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PubMedDate not supplied

Monotherapy may be suboptimal for severe bacteremic pneumococcal pneumonia.

BACKGROUND: Although monotherapy for pneumococcal pneumonia is standard, a survival benefit of combination beta-lactam and macrolide therapy has been suggested. HYPOTHESIS: Initial empirical therapy with a combination of effective antibiotic agents would have a better outcome than a single effective antibiotic agent in patients with bacteremic pneumococcal pneumonia. METHODS: A review of adult bacteremic pneumococcal pneumonia within the Methodist Healthcare System, Memphis, Tenn, between January 1, 1996, and July 31, 2000. Empirical therapy was defined as all antibiotic agents received in the first 24 hours after presentation. On the basis of culture results, empirical therapy was classified as single effective therapy (SET), dual effective therapy (DET), or more than DET (MET). Acute Physiology and Chronic Health Evaluation II (APACHE II)-based predicted mortality, and Pneumonia Severity Index scores were calculated. RESULTS: Of the 225 patients identified, 99 were classified as receiving SET, 102 as receiving DET, and 24 as receiving MET. Compared with the other groups, patients who received MET had statistically significantly more severe pneumonia as measured by the Pneumonia Severity Index score (P =.04) and predicted mortality (P =.03). Mortality within the SET group was significantly higher than within the DET group (P =.02, odds ratio, 3.0 [95% confidence intervals, 1.2-7.6]), even when the DET and MET groups (P =.04) were combined. In a logistic regression model including antibiotic therapy and clinical risk factors for mortality, SET remained an independent predictor of mortality with a predicted mortality-adjusted odds ratio for death of 6.4 (95% confidence intervals, 1.9-21.7). All deaths occurred in patients with a Pneumonia Severity Index score higher than 90, and the predicted mortality-adjusted odds ratio for death with SET in this subgroup was 5.5 (95% confidence intervals, 1.7-17.5). CONCLUSIONS: We found that SET is associated with a significantly greater risk of death than DET. Therefore, monotherapy may be suboptimal for patients with severe bacteremic pneumococcal pneumonia who have Pneumonia Severity Index scores higher than 90.

APACHE↗
PubMed2004

IL-10 is an important mediator of the enhanced susceptibility to pneumococcal pneumonia after influenza infection.

Secondary pneumococcal pneumonia is a serious complication during and shortly after influenza infection. We established a mouse model to study postinfluenza pneumococcal pneumonia and evaluated the role of IL-10 in host defense against Streptococcus pneumoniae after recovery from influenza infection. C57BL/6 mice were intranasally inoculated with 10 median tissue culture infective doses of influenza A (A/PR/8/34) or PBS (control) on day 0. By day 14 mice had regained their normal body weight and had cleared influenza virus from the lungs, as determined by real-time quantitative PCR. On day 14 after viral infection, mice received 10(4) CFU of S. pneumoniae (serotype 3) intranasally. Mice recovered from influenza infection were highly susceptible to subsequent pneumococcal pneumonia, as reflected by a 100% lethality on day 3 after bacterial infection, whereas control mice showed 17% lethality on day 3 and 83% lethality on day 6 after pneumococcal infection. Furthermore, 1000-fold higher bacterial counts at 48 h after infection with S. pneumoniae and, particularly, 50-fold higher pulmonary levels of IL-10 were observed in influenza-recovered mice than in control mice. Treatment with an anti-IL-10 mAb 1 h before bacterial inoculation resulted in reduced bacterial outgrowth and markedly reduced lethality during secondary bacterial pneumonia compared with those in IgG1 control mice. In conclusion, mild self-limiting influenza A infection renders normal immunocompetent mice highly susceptible to pneumococcal pneumonia. This increased susceptibility to secondary bacterial pneumonia is at least in part caused by excessive IL-10 production and reduced neutrophil function in the lungs.

Animals↗
PubMed2000

Antibody to capsular polysaccharide of Streptococcus pneumoniae at the time of hospital admission for Pneumococcal pneumonia.

