Pneumococcal
Infections
DEFINITION:
Illness
caused by bacteria called Streptococcus pneumoniae.
SYMPTOMS:
Depending
on the site of infection, pneumococcus can cause various illnesses
with multiple symptoms: pneumonia, otitis media (ear infections),
sinusitis, pharyngitis (sore throat), peritonitis (abdominal
infection), bacteremia (bacteria in the blood stream), sepsis,
mastoiditis (infection of the bone behind the ear), septic
arthritis, osteomyelitis, endocarditis, brain abscess, and
meningitis. Symptoms can include fever, pain, cough, difficulty
breathing, headache, stiff neck, lethargy, and coma. Infection
from this organism can in some cases lead to death.
CAUSES:
There are multiple strains of pneumococcal bacteria. The different
bacteria, called serotypes, cause the different illnesses.
Many people carry the bacteria in their respiratory tract
without symptoms, but can transmit this to others causing
disease. Once the bacteria enters the upper respiratory tract,
it can travel through the blood stream to other parts of the
body.
CONTAGION:
Pneumococcus is spread from person to person through respiratory
droplets. The incubation period is 3-7 days.
DIAGNOSIS:
The
diagnosis of pneumococcal disease is made by observation of
the symptoms of the specific illness and a culture of the
organism. For infections such as otitis media, sinusitis,
and pneumonia, cultures are not generally taken. In these
cases, statistics show that this is the most likely cause
of these illnesses. Enough cultures have been done in studies
to show that this is the case. For other infections such as
bacteremia, sepsis, meningitis, osteomyelitis, septic arthritis
and mastoiditis, a culture of blood, spinal or joint fluid,
or bone aspirate can show the organism. In other pneumococcal
infections such as endocarditis and brain abscess a blood
culture may or may not show the pneumococcal bacteria. In
these cases, treatment is started assuming the pneumococcal
bacteria is a likely cause.
TREATMENT:
The treatment for
pneumococcal infection is the administration of antibiotics.
The type of antibiotic, whether oral or intravenous, and the
length of the course of treatment depends on the site of infection.
For example, the treatment of choice for otitis media is a
ten-day course of oral amoxicillin. For meningitis, intravenous
antibiotics with very strong medicines such as vancomycin
and cefotaxime may be used until the culture is done and the
sensitivities of the organism are determined. If the organism
is found to be sensitive to another particular drug, the treatment
can then be changed. Steroids can be used to prevent complications
in meningitis.
OUTCOME:
Depends on the illness caused. Otitis media, pharyngitis,
and sinusitis have excellent outcomes with treatment. Meningitis,
bacteremia and sepsis can have good or bad results. One child
may be perfectly well after treatment while another may suffer
permanent hearing loss, deafness, developmental delay and
lifetime sequelae. In some, the illness can be deadly.
DISCUSSION:
Pneumococcal disease can be a simple or a complex illness
depending on the serotype of the organism and the site of
infection. There is not just one pneumococcal bacteria, instead
there are over eighty serotypes causing different illnesses
of different severities. In many cases such as in otitis media
and sinusitis, the child is treated with the knowledge that
there is a 60% chance that the offending organism is pneumococcus.
In these milder forms of illness, an oral antibiotic will
be started. If it fails, a switch to another antibiotic may
be necessary. In otitis
media, (ear infections), the pneumococcal bacteria are
showing increasing resistance. As a matter of fact, pneumococcal
bacteria are now classified as sensitive, intermediately resistant,
or highly resistant. In certain cases of otitis media, no
antibiotic will provide benefit and ventilation tubes may
be necessary. In illnesses such as meningitis and bacteremia,
a culture of blood or spinal fluid will show the organism
and sensitivities to antibiotics will determine the optimal
course of treatment. Due to the resistance of the bacteria,
these more serious illnesses require that very potent intravenous
drugs be started and decreased only after a sensitivity test
proves that the organism is sensitive to a different antibiotic.
With the routine use of the more potent antibiotics, the bacteria
will eventually become even more resistant leaving us with
few options for treatment.
The best way to combat this illness is to avoid getting it
in the first place. This cannot always be accomplished, but
ways to decrease the possibility of infection include vaccination,
breastfeeding the infant and young child, avoiding daycare,
avoiding exposure to cigarette smoke, and avoiding obviously
sick individuals.
A vaccine was licensed in early 2000 which can prevent the
seven most common and most severe forms of pneumococcal disease.
It will prevent the most serious forms of pneumococcal infection
and lessen the occurrence of ear infections by 10%. This 7
valent pneumococcal vaccine is meant for all children under
the age of two and for children two to five years of age who
fall under certain risk categories. These risk categories
include children in day care, and children in certain ethnic
and socioeconomic groups. There is also a 23-valent vaccine
that can be given to children over two years of age. This
vaccine is made differently and is much less effective that
the 7 valent vaccine. This vaccine has been given for years
to children over two years of age with risk factors including
sickle cell disease, having no spleen, a kidney disease called
nephrotic syndrome, or a blood disorder called hemoglobinopathy.
Although this vaccine is 23 valent as opposed to the 7 valent,
and provides protection from an extra 16 serotypes of pneumococcus,
the vaccine is not currently recommended as part of the routine
schedule for healthy children.
New
recommendations for the 7 valent and 23 valent vaccines have
been issued by the AAP. All children under 2 years of age
and all children ages 24-59 months of age at high risk should
receive the 7 valent vaccine. Children over the age of 2 with
risk factors should also receive the 23 valent vaccine. All
children over the age of 2 can receive both the 7 and 23 valent
vaccine as well.
For
the latest AAP Recommendations:
http://www.aap.org/policy/pcv76-5.pdf
Pictures
of Children with pneumococcal infections
[Warning: Graphic]
ONE
DOCTOR'S OPINION:
The illnesses caused by pneumococcus are getting more difficult
to treat as time goes on. The bacteria are becoming more resistant
and the antibiotic failures are becoming more frequent. Hopefully
this vaccine will provide some relief from this potentially
harmful bacteria. Every child under two years of age should
receive the 7 valent vaccine. Pneumococcal meningitis is the
most common form of bacterial meningitis and can now for the
first time be prevented. Many cases of pneumonia will be prevented
and ear infections will decrease in number by 10%. The jury
is still out on what to do with the 23 valent vaccine. Some
infectious disease experts suggest using both to cover as
much as possible, others feel that the 23 valent is ineffective
and unnecessary especially with the advent of the more effective
7 valent vaccine which covers the 7 most common and serious
forms of pneumococcus. Decisions on recommendations are expected
in the future, but for now the 7 valent should be received
while the 23 valent can be used in children with known risk
factors or if the parent wants to give every protection possible.
