Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point of care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

For more information, click below.


Subscribers log in here


Pneumococcal pneumonia in children

INTRODUCTION

Pneumococcus (Streptococcus pneumoniae) is a common cause of invasive bacterial infection in children and a frequent cause of community-acquired pneumonia [1,2]. Intermediate or high-level resistance to penicillin has become a significant problem. Children, particularly those in child care facilities and those receiving frequent courses of antibiotics, appear to be important carriers of resistant strains [3-5].

The clinical features, diagnosis, and treatment of pneumococcal pneumonia will be reviewed here. An overview of the clinical features and diagnosis of community-acquired pneumonia in children and the microbiology, pathogenesis, and epidemiology of S. pneumoniae are discussed separately. (See "Clinical features and diagnosis of community-acquired pneumonia in children" and "Microbiology and pathogenesis of Streptococcus pneumoniae".)

PATHOGENESIS

The pneumococcus is acquired by aerosol or inhalation, leading to colonization of the nasopharynx; pneumococci are carried asymptomatically in approximately 50 percent of individuals at any point in time [6]. In children, the incidence of pneumococcal carriage may be as high as 60 percent, even after immunization with the pneumococcal conjugate vaccine [7-9]. (See "Microbiology and pathogenesis of Streptococcus pneumoniae", section on 'Pathogenesis'.) Antibiotic-resistant strains are increasingly common [10]. (See "Resistance of Streptococcus pneumoniae to beta-lactam antibiotics" and "Resistance of Streptococcus pneumoniae to the fluoroquinolones, doxycycline, and trimethoprim-sulfamethoxazole" and "Resistance of Streptococcus pneumoniae to the macrolides, azalides, lincosamines, and ketolides".)

Invasive disease most commonly occurs upon acquisition of a new serotype, typically after an incubation period of one to three days.

The incidence of disease increases strongly in association with a viral illness, such as influenza, parainfluenza, respiratory syncytial virus, adenovirus, or human metapneumovirus [11-14]. This association is believed to be related to increased expression of receptors for pneumococcal attachment on virally activated respiratory epithelial cells [15].

                                

