Pneumococcal Pneumonia in Children

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Pneumococcal pneumonia in children

Authors: Elaine I Tuomanen, MD, Sheldon L Kaplan, MD, Liset C Olarte, MD, MSc
Section Editor: Morven S Edwards, MD
Deputy Editor: Mary M Torchia, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2023. | This topic last updated: Feb 28, 2023.
INTRODUCTION
Pneumococcus (Streptococcus pneumoniae) is a common cause of invasive bacterial infection

in children and a frequent cause of community-acquired pneumonia (CAP) [1,2].
Intermediate or high-level resistance to penicillin is a significant problem worldwide.
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 CAP in children and the
microbiology, pathogenesis, and epidemiology of S. pneumoniae are discussed separately.
(See "Community-acquired pneumonia in children: Clinical features and diagnosis" and
"Streptococcus pneumoniae: Microbiology and pathogenesis of infection".)
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
(PCV) [7-10]. Higher pneumococcal carriage rates (up to 90 percent) have been described in
resource-limited countries with low vaccination coverage [11]. Pneumococcal acquisition is
also common in adults, particularly those who live with children. In a small study,
approximately 20 percent of adults were intermittent carriers and 10 percent were carriers
for >4 months (median duration seven weeks) [12]. (See "Streptococcus pneumoniae:
Microbiology and pathogenesis of infection", section on 'Pathogenesis'.)
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Antibiotic-resistant strains remain a concern but penicillin resistance has declined since the
introduction of PCVs [11,13-15]. (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, lincosamides, and ketolides".)
Invasive disease most commonly occurs upon acquisition of a new serotype, typically after
an incubation period of one to three days.
Pneumococci are presumably aerosolized from the nasopharynx to the alveolus, where they
interact with alveolar type II cells and activate innate and cellular host defenses. Given the
strong association of pneumococcal disease with viral illness [16-21], it is believed that viral
activation of respiratory epithelial cells may increase expression of receptors for
pneumococcal attachment and decrease the capacity of the pulmonary immune response to
clear bacteria [22].
The pneumonic lesion progresses as pneumococci multiply in the alveolus and invade the
alveolar epithelium. Pneumococci pass from alveolus to alveolus creating inflammation and
consolidation strictly along lobar compartments. The center of the spreading lesion shows
more advanced inflammation than do the edges. Lung consolidation evolves over two to
three days and remains prominent after fever resolves [23-25].
EPIDEMIOLOGY
Burden of disease — Pneumonia is a common cause of death in children worldwide [26].

Community-acquired pneumonia (CAP) can be caused by a variety of bacterial and viral
pathogens, and the predominant pathogen varies with age. S. pneumoniae is the most
common typical bacterial cause of CAP, although in many cases an organism cannot be
isolated. (See "Pneumonia in children: Epidemiology, pathogenesis, and etiology", section on
'Community-acquired pneumonia'.)
In the United States, the incidence of pneumococcal pneumonia in children declined after
the 7-valent pneumococcal conjugate vaccine (PCV7) was replaced with the 13-valent
pneumococcal conjugate vaccine (PCV13) in 2010 [27-29]. A 2023 systematic review including
studies from most World Health Organization regions reported a median decline of 69
percent in hospitalization rates due to bacteremic pneumococcal pneumonia in children <5
years of age after introduction of PCV13 or the 10-valent pneumococcal conjugate vaccine
(PCV10) [30]. However, vaccine-induced protection from pneumonia remains modest at best,
in contrast to potent efficacy against bacteremia. (See "Pneumococcal vaccination in
children", section on 'Pneumonia and empyema'.)

Serotypes — The pneumococcal serotypes isolated from children with pneumococcal

pneumonia have changed with the introduction of PCVs ( table 1) to the routine childhood
immunization schedule in the United States. Following introduction of PCV7 in 2000,
serotypes not included in PCV7, including serotypes 1, 3, 5, 7F, 12, and 19A, were more
frequently isolated, particularly from children with complicated pneumonia [31-36]. PCV13,
which contains all of these serotypes except 12, replaced PCV7 in 2010. However, between
2014 and 2017, 50 of 119 (42 percent) isolates from children hospitalized with culture-proven
pneumococcal pneumonia at the eight children's hospitals in the United States Pediatric
Multicenter Pneumococcal Surveillance Study Group were PCV13 serotypes; 19A and 3 were
most common [28,37]. Serotype 3 remains an important cause of complicated pneumonia in
children despite widespread use of PCV13 [38,39]. A 15-valent pneumococcal conjugate
vaccine (PCV15) that contains serotypes 22F and 33F in addition to those in PCV13 was
licensed for use in children in the United States in 2022 and can be used interchangeably
with PCV13. (See 'Complications' below and "Pneumococcal vaccination in children", section
on 'Conjugate vaccines'.)
Risk factors — Risk factors for invasive pneumococcal disease are listed in the table
( table 2).
Antibiotic resistance — Resistance of S. pneumoniae to multiple antibiotics was an

increasingly important clinical problem before the introduction of PCVs. Resistance
continues to develop in strains that emerge in nonvaccine serotypes. A discussion of
pneumococcal drug resistance is presented separately. (See "Resistance of Streptococcus
pneumoniae to beta-lactam antibiotics" and "Resistance of Streptococcus pneumoniae to the
macrolides, azalides, lincosamides, and ketolides" and "Resistance of Streptococcus
pneumoniae to the fluoroquinolones, doxycycline, and trimethoprim-sulfamethoxazole".)
CLINICAL FEATURES
Transmission and incubation period — S. pneumoniae is transmitted from person to

