Streptococcus pneumoniae

(Pneumococcal) Infection
Dr. dr. Ari Prayitno , Sp.A (K)

Department Child Health Sciences

Faculty University of Indonesia Medicine
RSUPN dr. Cipto Mangunkusumo
 Outline
Introduction : Streptococcus Diseases caused by spread _ direct (non-
1 5 invasive )
Pneumococci

Disease caused _ spread through blood /

2 Epidemiology 6 Pneumococci Invasive (IPD)

3 Diagnostic Approach 7 Inspection Support Diagnostic

4 Signs and symptoms 8 Management / Administration

ARE STREPTOCOCCUS THE SAME AS
PNEUMOCOCUS?
 Streptococcus
• Streptococcus is one of the genus of non-motile bacteria which are Gram
positive cells , round shaped, oval and chain short , chain long or pair
• Some of them are a pathogenic and non- pathogenic .
• Pathogenic ones can cause disease such as pneumonia, meningitis,
necrotizing fasciitis, erysipelas , inflammation throat , and endocarditis
• Classification based on traits hemolytics : alpha hemolytic streptococcus ,
beta hemolytic and gamma hemolytic
• Classification based on combination antigenic properties, hemolytic and
physiological , are divided become Streptococcus groups A, B, C, D, F, and G
 • Domain: Bacteria
• Phylum: Firmicutes
• Class : Bacilli
• Order: Lactobacillales
Classification scientific for Streptococcus • Family : Streptococcaceae
• Genus: Streptococcus
 Species Streptococcus
• Streptococcus agalactiae • Streptococcus intermedius • Streptococcus ratti
• Streptococcus anginosus • Streptococcus milleri • Streptococcus salivarius
• Streptococcus bovis • Streptococcus mitis • Streptococcus tigurinus
• Streptococcus canis • Streptococcus mutans • Streptococcus thermophilus
• Streptococcus constellatus • Streptococcus oralis • Streptococcus sanguinis
• Streptococcus downei • Streptococcus orisratti • Streptococcus sobrinus
• Streptococcus dysgalactiae • Streptococcus parasanguinis • Streptococcus suis
• Streptococcus equinus • Streptococcus peroris • Streptococcus uberis
• Streptococcus ferrus • Streptococcus pneumoniae • Streptococcus vestibularis
• Streptococcus infantarius • Streptococcus pseudopneumoniae • Streptococcus viridans
• Streptococcus iniae • Streptococcus pyogenes • Streptococcus zooepidemicus
 Between Streptococci and Pneumococci
•Classification scientific for Streptococcus pneumoniae:
• Domain: Bacteria
• Phylum: Bacillota
• Class: Bacilli
• Order: Lactobacillales
• Family: Streptococcaceae
• Genus: Streptococcus
• Species: Streptococcus pneumoniae
 History of Pneumococcus

• T 1881 : isolated first by George Sternberg and Louis Pasteur

• 1886: known as pneumococcus because his role as cause of
pneumonia
• 1920: called Diplococcus pneumoniae due to its characteristic
appearance is in Gram - stained sputum
• 1974: the name changed become Streptococcus pneumoniae
 Streptococcus infection

•Pneumococcal infection caused by bacteria Streptococcus

pneumoniae
• The main cause of community acquired pneumonia ( CAP),
bacterial meningitis , bacteremia , and acute otitis media and
also caused important sinusitis, arthritis septic , osteomyelitis
, peritonitis, and endocarditis
 Epidemiology

• Incidence of pneumococcal pneumonia in children in the United

States decrease after found it vaccine conjugate pneumococcal (
Pneumococcal Conjugate Vaccine = PCV) 7-valent (PCV7) which
then Replaced PCV13 in 2010
• Systematic studies in 2023 report reduction averaged 69% of
hospitalized patients due to pneumococcal pneumonia in
toddlers after introduction of PCV13 and PCV10.
 Epidemiology
Proportion of causes of post-neonatal death Proportion of causes of death of children
(29 days-11 months) in Indonesia in 2021 under five (12-59 months) in Indonesia in
2020

Indonesian Ministry of Health. Disease Control. In: Indonesian Health Profile. Jakarta: Indonesian Ministry of Health; 2020
 Epidemiology
Scope Discovery of Pneumonia in Toddlers in Indonesia 2011-2021

Indonesian Ministry of Health. Disease Control. In: Indonesian Health Profile. Jakarta: Indonesian Ministry of Health; 2021
 Structure
pneumococcus

• Structure S. pneumoniae consists from capsule

polysaccharides , wall cells , membranes cells ,
cytoplasm , and deoxyribonucleic acid (DNA).
• Layer capsule polysaccharides contain a number of
surface proteins become base grouping serogroup and
serotype S. Pneumoniae and is starting component _
response immune protective Specific organism This
 Serogroup and serotype of Pneumococcus

• 19A 🡪 19 and A 🡪 19 is the serogroup and A is the serotype

• Capsule polysaccharides is very heterogeneous 🡪 46 types are known
serogroups and more of 90 serotypes different pneumococci _
• Capsule polysaccharides is factor virulence the most important
pneumococcus Because protect bacteria from phagocytosis
• The more thick surface polysaccharides and pneumococcus the more
virulent
• Layer polysaccharides , antibodies and complement 🡪 reduce access
to surface pneumococcus 🡪 pneumococcus protected from
annihilation by the system immune
 Serogroup and serotype Pneumococci
• It has known more of 90 serotypes different pneumococcus 🡪 No all
serotype with the same potential cause the disease.
• Only 20 to 30 serotypes have been proven the ability invasiveness and
factors can causes occurrence of IPD 🡪 serotype vaccine-type (VT)
 Diagnostic Approach
Disease caused by disseminated pneumococcus through
blood and severe clinical/fatal is called with Invasive
Pneumococcal Diseases = IPD) which have high morbidity and
mortality in children

