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PubMed1999

Pneumococcal Pneumonia.

Pneumococcal pneumonia accounts for about one-sixth to two-thirds of all cases of community-acquired pneumonia. Its high frequency of occurrence worldwide and the high number of deaths associated with it--especially with bacteremic (invasive) disease--mark its importance. Invasive disease is associated with case-fatality rates of 15% to 25% among elderly adults. Penicillin-resistant Streptococcus pneumoniae (PRSP) first appeared in the 1970s, and its increased incidence in the late 1980s signaled its emerging importance. In individual patients in whom PRSP infection is suspected, the clinician must follow guidelines for empiric antibiotic therapy for community-acquired pneumonia until microbiological test results are known. When a diagnosis of pneumococcal pneumonia is established, the clinician should change to a regimen that targets the pneumococcus. Adults at highest risk for death from pneumococcal pneumonia include immunocompetent persons with underlying chronic diseases, immunocompromised persons, elderly persons, and unvaccinated residents of nursing homes and other chronic care facilities. Safe and effective, polyvalent polysaccharide pneumococcal vaccine should be used in persons 2 years of age and older who are at increased risk for serious pneumococcal pneumonia and in all persons 65 years of age and older.

Journal Article↗
PubMed2001

Microbiological and inflammatory factors associated with the development of pneumococcal pneumonia.

Pneumococcal pneumonia still is associated with a high mortality rate, despite appropriate antimicrobial therapy. Many gaps remain in the understanding of the pathogenesis of this deadly infection. The microbial and inflammatory events that characterize survival or death after intranasal inoculation of mice with an LD(50) inoculum of Streptococcus pneumoniae were investigated. Survival was associated with rapid bacterial clearance and low inflammation (surfactant and red blood cells in alveoli), but no neutrophil recruitment or lung tissue injury was noted. By contrast, death was preceded by strong bacterial growth that peaked 48 h after the infection and was associated with gradual increases in pulmonary levels of interleukin-6, macrophage inflammatory protein (MIP)-1alpha, MIP-2, monocyte chemoattractant protein-1, KC, and neutrophil recruitment. The injection of tumor necrosis factor-alpha or the addition of lipopolysaccharide or heat-killed S. pneumoniae to the inoculum enhanced early host response and survival. These observations may help develop appropriate markers of evolution of pneumonia, as well as new therapeutic strategies.

Animals↗
PubMedDate not supplied

Pathogenesis of pneumococcal pneumonia.

Pneumococcal pneumonia poses a serious threat to children in developing countries and remains an important disease in the industrialized world. Capsular polysaccharide is the only bacterial factor proven to contribute to pathogenesis. However, the mechanisms responsible for the hypoxemia, toxemia, crisis, and death associated with this common infection are poorly understood. Toxins secreted by the bacteria, byproducts of bacterial breakdown (e.g., pneumolysin or teichoic acid), or constituents of the intense inflammatory response in the lung might play a role in these phenomena. Malnourished children presumably carry less metabolic reserve with which they can resist the exceptional stresses of pneumococcal disease, and underlying parasitic infestation or other chronic infections, through release of potent mediators such as tumor necrosis factor or platelet-activating factor, might prime the mechanisms of host defense for a more fulminant and systemic response to infection. Vaccines that can protect infants are badly needed, and a better understanding must be gained of the mechanisms by which this pathogen continues to cause such devastating disease in the world's children and elderly.

Child↗
PubMed1988

Diagnosis of pneumococcal pneumonia.

Pneumococcal pneumonia presents peculiar problems to the diagnostician. It is at once the most common form of community-acquired bacterial pneumonia and simultaneously the most difficult to document microbiologically. Bacteremia, empyema, meningitis, or septic arthritis due to S pneumoniae unmistakably verifies this bacterium as the cause of a coexistent pneumonia; this coexistence fortunately occurs infrequently. The diagnostic dilemma arises in the less sick patient. While recognizing the common presence of pneumococci in the oropharynx of healthy individuals, we give undue credence to S pneumoniae cultured from sputum obtained by expectoration. At the same time, pneumococci are frequently not found in cultures of sputum obtained from patients with confirmed bacteremic disease. More invasive techniques (transtracheal aspiration, protected bronchoscopic catheter, lung needle aspiration) are too complex, dangerous, or both for routine use. Attempts to detect pneumococcal antigen in blood, sputum, or urine by modern immunologic techniques give promise of avoiding the problems of either contamination or lack of bacteriologic growth. However, they have not yet been evaluated in sufficiently large groups with pneumonia of independently determined bacterial etiology to calculate test sensitivity and specificity. At the present time then, the careful clinician will use all the epidemiologic and clinical evidence at hand, including a careful Gram's stain and culturing of sputum, blood, and other sources, to arrive at the most likely etiology. The probabilities must be weighed in light of the imprecision of current laboratory confirmation and modified by clinical course. Choice of antimicrobial therapy still favor penicillin for patients with community pneumonia severe enough to warrant hospitalization, despite ominous trends in multiple resistance of S pneumoniae.