person through contact with respiratory droplets [2]. The period of communicability is not
known but is probably less than 24 hours after initiation of appropriate antimicrobial
therapy. The incubation period depends upon the type of infection but may be as short as
one day [2].
Clinical manifestations — Pneumococcal pneumonia is the paradigm of classic lobar

bacterial pneumonia [23]. The most common clinical signs and symptoms are fever,
nonproductive cough, tachypnea, and decreased breath sounds over the affected area.
Auscultatory findings of crepitant rales (crackles) and tubular breath sounds are highly
localized to the involved segment or lobe. These findings may disappear at the height of

consolidation and reappear on resolution (redux crepitus). (See "Community-acquired

pneumonia in children: Clinical features and diagnosis", section on 'Clues to etiology'.)
In a retrospective review of 254 children and young adults (age <1 month to 26 years) with
pneumococcal pneumonia (confirmed by blood or pleural fluid culture), the most common
signs and symptoms and their approximate frequencies are listed below [40]:
● Fever – 90 percent (mean duration three days before diagnosis)

● Cough – 70 percent; productive cough: 10 percent
● Tachypnea – 50 percent
● Malaise/lethargy – 45 percent
● Emesis – 43 percent
● Hypoxemia (oxygen saturation ≤95 percent) – 50 percent
● Decreased breath sounds – 55 percent
● Crackles – 40 percent
● Retractions – 30 percent
● Grunting – 25 percent
● Abdominal pain – 20 percent
● Chest pain – 10 percent
Radiographic features — Pneumococci can cause lobar or bronchopneumonia.
S. pneumoniae is the most common bacterial cause of sphere-shaped consolidation (ie,

"round pneumonia"). However, this finding is not pathognomonic because round pneumonia
can also be caused by other streptococci, Haemophilus influenzae, Staphylococcus aureus,
Mycoplasma pneumoniae, lung abscess, and noninfectious conditions. (See "Community-
acquired pneumonia in children: Clinical features and diagnosis", section on 'Etiologic clues'.)
Complications — In ambulatory children, pneumococcal pneumonia characteristically is

uncomplicated, with complete recovery of normal pulmonary architecture and function.
However, complications occur in approximately 40 to 70 percent of children hospitalized with
pneumococcal pneumonia [28,41,42].
In reviews of children hospitalized with confirmed pneumococcal pneumonia, the

frequencies of pulmonary complications (which were not mutually exclusive) were as follows
[28,41,42]:
● Pleural effusion – 36 to 83 percent

● Empyema – 49 to 52 percent
● Necrotizing pneumonia – 31 percent
● Lung abscess ( image 1) – 5 percent
● Pneumatocele – 19 percent

● Pneumothorax – 10 percent
In addition, cardiac events are common during acute pneumococcal pneumonia and
recovery from acute pneumococcal pneumonia [43,44]. These events are readily
recognizable in adults and may also occur in children. In a nonhuman primate model,
pneumococcal microlesions arose in the myocardium during pneumonia and led to
arrhythmias and acute coronary syndromes [45].
Pneumococcal pneumonia has also been associated with hemolytic uremic syndrome
[46,47]. In a review from the post-PCV era, 4 percent of children hospitalized with
pneumococcal pneumonia had hemolytic uremic syndrome [28]. (See "Overview of hemolytic
uremic syndrome in children", section on 'Streptococcus pneumoniae'.)
In the post-PCV era, complicated pneumonia was associated with longer duration of fever
before admission (5 versus 2 days), longer hospitalization (12 versus 5 days), and longer
duration of antibiotic therapy (21 versus 14 days) [28]. Comorbidity (eg, sickle cell disease)
was more common in children with uncomplicated than complicated pneumonia (52 versus
23 percent). The rate of viral co-infection was similar in children with complicated and
uncomplicated pneumonia (approximately 25 percent).
The clinical features, diagnosis, and management of parapneumonic effusions are discussed
separately. (See "Epidemiology, clinical presentation, and evaluation of parapneumonic
effusion and empyema in children" and "Management and prognosis of parapneumonic
effusion and empyema in children".)
The clinical features and diagnosis of the other complications are discussed separately. (See
"Community-acquired pneumonia in children: Clinical features and diagnosis", section on
'Complications'.)
DIAGNOSIS
Community-acquired pneumonia — The history, physical findings, and finding of an

infiltrate on chest radiograph usually establish the diagnosis of pneumonia. Although lobar
consolidation is suggestive of bacterial pneumonia, radiologists cannot reliably differentiate
bacterial from nonbacterial pneumonia on the basis of the radiographic appearance [48].
The approach to diagnosis of community-acquired pneumonia (CAP) in children is discussed
separately. (See "Community-acquired pneumonia in children: Clinical features and
diagnosis", section on 'Diagnosis'.)
Pneumococcal pneumonia — Confirmation of pneumococcal pneumonia is necessary to

provide targeted antimicrobial therapy. This is particularly important in children who are
admitted to the hospital. Etiologic testing is not usually recommended for children who will
be treated as outpatients. (See "Community-acquired pneumonia in children: Clinical

