Pneumococcus

Susan Shoshana Weisberg, MD, FCP, FAAP

Streptococcus pneumoniae are lancet-shaped, gram-positive diplococci,
with over 90 individual serotypes identified so far. The germ was first
isolated and identified under the microscope in 1886, simultaneously but
independently in both Germany and the United States. Pneumococcal
germs are ubiquitous. There are many asymptomatic carriers, including 2
of 3 healthy toddlers in 1 study.1,2 Transmission is thought to be
person-to-person, via respiratory droplet spread. Full blown pneumococ-
cal disease occurs most often in the winter. Although cluster outbreaks of
pneumococcal illnesses have occurred,3 most cases are sporadic. People
at increased risk for invasive pneumococcal infections include American
Indians, Alaskan Eskimos, Australian Aborigines, and children who
attend day care.4 People with asthma have at least double the risk of
severe pneumococcal disease compared with non-asthmatics,5 and boys
have higher rates of pneumococcal disease than girls.6
Pneumococcal infections have been known to hit almost every body
organ. Streptococcus pneumoniae organisms are a common culprit in
otitis media in children, and ear infections caused by pneumococcus are
worse with more complications than those of other etiologies.7 Pneumo-
coccus also causes pneumonia, meningitis, bacterimia, sinusitis, ophthal-
mic infections,8 infections of bones, joints, skin,9 and even parotid gland
infections.10 Pneumococcus causes up to 1 in 330 cases of appendici-
tis.11,12 It can cause endocarditis, and hemolytic uremic syndrome with
renal failure.13-16 There is a documented case of pneumococcal en-
dopthalmitis causing blindness,17 and 2 more case reports of pneumococ-
cal infections causing blindness after corneal transplants from the same
child donor.18 A outbreak of conjunctivitis in New Hampshire in 2002
affected 574 students on a college campus.19 The next year, outbreaks in
Minnesota caused 735 cases of conjunctivitis.20 Before widespread
immunization against it, over 1 in every 600 American children had
pneumococcal bacteremia before their second birthday,21 making it the
most common cause of life-threatening infection in children over 1 month
of age.22,23 A study from Argentina found that 1 in every 38 toddlers there