Anti-Bacterial Agents↗
PubMed1999

Pathogenesis of pneumococcal pneumonia.

Pneumococcal pneumonia is the most severe of the common community-acquired pulmonary infections. The recent release of the complete DNA sequence reveals the entire capability of the bacteria and the current challenge is to map gene products to the mechanics of disease. This process will reveal antibiotic targets and protein vaccine candidates crossing serotype boundaries. Choline is a major constituent of surfactant and it is also a required nutrient for the pneumococcus. It appears that choline incorporated into the cell wall can bind the bacteria to the receptor for platelet activating factor, the gateway to invasion. The choline also serves as an antenna to which multifunctional proteins dock, thereby decorating the bacterial surface. This set of 12 choline binding proteins is subject to phase variation of expression resulting in display of different combinations of proteins that adapt the bacteria to survival on the mucosa versus the blood stream. These changes affect protective antigens, adhesions, and lytic proteins tying together the major elements of pneumococcal physiology: natural DNA transformation, adherence and invasion of host cells, and autolysis. Taking these components and building an understanding of disease is challenging. Clearly, the toxin pneumolysin is a major mediator of cell damage in the lung. Inflammation is also incited by cell wall components. The signal transduction pathways that explain pneumococcal inflammation are more complex than those for gram-negative endotoxin.

Animals↗
PubMed2006

Māori have a much higher incidence of community-acquired pneumonia and pneumococcal pneumonia than non-Māori: findings from two New Zealand hospitals.

To determine the incidence rates of community-acquired pneumonia and pneumococcal pneumonia requiring hospitalisation among Maori and non-Maori, an observational study was conducted in Christchurch and Hamilton. Self-reported data were collected using an interviewer-administered questionnaire. Routine clinical, radiological, and microbiological techniques were used apart from the BinaxNow pneumococcal antigen test for diagnosis of this infection. Census data was used to determine the denominator for statistical analyses. The pneumonia rate overall was 3.03 times higher among Maori than non-Maori (p<0.001). Differences were significant for each 10-year age group from age 45-74 years (p<0.05). The rate of pneumococcal pneumonia was 3.23 fold higher for Maori than non-Maori (p<0.001), but it did not reach statistical significance in the age-related comparisons. These ethnic disparities are of major concern, and policy planners should consider further interventions to improve the efficacy of current anti-smoking campaigns and to undertake studies of conjugate pneumococcal vaccines for Maori.

Adolescent↗
PubMed1979

Pneumonia and pneumococcal infections, with special reference to pneumococcal pneumonia. The 1979 J. Burns Amberson lecture.

An etiologic classification of acute pneumonia was presented and the relative importance of some of the causative agents was briefly reviewed. The early developments of the therapy of pneumococcal pneumonia with type-specific antisera, sulfonamide drugs, and antimicrobial drugs were reviewed, mostly from the experiences of the author at Boston City Hospital. Changes in the occurrence and relative importance of the pneumococcus as a cause of infections associated with bacteremia, empyema, and meningitis were demonstrated, based on cases observed at Boston City Hospital during 12 selected years between 1935 and 1972. These findings, among others, indicate that the pneumococcus is still one of the most important causes of serious bacterial infections and of mortality from such infections, particularly in the elderly. Some possible indications for polyvalent pneumococcal capsular polysaccharide vaccine were discussed, and the need for further extensive clinical and field trials to demonstrate its range of effectiveness was stressed.

Age Factors↗
PubMed1989

[Serious infections in alcoholics. 1. Bacteremia, lobar pneumococcal pneumonia and pneumococcal meningitis in alcoholics 1974-1987].

During the period 1974-1987, the frequency of infections in alcoholics discharged from hospitals in Funen showed an increase of 5.53 +/- 3.38 (p = 0.0039) per 10,000 alcoholics discharged per year. The frequency of discharged alcoholics increased by 3.72 +/- 0.60 per 10,000 discharged patients per year. Infections were diagnosed in 0.48 per cent of the discharged alcoholics and in 0.18 per cent of the discharged non-alcoholics (p less than 0.00001). Pneumococcal infections were relatively more frequent in alcoholics (p less than 0.05).