features and diagnosis", section on 'Etiologic diagnosis'.)
The following sections describe the utility of various microbiologic tests for identifying S.
pneumoniae as the etiology in children with a clinical diagnosis of pneumonia. However,
standard diagnostic testing (blood culture, sputum culture, and pneumococcal urinary
antigen test [for adults]) detects S. pneumoniae in <30 percent of cases of CAP [49].
● Blood cultures – Cultures of the blood are an important method for identifying the
etiology of pneumonia. In a cross-sectional study of previously healthy children
hospitalized with CAP (according to discharge diagnosis code), 2.5 percent of blood
cultures were positive; among the positive cultures, 78 percent grew S. pneumoniae
[50]. Higher rates of positive blood cultures are likely in children with radiographically
confirmed CAP or complicated pneumonia [51]. (See "Community-acquired pneumonia
in children: Clinical features and diagnosis", section on 'Approach to microbiologic
testing'.)
● Pleural fluid cultures – Pleural fluid cultures are an important method for identifying
the etiology of pneumonia. The indications for obtaining and testing pleural fluid are
discussed separately. (See "Epidemiology, clinical presentation, and evaluation of
parapneumonic effusion and empyema in children", section on 'Evaluation'.)
● Sputum Gram stain and culture – Sputum Gram stain and culture are of little value in
children because most children are unable to produce an adequate sputum specimen
and many have received antibiotics before presentation.
If the child is able to produce an adequate sputum sample, a Gram stain should be
performed and the specimen should be analyzed for the presence of
polymorphonuclear leukocytes (PMN), epithelial cells, and bacteria.
• A specimen that has more than 25 PMN and less than 10 epithelial cells per low
power field (x100) represents a purulent specimen. Individual microbiology
laboratories may use slightly different criteria. However, all define purulence based
upon an increased number of PMN and a low (or absent) number of epithelial cells.
• The finding of predominant gram-positive diplococci ( picture 1) may suggest S.

pneumoniae as the cause of pneumonia. However, in a prospective study, sputum
culture detected <10 percent of cases of pneumococcal CAP [52].
● Polymerase chain reaction – Polymerase chain reaction (PCR) tests for pneumococcus
in sputum and blood have been developed [53,54]. Improved sensitivity (57 percent)
and specificity (85 percent) of diagnosis has been achieved by targeting the autolysin
lytA gene for quantitative PCR [55]. This improvement suggests PCR as a diagnostic
method of choice in children. In a prospective study, PCR detected approximately 25

percent of cases of pneumococcal pneumonia, while sputum culture detected <10
percent [52].
Pleural fluid PCR can detect evidence of S. pneumoniae in patients with culture-negative
pleural fluid and is increasingly available, particularly in large children's hospitals [56].
In a prospective study of children with parapneumonic effusion and pleural empyema,
45 percent of pleural fluid samples were PCR positive for a respiratory pathogen; of
those, 90 percent were S. pneumoniae positive [57].
● Antigen detection – Although the urine antigen test for S. pneumoniae is sensitive in
adult patients (ranging from 59 to 87 percent) [49], it is not recommended for
diagnosing pneumococcal pneumonia in children because it may be positive in children
with asymptomatic colonization as well in children with pneumococcal disease [58-60].
On the other hand, given its high specificity (>90 percent) [49], a negative urine antigen
test is helpful in excluding S. pneumoniae.
In children with parapneumonic effusion or empyema who were treated with

antibiotics before pleural fluid was obtained, detection of pneumococcal antigen in
pleural fluid can confirm the diagnosis [61]. (See "Epidemiology, clinical presentation,
and evaluation of parapneumonic effusion and empyema in children", section on
'Microbial analysis'.)
TREATMENT
The treatment recommendations below are consistent with those in the clinical practice
guidelines of the American Academy of Pediatrics [2] and the Pediatric Infectious Diseases
Society and the Infectious Diseases Society of America [59].
Supportive care — Supportive care for children with pneumonia is discussed separately.
(See "Community-acquired pneumonia in children: Outpatient treatment", section on
'Supportive care' and "Pneumonia in children: Inpatient treatment", section on 'Supportive
care'.)
Empiric therapy — Most patients with community-acquired pneumonia (CAP) are treated
empirically. Whether or not to include agents with activity against S. pneumoniae depends
upon the age of the child, epidemiologic and clinical information, and laboratory and
imaging studies if such studies were obtained. Empiric therapy for S. pneumoniae is generally
included for children who require inpatient treatment for CAP and children who have clinical
findings compatible with bacterial pneumonia (eg, lobar or round consolidation on
radiograph, leukocytosis, elevated C-reactive protein, complications). Empiric therapy for

CAP is discussed separately. (See "Community-acquired pneumonia in children: Outpatient

treatment", section on 'Empiric therapy' and "Pneumonia in children: Inpatient treatment",
section on 'Empiric therapy'.)
Specific therapy
Positive culture — When there is a positive culture for S. pneumoniae, the antibiotic
susceptibility pattern ( table 3) should guide therapy. Parenteral and oral regimens for
antipneumococcal agents are provided in the table ( table 4).
● Penicillin-susceptible strains – Penicillin or ampicillin is the drug of choice for

