Streptococcus pneumoniae

Clinical Background

Streptococcus pneumoniae causes pneumococcal disease.

Epidemiology

Incidence - kills more people in the U.S. (40,000) than any other vaccine-preventable disease
Transmission - humans are the natural reservoir for S. pneumoniae; organism colonizes in nasopharynx

Organism

S. pneumoniae are typically gram-positive, lancet-shaped diplococci
S. pneumoniae that are pathogenic in humans are heavily encapsulated
- Virulence determined by composition of capsular polysaccharide
- Antibodies to capsular polysaccharides confer type-specific immunity

Clinical Presentation

Pneumonia
- S. pneumoniae responsible for 50% of all cases of community-acquired pneumonia
  - Often develops during upper respiratory tract viral infections with influenza and measles
  - Bacteremia occurs in 25-40% of patients
    - S. pneumoniae causes 85% of all cases of bacteremia in pediatric population
    - Overall mortality rate for bacteremia is 20% but may reach 60% in elderly patients
Otitis media
- Responsible for 30-50% of otitis media cases
  - About 90% of children in U.S. have at least 1 episode by age 3
  - 50% have >6 episodes
Sinusitis
- Responsible for 40% of sinusitis cases
Meningitis

Treatment

Effectively treated with antibiotics unless:
- Treatment is delayed
- Bacteria are resistant
- Patient has another debilitating illness or is immunocompromised
Current vaccines recommended by the CDC
- Adults - 23-valent polysaccharide vaccine (PPV23, Pneumovax™)
- Pneumovax™ - serotypes included in the vaccine are 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, 33F
- Infants and toddlers - 7-valent polysaccharide conjugate vaccine (PCV7, Prevnar™)
- Prevnar™ - serotypes included in the vaccine are 4,6B, 9V, 14,18C, 19F, 23F
- Currently, clinical trials in progress for 9 and 11 valent-conjugated vaccines that will add serotypes 1 and 5, followed by serotypes 3 and 7F

See Also

Meningitis, Acute

Tests

Tests generally appear in the order most useful for common clinical situations

Test name: Streptococcus pneumoniae Antigen, Urine

ARUP #: 0060228

Methodology: Immunochromatographic Assay

Use:

Rapid diagnostic test for invasive disease from S. pneumoniae (e.g., bacteremia, pneumonia, meningitis)

Vaccination, pre- and post-antibody titer may aid in diagnosis of patients with suspected antibody deficiency and chronic/recurrent sinopulmonary infections

Limitations:

False-positives may occur because of cross-reactivity with other members of S. mitis group or asymptomatic colonization of S. pneumoniae
Clinical correlation is recommended

Follow-up:

Test name: Streptococcus pneumoniae Antigen, CSF

ARUP #: 0061162

Methodology: Immunochromatographic Assay

Use:

Diagnostic test for pneumonococcal meningitis

Vaccination, pre- and post-antibody titer may aid in diagnosis of patients with suspected antibody deficiency and chronic/recurrent sinopulmonary infections

Limitations:

False-positives may occur because of cross-reactivity with other members of S. mitis group
Clinical correlation is recommended

Follow-up:

Test name: Streptococcus pneumoniae Antibodies, IgG (14 serotypes)

ARUP #: 0050725

Methodology: Multi-Analyte Fluorescent Detection

Use:

Quantify antibody levels to pneumococcal polysaccharides in persons receiving vaccine to determine response to vaccine and whether protective antibody levels are reached at 1 month post-immunization

Vaccination, pre- and post-antibody titer may aid in diagnosis of patients with suspected antibody deficiency with chronic/recurrent sinopulmonary infections

Limitations:

Test not designed to determine protection against Streptococcus pneumoniae based on a single sample

Follow-up:

Test name: Aerobic Organism Identification with Reflex to Susceptibility

ARUP #: 0065070

Methodology: Standard reference procedures for aerobic bacterial identification and/or 16s rDNA sequencing for select bacterial isolates and susceptibility tests.

Use:

Gold standard for identification of S. pneumoniae

Limitations:

Follow-up:

Additional Information

Pre-vaccine and 1-month post-immunization samples should be run simultaneously, dated and marked as pre-vaccine or post-vaccine.

Response to >50% of the antigens contained in vaccination most likely indicative of normal response. Long-term protection generally thought to be associated with a 1 month post-vaccine response of 1 µg/mL in children and adults.

