, prevalence, and distribution.

Classification

Streptococcus pneumoniae infections may be classified as follows:

 
 
 
 
 
 
 
 
Streptococcus Pneumoniae Infection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Community Acquired Pneumonia
 
Endocarditis
 
Sinusitis
 
Bronchitis
 
Meningitis
 
 
 
 
 
 

Laboratory Findings

Depending on the nature of infection, an appropriate sample is collected from the infected area for laboratory identification. Commonly found

Laboratory Diagnosis

Diagnosis of streptococcus pneumoniae infection is generally made based on clinical suspicion along with a positive culture from a sample from virtually any place in the body.

Treatment

  • Streptococcus pneumonia treatment
  • 1. Lung (Community-acquired pneumonia)[6]
  • 1.1 Penicillin sensitive (minimum inhibitory concentration < 2 mcg/ml)
  • 2.Endocarditis[7]
  • Preferred regimen (1): Aqueous crystalline Penicillin-G 6 MU q4-6h IV for 4 weeks
  • Preferred regimen (2) (who are unable to tolerate beta lactams therapy): Vancomycin 15 mg/kg IV q12h (target trough concentration, 10-15 mcg/mL); for troughs of 15-20 mcg/mL (MIC, 1 mcg/mL or less), 15-20 mg/kg (actual body weight) IV q8-12h for most patients with normal renal function
  • Preferred regimen (3) (If the isolate is resistant (MIC 2 g/mL) to cefotaxime): Cefotaxime 1-2 g q8-12h IV/IM (max dose: 12 g/24 hr) AND Vancomycin 15 mg/kg/day IV q12h AND Rifampin 300 mg IV/PO q8h for 6 weeks, in combination with appropriate antimicrobial therapy
  • Alternative regimen (1): Cefazolin 0.5-2 g q8h IV/IM (max dose: 12 g/24 hr)
  • Alternative regimen (2): Ceftriaxone 2 g IV q12h
  • Note : Streptococcus pneumoniae with intermediate doses minimum inhibitory concentration (MIC) 0.12 g/mL–0.5 g/mL Penicillin resistance (MIC 0.1 to 1.0 g/mL) or high Penicillin resistance (MIC 2.0 g/mL) is being recovered from patients with bacteremia.
  • 3. Sinuses (sinusitis)[8]
  • Empiric therapy
  • 3.1 For initial empiric treatment of acute bacterial rhinosinusitis in adults
  • 3.2 For second-line high-dose therapy for acute bacterial rhinosinusitis in adults
  • Preferred regimen: Amoxicillin 2 g/Clavulanate 125 mg PO bid recommended by the Infectious Disease Society of America (IDSA).
  • Note: The second line high dose therapy is recommended in adults who have failed initial therapy, in regions of high endemic rates (10% or greater) of invasive Penicillin-nonsusceptible Streptococcus pneumoniae, severe infection.
  • 4. Bronchi (acute exacerbation of chronic bronchitis)[9]
  • Preferred regimen (1): Amoxicillin 875 mg PO q12h or 500 mg PO q8h
  • Preferred regimen (2): Doxycycline 100 mg PO q12h
  • 5. CNS (meningitis)[10]
  • Empiric therapy
Note: Middle ear infections (otitis media), peritoneum infections (spontaneous bacterial peritonitis), pericardium infections (purulent pericarditis), skin infections (cellulitis) and eye infections (conjunctivitis) caused by Streptococcus pneumonia.

Prevention

  • General principles
  • 1. Pneumovax (23-valent) prevents bacteremia; impact on rates of CAP are modest or nil.
  • 2. Prevnar vaccine for children <2 yrs age prevents invasive pneumococcal infection in adults by herd effect. Impact is impressive with rates of invasive pneumococcal infection down 80% in peds and 20-40% in adults.
  • 3. Risk for bacteremia in splenectomy, HIV, smokers, black race, multiple myeloma, asthma.