parenteral treatment of pneumococcal pneumonia caused by isolates with penicillin
MICs ≤2 mcg/mL ( table 3 and table 4) [59,62-67]. Penicillin and ampicillin are less
expensive and have a narrower spectrum of activity than alternative agents for
penicillin-susceptible strains. Alternative parenteral therapies (if the isolate is
susceptible) include ceftriaxone (or cefotaxime if available), clindamycin, vancomycin,
and levofloxacin. Clindamycin is an alternative for patients with severe hypersensitivity
to beta-lactam antibiotics. Ceftriaxone is preferred for outpatient parenteral therapy.
Vancomycin may be warranted for children with severe hypersensitivity to beta-lactam
antibiotics, an isolate resistant to clindamycin, or life-threatening infection.
Oral amoxicillin is the drug of choice for oral treatment of pneumococcal pneumonia
caused by isolates with penicillin MICs ≤2 mcg/mL. It is less expensive and has a
narrower spectrum of activity than alternative agents. Alternative oral therapies (if the
isolate is susceptible) include cefpodoxime, cefprozil, cefuroxime, and levofloxacin
( table 4). Cefpodoxime, cefprozil, and cefuroxime are the only oral cephalosporins
recommended for the treatment of pneumococcal pneumonia. Clindamycin or
levofloxacin are alternatives for patients with severe hypersensitivity to beta-lactam
antibiotics if the isolate is susceptible ( table 3).
● Penicillin-intermediate and resistant strains – Ceftriaxone or cefotaxime are

preferred for parenteral treatment for pneumococcal pneumonia caused by isolates
with penicillin MICs ≥4 mcg/mL ( table 3 and table 4). Nonsusceptibility to
ceftriaxone or cefotaxime appears to be decreasing with the decreasing frequency of
serotype 19A (which is included in the 13-valent (PCV13) and 15-valent pneumococcal
conjugate vaccines, licensed in 2010 and 2022, respectively) [68,69]. Ceftaroline,
vancomycin, levofloxacin, linezolid, and clindamycin are alternatives to ceftriaxone or
cefotaxime.
Oral levofloxacin or linezolid are the drugs of choice for oral treatment of
pneumococcal pneumonia caused by isolates with penicillin MICs ≥4 mcg/mL.
Clindamycin is an alternative parenteral or oral therapy (if the isolate is susceptible).

Before licensure of PCV13, clones of the pneumococcal serotype 19A often were
resistant to penicillin, macrolides, clindamycin, and trimethoprim-sulfamethoxazole
[70-72]. In the post-PCV13 era, serotypes 35B and 15A have the highest incidence of
multidrug nonsusceptibility among isolates causing invasive pneumococcal disease
[15]. Such multidrug-resistant isolates may require treatment with vancomycin,
linezolid, ceftaroline, or levofloxacin.
Negative culture — For children whose cultures are negative for S. pneumoniae (eg,
because of pretreatment with antibiotics), but who are presumed to have S. pneumoniae, we
continue initial empiric therapy, provided that the child has responded as expected to the
first 24 to 48 hours of treatment. For children who fail to improve or who worsen during
initial empiric therapy, after excluding a complication that requires source control, we
change antibiotics to include activity against penicillin-intermediate or penicillin-resistant S.
pneumoniae as described above.
Duration of therapy — Therapy generally is continued for a total period of five to seven
days for uncomplicated pneumonia or until the patient is afebrile for five days in more
severe cases. (See "Community-acquired pneumonia in children: Outpatient treatment",
section on 'Duration' and "Pneumonia in children: Inpatient treatment", section on 'Duration
of treatment'.)
Empyema — The treatment of empyema is discussed separately. (See "Management and

prognosis of parapneumonic effusion and empyema in children".)
RESPONSE TO THERAPY
Children with pneumonia who are appropriately treated should show signs of improvement
within 24 to 48 hours. Failure to improve as anticipated may indicate:
● Alternative or coincident diagnosis (eg, foreign body aspiration) (see "Community-

acquired pneumonia in children: Clinical features and diagnosis", section on
'Differential diagnosis')
● Ineffective antibiotic coverage (eg, resistant organism) (see "Resistance of

Streptococcus pneumoniae to beta-lactam antibiotics" and "Resistance of
Streptococcus pneumoniae to the macrolides, azalides, lincosamides, and ketolides"
and "Resistance of Streptococcus pneumoniae to the fluoroquinolones, doxycycline, and
trimethoprim-sulfamethoxazole")
● Development of complications (see 'Complications' above)

These possibilities are discussed separately. (See "Community-acquired pneumonia in

children: Outpatient treatment", section on 'Treatment failure' and "Pneumonia in children:
Inpatient treatment", section on 'Treatment failure'.)
FOLLOW-UP
The clinical and radiographic follow-up for children with pneumonia are discussed
separately. (See "Pneumonia in children: Inpatient treatment", section on 'Follow-up' and
"Community-acquired pneumonia in children: Outpatient treatment", section on 'Follow-up'.)
OUTCOME
Most otherwise healthy children with pneumococcal pneumonia, even complicated

pneumococcal pneumonia, recover without sequelae. The Centers for Disease Control and
Prevention examined pneumococcal pneumonia in 5837 patients from nine geographic
areas in the United States; 7 percent were younger than 18 years old [73]. The case fatality
rates for pneumococcal pneumonia for children in the United States from 1995 to 1997 (not
adjusted for comorbid conditions) were estimated to be 4 percent in children younger than
two years and 2 percent in children 2 to 17 years [73].
PREVENTION
Infection control — Standard isolation precautions are recommended for children with
pneumococcal pneumonia [2]. (See "Infection prevention: Precautions for preventing
transmission of infection", section on 'Standard precautions'.)
Active immunization — Immunization with the pneumococcal conjugate vaccine (PCV) is