Responder status determined by ratio of post- to pre-vaccination concentration of pneumococcal IgG antibody

Ratio <twofold identifies a nonresponder
Ratio of two to fourfold identifies a weak responder
Ratio greater than or equal to fourfold identifies a good responder

References

Guidelines

Improving influenza, pneumococcal polysaccharide, and hepatitis B vaccination coverage among adults aged <65 years at high risk. A report on recommendations of the Task Force on Community Preventive Services. Task Force on Community Preventive Services - Independent Expert Panel. 2005 Apr 1. 11 pages. NGC:004254

Recommended immunization schedules for children and adolescents: United States, 2007. American Academy of Family Physicians - Medical Specialty Society American Academy of Pediatrics - Medical Specialty Society Centers for Disease Control and Prevention - Federal Government Agency [U.S.]. 2004 Apr 30 (revised 2007 Jan). 4 pages. NGC:005439

Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Infectious Diseases Society of America - Medical Specialty Society. 2000 Feb (revised 2003 Dec 1). 29 pages. NGC:003360

General References

Ambrosino DM, Siber GR, Chilmonczyk BA, Jernberg JB, Finberg RW. An immunodeficiency characterized by impaired antibody responses to polysaccharides. N Engl J Med. 1987;316(13):790-793.

Balmer P, Cant AJ, Borrow R. Anti-pneumococcal antibody titre measurement: what useful information does it yield?. J Clin Pathol. 2007;60(4):345-350.

Bridy-Pappas AE, Margolis MB, Center KJ, Isaacman DJ. Streptococcus pneumoniae: description of the pathogen, disease epidemiology, treatment, and prevention. Pharmacotherapy. 2005;25(9):1193-1212.

Dear K, Holden J, Andrews R, Tatham D. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Syst Rev. 2003;(4):CD000422.

Garcia-Suarez Mdel M, Vazquez F, Mendez FJ. Streptococcus pneumoniae virulence factors and their clinical impact: An update. Enferm Infecc Microbiol Clin. 2006;24(8):512-517.

Hausdorff WP. The roles of pneumococcal serotypes 1 and 5 in paediatric invasive disease. Vaccine. 2007;25(13):2406-2412.

Jacobs MR. Streptococcus pneumoniae: epidemiology and patterns of resistance. Am J Med. 2004;117 Suppl 3A:3S-15S.

Lieberthal AS. Acute otitis media guidelines: review and update. Curr Allergy Asthma Rep. 2006;6(4):334-341.

Lopez R. Pneumococcus: the sugar-coated bacteria. Int Microbiol. 2006;9(3):179-190.

Lucero MG, Dulalia VE, Parreno RN, Lim-Quianzon DM, Nohynek H, Makela H, Williams G. Pneumococcal conjugate vaccines for preventing vaccine-type invasive pneumococcal disease and pneumonia with consolidation on x-ray in children under two years of age. Cochrane Database Syst Rev. 2004;(4):CD004977.

Mitchell TJ. Streptococcus pneumoniae: infection, inflammation and disease. Adv Exp Med Biol. 2006;582:111-124.

Nohynek H. Diagnosis and prevention of pneumococcal disease. Adv Exp Med Biol. 2006;582:137-150.

Ortqvist A, Hedlund J, Kalin M. Streptococcus pneumoniae: epidemiology, risk factors, and clinical features. Semin Respir Crit Care Med. 2005;26(6):563-574.

Pickering JW, Martins TB, Schroder MC, Hill HR. Comparison of a multiplex flow cytometric assay with enzyme-linked immunosorbent assay for auantitation of antibodies to tetanus, diphtheria, and Haemophilus influenzae Type b. Clin Diagn Lab Immunol. 2002;9(4):872-876.

Shapiro GG, Virant FS, Furukawa CT, Pierson WE, Bierman CW. Immunologic defects in patients with refractory sinusitis. Pediatrics. 1991;87(3):311-316.

Whiteside J, Grover M, Hitchcock K, Kim R. Clinical inquiries. Should patients receive 23-valent pneumococcal vaccination more than once?. J Fam Pract. 2006;55(9):809-812.

References from the ARUP Institute for Clinical and Experimental Pathology Research®

Petti CA, Woods CW, Reller LB. Streptococcus pneumoniae antigen test using positive blood culture bottles as an alternative method to diagnose pneumococcal bacteremia. J Clin Microbiol. 2005;43(5):2510-2512.

Pickering JW, Hoopes JD, Groll MC, Romero HK, Wall D, Sant H, Astill ME, Hill HR. A 22-plex chemiluminescent microarray for pneumococcal antibodies. Am J Clin Pathol. 2007;128(1):23-31.

Pickering JW, Martins TB, Greer RW, Schroder MC, Astill ME, Litwin CM, Hildreth SW, Hill HR. A multiplexed fluorescent microsphere immunoassay for antibodies to pneumococcal capsular polysaccharides. Am J Clin Pathol. 2002;117(4):589-596.

Medical Reviewers

Hill, Harry R., M.D. Group Medical Director, Laboratory of Immunology, ARUP Laboratories, and Executive Director of the ARUP Institute for Clinical and Experimental Pathology; Professor and Division Head, Clinical Pathology, University of Utah

Litwin, Christine, M.D. Medical Director, Immunology at ARUP Laboratories; Professor, Clinical Pathology, University of Utah

Petti, Cathy A., M.D. Medical Director, Infectious Diseases at ARUP Laboratories; Assistant Professor, Pathology and Medicine, University of Utah

Comprehensive Review: January 2008
Last Update: May 2008