IgG to capsular polysaccharide (CPS) of Streptococcus pneumoniae is thought to provide the greatest degree of protection against pneumococcal disease. Serum obtained at hospital admission from 14 (27%) of 51 patients with bacteremic pneumococcal pneumonia and 11 (37%) of 30 with nonbacteremic pneumococcal pneumonia contained IgG to CPS of the infecting serotype; these percentages are similar to the prevalence of IgG to CPS in a control population. However, when compared with antibody from healthy adults, this IgG had far less capacity to opsonize the infecting pneumococcal serotype for phagocytosis in vitro by normal human polymorphonuclear leukocytes or to protect mice against experimental challenge. Failure to opsonize correlated closely with failure to protect mice, and each of these parameters correlated well with poor avidity for CPS. Future vaccine studies may need to examine the functional capacity of antibodies as a surrogate for infection, in addition to measuring their concentration in serum.

Animals↗
PubMed1989

Pneumonia due to Legionella pneumophila and pneumococcal pneumonia: similarities and differences on presentation.

We compared clinical, radiological and laboratory data from 32 cases of community-acquired pneumonia due to Legionella pneumophila, with 37 cases of pneumococcal pneumonia (PP). This study revealed few clinical differences between the two types of pneumonia: in our experience Legionnaire's disease presents like a "typical" bacterial pneumonia. Given the difficulty of making a diagnosis on clinical data alone, we propose early aetiological diagnostic measures and recommend that the choice of initial treatment be based not only on the features at the time of presentation, but also on a consideration of the epidemiology of different types of pneumonia in a given area.

Adult↗
PubMed1987

Diagnosis of pneumococcal pneumonia by enzyme-linked immunosorbent assay of antibodies to pneumococcal hemolysin (pneumolysin).

An enzyme-linked immunosorbent assay (ELISA) with a highly purified pneumolysin as the antigen was evaluated for serological diagnosis of pneumococcal pneumonia. One hundred four healthy controls were tested, and the specificity of the test was set to 95%. In samples from patients with bacteremic pneumococcal pneumonia, 82% (18 of 22) were positive, i.e., at least one serum sample had a titer above the upper normal limit or at least a twofold rise in antibody titers was noted. In nonbacteremic pneumococcal pneumonia, 45% (21 of 47) of samples were positive. All sera were negative for patients with pneumonia caused by Haemophilus influenzae, Legionella pneumophila, Chlamydia psittaci, and influenza A virus. However, in patients with a diagnosis of Mycoplasma pneumoniae infection, 8 of 25 (32%) samples were positive for antibodies to pneumolysin. All sera, including those from patients with mycoplasma infection, were negative to a protein control antigen by ELISA. Serum immunoglobulin G response to pneumolysin as measured by ELISA might thus be an aid in the laboratory diagnosis of pneumococcal pneumonia. This assay may also help to further elucidate the occurrence of dual infections with pneumococci.

Adolescent↗
PubMed2006

Severe pneumococcal pneumonia: new strategies for management.

PURPOSE OF REVIEW: Streptococcus pneumoniae is the leading cause of community-acquired pneumonia worldwide and is the most likely causative pathogen in patients with community-acquired pneumonia admitted to the intensive care unit. Bacteremic pneumococcal pneumonia is an advanced stage of severe pneumococcal pneumonia. Improvement in the management of bacteremic pneumococcal pneumonia has the potential for improving the survival for severe pneumococcal pneumonia. RECENT FINDINGS: Non-culture methods, especially the Binax urinary antigen test, can increase the diagnostic yield for pneumococcal pneumonia, allowing targeted antimicrobial therapy (specifically penicillin). In-vitro resistance to penicillin has increased over the past decade; however, it has not led to clinical failure when used for pneumococcal pneumonia. SUMMARY: Hospitalized patients with community-acquired pneumonia should have blood cultures obtained to confirm the possibility of bacteremic pneumococcal pneumonia. Based on pharmacodynamic properties, parenteral penicillin remains the drug of choice to treat pneumococcal pneumonia regardless of in-vitro resistance. Combination antimicrobial therapy will likely improve survival of patients with bacteremic pneumococcal pneumonia among the subset of critically ill patients.

Adult↗
PubMed1993

Oropharyngeal production of pneumococcal capsular antigen and the potential for contamination of expectorated sputum samples in pneumococcal pneumonia.