recommended for all infants in the United States. The efficacy of PCV in preventing
pneumonia is discussed separately. (See "Pneumococcal vaccination in children", section on
'Immunization of high-risk children and adolescents'.)
Children who are at increased risk of invasive pneumococcal disease ( table 2) also should
receive the pneumococcal polysaccharide vaccine (PPSV) beginning at two years of age; PPSV
should be administered at least eight weeks after PCV.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Pediatric
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pneumonia".)
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Here are the patient education articles that are relevant to this topic. We encourage you to
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● Basics topics (see "Patient education: Pneumonia in children (The Basics)")
SUMMARY AND RECOMMENDATIONS
● Epidemiology – Streptococcus pneumoniae is the most common cause of typical

bacterial pneumonia. However, in certain age groups, other causes of pneumonia
predominate. (See 'Burden of disease' above and "Pneumonia in children:
Epidemiology, pathogenesis, and etiology", section on 'Etiologic agents'.)
● Clinical manifestations – The most common clinical manifestations of pneumococcal

pneumonia are fever, nonproductive cough, tachypnea, and decreased breath sounds
over the affected area. Auscultatory findings of crepitant rales (crackles) and tubular
breath sounds are highly localized to the involved segment or lobe. (See 'Clinical
manifestations' above.)
● Complications – Complications, which are present in 40 to 70 percent of children

hospitalized with pneumococcal pneumonia, include pleural effusion, empyema, lung
abscess, necrotizing pneumonia, pneumatocele, and pneumothorax. (See
'Complications' above.)
● Evaluation and diagnosis – History, examination, and radiographic findings usually

establish the diagnosis of pneumonia. Although lobar consolidation is suggestive of
bacterial pneumonia, radiographic features cannot reliably differentiate bacterial from

nonbacterial pneumonia. Specific diagnosis of pneumococcal pneumonia in children is

usually made through culture of the blood or pleural fluid. (See 'Diagnosis' above.)
● Management
• Most patients with community-acquired pneumonia are treated empirically. If S.

pneumoniae is a consideration, empiric therapy generally includes a beta-lactam
antibiotic (ie, penicillin or cephalosporin). (See 'Empiric therapy' above and
"Community-acquired pneumonia in children: Outpatient treatment", section on
'Empiric therapy' and "Pneumonia in children: Inpatient treatment", section on
'Empiric therapy'.)
• When there is a positive culture for S. pneumoniae, the antibiotic susceptibility

pattern should guide therapy ( table 3 and table 4). (See 'Specific therapy'
above.)
- We suggest penicillin or ampicillin as the parenteral drug of choice and

amoxicillin as the oral drug of choice for pneumococcal pneumonia caused by
isolates with penicillin minimum inhibitory concentrations (MICs) ≤2 mcg/mL
(Grade 2C). Alternative parenteral agents include cefotaxime, ceftriaxone,
ceftaroline, clindamycin, vancomycin, or levofloxacin if the isolate is susceptible.
Alternative oral therapies include cefpodoxime, cefprozil, cefuroxime, or
levofloxacin. Doses are provided in the table ( table 4).
- We suggest ceftriaxone or cefotaxime as the preferred parenteral treatment

and oral levofloxacin or linezolid as the preferred oral treatment for
pneumococcal isolates with penicillin MICs ≥4 mcg/mL ( table 4) (Grade 2C).
Ceftaroline, vancomycin, levofloxacin, linezolid, and clindamycin (if the isolate is
susceptible) are alternatives.
• Therapy generally is continued for five to seven days for uncomplicated disease or
until the patient is afebrile for five days in more severe cases. (See 'Duration of
therapy' above.)
● Outcome – Most otherwise-healthy children with pneumococcal pneumonia, even

complicated pneumococcal pneumonia, recover without sequelae. The case fatality
rates for pneumococcal pneumonia for children in the United States are estimated to
be 4 percent in children younger than two years and 2 percent in children 2 to 17 years.
(See 'Outcome' above.)
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Society of America. Clin Infect Dis 2011; 53:e25.
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pneumococcus and risk of treatment failure in pneumonia. Arch Dis Child 2008; 93:221.
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and penicillin-susceptible pneumococcal disease. Pediatr Infect Dis J 1995; 14:885.
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s in children among 8 children's hospitals in the United States 2011 to 2013. https://idsa.
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4).
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013. www.cdc.gov/abcs/reports-findings/survreports/spneu13.html (Accessed on Nove
mber 17, 2014).
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resistant Pneumococcus in Massachusetts following universal immunization of infants
with pneumococcal conjugate vaccine. Pediatr Infect Dis J 2007; 26:468.
71. 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.
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treatment of children with community-acquired pneumonia. Pediatr Infect Dis J 2007;
26:868.
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pneumonia in the era of antibiotic resistance, 1995-1997. Am J Public Health 2000;
90:223.
Topic 6060 Version 30.0

GRAPHICS
Comparison of serotypes in pneumococcal vaccines
Polysaccha
Conjugate vaccines
vaccin
PCV7
PCV13 ¶ PCV20 Δ
(Prevnar PCV10* PCV10* PCV15 ¶ PPSV23
7, no (Prevnar (Prevnar
(Synflorix) (Pneumosil) (Vaxneuvance) (Pneumova
longer 13) 20)
available)
– 1 1 1 1 1 1
– – – – – – 2
– – – 3 3 3 3
4 4 – 4 4 4 4
– 5 5 5 5 5 5
– – 6A 6A 6A 6A –
6B 6B 6B 6B 6B 6B 6B
– 7F 7F 7F 7F 7F 7F
– – – – – 8 8
– – – – – – 9N
9V 9V 9V 9V 9V 9V 9V
– – – – – 10A 10A
– – – – – 11A 11A
– – – – – 12F 12F
14 14 14 14 14 14 14
– – – – – 15B 15B
– – – – – – 17F
18C 18C – 18C 18C 18C 18C
– – 19A 19A 19A 19A 19A
19F 19F 19F 19F 19F 19F 19F
– – – – – – 20
– – – – 22F 22F 22F
23F 23F 23F 23F 23F 23F 23F
– – – – 33F 33F 33F

