Pneumococcus Notes Allied

Pneumococcus ( Streptococcus pneumoniae)
Clinical syndrome
Ninety serotypes of S. pneumoniae have been identified with varying degrees of pathogenicity,
out of which 23 serotypes are known to cause disease in humans. S.pneumoniae serotypes 3,
4, 6B, 9V, 14, 18C, 19F, and 23F cause the majority of invasive disease. S. pneumoniae causes
(a) Pneumonia
( b) Meningitis
(c) Sinusitis and Otitis media
(d ) Bacteremia
(e) Other infections.
Pneumonia
• S. pneumoniae is the leading cause of bacterial pneumonia, both lobar and broncho
pneumonia.
• Pneumonia develops when bacterium multiplies in the alveoli.
• The disease is associated with aspiration and is localized in the lower lobes of the lungs,
it is called lobar pneumonia.
• When it localizes in bronchioles, it is broncho pneumonia.
• S. pneumoniae is the most common bacterial cause of childhood pneumonia, especially
in children younger than 5 years. Serotypes 6, 14, 18, 19, and 23 are responsible for
most cases of pneumonia in children.
• Serotypes 1, 3, 4, 7, 8, and 12 cause pneumonia in adults leading to mortality in more
than 5–10%.
Meningitis
• Meningitis refers to infection of the menenges membrane of the brain and the spinal
cord.
• Pneumococcus is the most common cause of pyogenic meningitis in children, although
the condition can occur in all age groups.
• Meningitis is always secondary to other pneumococcal infections, such as pneumonia,
bacteremia, infections of the ear or sinuses.
• The bacteria reach the brain through blood stream or from nasopharynx (following head
trauma or dural tear particularly with cerebrospinal fluid leak).
• Pneumococcal meningitis is now emerging as a common cause of death in children and
in adults.
• Meningitis caused by S. pneumoniae is associated with a higher mortality and more
neurological complications than the meningitis caused by any other bacteria.
• Even with antibacterial therapy, the mortality due to pneumococcal meningitis is nearly
25%.
Sinusitis and otitis media

• Sinusitis refers to inflammation of the lining of sinuses in the face , otitis media refers
to inflammation of the middle ear.
• Sinusitis and otitis media occur in patients with prior viral infections. The viral infection
lowers the mucosal immunity,facilitating the invasion by S. pneumoniae.
• Sinusitis caused by the pneumococci occurs in patients of all ages, but otitis media
caused by the bacteria is seen only in young children.
• Pneumococci cause approximately 40% of otitis media cases.
Bacteremia
• Bacteremia refers to the presence of bacteria in the bloodstream.
• This condition is more frequent in children than in adults.
• Bacteremia occurs in more than two-thirds of patients with meningitis and in one-
fourth of the patients with pneumococcal pneumonia.
• This does not occur in patients with sinusitis or otitis media.
Other infections
These include spontaneous bacterial peritonitis, post splenectomy sepsis, endocarditis
associated with rapid destruction of heart valves, bone and joint infections (prosthetic or
natural ) joint septic arthritis, occasionally as a complication of rheumatoid arthritis),myositis,
and brain and epidural abscesses. All these infections result from seeding of tissues during
bacteremia.
Laboratory Diagnosis
Specimens
Sputum, endotracheal aspirate, bronchoalveolar lavage fluid,cerebrospinal fluid (CSF),
pleural fluid, joint fluid, abscess fluid, bones, and other biopsy material are the specimens
collected for Gram staining and culture.
Microscopy
Gram staining of sputum
• It is a rapid method for diagnosis of acute pneumonia.
Result: Stained smears showing lanceolate shaped,Gram-positive cocci in pairs surrounded
by a capsule is good evidence for pneumococcal infection.
Gram staining of sputum: It is a rapid method for diagnosis of acute pneumonia. Stained
smears showing lanceolateshaped, Gram-positive cocci in pairs surrounded by a capsule is
good evidence for pneumococcal infection. The morphology of the pneumococci may be
altered in the patient receiving antibacterial therapy
Gram staining of a buffy coat or blood smear: It is frequentlypositive in cases of