The presence of pneumococcal capsular antigen (PCA) in the oropharynx was sought in subjects without respiratory tract infection. Saliva specimens from 239 subjects were analysed by counter-current immunoelectrophoresis using 'Omniserum'. 15.5% gave positive reactions but only 24% of positive samples were typable and therefore due to pneumococcal or pneumococcal-like antigens. Given that oropharyngeal production of antigens occurs we investigated whether PCA in expectorated sputum arose from oropharyngeal contamination. Sixteen patients with pneumococcal pneumonia, and with sputum positive for PCA, were investigated in detail. On the basis of serotyping and concentration the PCA in sputum was thought to arise from the lower respiratory tract in all cases. This was confirmed by a simple, novel approach involving the comparison of concentrations in concomitant samples of saliva and sputum. Thus while oropharyngeal production of antigens poses a potential diagnostic problem the latter approach can be used to exclude contamination.

Adolescent↗
PubMed1988

Bacteremic pneumococcal pneumonia in Sweden: clinical course and outcome and comparison with non-bacteremic pneumococcal and mycoplasmal pneumonias.

279 patients with 285 episodes of bacteremic pneumococcal pneumonia (Pnb), treated at the 2 departments for infectious diseases in Stockholm, Sweden, were reviewed retrospectively. Almost half of all episodes were caused by serotypes 3, 9 and 4 (in that order). The overall mortality rate was 7% and as low as 5% if patients with extrapulmonary complications were excluded. As in other studies male sex, alcoholism and absence of leukocytosis on admission to hospital were all associated with a higher mortality rate. However, the prognosis for old patients was much better than in most other studies. This was true also when the infecting strain was of serotype 3. For 89 consecutive patients out of the 279 ones with Pnb the clinical, laboratory and chest X-ray data were compared with those of 44 patients with non-bacteremic pneumococcal pneumonia (Pn) and 27 patients with Mycoplasma pneumoniae pneumonia (MP). Within the pneumococcal group almost all non-bacteremic patients had respiratory tract symptoms compared to less than half of the patients with bacteremic disease. High age, alcoholism, chills, pleuritic chest pain, a leukocyte count of greater than 15 x 10(9)l and an elevated CRP were factors significantly more common among those with pneumococcal pneumonia than among the MP patients. On chest X-ray an alveolar pattern was seen in all but 2 of the totally 133 patients with a pneumococcal pneumonia, but also in half the patients with MP.

Adolescent↗
PubMed1981

A cost-benefit analysis of immunization for pneumococcal pneumonia.

To determine whether immunization against pneumococcal pneumonia could be justified on the basis of a favorable benefit to cost ratio, we evaluated the projected impact of a program of pneumococcal vaccination on the population of a health maintenance organization. Retrospective data on average provider and patient costs associated with episodes of pneumococcal pneumonia were coupled with forecasts of the likely effectiveness of currently available vaccine and its impact on anticipated incidence of pneumonia. We found that when provider-centered and patient-centered costs and benefits were added, a program of immunizing those traditionally considered to be at high risk of contracting pneumococcal pneumonia (50 years of age and older; patients with chronic diseases of the heart, liver, lungs, or kidneys; and those with diabetes mellitus) was justified on a cost-benefit basis.

Adolescent↗
PubMed2003

Classical and latent class analysis evaluation of sputum polymerase chain reaction and urine antigen testing for diagnosis of pneumococcal pneumonia in adults.

Diagnosis of pneumococcal pneumonia is complicated by the lack of a diagnostic reference standard that is highly sensitive and specific. Latent class analysis (LCA) is a mathematical technique that relates an unobserved ("latent") infection to multiple diagnostic test results by use of a statistical model. We used classical analysis and LCA to evaluate the sensitivity and specificity of blood culture, sputum Gram stain, sputum polymerase chain reaction (PCR), and urine antigen testing for diagnosing pneumococcal pneumonia among 149 adults with community-acquired pneumonia. On the basis of LCA models, sensitivity of autolysin PCR and pneumolysin PCR was 82% and 89%, respectively, but specificity was low, 38% and 27%, respectively. For urine antigen testing, sensitivity was 77%-78%, and specificity was 67%-71%. Results of the LCA models were comparable with those obtained from classical analysis. LCA may be useful for diagnostic test evaluation and for determining the prevalence of pneumococcal infection in epidemiological studies of community-acquired pneumonia and in vaccine efficacy trials.

Adult↗
PubMed1975

Preservation of hypoxic pulmonary pressor response in canine pneumococcal pneumonia.