Subscribers log in here

To continue reading this article you must have access through your hospital or your group practice, log in to your personal subscription, or purchase a personal subscription. For more information, click below.
Literature review current through: Apr 2013. | This topic last updated: Nov 28, 2012.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2013 UpToDate, Inc.
References
Top
  1. Wubbel L, Muniz L, Ahmed A, et al. Etiology and treatment of community-acquired pneumonia in ambulatory children. Pediatr Infect Dis J 1999; 18:98.
  2. American Academy of Pediatrics. Pneumococcal infections. In: Red Book: 2012 Report of the Committee on Infectious Diseases, 29th Ed, Pickering LK, Baker CJ, Kimberlin DW, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2012. p.571.
  3. Thornsberry C, Ogilvie PT, Holley HP Jr, Sahm DF. Survey of susceptibilities of Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis isolates to 26 antimicrobial agents: a prospective U.S. study. Antimicrob Agents Chemother 1999; 43:2612.
  4. Sisson BA, Buck G, Franco SM, et al. Penicillin minimum inhibitory concentration drift in identical sequential Streptococcus pneumoniae isolates from colonized healthy infants. Clin Infect Dis 2000; 30:191.
  5. Raymond J, Le Thomas I, Moulin F, et al. Sequential colonization by Streptococcus pneumoniae of healthy children living in an orphanage. J Infect Dis 2000; 181:1983.
  6. Austrian R. Some aspects of the pneumococcal carrier state. J Antimicrob Chemother 1986; 18 Suppl A:35.
  7. Millar EV, O'Brien KL, Watt JP, et al. Effect of community-wide conjugate pneumococcal vaccine use in infancy on nasopharyngeal carriage through 3 years of age: a cross-sectional study in a high-risk population. Clin Infect Dis 2006; 43:8.
  8. Huang SS, Platt R, Rifas-Shiman SL, et al. Post-PCV7 changes in colonizing pneumococcal serotypes in 16 Massachusetts communities, 2001 and 2004. Pediatrics 2005; 116:e408.
  9. Park SY, Moore MR, Bruden DL, et al. Impact of conjugate vaccine on transmission of antimicrobial-resistant Streptococcus pneumoniae among Alaskan children. Pediatr Infect Dis J 2008; 27:335.
  10. Overturf GD. American Academy of Pediatrics. Committee on Infectious Diseases. Technical report: prevention of pneumococcal infections, including the use of pneumococcal conjugate and polysaccharide vaccines and antibiotic prophylaxis. Pediatrics 2000; 106:367.
  11. Madhi SA, Klugman KP, Vaccine Trialist Group. A role for Streptococcus pneumoniae in virus-associated pneumonia. Nat Med 2004; 10:811.
  12. Madhi SA, Ludewick H, Kuwanda L, et al. Pneumococcal coinfection with human metapneumovirus. J Infect Dis 2006; 193:1236.
  13. Ampofo K, Bender J, Sheng X, et al. Seasonal invasive pneumococcal disease in children: role of preceding respiratory viral infection. Pediatrics 2008; 122:229.
  14. O'Brien KL, Walters MI, Sellman J, et al. Severe pneumococcal pneumonia in previously healthy children: the role of preceding influenza infection. Clin Infect Dis 2000; 30:784.
  15. Tuomanen EI, Austrian R, Masure HR. Pathogenesis of pneumococcal infection. N Engl J Med 1995; 332:1280.
  16. Cundell DR, Gerard NP, Gerard C, et al. Streptococcus pneumoniae anchor to activated human cells by the receptor for platelet-activating factor. Nature 1995; 377:435.
  17. Weiser JN, Pan N, McGowan KL, et al. Phosphorylcholine on the lipopolysaccharide of Haemophilus influenzae contributes to persistence in the respiratory tract and sensitivity to serum killing mediated by C-reactive protein. J Exp Med 1998; 187:631.
  18. Heffron, R. Pneumonia. Commonwealth Fund, New York 1939.
  19. Tuomanen E, Rich R, Zak O. Induction of pulmonary inflammation by components of the pneumococcal cell surface. Am Rev Respir Dis 1987; 135:869.
  20. Bergeron Y, Ouellet N, Deslauriers AM, et al. Cytokine kinetics and other host factors in response to pneumococcal pulmonary infection in mice. Infect Immun 1998; 66:912.
  21. UNICEF. Pneumonia: The forgotten killer of children. UNICEF/WHO 2006. www.unicef.org/publications/index_35626.html (Accessed on June 20, 2012).