Vaccination in the USA

  • A heptavalent pneumococcal conjugate vaccine vaccine (PCV 7) (e.g. Prevnar) is recommended in the USA since 2000 for all children between 2 to 23 months of age. PCV 7 is also recommended for children between 24 to 59 months of age if they are at risk of getting the infection.
  • The vaccination is generally given as a 4-doses series at 2, 4, 6 & 12 - 14 months of age.
  • The PCV 7 provides a good protection is good against deep pneumococcal infections (especially septicemia and meningitis). Some new vaccines being tested are 9- and 13-valent. No protection is offered if the child is infected by a pneumococcus serotype that is not a component of the current vaccine. The ability of capsular-polysaccharide conjugate vaccines to promote the spread of non-covered serotypes and the limitation has led to research into vaccines that would provide species-wide protection.
  • Pneumovax™ which is one trade name for the Pneumococcal polysaccharide vaccine which approximately provides 85% protection for 5 or more years in individuals younger than age 55.
  • Individuals at a high risk of infection such as those who are 65 years or older are recommended to get the vaccine.
  • Generally it is a single once in a lifetime dose as it is associated with high risk of side effects with repitition. The standard 23-valent vaccines are not effective for children who are less than two years old.
  • The American College of Physicians in its current guidelines recommends immunization administration between 2 to 65 years old in the presence of indications, or at age 65. If someone received the immunization before age 60, the guidelines call for a one-time revaccination.

Vaccination in the UK

  • It was announced in February 2006 that the UK government would introduce vaccination with the conjugate vaccine in children aged 2, 4 and 13 months.[11][12] This is expected to start on September 4, 2006 and is to include changes to the immunisation programme in general.[13]

Vaccination Worldwide

References

  1. Ryan KJ; Ray CG (editors) (2004). Sherris Medical Microbiology (4th ed. ed.). McGraw Hill. ISBN 0-8385-8529-9.
  2. Dagan R. "Treatment of acute otitis media - challenges in the era of antibiotic resistance". Vaccine. 19 Suppl 1: S9–S16. PMID 11163457.
  3. Siemieniuk, Reed A.C. (Nov 2011). "The persisting burden of invasive pneumococcal disease in HIV patients: an observational cohort study" (PDF). BMC Infectious Diseases. 11: 314. doi:10.1186/1471-2334-11-314. PMC 3226630. PMID 22078162. Unknown parameter |coauthors= ignored (help)
  4. Pikis, A; Campos, JM; Rodriguez, WJ; Keith, JM (2001). "Optochin resistance in Streptococcus pneumoniae: mechanism, significance, and clinical implications". Journal of Infectious Diseases. 184 (5): 582–590. doi:10.1086/322803. PMID 11474432.
  5. Zheng CJ, Sohn MJ, Kim WG. (2006). "Atromentin and leucomelone, the first inhibitors specific to enoyl-ACP reductase (FabK) of Streptococcus pneumoniae". Journal of Antibiotics. 59 (12): 808–12. doi:10.1038/ja.2006.108. PMID 17323650.
  6. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC; et al. (2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clin Infect Dis. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083.
  7. Baddour LM, Wilson WR, Bayer AS, Fowler VG, Bolger AF, Levison ME; et al. (2005). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145.
  8. Chow AW, Benninger MS, Brook I, Brozek JL, Goldstein EJ, Hicks LA; et al. (2012). "IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults". Clin Infect Dis. 54 (8): e72–e112. doi:10.1093/cid/cir1043. PMID 22438350.
  9. Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  10. Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM; et al. (2004). "Practice guidelines for the management of bacterial meningitis". Clin Infect Dis. 39 (9): 1267–84. doi:10.1086/425368. PMID 15494903.
  11. "Children to be given new vaccine" BBC News, February 08, 2006, retrieved August 25, 2006
  12. "Pneumococcal vaccine added to the childhood immunisation programme" February 08, 2006
  13. "Changes to the immunisation programme in the UK" Meningitis Research Foundation, retrieved August 25, 2006
  14. "PneumoADIP website"