IPD Risk Factors

▪ very young children (under five years old, especially under
two years old
▪ not receiving exclusive breast milk
▪ exposure to cigarette smoke
▪ many are placed in child care
▪ density of household members
▪ not receiving or incomplete immunization with
pneumococcal conjugate vaccine

Weiser JN, Ferreira DM, Paton JC. Streptococcus pneumoniae: transmission, colonization and invasion. Nat Rev Microbiol. 2018 Jun;16(6):355-367. doi : 10.1038/s41579-018-0001-8. PMID: 29599457; PMCID: PMC5949087.
 Signs and symptoms
Patient child with infection pneumococcus usually temperature more than 38 ⁰
Celcius, along with symptom infection specific, as following :

• Otitis Media: otalgia, symptoms Respiratory part above , vomiting

• Sinusitis: pain headache, pain in the face (more rare in children than adults ) ,
symptoms infection of respiratory tract for 10 days or more .
• Occult bacteremia : fever without source localization in children aged 2-24
months
• Pneumonia: cough, chest pain , shortness of breath or difficulty breathing ,
malaise and anorexia
• Meningitis: stiffness neck, vomiting, pain head (old child), high fever (>38⁰ C),
lethargic, irritable, anorexia, crying
 Signs and symptoms
On physical examination, accompanying abnormalities:
• Otitis Media: bulging , colored tympanic membrane reddish and present pussy
fluid that will visible behind tympanic membrane
• Sinusitis: felt pain on pressure over the maxillary sinus or frontal and exit fluid
nose with colour secrets
• Bacteremia fever (≥38°C) and tachycardia
• Pneumonia: rales or breathing sounds are heard weakened in areas of
consolidation , percussion faint , retracted or tachypnea
• Meningitis or other CNS infections : toxic appearance, stiffness neck, easy
mental status changed with response poor consciousness and other
abnormality neurological conditions ( e.g. , interference nerve cranial , ataxia ,
weakness ), perfusion poor peripheral and signs shock in the patient with
pneumococcal sepsis
 Diseases caused by direct spread (non-invasive)

Conjunctivitis Otitis media (OM) Sinusitis Pneumonia

Diseases caused by spread through the blood/Invasive
Pneumococcus (IPD)

Meningitis Bacteremia Joint and bone

infections

Soft tissue infections Peritonitis Heart infection

 Inspection Support Diagnostic
1. Blood 4. Pleural fluid or lung aspiration
• complete peripheral blood, count • fluid analysis and pleural fluid culture
the type and markers of infection
5. Joint fluid
(C-reactive protein and/or
procalcitonin) • fluid analysis and joint fluid culture
2. Cerebrospinal fluid (CSF) 6. Bone
• examination of CSF fluid analysis and • Bone X-ray photo
culture 7. Abscess or other tissue specimen
3. Sputum
• sputum analysis and sputum culture

Urine Antigen Test 🡪 for pediatric patients whose sputum is difficult

to obtain; in adults who have a nonproductive cough
 Diagnosis
Recommended for specific inspection for syndrome clinical certain :
1. OM or sinusitis 4. Pneumonia
• tympanocentesis and bacterial culture • blood cultures, sputum cultures are difficult to
of middle ear fluid if the otitis media is obtain from children, and results may be false
chronic or resistant to antibiotics positive (contamination with saliva)
2. Sinusitis 5. Meningitis
• sinus fluid culture if sinusitis is • lumbar puncture with CSF fluid analysis (cell
unresponsive/resistant to antibiotics count, protein content, glucose content, Gram
staining and CSF culture) and blood culture
3. Occult bacteremia
• blood culture (≥2 mL) 6. Osteomyelitis or septic arthritis
• biopsy or joint fluid aspiration, fluid/bone
marrow culture and blood culture
 Diagnosis
Imaging examination as a supporting examination :

Thoracic radiography Computed tomography Magnetic resonance

(CT) scan of the head imaging (MRI) of the
(if necessary) head
 Management / Administration
OM or sinusitis (initial treatment)

• Amoxicillin for 5-10 days (otitis media) or 10-21 days (sinusitis)

OM or sinusitis that does not improve with standard doses of amoxicillin

• High-dose amoxicillin, amoxicillin-clavulanate, cefuroxime, or ceftriaxone (IM)

Pneumonia (outpatient)

• Amoxicillin for 10 days

Pneumonia (hospitalization)

• IV ceftriaxone until clinical improvement, then 10 days of outpatient treatment. In critical illness, the
addition of vancomycin should be considered

Other invasive pneumococcal diseases

• Third or fourth generation parenteral cephalosporins (ceftriaxone, cefotaxime, cefepime), in critical illness
or absence of clinical improvement, the addition of vancomycin should be considered
 Management / Administration
Meningitis

• Ceftriaxone or cefotaxime with meropenem are alternatives in cases of ceftriaxone resistance,

vancomycin is always added until the resistance test results are known, rifampicin can be added after
24-48 hours of no clinical improvement or high MIC levels

Penicillin allergy (OM, sinusitis, outpatient treatment of pneumonia)

• Azithromycin (or other macrolides), clindamycin, cefuroxime (if no cephalosporin allergy), or cefprozil

Penicillin allergy (inpatient treatment of pneumonia or other invasive

infections)

• IV ceftriaxone (if no cephalosporin allergy), alternatively: IV clindamycin or meropenem, vancomycin

may be considered if the patient is seriously ill and antimicrobial sensitivity test results are unknown.
Thank you!