Alcoholism↗
PubMedDate not supplied

IL-1beta and IL-6 in community-acquired pneumonia: bacteremic pneumococcal pneumonia versus Mycoplasma pneumoniae pneumonia.

Interleukin-1beta (IL-1beta) and interleukin-6 (IL-6) levels in 20 patients with bacteremic Streptococcus pneumoniae community-acquired pneumonia (CAP) were compared with these cytokine levels in 20 patients with Mycoplasma pneumoniae CAP. All 40 patients survived hospitalization and underwent a follow-up examination one month later. Serum IL-1beta and IL-6 levels were determined by the enzyme immunoassay (EIA) method using commercial kits. In the acute phase of CAP, IL-6 levels were significantly higher in the S. pneumoniae group (p = 0.014), while IL-1beta levels were higher in the M. pneumoniae group (p = 0.046). In the convalescence phase, the two cytokines were detected in a considerable number of patients in both groups. In this phase, only the level of IL-1beta was significantly higher in the M. pneumoniae group than in the S. pneumoniae group (p = 0.03). We conclude that the levels of IL-1beta and IL-6 are different between patients with S. pneumoniae-CAP and M. pneumoniae-CAP during the acute phase. In the convalescence phase, cytokine levels remain high in some of the CAP patients, but a significant difference between the groups exists only for IL-1beta. Further studies are required.

Adult↗
PubMed2005

Intrathoracic lymphadenopathy in hospitalized patients with pneumococcal pneumonia.

PURPOSES: Pneumococcal pneumonia is the most common etiology for community-acquired pneumonia. The prevalence of lymphadenopathy seen on CT scans in these patients is uncertain. The purpose of this series was to assess the prevalence of intrathoracic lymphadenopathy in hospitalized patients with pneumococcal pneumonia. MATERIALS AND METHODS: We retrospectively identified 35 hospitalized patients with pneumococcal pneumonia who had been evaluated with CT scanning between January 1998 and April 2002. There were 18 men and 17 women with a mean age of 56 years. The study inclusion criteria were as follows: blood culture positive for Streptococcus pneumoniae, clinical diagnosis of pneumonia, and chest CT scan. The study exclusion criteria were known causes of lymphadenopathy. Charts were reviewed for HIV status, smoking history, and comorbidities. CT scans were reviewed for the presence and degree of lymphadenopathy, and the characteristics of pneumonia. The number of enlarged lymph nodes was graded as few (one to two), moderate (three to five), or many (six or more). Pneumonias were described by location, the number of involved lobes, the presence of cavitation, and the presence of pleural effusion. Patients with different comorbidities and different imaging characteristics of pneumonia were compared. RESULTS: Among the 35 patients with pneumococcal pneumonia, intrathoracic lymphadenopathy was present on CT scans in 54% of patients (19 of 35 patients). The lymphadenopathy was ipsilateral to the pneumonia in 100% of patients (19 of 19 patients). One patient also had contralateral lymphadenopathy. The lymphadenopathy was graded as few in 37% of patients (7 of 19 patients), moderate in 37% of patients (7 of 19 patients), and many in 26% of patients (5 of 19 patients). The pneumonia was right-sided in 26% of patients (9 of 35 patients), left-sided in 17% of patients (6 of 35 patients), and bilateral in 57% of patients (20 of 35 patients). Comorbidities included the following: HIV infection (n = 15); smoking (n = 21); emphysema (n = 5); hepatitis C (n = 5); and diabetes (n = 3). The characteristics of pneumonia included the following: multilobar (n = 25); pleural effusion (n = 25); and cavitation (n = 5). The prevalence of lymphadenopathy according to comorbidities and characteristics of pneumonia ranged from 40 to 100%. None of the differences in prevalence of lymphadenopathy among the subgroups was statistically significant. CONCLUSION: Lymphadenopathy is a common CT scan feature of pneumococcal pneumonia in hospitalized patients, in a variety of settings. Therefore, when a patient with pneumococcal pneumonia has lymphadenopathy seen on a CT scan, other etiologies for the lymphadenopathy need not be suspected.

Adult↗
PubMed2006

Validation of urinary antigen test for Streptococcus pneumoniae in patients with pneumococcal pneumonia.