PCV7: 7-valent pneumococcal conjugate vaccine; PCV10: 10-valent pneumococcal conjugate

vaccine; PCV13: 13-valent pneumococcal conjugate vaccine; PCV15: 15-valent pneumococcal
conjugate vaccine; PCV20: 20-valent pneumococcal conjugate vaccine; PPSV23: 23-valent
pneumococcal polysaccharide vaccine.
* Not available in the United States.
¶ Licensed in the United States for people age 6 weeks and older.
Δ Licensed in the United States for people age 18 years and older.
◊ Licensed in the United States for people age 2 years and older.
Graphic 77274 Version 10.0

Conditions associated with an increased risk of invasive pneumococcal

disease in children and adolescents
Risk group Condition
Immune- Functional or anatomic asplenia (eg, sickle cell disease and other
compromised children hemoglobinopathies, congenital or acquired asplenia or splenic
dysfunction)
Congenital or acquired immunodeficiencies – Includes B- or T-

lymphocyte deficiency, complement deficiencies (particularly C1, C2, C3,
and C4 deficiencies), and phagocytic disorders (except CGD)
HIV infection
Chronic kidney disease
Nephrotic syndrome
Generalized malignancy (eg, metastatic disease treated with

chemotherapy)
Hematologic malignancy (eg, leukemia, lymphoma, Hodgkin disease,

multiple myeloma)
Iatrogenic immunosuppression (eg, solid organ transplant, long-term

systemic glucocorticoids, tumor necrosis alpha inhibitors [eg, etanercept,
infliximab], radiation therapy)
Immune-competent Cerebrospinal fluid leaks

children with
anatomic barrier Cochlear implant (or candidate for cochlear implant)
defects
Immune-competent Chronic heart disease, particularly cyanotic congenital heart disease,

children with chronic cardiac failure, and cardiomyopathy
conditions*
Chronic lung disease (including asthma if treated with high-dose oral
glucocorticoid therapy ¶ )
Diabetes mellitus
CGD: chronic granulomatous disease.
* Alaska Native/American Indian children age 24 through 59 months may also be at increased
risk if they live in areas with an increased prevalence of invasive pneumococcal disease.
¶ High-dose oral glucocorticoid therapy is defined as ≥20 mg per day (or >2 mg/kg per day for
patients who weigh <10 kg) of prednisone or equivalent for ≥14 days.
Data from:
1. Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-
valent pneumococcal polysaccharide vaccine among children aged 6-18 years with immunocompromising
conditions: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal
Wkly Rep 2013; 62:521.

2. Kobayashi M, Farrar JL, Gierke R et al. Use of 15-valent pneumococcal conjugate vaccine among US children:
Updated recommendations of the Advisory Committee on Immunization Practices - United States 2022. MMWR
Morb Mortal Wkly Rep 2022; 71:1174.
3. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the
immunocompromised host. Clin Infect Dis 2014; 58:e44.
4. Centers for Disease Control and Prevention. Child and adolescent immunization schedule by age.
Recommendations for ages 18 years or younger, United States, 2023. Available at:
www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html. Accessed on February 23, 2023.

Pneumococcal pneumonia: Complications
Radiographic images of the complications of pneumococcal

pneumonia.
(Left panel) Lung abscess with an air-fluid level in the right lung.
Abscess cavity material is nearly always culture positive, and patients
commonly defervesce within 48 hours of interventional drainage.
(Right panel) Radiograph of necrotizing pneumonia in the left lung.

Sputum from a patient with pneumococcal

pneumonia
Gram stain of sputum (x1000) shows abundant inflammatory cells

and gram-positive diplococci; Streptococcus pneumoniae was
identified from this specimen by culture and by the optochin disk
test.
Courtesy of Harriet Provine.

Interpretive breakpoints for Streptococcus pneumoniae for selected

antibiotics
Antibiotic Susceptible Intermediate Resistant
Penicillin G (parenteral)
Meningitis ≤0.06 mcg/mL – ≥0.12 mcg/mL
Non-meningitis* ≤2 mcg/mL 4 mcg/mL ≥8 mcg/mL
Penicillin V (oral)* ≤0.06 mcg/mL 0.12 to 1 mcg/mL ≥2 mcg/mL
Amoxicillin (non-meningitis) ≤2 mcg/mL 4 mcg/mL ≥8 mcg/mL
Cefuroxime
Parenteral ≤0.5 mcg/mL 1 mcg/mL ≥2 mcg/mL
Oral ≤1 mcg/mL 2 mcg/mL ≥4 mcg/mL
Cefotaxime, Ceftriaxone
Meningitis ≤0.5 mcg/mL 1 mcg/mL ≥2 mcg/mL
Non-meningitis ≤1 mcg/mL 2 mcg/mL ≥4 mcg/mL
Cefpodoxime ≤0.5 mcg/mL 1 mcg/mL ≥2 mcg/mL
Cefdinir ≤0.5 mcg/mL 1 mcg/mL ≥2 mcg/mL
Ceftaroline ≤0.5 mcg/mL – –
Clindamycin ≤0.25 mcg/mL 0.5 mcg/mL ≥1 mcg/mL
Rifampin ≤1 mcg/mL 2 mcg/mL ≥4 mcg/mL
Azithromycin ≤0.5 mcg/mL 1 mcg/mL ≥2 mcg/mL
Clarithromycin ≤0.25 mcg/mL 0.5 mcg/mL ≥2 mcg/mL
Gemifloxacin ≤0.12 mcg/mL 0.25 mcg/mL ≥0.5 mcg/mL
Levofloxacin ≤2 mcg/mL 4 mcg/mL ≥8 mcg/mL
Moxifloxacin ≤1 mcg/mL 2 mcg/mL ≥4 mcg/mL
When the E-test is used to determine minimum inhibitory concentrations (MICs), exact results
are reported rather than the twofold dilutions that were used when the cut-offs were defined. An
MIC value that falls between standard twofold dilutions must therefore be rounded up to the
next dilution in order to be categorized. As an example, an S. pneumoniae isolate from a patient
with meningitis with a cefotaxime/ceftriaxone MIC of 1.5 mcg/mL would be rounded up to 2
mcg/mL and would be considered resistant.
* For nonmeningitis isolates, the penicillin MIC can predict susceptibility to other beta-lactams as
follows:
Penicillin MICs ≤0.06 mcg/mL indicate susceptibility to ampicillin (oral or parenteral),