  22. Juvén T, Mertsola J, Waris M, et al. Etiology of community-acquired pneumonia in 254 hospitalized children. Pediatr Infect Dis J 2000; 19:293.
  23. Kaplan SL, Mason EO Jr, Wald E, et al. Six year multicenter surveillance of invasive pneumococcal infections in children. Pediatr Infect Dis J 2002; 21:141.
  24. Tan TQ, Mason EO Jr, Wald ER, et al. Clinical characteristics of children with complicated pneumonia caused by Streptococcus pneumoniae. Pediatrics 2002; 110:1.
  25. Byington CL, Hulten KG, Ampofo K, et al. Molecular epidemiology of pediatric pneumococcal empyema from 2001 to 2007 in Utah. J Clin Microbiol 2010; 48:520.
  26. Schutze GE, Tucker NC, Mason EO Jr. Impact of the conjugate pneumococcal vaccine in arkansas. Pediatr Infect Dis J 2004; 23:1125.
  27. Byington CL, Samore MH, Stoddard GJ, et al. Temporal trends of invasive disease due to Streptococcus pneumoniae among children in the intermountain west: emergence of nonvaccine serogroups. Clin Infect Dis 2005; 41:21.
  28. Chibuk TK, Robinson JL, Hartfield DS. Pediatric complicated pneumonia and pneumococcal serotype replacement: trends in hospitalized children pre and post introduction of routine vaccination with Pneumococcal Conjugate Vaccine (PCV7). Eur J Pediatr 2010; 169:1123.
  29. Yu J, Salamon D, Marcon M, Nahm MH. Pneumococcal serotypes causing pneumonia with pleural effusion in pediatric patients. J Clin Microbiol 2011; 49:534.
  30. Thomas MF, Sheppard CL, Guiver M, et al. Emergence of pneumococcal 19A empyema in UK children. Arch Dis Child 2012; 97:1070.
  31. Tan TQ, Mason EO Jr, Barson WJ, et al. Clinical characteristics and outcome of children with pneumonia attributable to penicillin-susceptible and penicillin-nonsusceptible Streptococcus pneumoniae. Pediatrics 1998; 102:1369.
  32. Wexler ID, Knoll S, Picard E, et al. Clinical characteristics and outcome of complicated pneumococcal pneumonia in a pediatric population. Pediatr Pulmonol 2006; 41:726.
  33. Byington CL, Spencer LY, Johnson TA, et al. An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: risk factors and microbiological associations. Clin Infect Dis 2002; 34:434.
  34. Ramphul N, Eastham KM, Freeman R, et al. Cavitatory lung disease complicating empyema in children. Pediatr Pulmonol 2006; 41:750.
  35. Bender JM, Ampofo K, Korgenski K, et al. Pneumococcal necrotizing pneumonia in Utah: does serotype matter? Clin Infect Dis 2008; 46:1346.
  36. Waters AM, Kerecuk L, Luk D, et al. Hemolytic uremic syndrome associated with invasive pneumococcal disease: the United kingdom experience. J Pediatr 2007; 151:140.
  37. Bender JM, Ampofo K, Byington CL, et al. Epidemiology of Streptococcus pneumoniae-induced hemolytic uremic syndrome in Utah children. Pediatr Infect Dis J 2010; 29:712.
  38. Byington CL, Korgenski K, Daly J, et al. Impact of the pneumococcal conjugate vaccine on pneumococcal parapneumonic empyema. Pediatr Infect Dis J 2006; 25:250.
  39. Grijalva CG, Nuorti JP, Zhu Y, Griffin MR. Increasing incidence of empyema complicating childhood community-acquired pneumonia in the United States. Clin Infect Dis 2010; 50:805.
  40. Hardie WD, Roberts NE, Reising SF, Christie CD. Complicated parapneumonic effusions in children caused by penicillin-nonsusceptible Streptococcus pneumoniae. Pediatrics 1998; 101:388.
  41. Marrie TJ. Community-acquired pneumonia. Clin Infect Dis 1994; 18:501.
  42. Le Monnier A, Carbonnelle E, Zahar JR, et al. Microbiological diagnosis of empyema in children: comparative evaluations by culture, polymerase chain reaction, and pneumococcal antigen detection in pleural fluids. Clin Infect Dis 2006; 42:1135.
  43. Resti M, Moriondo M, Cortimiglia M, et al. Community‐acquired bacteremic pneumococcal pneumonia in children: diagnosis and serotyping by real‐time polymerase chain reaction using blood samples. Clin Infect Dis 2010; 51:1042.
  44. Azzari C, Moriondo M, Indolfi G, et al. Realtime PCR is more sensitive than multiplex PCR for diagnosis and serotyping in children with culture negative pneumococcal invasive disease. PLoS One 2010; 5:e9282.
