Leonard Emuren, MD, MPH, PhD
Division Director, Pediatric Infectious Diseases,
Newark Beth Israel Medical Center
Pneumococcal infections are caused by the bacteria Streptococcus pneumoniae or, simply, pneumococcus. This organism commonly lives in the nose and throat and can be spread by direct contact with respiratory secretions such as mucus or saliva. There are many types of pneumococcal infections or diseases, ranging from mild to severe, depending on the part of the body that is affected. Middle ear infection is referred to as otitis media, and sinus infection as sinusitis. More severe infections or invasive diseases include pneumonia or lung infection, bacteremia or bloodstream infection, and meningitis or infection of the lining of the brain and spinal cord.
Individuals who harbor pneumococcus in their nose and/or throat (pharynx) are known as carriers. The nasopharyngeal carriage rate varies by age and population. It is about 21% in developed countries but may be as high as 90% or more in resource-limited settings. Viral infections of the upper respiratory tract, such as those due to influenza and respiratory syncytial virus (RSV), can make the individual more prone to pneumococcal infections, including pneumonia. Perhaps for the same reasons, pneumococcal infections are most common in the winter seasons.
Anyone can be affected by pneumococcal infections but certain factors may increase the risk of getting pneumococcal diseases, such as young age (less than 5 years) and adults older than 65 years of age; people of certain races and ethnicities (Alaska Native, American Indian, and African American); children attending daycare; and certain medical conditions that limit the ability of the body to fight infections such as those with cancer or receiving treatment for cancer, those with HIV and those with sickle cell anemia.
The individual’s symptoms will depend on the affected part of the body. For example, a middle ear infection may present as fever, ear pain/tugging of the ear, irritability, poor feeding, and sensation of fullness in the ear. These symptoms often are nonspecific, so a healthcare professional’s examination of the ear is warranted for diagnosis. Fever and chill, cough, and increased work of breathing or difficulty breathing are the likely symptoms of pneumococcal pneumonia, often referred to as community-acquired pneumonia. Fever and chills may be the only manifestation of bloodstream infection. Symptoms of pneumococcal meningitis are fever, headache, confusion, irritability, poor feeding (infants and neonates), neck stiffness in older children, and sensitivity to light (photophobia). Invasive pneumococcal diseases may result in long-term complications such as hearing loss and cerebral palsy from meningitis, sepsis (a life-threatening emergency affecting multiple body organs) from bacteremia, and death.
Generally, invasive pneumococcal infections would require hospitalization and treatment with antibiotics and other supportive care, including respiratory support, depending on the severity of the illness. For the diagnosis of meningitis, a lumbar puncture is indicated for examination of the cerebrospinal fluid and for laboratory testing to determine the specific bacteria that grow in the fluid, as other organisms can also cause meningitis. Molecular testing can also be used to identify the organism. Blood cultures are also obtained. With cultures, the healthcare provider can test for the best antibiotic to kill the bacteria. This is an advantage of cultures over molecular tests. Pneumonia can be a clinical diagnosis, but a chest XR is often used to confirm the diagnosis in the inpatient setting. Severe disease may require more advanced testing, such as a chest CT scan, to evaluate the extent of lung tissues involved and associated complications.
The best way to prevent pneumococcal disease is by vaccination. The Centers for Disease Control and Prevention (CDC) recommends pneumococcal vaccine for all children younger than 5 years old and adults 65 years or older. Vaccination is also recommended for people 5 to 64 years old at increased risk of acquiring pneumococcal infections. The first pneumococcal vaccine produced was the 7-valent pneumococcal conjugate vaccine (PCV7), introduced in the United States in 2000. PCV7 was replaced by PCV13 in 2010. PCV13 contained the 7 serotypes in PCV7 (4, 6B, 9V, 14, 18C, 19F, and 23F) and 6 additional serotypes (1, 3, 5, 6A, 7F, and 19A). There are about 100 Streptococcus pneumoniae strains, which are known as serotypes. The vaccines are targeted against the serotypes likely to cause pneumococcal diseases. For example, PCV7 targeted 7 prevalent pneumococcal serotypes causing disease, and PCV13 targeted 13 serotypes. Since the introduction of PCV7 and PCV13, there has been a significant reduction in invasive pneumococcal diseases, including pneumonia and meningitis. However, over the years, the cases of invasive pneumococcal diseases caused by non-PCV13 serotypes have increased. This led to the introduction of PCV15 (approved in 2021) and PCV20, which was approved for adults in 2021 and for children in 2023.
The CDC and the American Academy of Pediatrics (AAP) recommend PCV15 or PCV20 for all children 2 through 59 months of age. The vaccine is administered at 2, 4, 6, and 12 through 15 months of age. Catch-up vaccination with either PCV15 or PCV20 is also recommended for children 59 months of age or younger. 23-Valent Pneumococcal Polysaccharide Vaccine (PPS23) is recommended for children in high-risk groups (Table 1) who received PCV13. The AAP does not recommend PCV20 over PCV15. However, children in high-risk groups who received PCV15 will still need PPS23 but not for those who received PCV20. PPS23 is administered 8 or more weeks after receipt of PCV15.
Table 1: Children in High-Risk Group Requiring 23-Valent Pneumococcal Polysaccharide Vaccine (PPS23) or PCV20*
*Reproduced with modifications from the Redbook by the AAP
Detailed discussion on catch-up vaccination is beyond the scope of this write-up but is publicly available on the CDC website:
https://www.cdc.gov/vaccines/hcp/imz-schedules/child-adolescent-catch-up.html#table-2. I recommend discussing specific questions with your child’s pediatrician, healthcare professional, or pediatric infectious disease expert. Adverse reactions after administration of pneumococcal vaccines are generally mild to moderate and include local reactions at the injection site, pain, redness, swelling, irritability, and decreased appetite. Talking to your healthcare professional when adverse effects are noted is always advisable.
Daily antibiotics prophylaxis is recommended for children with sickle cell anemia (SCA) who have non-functional spleen or those who have an anatomic removal of their spleen after rupture of the spleen from accidents. Oral penicillin is the drug of choice for this. While some experts may continue prophylaxis in those with SCA throughout childhood, others may discontinue after 5 years of age if they are fully vaccinated and otherwise doing well.
The ASP, representing pediatric providers, including pediatric infectious disease specialists and pharmacists, exchange ideas, discuss case management strategies and develop and implement guidelines to be shared system wide, as well as serve as a resource for community physicians.
For more educational information, research and best practices from the Children’s Health Network at RWJBarnabas Health, visit rwjbh.org/childrenshealthresearch.