ampicillin-sulbactam, cefaclor, cefdinir, cefditoren, cefpodoxime, cefprozil, ceftizoxime,

cefuroxime, imipenem, loracarbef, and meropenem.

Penicillin MICs ≤2 mcg/mL indicate susceptibility to amoxicillin, amoxicillin-clavulanate,
cefepime, cefotaxime, ceftriaxone, and ertapenem.
Data from:
1. Clinical and Laboratory Standards Institute (CLSI). Performance Standards for Antimicrobial Susceptibility
Testing; Nineteenth Informational Supplement. CLSI document M100-S19. Clinical and Laboratory Standards
Institute 2009.
2. Clinical and Laboratory Standards Institute (CLSI). Performance Standards for Antimicrobial Susceptibility
Testing, 31 st ed. CLSI Supplement M100. Clinical and Laboratory Standards Institute 2021, p.95.

Doses of drugs used in the treatment of Streptococcus pneumoniae

pneumonia in children >3 months
Agent Regimen Maximum daily dose
Intravenous therapy
Ampicillin* Penicillin susceptible (MIC ≤2 6 g/day

mcg/mL):
150 to 200 mg/kg per day divided in 4
doses
Penicillin resistant or intermediate 12 g/day

(MIC ≥4 mcg/mL):
doses
Cefotaxime ¶ 150 mg/kg per day divided in 3 doses 6 g/day
Ceftaroline 2 through 23 months: 1.2 g/day

24 mg/kg per day divided in 3 doses
2 through 17 years:
≤33 kg: 36 mg/kg per day
divided in 3 doses
>33 kg: 1.2 g per day divided in
2 or 3 doses
≥18 years:
1.2 g per day divided in 2 doses
Ceftriaxone ¶ Penicillin susceptible (MIC ≤2 2 g/day

mcg/mL):
or 2 doses
Penicillin resistant or intermediate 4 g/day

(MIC ≥4 mcg/mL):
100 mg/kg per day divided in 1 or 2
doses
Clindamycin Δ 40 mg/kg per day divided in 3 or 4 2.7 g/day

(if susceptible) doses
Penicillin G* 200,000 to 250,000 units/kg per day 24 million units/day

divided in 4 or 6 doses
Levofloxacin Δ 6 months to 5 years: 750 mg/day

(if susceptible) 16 to 20 mg/kg per day divided in 2
doses
5 to 16 years:
8 to 10 mg/kg once daily

Linezolid <12 years: 1.8 g/day

≥12 years: 1.2 g/day

Vancomycin Δ 40 to 60 mg/kg per day divided in 3 4 g/day ◊

or 4 doses ◊
Oral therapy (for mild infection or completion of a course of therapy initiated

intravenously)
Amoxicillin* 90 mg/kg per day divided in 2 doses 4 g/day
45 mg/kg per day divided in 3 doses 4 g/day
Cefpodoxime 10 mg/kg per day divided in 2 doses 400 mg/day
Cefprozil 15 to 30 mg/kg per day divided in 2 1 g/day

doses
Cefuroxime 20 to 30 mg/kg per day divided in 2 1 g/day

doses
Clindamycin Δ 30 to 40 mg/kg per day divided in 3 1.8 g/day

(if susceptible) doses
Levofloxacin ¶ 6 months to 5 years: 750 mg/day

(if susceptible) 16 to 20 mg/kg per day divided in 2
doses
5 to 16 years:
8 to 10 mg/kg once daily
Linezolid ¶ <12 years: 1.8 g/day

≥12 years: 1.2 g/day

The doses recommended above are intended for patients with normal renal function; the doses
of some of these agents must be adjusted in patients with renal insufficiency.
* Preferred agents for penicillin susceptible S. pneumoniae.
¶ Preferred agents for penicillin nonsusceptible S. pneumoniae.
Δ Alternative agents for children with severe allergic reactions to beta-lactam antibiotics.
◊ 60 mg/kg per day is recommended for children with serious infections (eg, toxic-appearing or
have evidence of complications such as empyema). Adjustment of dose and frequency may be
necessary based upon serum concentration monitoring.
Adapted from: 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.