To determine the role of hypoxic pulmonary vasoconstriction in pneumococcal pneumonia, hemodynamic measurements were made in 16 dogs before, and within 36 hours after, intrapulmonary administration of type III pneumococcus. Ten dogs with one lobe or more of pneumonia increased their pulmonary vascular resistances and slightly decreased their arterial O2 tensions. Hypoxia increased and hyperoxia decreased their pulmonary vascular resistances. During O2 breathing, arterial PO2 was less during than before the pneumonia and increased when pulmonary perfusion was diverted away from the diseased lung. In 2 dogs breathing air, forcing the cardiac output through the diseased lung caused an increase in vascular resistance that could clearly be reduced by O2 breathing. In 5 dogs, lung mast cell counts showed no decrease in the lobes with pneumonia. In pneumococcal pneumonia, the hypoxic pulmonary pressor mechanism serves to decrease blood flow to the diseased lobes and, thus, to maintain the arterial PO2. Lung mast cells could participate in this response.

Animals↗
PubMed1993

Antigen detection in oropharyngeal secretions for rapid diagnosis of pneumococcal pneumonia.

To determine the value of detection of antigen in the oropharynx in the diagnosis of pneumococcal pneumonia, oropharyngeal secretions were cultured for the presence of Streptococcus pneumoniae and tested for the presence of pneumococcal antigen. Sputum (if available) collected on the same day was also investigated for the presence of antigen. Detection of pneumococcal antigen was found to be directly related to the severity of pneumococcal carriership or infection (p < 0.0001) and was not related to culture results. Patients with pneumococcal pneumonia had the highest antigen detection rate (38%), followed by patients with pneumonia of unknown etiology (32%) and patients with an acute lower respiratory tract infection due to Streptococcus pneumoniae (20%). Pneumococcal carriers had a detection rate of only 9%. Antigen could be detected in only one patient of the control groups. Although antigen detection in sputum was superior to that in oropharyngeal secretions, concordant results were obtained in 8 (40%) and 6 (36%) patients with pneumococcal pneumonia and pneumonia of unknown etiology respectively. The results strongly suggest that pneumococcal carriage seldom leads to a detectable level of antigen, and that antigen detection in the oropharynx appears to be of additive value in the diagnosis of pneumococcal pneumonia.

Antigens, Bacterial↗
PubMed1982

Pneumococcal pneumonia: experience in a community hospital.

Cases of patients admitted to hospital with community-acquired pneumonia over a three-year period were reviewed to determine whether pneumococcal pneumonia and pneumococcal bacteremia occurred as frequently as reported in urban and university-based studies. Pneumococcus was isolated in only 25 of 202 patients (12 percent) in whom adequate attempts at culture were made, only one patient had documented pneumococcal bacteremia and no patients died of pneumococcal pneumonia proved by culture. Prospective studies in community hospitals should be considered to define more clearly the epidemiology of pneumococcal pneumonia in the nonurban United States population. These studies would also contribute to a rational policy for use of pneumococcal vaccine in this country.

Adolescent↗
PubMed1984

Comparative radiographic features of community acquired Legionnaires' disease, pneumococcal pneumonia, mycoplasma pneumonia, and psittacosis.

The features of the chest radiographs of 49 adults with legionnaires' disease were compared with those of 91 adults with pneumococcal pneumonia (31 of whom had bacteraemia or antigenaemia), 46 with mycoplasma pneumonia, and 10 with psittacosis pneumonia. No distinctive pattern was seen for any group. Homogeneous shadowing was more frequent in legionnaires' disease (40/49 cases) (p less than 0.005), bacteraemic pneumococcal pneumonia (25/31) (p less than 0.01) and non-bacteraemic pneumococcal pneumonia (42/60) (p less than 0.05) than in mycoplasma pneumonia (23/46). Multilobe disease at presentation was commoner in bacteraemic pneumococcal pneumonia (20/31) than in non-bacteraemic pneumococcal pneumonia (15/60) (p less than 0.001) or legionnaires' disease (19/49) (p less than 0.025). In bacteraemic pneumococcal pneumonia multilobe disease at presentation was associated with increased mortality. Pleural effusions and some degree of lung collapse were seen in all groups, although effusions were commoner in bacteraemic pneumococcal pneumonia. Cavitation was unusual. Lymphadenopathy occurred only in mycoplasma pneumonia (10/46). Radiographic deterioration was particularly a feature of legionnaires' disease (30/46) and bacteraemic pneumococcal pneumonia (14/27), and these groups also showed slow radiographic resolution in survivors. Radiographic resolution was fastest with mycoplasma pneumonia; psittacosis and non-bacteraemic pneumococcal pneumonia cleared at an intermediate rate. Residual intrapulmonary streaky opacities remained in over a quarter of survivors from legionnaires' disease (12/42) and bacteraemic pneumococcal pneumonia (5/19).

