Streptococcus pneumoniaeLecture 9

Summer, 2004

Demosthenes Pappagianis, MDMMI 480B

Type of Infection Annual Deaths

Acute respiratory infections (primarily pneumonia)

4,300,000

Diarrheal diseases 3,200,000 Tuberculosis 3,000,000 Hepatitis B 1,000,000 – 2,000,000 Malaria 1,000,000 Measles 880,000 Neonatal tetanus 600,000 AIDS 550,000 Pertussis 360,000

The world’s deadliest infections*

AIDS, acquired immunodeficiency synodrome.

*Worldwide mortality data, for 1990(complied by the World Health Organization and the Harvard School of Public Health

Representative Organisms

Lower Respiratory Tract Infections

EMDiplococci - Strep

Lancet

Portion of cell wall peptidoglycan

Amidase action

Streptococcus pneumoniae (pneumococcus) type 3 pneumococcus

Type 3 and Type 8 antigens pneumococcus cross reaction

Predominant type in descending order of frequency

Present in “23-valent” vaccine

In Children

26*(6B Danish)

19* (19F Dan)

23* (23F Dan)

1

4

9* (9F Dan)

43 (11A Dan)

14*

15 (15F Dan)

85%

In Adults

8431451 (7F Dan)12 (12F Dan)9 (9N Dan)156 (18C Dan)19 (19F Dan)26 (6B Dan)23 (23F Dan)

85%

* most often in pneumonia:

23, 26 (6B), 9(9F) in meningitis

1 202 223 23 (23F Dan)4 34 (10A Dan)5 43 (11A Dan)26 (6B Dan) 51 (7F Dan)8 54 (15B Dan)9 (9N Dan) 56 (18C Dan)12 57 (19A Dan)14 68 (9V Dan)17 70 (33F Dan)19 (19F Dan)

Serotypes (Capsular) of Streptococcus pneumoniae

Pneumonias Community Acquired Nosocomial% of patients % of patients65 Streptococcus pneumoniae Co Klebsiella pneumoniae12 Haemophilus influenza Escherichia coli Co 2 Staphylococcus aureus CO 60 Serratia marcescens Co 1 Gram negative aerobic bacilli Co Enterobacter spp Co 4 Miscellaneous agents * Co Pseudomonas sp Co 4 Legionella spp Co 13 Staphylococcus aureus 7 Mycoplasma pneumoniae 8 Streptococcus pneumoniae Co 1 Chlamydia pneumoniae 3 Viruses

*Moraxella catarrhalisMycobacterium tuberculosisEndemic fungiCo = Comorbid condition

Influenza

Normal respiratoryciliated pseudostratified epithelium

Epithelium damaged by influenza virus

Pneumococci Type I Alveolar Edema

Pneumonia/Congestion

Lobar Pneumonia

Bronchopneumonia in 4 1/2 y/o female

Bronchopneumonia in 4 1/2 y/o female

Alveolar exudate

Untreated Lobar Pneumonia

Premature and neonate: Grp B Strep. agalactiae, E. coli K1, other enteric bacilli, Listeria monocytogenes, Enterococcus sp..

2 weeks – 3 months: E. coli K1. Strep. agalactiae, L. monocytogenes, Strep. pneumoniae.

3 months – 4 years: S. pneumoniae, N. meningitidis, H. influenzae*, other Strep.. G(-) bacilli.

5 years – 50 years: N. meningitidis, Strep. pneumoniae, H. influenzae*, G(-) bacilli**, Staph. aureus*, Streptococcus species

>50 years: Strep. pneumoniae, N. meningitidis, G(-) bacilli**, S. aureus, Strep. agalactiae, L. monocytogenes**

Acute Bacterial Meningitis

* Has become infrequent in USA

** Especially in hospitalized patients

*** Especially with underlying disease, e.g. renal failure

76 y/o man - died of acute pneumococcal meningitis

Arrows point to depressed scar

Exudate

Percentage of persons aged >/= 65 years who reported receiving influenza or pneumococcal vaccine, by year

Behavioral Risk Factor Surveillance System, United States, 1993-1999

Strep. pneumoniae

Sites of resistance to antimicrobials

Prevalence of bacterial causes of common infections

Bacteria Pneumoniae Otitis media Sinusitis Meningitis

Streptococcus pneumoniae 8.4% 40% 30% 35%

Legionella species 6% -- -- --

Hemophilus influenzae 5.3% 25% 20% 10%

Mycoplasma pneumoniae 3.6% -- -- --

Moraxella (Branhamella) -- 10% 20% --

Catarrhalis

Neisseria meningitidis -- -- -- 35%

Mycobacterium tuberculosis 1.5% -- -- --

Unknown 43% 25%30% --

*Percentages do not add up to 100% in some cases because not all species are included.

Infection *

Organism No. of Cases

Reported

Percentage Of Total*

Incidence Case Fatality Rate (%)

Haemophilus influenzae

18 7 0.2 6

Streptococcus pneumoniae

117 47 1.1 21

Neisseria meningitidis 62 25 0.6 3

Group B streptococcus 31 12 0.3 7

Listeria monocytogenes

20 8 0.2 15

Bacterial Meningitis in the United States in 1995

• Causes of 248 Cases of Bacterial Meningitis in 1995 and Overall Case Fatality Rate According to Organism

*Because of rounding, the percentages do not total 100.

+The incidence is the number of cases per 100,000 population.

++Outcome data were missing for 11 cases of meningitis (4 percent). The case fatality rates are based on cases with known outcomes.

Resistance of Strep. Pneumoniae to fluoroquinolones

Aural TraumaStrep. pneumo.

meningitis

Aural TraumaStrep. pneumo.

meningitis

Early Consolidation - alveoli with Strep. pneumoniae

Inner Zone of Advanced

Consolidation (pneumococi

phagocytosed)

Type Adults Children Type Adults Children I 22.0 14.1 XVII 1.2 1.4 II 7.4 2.2 XVIII 2.5 2.9 III 12.8 3.9 XIX 2.4 8.2 IV 5.7 4.6 XX 1.6 1.4 VII 9.3 4.0 XXIII 0.7 3.0 VIII 8.0 1.4 XXIV 0.6 0.7 IX 2.2 1.6 XXV 1.1 0.03 X 1.1 0.8 XXVII 0.3 0.003 XI 1.1 1.6 XXVIII 0.4 0.9 XII 1.6 O.4 XXIX 0.8 1.3 XIV 4.1 17.2 XXXII 0.2 0.01 XV 0.9 2.8 XXXIII 0.5 0.5 XVI 0.8 1.4

Type Distribution of Pneumoccoccal Pneumonias in Adults and Children

(Collected from various sources)

Incidence (Per cent)

Streptococcus pneumoniae

Streptococcus pneumoniae type 1 in alveoli clumped by antibody

Leukocyte containing opsonized pneumococci

Lung, organizing pneumonia

Lobar Pneumonia

Optochin disk, Strep. pneumoniae

P = oPtochin disc