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between 2 months and 2 years of age suffered pneumococcal pneumo-
nia.24 In the United States alone, as of 1997, over 7.5 million antibiotic
prescriptions were being written per year for pneumococcal infections.25
Worldwide, the World Health Organization reports that, as of 2004,
pneumococcal infections were killing twice as many children per year as
AIDS.26 In 2005 it was killing more people than malaria.27 From 1.2 to
1.6 million people were still dying of pneumococcus annually,28 includ-
ing up to 1 million children.29 In Latin America and the Caribbean
Islands, 2 children die of pneumococcal infection every hour.30
Pneumococcus spread hematogenously starts trouble. Up to one-quarter
of all pneumonia cases are caused by pneumococcus,31 and it is second
only to tuberculosis in causing severe lung abscesses.32 Pneumococcus
used to be the most common cause of bacterial meningitis in America.22
As of 1997, up to 1 of every 14,000 American children less than 2 years
of age got pneumococcal meningitis. Up to 1 in 12 of pneumococcal
meningitis cases is fatal, and 25% leave neurological sequalae, from
seizures to mental retardation. Up to 1 in 3 pneumococcal meningitis
survivors is left with hearing loss, sometimes total deafness.33 One review
of all children admitted to 1 French intensive care unit with pneumococ-
cal meningitis between 1990 and 2002 found that one-half of them died.
Of the survivors, one-half were left with neurological impairment,
including hearing loss in 90%.34
Pneumococcus also kills in combination with other germs. It is often a
silent, secondary infector in influenza infections. In the catastrophic 1918
“Spanish flu” epidemic that took the lives of over 40 million people
worldwide, pneumococcus was found in 55 of 89 heart blood cultures
taken from American soldier victims immediately post mortem. It was
also found in almost one-half of living soldiers with Spanish flu in 1
study.35 Almost a century later, in 2006, it has been noted that types of
pneumococcal germs not protected against by vaccination are an increas-
ing cause of severe empyema. The data showing that also seem to show
a connection between the timing of those complicated pneumonias and flu
season.36,37
As of 1990, about 40,000 Americans were being killed by pneumococ-
cus every year.38 In developing nations, pneumococcal infections are
much more deadly. In Mali, one-quarter of children hospitalized with
pneumococcal infections in 2003 died from them, and in Costa Rica in
2001, the death rate in such cases was 1 in 7.39 Overall, over 1 in 10
people with severe, full blown pneumococcal infections dies of it within
5 days, whether or not they get antibiotics.40
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 Further complicating these situations are the changing patterns of which
antibiotics work against pneumococcal germs. It is now recommended
that pneumococcal meningitis be treated with combination therapy using
vancomycin and either cefotaxime or ceftriaxone.41 One study, however,
has found that vancomycin may not be useful, and may even be associated
with an increased hearing loss. Its authors suggested delaying the first
vancomycin until more than 2 hours after the first cephalosporin dose.42
The use of dexamethasone in pneumococcal meningitis has also been
debated. Official recommendations are that, if used, it should be given
with or before antibiotics.41
Pneumococcal infection is also addressed through vaccination. There
are two pneumococcal vaccines currently licensed for use in the United
States. The older, polysaccharide-type vaccine was licensed in 1983, for
use in adults and children over 2 years of age. In February 2000, a
conjugated, seven-strain pneumococcal vaccine was also approved for
infants and children. Four months later, the American Academy of
Pediatrics recommended use of the vaccine for all children under 2 years
of age. For older children, between 2 and 5 years of age, use of the
vaccine was recommended for children at higher than average risk for
pneumococcal disease.
In 1974, the first severe pneumococcal infection resistant to penicillin was
reported, in a child with sickle cell anemia and invasive infection.43 By 1992,
up to 1 in 10 pneumococcus germs were resistant to first line antibiotics.44
Between 1993 and 1996 that number doubled to 1 in 5,45 and by 1997 a
CDC survey found a quarter of pneumococcal germs to be antibiotic
resistant.46 A year later, in 1998, that number had risen to one-third in
some American states.47 A study published in 2003 found resistance to at
least 1 antibiotic in slightly over one-half of pneumococcus germs
isolated from healthy children in day care centers in Israel.48 In Ohio in
2004, the rate of amoxicillin resistance in pneumococcal germs in day
care attendees’ throats was over 40%,49 the same percentage quoted in
another study for the overall rate of resistance in America.50
In 2006, it was reported that the tide might be turning. In France, a
survey was conducted with nasal and throat culture samples collected on
toddlers with ear infections by 89 pediatricians throughout the country. It
was found that over the 3 years between 2001 and 2004, the percentage
of pneumococcus immunized children increased from 8% to 61%,
accompanied by a decrease in the percentage of children treated with
antibiotics over a 3-month period from 52% to 41%. The percentage of
children carrying pneumococcus in their throats fell as well, as did the
percentage of those germs that were resistant to penicillin. There were
DM, October 2007 497
differences in findings in children who had been pneumococcal vacci-
nated versus those who hadn’t. Only 1 in 25 immunized children who
hadn’t received antibiotics carried pneumococcus, compared with 1 in 6
unimmunized children who had been antibiotic treated.51 In 2005 in
America, the CDC’s Emerging Infectious Program surveillance project
reported that, after peaking in 1999, the proportion of pneumococcal
germs resistant to antibiotics had gone down by 2004.52,53 Even more
data published in 2005, from Atlanta, found much less resistance to
macrolid antibiotics in pneumococcal germs in 2003 compared with 1994.
The rate of resistant disease in children under 2 years of age dropped
85%.54
A study published in 2005 looked at 75 years’ culture results in infants
with blood sepsis at Yale, between 1928 and 2003. In the early years,
pneumoccocus was common, but by the end of the time period studied
there were no episodes of sepsis from pneumocccus identified.55 In
another survey from Yale, from 2006, only 1 case of serious disease from
pneumococcus was identified in 429 consecutive infants with fevers that
came to their emergency room.56 CDC data published the same year
found a 94% decline in severe pneumococcal infections in children since
1999.57 A study from California published in 2006 showed an 84% fall in
cases of pneumococcal sepsis, and called such cases “a rare event.”58
Follow-up studies conducted after licensure and widespread use of the
conjugate pneumococcal vaccine have also shown effects for others
besides actual vaccine recipients. Pneumococcal infections in babies
under 2 months of age, too young to have been immunized yet
themselves, are also down by 42% overall since the introduction of the
pneumococcal vaccine.59 Data collected between 1998 and 2003 showed
that, in adults over 50 years of age, the risk of pneumococcal disease from
strains in the vaccine fell by 55%, whereas the rate infections from
non-vaccine strains showed no change.60 Another survey found an overall
decrease in pneumococcal infections of 42% in adults 18-49 years of age.
For those over 64 years of age, the rate fell 30%.61 The CDC has
calculated that pneumococcal vaccination prevents more cases in adults
over 65 years of age than it does in children. Overall, 70% of cases
prevented are indirect “herd” protection cases.57
The decline in pneumococcal disease rates in unimmunized people
parallels the fall in the rates of asymptomatic pneumococcal carriage.
Cutting down the numbers of people quietly carrying pneumococcal
germs lowers everyone’s reservoir of exposure.62,63 Unimmunized
younger siblings of toddlers attending day care centers were found to
carry pneumococcal germs in their throats one-third less often when their
498 DM, October 2007
older siblings had been vaccinated.64 Another study found that immuni-
zation lowered pneumococcal carriage in vaccine recipients themselves
from 22% to 2%.65
Pneumococcal vaccination prevents more than just pneumococcal
disease. Protection extends to the prevention of other infections, as well.
Children immunized against pneumococcus have less viral pneumonias.66
In the medical literature, terms like “plummet” and “dramatic” are used
to describe the falls in pneumoccal disease, and there are now references
to a “post-pneumococcal vaccine era.”67

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