The study was undertaken to prospectively evaluate a Streptococcus pneumoniae urinary antigen test for diagnosis of pneumococcal pneumonia among patient and control groups between 2004 and 2006. Microbiological analysis for these patients included Gram staining for sputum, sputum and blood culture. Nonconcentrated urine samples were tested using an immunochromatographic assay, the NOW S.pneumoniae antigen test. The urinary antigen test was positive in 9 (15.3%) of 59 patients enrolled in the study and in 8 (73%) of 11 patients with pneumococcal pneumonia confirmed by conventional methods. The test revealed a sensitivity of 72.7% and a specificity of 97.6% with conventional microbiological criteria used as the reference standard. The positive predictive value was 88.9% and the negative predictive value was 93%. We concluded that the urinary antigen test can supplement conventional microbiological tests in the diagnosis of pneumococcal pneumonia.

Adolescent↗
PubMed2003

[Analysis of period of positive urinary antigen detection kit for Streptococcus pneumoniae in patients with pneumococcal pneumonia].

The objectives of this study were to investigate the usefulness of the urinary antigen detection kit for Streptococcus pneumoniae and to analyze the duration of urinary antigen presence in pneumococcal pneumonia. We evaluated this kit in 51 patients whose symptoms and laboratory data suggested pneumococcal pneumonia and who were admitted to Toho University Hospital (Tokyo, Japan) between July 2000 and June 2001. S. pneumoniae urinary antigen was detected in 21 of 51 patients. These 21 patients were further investigated with their clinical characteristics and the duration of a positive urinary antigen reaction. S. pneumoniae was isolated by sputum or blood culture in 10 cases (47.6%), whereas 11 cases (52.4%) showed positive results only with urinary antigen but not in cultures. When the urinary antigen kits were tested, 19 cases (90.5%) were treated with antibiotics. Eleven of the 21 patients were continuously tested with this kit. The mean duration for which these patients were urinary antigen-positive was 7.3 weeks. Patients whose pneumonia was severe or who had positive culture results tended to be positive for urinary antigen for a prolonged period. This kit has high sensitivity and specificity, is suitable for rapid diagnosis and is effective after antibiotic therapy. However, because the positive test kit results are prolonged after recovery from pneumonia in some cases, this kit is not suitable for the evaluation of therapeutic effect.

Adult↗
PubMed2005

Impact of pediatric vaccination with pneumococcal conjugate vaccine on the risk of bacteremic pneumococcal pneumonia in adults.

Invasive pneumococcal disease in adults may be declining, reflecting a form of herd protection from a new pediatric pneumococcal conjugate vaccine. Our aim was to determine whether vaccination of children protects adults in the same home from bacteremic pneumococcal pneumonia. We conducted a case-control study with 43 participating hospitals across a five-county region in Pennsylvania. Eligible cases were adults with bacteremic pneumococcal pneumonia identified by the microbiology laboratories at participating hospitals. Controls were healthy adults from the region identified through random digit dialing. Cases and controls were interviewed by telephone. We analyzed vaccine protection in those adults who reported living in homes with at least one child < or =6 years of age. From April 2002 through June 2004, there was a significant decline in the proportion of adult pneumococcal bacteremia due to any of the seven serotypes in the conjugate vaccine (p=0.006). Within this time period, 17% of cases and controls reported living in homes with at least one child < or =6 years of age. In adjusted analysis, vaccination of the youngest child in the home was associated with an 80% reduction in the odds of bacteremic pneumococcal pneumonia among adults with children in the home (OR=0.2, 95% CI 0.1-0.8). We conclude that introduction of a pneumococcal conjugate vaccine for children has reduced the population rate of adult pneumococcal bacteremia due to vaccine serotypes and is associated with a reduced risk of bacteremic pneumococcal pneumonia for adults with children in the home.

Adult↗
PubMed1984

Bacteremic pneumococcal pneumonia in the elderly.

Pneumococcal pneumonia is an increasingly important disorder of the elderly. We reviewed, retrospectively, the clinical and laboratory manifestations of 29 elderly patients with bacteremic pneumococcal pneumonia during a five year period and surveyed the capsular serotypes of all blood isolates. Pneumococcal pneumonia frequently presented with subtle manifestations in these elderly patients: 50% lacked historical features suggestive of pneumonia at the time of diagnosis. A common presentation was fever, altered mental status and dehydration. Recognizing this will allow earlier diagnosis and initiation of therapy. Sixty percent of patients had potential pulmonary pathogens other than pneumococcus in cultures of sputum at the time of pneumococcal bacteremia. Reversible abnormalities of liver function were frequent. Sixty-nine percent of pneumonias were caused by serotypes included in the commercially available vaccine. Continued surveillance of pneumococcal serotypes is important to determine if the widespread use of the vaccine will result in an increased incidence of infection by serotypes which are not in the vaccine. The high mortality associated with pneumococcal pneumonia (31% in this series), particularly in the elderly, emphasizes the need for an effective vaccine.