  45. Ramirez M, Melo-Cristino J. Expanding the diagnosis of pediatric bacteremic pneumococcal pneumonia from blood cultures to molecular methods: advantages and caveats. Clin Infect Dis 2010; 51:1050.
  46. Avni T, Mansur N, Leibovici L, Paul M. PCR using blood for diagnosis of invasive pneumococcal disease: systematic review and meta-analysis. J Clin Microbiol 2010; 48:489.
  47. Rein MF, Gwaltney JM Jr, O'Brien WM, et al. Accuracy of Gram's stain in identifying pneumococci in sputum. JAMA 1978; 239:2671.
  48. 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:e25.
  49. Chumpa A, Bachur RG, Harper MB. Bacteremia-associated pneumococcal pneumonia and the benefit of initial parenteral antimicrobial therapy. Pediatr Infect Dis J 1999; 18:1081.
  50. Choi EH, Lee HJ. Clinical outcome of invasive infections by penicillin-resistant Streptococcus pneumoniae in Korean children. Clin Infect Dis 1998; 26:1346.
  51. Deeks SL, Palacio R, Ruvinsky R, et al. Risk factors and course of illness among children with invasive penicillin-resistant Streptococcus pneumoniae. The Streptococcus pneumoniae Working Group. Pediatrics 1999; 103:409.
  52. Cardoso MR, Nascimento-Carvalho CM, Ferrero F, et al. Penicillin-resistant pneumococcus and risk of treatment failure in pneumonia. Arch Dis Child 2008; 93:221.
  53. Clifford V, Tebruegge M, Vandeleur M, Curtis N. Question 3: can pneumonia caused by penicillin-resistant Streptococcus pneumoniae be treated with penicillin? Arch Dis Child 2010; 95:73.
  54. Friedland IR. Comparison of the response to antimicrobial therapy of penicillin-resistant and penicillin-susceptible pneumococcal disease. Pediatr Infect Dis J 1995; 14:885.
  55. Pírez MC, Martínez O, Ferrari AM, et al. Standard case management of pneumonia in hospitalized children in Uruguay, 1997 to 1998. Pediatr Infect Dis J 2001; 20:283.
  56. Kaplan SL, Mason EO Jr, Barson WJ, et al. Outcome of invasive infections outside the central nervous system caused by Streptococcus pneumoniae isolates nonsusceptible to ceftriazone in children treated with beta-lactam antibiotics. Pediatr Infect Dis J 2001; 20:392.
  57. Critchley IA, Brown SD, Traczewski MM, et al. National and regional assessment of antimicrobial resistance among community-acquired respiratory tract pathogens identified in a 2005-2006 U.S. Faropenem surveillance study. Antimicrob Agents Chemother 2007; 51:4382.
  58. Critchley IA, Jacobs MR, Brown SD, et al. Prevalence of serotype 19A Streptococcus pneumoniae among isolates from U.S. children in 2005-2006 and activity of faropenem. Antimicrob Agents Chemother 2008; 52:2639.
  59. Plouffe JF, Breiman RF, Facklam RR. Bacteremia with Streptococcus pneumoniae. Implications for therapy and prevention. Franklin County Pneumonia Study Group. JAMA 1996; 275:194.
  60. Pallares R, Liñares J, Vadillo M, et al. Resistance to penicillin and cephalosporin and mortality from severe pneumococcal pneumonia in Barcelona, Spain. N Engl J Med 1995; 333:474.
  61. MIC Interpretive Standards (mcg/mL) for Streptococcus pneumoniae. In: Performance Standards for Antimicrobial Susceptibility Testing; Eighteenth Informational Supplement. CLSI/NCCLS M100-S18. Wayne, PA 2008.
  62. Pelton SI, Huot H, Finkelstein JA, et al. Emergence of 19A as virulent and multidrug resistant Pneumococcus in Massachusetts following universal immunization of infants with pneumococcal conjugate vaccine. Pediatr Infect Dis J 2007; 26:468.
  63. Moore MR, Gertz RE Jr, Woodbury RL, et al. Population snapshot of emergent Streptococcus pneumoniae serotype 19A in the United States, 2005. J Infect Dis 2008; 197:1016.
  64. Bradley JS, Arguedas A, Blumer JL, et al. Comparative study of levofloxacin in the treatment of children with community-acquired pneumonia. Pediatr Infect Dis J 2007; 26:868.
  65. Feikin DR, Schuchat A, Kolczak M, et al. Mortality from invasive pneumococcal pneumonia in the era of antibiotic resistance, 1995-1997. Am J Public Health 2000; 90:223.