Streptococcus pneumoniae infection medical therapy

Streptococcus pneumoniae infection Microchapters
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Classification Community Acquired Pneumonia Endocarditis Sinusitis Bronchitis Meningitis
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Medical Therapy
Primary Prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Antimicrobial therapy is the mainstay of therapy for infections caused by Streptococcus pneumoniae.

Medical therapy

• Streptococcus pneumonia treatment

• 1. Lung (Community-acquired pneumonia)

• 1.1 Penicillin sensitive (minimum inhibitory concentration < 2 mcg/ml)

• Preferred regimen: Penicillin G 5 to 24 MU IV in equally divided doses q4-6h, Amoxicillin 1 g PO tid (+/- macrolide)
• Alternative regimen: Macrolides (Azithromycin (IV) 500 mg IV qd for at least 2 days followed by 500 mg PO qd 7 to 10 days or Clarithromycin extended-release tablets 1000 mg PO qd for 7 days) and Oral Cephalosporins-Cefpodoxime 200 mg PO bd, (Cefprozil 500 mg PO bd, Cefditoren 400 mg PO bd, Cefdinir 300 mg PO bd), OR parenteral Cephalosporins-Ceftriaxone 2 g IV q24h (or Cefotaxime 1-2 g IV q6-8h), Clindamycin 600 to 1200 mg IV or IM q6-12h, do not give single IM doses >600 mg; IV infusion rates should not exceed 30 mg/min , Doxycycline 100 mg PO bd, respiratory flouroquniolones.

• 1.2 Penicillin-resistant (Penicillin minimum inhibitory concentration ≥2)

• Preferred regimen: Ceftriaxone 2 g IV q24h (or Cefotaxime 1-2 g IV q6-8h), respiratory Flouroquniolones Levofloxacin (Levaquin) 500 mg IV/PO q24h for 7 to 14 days or 750 mg IV/PO q24h for 5 days (or Moxifloxacin (Avelox) 400 mg PO/IV over 60 minutes q24h for 7 to 14 days)
• Alternative regimen: Vancomycin 2 g/day IV q6-12h over at least 60 minutes, Linezolid 600 mg IV/PO q12h for 7 to 21 days , high-dose Amoxicillin (3 g qd with Penicillin minimum concentration of inhibitory <4 mcg/mL).

• 2.Endocarditis

• Preferred regimen (1): Aqueous crystalline Penicillin-G 6 MU q4-6h IV for 4 weeks
• Preferred regimen (2) (who are unable to tolerate beta lactams therapy): Vancomycin 15 mg/kg IV every 12 hours (target trough concentration, 10 to 15 mcg/mL) [9]; for troughs of 15 to 20 mcg/mL (MIC, 1 mcg/mL or less), dose 15 to 20 mg/kg (actual body weight) IV every 8 to 12 hours for most patients with normal renal function
• Preferred regimen (3) (If the isolate is resistant (MIC 2 g/mL) to cefotaxime): Cefotaxime 1-2 g q8-12h IV or IM (max dose: 12 g/24 hr) AND Vancomycin 15 mg/kg/day IV q12h AND Rifampin 300 mg IV/PO q8h for 6 weeks, in combination with appropriate antimicrobial therapy
• Alternative regimen (1): Cefazolin 0.5-2 g q8h IV or IM (max dose: 12 g/24 hr)
• Alternative regimen (2): Ceftriaxone 2 g IV q12h

• Note : Streptococcus pneumoniae with intermediate doses minimum inhibitory concentration (MIC) 0.12 g/mL–0.5 g/mL Penicillin resistance (MIC 0.1 to 1.0 g/mL) or high Penicillin resistance (MIC 2.0 g/mL) is being recovered from patients with bacteremia.

• 3. Sinuses (sinusitis)

• Empiric therapy

• 3.1 For initial empiric treatment of acute bacterial rhinosinusitis in adults

• Preferred regimen: Amoxicillin 500 mg/Clavulanate 125 mg PO tid or Amoxicillin 875 mg/Clavulanate 125 mg PO bid for 5 to 7 days recommended by the Infectious Disease Society of America (IDSA)
• Alternative regimen (1): Doxycycline 100 mg PO q12h

• Note: Doxycycline can be used in patients with Penicillin allergy.

• Alternative regimen (2): A respiratory Fluoroquinolone (Levofloxacin or Moxifloxacin) is another recommended drug for Penicillin-allergic patients.

• 3.2 For second-line high-dose therapy for acute bacterial rhinosinusitis in adults

• Preferred regimen: Amoxicillin 2 g/Clavulanate 125 mg PO bid recommended by the Infectious Disease Society of America (IDSA).
• Note: The second line high dose therapy is recommended in adults who have failed initial therapy, in regions of high endemic rates (10% or greater) of invasive Penicillin-nonsusceptible Streptococcus pneumoniae, severe infection.

• 4. Bronchi (acute exacerbation of chronic bronchitis)

• Preferred regimen (1): Amoxicillin 875 mg PO q12h or 500 mg PO q8h
• Preferred regimen (2): Doxycycline 100 mg PO q12h

• 5. CNS (meningitis)

• Empiric therapy

• Preferred regimen: Vancomycin 15 mg/kg/day IV q12h AND a third-generation cephalosporin (Ceftriaxone 2 g IV q12h OR Cefotaxime 2 g IV q4h or 3 g q6h) AND Rifampin 600 mg IV qd in combination with Vancomycin
• Alternative regimen: Meropenem, fluoroquinolones

Note: Middle ear infections (otitis media), peritoneum infections (spontaneous bacterial peritonitis), pericardium infections (purulent pericarditis), skin infections (cellulitis) and eye infections (conjunctivitis) caused by Streptococcus pneumonia.

• Prevention

• 1. Pneumovax (23-valent) prevents bacteremia; impact on rates of CAP are modest or nil.
• 2. Prevnar vaccine for children <2 yrs age prevents invasive pneumococcal infection in adults by herd effect. Impact is impressive with rates of invasive pneumococcal infection down 80% in peds and 20-40% in adults.
• 3. Risk for bacteremia in splenectomy, HIV, smokers, black race, multiple myeloma, asthma.

References

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