Aged↗
PubMed2001

Clinical profile of serologically diagnosed pneumococcal pneumonia.

OBJECTIVE: To describe the characteristics of serologically diagnosed pneumococcal pneumonia and compare them with those of respiratory syncytial virus (RSV) pneumonia and bacteremic pneumococcal pneumonia. METHODS: IgG antibodies to pneumococcal pneumolysin and C-polysaccharide as well as immune complexes containing IgG antibodies to pneumolysin and C-polysaccharide were measured from acute and convalescent sera of 254 children with community-acquired pneumonia. Evidence of pneumococcal infection was found in 93 children. Clinical and laboratory data were retrospectively collected from the records of 38 children with sole (all tests for 16 other microbes negative) pneumococcal pneumonia and compared with 26 sole RSV-induced pneumonia from the present series and with the data of our 85 bacteremic pneumococcal pneumonia cases reported earlier. RESULTS: Serologically diagnosed sole pneumococcal pneumonia clinically overlapped with RSV pneumonia, but RSV pneumonia was more often associated with tachypnea (45% vs. 17%, P < 0.05) and low white blood cell counts (means, 12.0 x 109/l vs. 20.8 x 109/l; P < 0.001) as well as low serum C-reactive protein levels (means, 28 mg/l vs. 137 mg/l; P < 0.001). Alveolar infiltrates were found in 15% of chest radiographs of children with RSV pneumonia compared with 76% of those in children with sole pneumococcal pneumonia (P < 0.001). Patients with bacteremic pneumonia more often appeared ill (79% vs. 50%, P < 0.001) and more often had typical pneumococcal pneumonia with high fever, leukocytosis and lobar infiltrates in their chest radiographs (70% vs. 34%, P < 0.05) than those with serologically diagnosed pneumococcal pneumonia. CONCLUSIONS: Serologically detected pneumococcal pneumonia differs significantly from RSV pneumonia in laboratory and chest radiography findings, but the clinical signs and symptoms overlap considerably. Bacteremic pneumococcal pneumonia is a more severe illness than the serologically diagnosed one.

Adolescent↗
PubMed1977

Cellulitis in complicated pneumococcal pneumonia.

Serious complications of pneumococcal pneumonia have become uncommon. This has been attributed to decline in pneumococcal infection (van Roy et al. 1971; Foy et al. 1975), but in this country it is more likely to be due to effective antibiotic therapy. We report a case of pneumococcal pneumonia with severe complications (including a very unusual one) which probably arose through antibiotic failure.

Aged↗
PubMed1982

Plasma volume expansion in canine pneumococcal pneumonia: its effects on respiratory gas exchange and pneumonia size.

Patients with pneumococcal pneumonia are often given fluids intravenously for hydration and maintenance of circulating blood volume. We studied the effects of plasma volume expansion on respiratory gas exchange and pneumonia size in a canine model of lobar pneumonia. Seven ventilated anesthetized dogs (Group T) with left lower lobe pneumococcal pneumonia were infused with dextran 75 in 0.9% saline solution to increase the pulmonary capillary wedge pressure to 10 mmHg for 3 h. These were compared with 7 control dogs (Group C) with left lower lobe pneumonia. Measurements of cardiac output, intrapulmonary shunt (QS/QT), and lobar distribution of perfusion were taken at baseline (B), immediately after volume infusion (V), and 3 h later (F); similar intervals were used in control animals. In Group T, QS/QT increased significantly from 24% at B to 34% at F. Part of this increase in QS/QT occurred immediately after volume infusion (29% at V) and was associated with the concomitant increase in cardiac output (4.7 L/min at B to 10.6 L/min at F). In Group C, there were no changes in cardiac output or QS/QT. At autopsy, mean wet weight for both lower lobes in Group T were greater than in Group C. Accordingly, small elevations in pulmonary capillary wedge pressure associated with fluid administration caused large increases in lobar wet weights. At least in part, these increases represented transudation of plasma and crystalloid into alveolar spaces and suggested large increases in extravascular lung liquid flux from inflamed vessels in infected lung.

Animals↗