Contributor Disclosures
Elaine I Tuomanen, MD Patent Holder: St Jude Children’s Research Hospital [Pneumococcal vaccine].
All of the relevant financial relationships listed have been mitigated. Sheldon L Kaplan,
MD Grant/Research/Clinical Trial Support: MeMed Diagnostics [Bacterial and viral infections]; Merck
[Staphylococcus aureus]; Pfizer [Streptococcus pneumoniae]. Consultant/Advisory Boards: MeMed
Advisory Board [Diagnostics bacterial and viral infections]. Other Financial Interest: Elsevier [Pediatric
infectious diseases]; Pfizer [PCV13]. All of the relevant financial relationships listed have been
mitigated. Liset C Olarte, MD, MSc Grant/Research/Clinical Trial Support: GSK [Meningococcal
vaccine]; Merck [Pneumococcal colonization, pneumococcal vaccine]; Pfizer [Pneumococcal vaccine];
Sanofi [Pneumococcal vaccine]. All of the relevant financial relationships listed have been
mitigated. Morven S Edwards, MD Grant/Research/Clinical Trial Support: Pfizer [Group B
Streptococcus]. Other Financial Interest: Texas State University personal services agreement [Chagas
disease]. All of the relevant financial relationships listed have been mitigated. Mary M Torchia, MD No
relevant financial relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
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3/4/23, 10:30 PM Pneumococcal pneumonia in children - UpToDate

Official reprint from UpToDate®

Pneumococcus (Streptococcus pneumoniae) is a common cause of invasive bacterial infection

The pneumococcus is acquired by aerosol or inhalation, leading to colonization of the

https://www-uptodate-com.ezp2.imu.edu.my/contents/pneumococcal-pneumonia-in-children/print?search=bronchopneumonia children&source=… 1/30

Burden of disease — Pneumonia is a common cause of death in children worldwide [26].

https://www-uptodate-com.ezp2.imu.edu.my/contents/pneumococcal-pneumonia-in-children/print?search=bronchopneumonia children&source=… 2/30

Serotypes — The pneumococcal serotypes isolated from children with pneumococcal

Antibiotic resistance — Resistance of S. pneumoniae to multiple antibiotics was an

Transmission and incubation period — S. pneumoniae is transmitted from person to

Clinical manifestations — Pneumococcal pneumonia is the paradigm of classic lobar

https://www-uptodate-com.ezp2.imu.edu.my/contents/pneumococcal-pneumonia-in-children/print?search=bronchopneumonia children&source=… 3/30

consolidation and reappear on resolution (redux crepitus). (See "Community-acquired

● Fever – 90 percent (mean duration three days before diagnosis)

Radiographic features — Pneumococci can cause lobar or bronchopneumonia.

S. pneumoniae is the most common bacterial cause of sphere-shaped consolidation (ie,

Complications — In ambulatory children, pneumococcal pneumonia characteristically is

In reviews of children hospitalized with confirmed pneumococcal pneumonia, the

● Pleural effusion – 36 to 83 percent

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Community-acquired pneumonia — The history, physical findings, and finding of an

Pneumococcal pneumonia — Confirmation of pneumococcal pneumonia is necessary to

be treated as outpatients. (See "Community-acquired pneumonia in children: Clinical

• The finding of predominant gram-positive diplococci ( picture 1) may suggest S.

method of choice in children. In a prospective study, PCR detected approximately 25

In children with parapneumonic effusion or empyema who were treated with

https://www-uptodate-com.ezp2.imu.edu.my/contents/pneumococcal-pneumonia-in-children/print?search=bronchopneumonia children&source=… 7/30

CAP is discussed separately. (See "Community-acquired pneumonia in children: Outpatient

● Penicillin-susceptible strains – Penicillin or ampicillin is the drug of choice for

● Penicillin-intermediate and resistant strains – Ceftriaxone or cefotaxime are

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Empyema — The treatment of empyema is discussed separately. (See "Management and

● Alternative or coincident diagnosis (eg, foreign body aspiration) (see "Community-

● Ineffective antibiotic coverage (eg, resistant organism) (see "Resistance of

● Development of complications (see 'Complications' above)

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These possibilities are discussed separately. (See "Community-acquired pneumonia in

Most otherwise healthy children with pneumococcal pneumonia, even complicated

Active immunization — Immunization with the pneumococcal conjugate vaccine (PCV) is

SOCIETY GUIDELINE LINKS

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INFORMATION FOR PATIENTS

● Basics topics (see "Patient education: Pneumonia in children (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Epidemiology – Streptococcus pneumoniae is the most common cause of typical

● Clinical manifestations – The most common clinical manifestations of pneumococcal

● Complications – Complications, which are present in 40 to 70 percent of children

● Evaluation and diagnosis – History, examination, and radiographic findings usually

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nonbacterial pneumonia. Specific diagnosis of pneumococcal pneumonia in children is

• Most patients with community-acquired pneumonia are treated empirically. If S.

• When there is a positive culture for S. pneumoniae, the antibiotic susceptibility

- We suggest penicillin or ampicillin as the parenteral drug of choice and

- We suggest ceftriaxone or cefotaxime as the preferred parenteral treatment

● Outcome – Most otherwise-healthy children with pneumococcal pneumonia, even

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6. Austrian R. Some aspects of the pneumococcal carrier state. J Antimicrob Chemother

13. Ben-Shimol S, Givon-Lavi N, Greenberg D, et al. Impact of pneumococcal conjugate

24. Tuomanen E, Rich R, Zak O. Induction of pulmonary inflammation by components of the

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29. Ouldali N, Levy C, Minodier P, et al. Long-term Association of 13-Valent Pneumococcal