Adolescent↗
PubMed1980

[Pneumococcal pneumonia: epidemiology, therapy, immunoprophylaxis].

Despite modern antibiotic therapies, pneumococcal pneumonia still remains a serious epidemiologic problem. Some 25% of pneumococcal pneumonias are accompanied by bacteremia. The mortality rate in these forms is some 17%, and in patients above 50 it is as high as 28%. Early toxic injury is responsible for the high mortality rate, which is as high as 13,000-60,000 deaths every year in the USA. Several resistant strains of pneumococci have recently been discovered, and for all these reasons research into active immunization against pneumococci has been resumed. A vaccine is now available which consists of polysaccharide antigens of the 14 most important serotypes and confers a protection rate of some 80% against pneumococcal pneumonia. Vaccination is recommended for elderly and debilitated persons in particular.

Antibodies, Bacterial↗
PubMedDate not supplied

Occult pneumococcal septicemia and pneumococcal pneumonia complicating pneumatoceles in a previously healthy child.

Fulminating pneumococcal septicemia without an obvious focus of infection is very rare in previously immunocompetent children older than two years. Furthermore, pneumatocele formation in pneumococcal pneumonia is uncommon. The majority of pneumatoceles are self-limited and disappear spontaneously. Here, we report a six-year-old healthy child with occult pneumococcal septicemia and pneumococcal pneumonia secondary to septicemia. Giant pneumatoceles causing respiratory insufficiency formed secondary to the pneumococcal pneumonia and were aspirated via needle under fluoroscopic guidance.

Child↗
PubMed2000

Clinical presentation, processes and outcomes of care for patients with pneumococcal pneumonia.

OBJECTIVE: To describe the presentation, resolution of symptoms, processes of care, and outcomes of pneumococcal pneumonia, and to compare features of the bacteremic and nonbacteremic forms of this illness. DESIGN: A prospective cohort study. SETTING: Five medical institutions in 3 geographic locations. PARTICIPANTS: Inpatients and outpatients with community-acquired pneumonia (CAP). MEASUREMENTS: Sociodemographic characteristics, respiratory and nonrespiratory symptoms, and physical examination findings were obtained from interviews or chart review. Severity of illness was assessed using a validated prediction rule for short-term mortality in CAP. Pneumococcal pneumonia was categorized as bacteremic; nonbacteremic, pure etiology; or nonbacteremic, mixed etiology. MAIN RESULTS: One hundred fifty-eight (6.9%) of 2,287 patients (944 outpatients, 1,343 inpatients) with CAP had pneumococcal pneumonia. Sixty-five (41%) of the 158 with pneumococcal pneumonia were bacteremic; 74 (47%) were nonbacteremic with S. pneumoniae as sole pathogen; and 19 (12%) were nonbacteremic with S. pneumoniae as one of multiple pathogens. The pneumococcal bacteremia rate for outpatients was 2.6% and for inpatients it was 6.6%. Cough, dyspnea, and pleuritic pain were common respiratory symptoms. Hemoptysis occurred in 16% to 22% of the patients. A large number of nonrespiratory symptoms were noted. Bacteremic patients were less likely than nonbacteremic patients to have sputum production and myalgias (60% vs 82% and 33% vs 57%, respectively; P <.01 for both), more likely to have elevated blood urea nitrogen and serum creatinine levels, and more likely to receive penicillin therapy. Half of bacteremic patients were in the low risk category for short-term mortality (groups I to III), similar to the nonbacteremic patients. None of the 32 bacteremic patients in risk groups I to III died, while 7 of 23 (30%) in risk group V died. Intensive care unit admissions and pneumonia-related mortality were similar between bacteremic and nonbacteremic groups, although 46% of the bacteremic group had respiratory failure compared with 32% and 37% for the other groups. The nonbacteremic pure etiology patients returned to household activities faster than bacteremic patients. Symptoms frequently persisted at 30 days: cough (50%); dyspnea (53%); sputum production (48%); pleuritic pain (13%); and fatigue (63%). CONCLUSIONS: There were few differences in the presentation of bacteremic and nonbacteremic pneumococcal pneumonia. About half of bacteremic pneumococcal pneumonia patients were at low risk for mortality. Symptom resolution frequently was slow.

Aged↗