Clinical Overview: Treatment Recommendations for Pneumococcal Disease

Introduction

Pneumococcal disease, defined as any type of illness caused by Streptococcus pneumoniae bacteria, is one of the leading causes of infectious mortality worldwide.¹ Pneumococcal disease consists of pneumonia, meningitis, bacteremia, sinusitis, and otitis media.

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Pneumococcal vaccines aid in protection against 100-plus serotypes of pneumococcal bacteria. Pneumococcal meningitis, bacteremia, and sinusitis, while still under the umbrella term of “pneumococcal disease,” have differing treatment options and are unlikely to be seen in the outpatient setting.

Therefore, they will not be discussed in this article, with the focus being on community-acquired bacterial pneumonia. Treatment for community-acquired pneumococcal disease is dependent on patient-specific factors such as allergies and severity of infection, whereas prevention with vaccinations is dependent on age and comorbidities. This article will briefly discuss treatment options and focus on prevention strategies for pneumococcal disease.

Treatment Recommendations - Pneumonia

Community-Acquired Pneumonia (CAP)

Pneumonia should be diagnosed based on a new pulmonary infiltrate on imaging, along with typical hallmarks of infection (i.e., leukocytosis, fever/chills, dyspnea, cough, sputum production, etc). With the most common causative pathogen of pneumonia being Streptococcus pneumoniae, along with Mycoplasma pneumoniae, Chlamydia pneumoniae, Haemophilus influenzae, and Legionella pneumophila, antimicrobial treatment options are aimed to target these species.

Empiric community-acquired pneumonia treatment is based on the severity of illness and the likelihood of each specific pathogen, although in up to 70% of cases, a pathogen is not detected. Treatment duration is generally recommended as 5 days; however, for instances in which clinical improvement is not achieved, clinical judgement should be used to decide on an extended treatment duration.²

^{Antimicrobial Treatment Options for CAP3}

Prevention – Vaccination

Pneumococcal disease can occur in people of any age but commonly occurs in children and adults over 65 years of age. Vaccination recommendations for the prevention of pneumococcal disease are regularly changing, with all updates posted by the Centers for Disease Control & Prevention (CDC). However, specific situations can warrant vaccination against pneumococcal disease across most ages.

There are currently 4 pneumococcal vaccines approved by the FDA in the United States—3 conjugate and 1 polysaccharide vaccine. Polysaccharide vaccines are composed only of the sugar component, the capsule, of the bacteria they protect against to elicit an immune response. In conjugate vaccines, the sugar component is attached to a carrier protein to elicit a stronger immune response.

Conjugate Vaccines

There are 3 conjugate pneumococcal vaccines: PCV13 (Prevnar13), PCV15 (Vaxneuvance), and PCV20 (Prevnar20). The differences between the conjugate vaccines are the number of serotypes in the vaccines.

Prevnar13 contains purified capsular polysaccharide of 13 serotypes of the bacterium S. pneumoniae (1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F). Vaxneuvance contains purified capsular polysaccharides of 15 serotypes of S. pneumoniae (1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F, and 33F). Prevnar20 includes saccharides of 20 serotypes of S. pneumoniae (1, 3, 4, 5, 6A, 6B, 7F, 8, 9V, 10A, 11A, 12F, 14, 15B, 18C, 19A, 19F, 22F, 23F, and 33F).⁴

Polysaccharide Vaccine

Prevnar23 (PPSV23) contains purified preparations of pneumococcal capsular polysaccharide, with polysaccharide antigens from 23 types of pneumococcal bacteria serotypes (1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, Page 3 2 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, and 33F).⁴

Vaccination Schedule

The CDC recommends that all children under 5 years of age and all adults over 65 years of age receive a pneumococcal vaccine. However, there are specific medical conditions outside of these age ranges in which a pneumococcal vaccine is also recommended.

PPSV23 is not recommended in children under 2 years of age, and PCV20 is not recommended in anyone younger than 19 years of age. If patients have received vaccines prior to these ages, these doses should not be counted toward their vaccination schedule.

Children

Children should receive routine vaccination with PCV13 as a 4-dose series at ages 2, 4, 6, and 12-15 months of age. The minimum age for PCV13 is 6 weeks, and the minimum age for PPSV23 is 2 years.⁵ There are certain situations in which vaccination beyond the routine 4-dose PCV13 is warranted, such as:^5,6

Table 1: Pneumococcal vaccination recommendations in children

Adults

Routine vaccination for adults aged 65 years and older who have not previously received a pneumococcal conjugate vaccine (or have an unknown history) includes 1 dose of PCV15 or PCV20. If PCV15 is received, this should be followed by 1 dose of PPSV23 a year later in all circumstances. Exceptions include cochlear implants, immunocompromised patients and CSF leak. In these patients doses are given 8 weeks apart.

Special situations exist for adults between the ages of 19 and 64 in which further vaccine recommendations are provided:⁷

Table 2: Pneumococcal vaccination recommendations in adults

References

1. Pneumococcal Vaccination | CDC [Internet]. 2022 [cited 2023 Jan 4]. Available from: https://www.cdc.gov/vaccines/vpd/pneumo/index.html
2. Uranga A, España PP, Bilbao A, Quintana JM, Arriaga I, Intxausti M, et al. Duration of Antibiotic Treatment in Community-Acquired Pneumonia: A Multicenter Randomized Clinical Trial. JAMA Internal Medicine. 2016 Sep 1;176(9):1257–65.
3. Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45–67.
4. About Pneumococcal Vaccine: For Providers | CDC [Internet]. 2022 [cited 2023 Jan 4]. Available from: https://www.cdc.gov/vaccines/vpd/pneumo/hcp/about-vaccine.html
5. CDC. Vaccine Schedules Based on Medical Indications [Internet]. Centers for Disease Control and Prevention. 2022 [cited 2023 Jan 5]. Available from: https://www.cdc.gov/vaccines/schedules/hcp/imz/child-indications.html
6. Centers for Disease Control and Prevention. [Prevention of Pneumococcal Disease Among Infants and Children – Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine]. MMWR 2010;59(No. RR-11):[6].
7. Adult Immunization Schedule by Vaccine and Age Group | CDC [Internet]. 2022 [cited 2023 Jan 5]. Available from: https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html