overwhelming pneumococcal sepsis and isuseful for rapid presumptive diagnosis of this
condition. In acute pneumococcal otitis media, Gram stain of an aspirated fluid
smear from middle ear is useful to demonstrate the bacteria.
Culture
❖ Sputum is plated on blood agar and incubated in the presenceof 5–10% carbon dioxide.
Gray colonies with alpha-hemolysis are observed after overnight incubation.
❖ Diagnosis of pneumococcal meningitisis confirmed by CSF culture and is positive in 90%

of untreated cases. However, the culture is negative in more than 50% of cases who have
received treatment even with a single dose of antibiotics.
❖ Culture of aspirated fluid from the middle ear or from the sinus is a definitive method for
diagnosis of otitis media or sinusitis.
Identification of bacteria
Optochin sensitivity test: S. pneumoniae is identified by its sensitivity to optochin. In this

method, a filter paper disc containing optochin (ethylhydrocupreine dihydrochloride) is applied
on the middle of blood agar plate streaked with pneumococci and is incubated overnight. A
zone of inhibition of 14 mm or more is observed around the disk after overnight incubation.
Bile solubility test: This is a very useful test to identify S. pneumoniae. It detects an autolytic
enzyme, amidase, present in pneumococci, which breaks the bond between alanine and
muramic acid of the peptidoglycan of the pneumococcal cell wall. The enzyme amidase is
activated by bile salts present in bile, resulting in lysis of pneumococci. The test is carried out
by applying a loopful of 10% sodium deoxycholate solution on the young colonies in the blood
agar. Most colonies of pneumococci are dissolved within a few minutes.
Inulin fermentation test: Pneumococci ferment inulin; hence inulin fermentation test is a
useful test to differentiate pneumococci from streptococci as the latter do not ferment it.
Animal inoculation: S. pneumoniae can be isolated from clinical specimens containing few
pneumococci by intraperitoneal inoculation in mice. Pneumococci are demonstrated in the
peritoneal exudate and heart blood of the mice, which die 1–3 days after inoculation.
Serodiagnosis
Pneumococcal antigen detection: The CIEP is a useful test to detect pneumococcal capsular
polysaccharide antigen in the CSF for diagnosis of meningitis, and in the blood or urine for
diagnosis of bacteremia and pneumonia. Latex agglutination test using the latex particles
coated with anti-CRP antibody is employed to detect C reactive protein. The CRP is used as a
prognostic marker in acute cases of acute pneumococcal pneumonia, acute rheumatic fever,
and other infectious diseases.CRP is found in sera from cases of acute pneumonia but is
absent during the convalescent phase of the disease.
Pneumococcal antibody detection: The indirect hemagglutination, indirect fluorescent

antibody test, and ELISA are used to demonstrate specific pneumococcal antibodies in invasive
pneumococcal diseases.
Treatment
Most pneumococci are susceptible to penicillin, amoxicillin, and erythromycin, these
antibiotics can be administrated.
Prevention and Control

Pneumococcal vaccines play an important role in prevention of pneumococcal diseases.
23-valent pneumococcal polysaccharide vaccine: The vaccine is effective and safe in
children older than 5 years.
7-valent pneumococcal conjugate vaccine: This is a vaccine made available recently for the
immunization of infants and toddlers against invasive pneumococcal disease caused by
capsular serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F.

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Pneumococcus ( Streptococcus pneumoniae)

Sinusitis and otitis media

Gram staining of a buffy coat or blood smear: It is frequentlypositive in cases of

❖ Diagnosis of pneumococcal meningitisis confirmed by CSF culture and is positive in 90%

Optochin sensitivity test: S. pneumoniae is identified by its sensitivity to optochin. In this

Pneumococcal antibody detection: The indirect hemagglutination, indirect fluorescent

Prevention and Control

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