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Pneumococcal infections

Introduction

Pneumococcal infections are acute infections that are caused by the bacterium known as streptococcus pneumoniae (S. pneumoniae).  There are over 90 different strains of S. pneumoniae bacteria, which are known as serotypes.

S. pneumoniae enters the human body through the nose and mouth.

Types of pneumococcal infection

Pneumococcal infections normally fall into one of two categories:

  • non-invasive pneumococcal infections - are infections that occur outside the major organs or the blood and tend to be less serious.
  • invasive pneumococcal infections - that occur inside a major organ or the blood and tend to be more serious.

The two types of infection are described in more detail below.

Non-invasive pneumococcal infections

Non-invasive pneumococcal infections include:

  • bronchitis: an infection of the bronchi, which are tubes that run from the windpipe down into the lungs
  • otitis media an infection of the middle ear, which usually affects children under the age of 10 
  • sinusitis an infection of the sinuses, the small air-filled cavities behind the cheekbones and forehead 

Invasive pneumococcal infections

Invasive pneumococcal infections include:

  • bacteraemia: a relatively mild infection of the blood : infection of the bone 
  • septicaemia (blood poisoning): a more serious blood infection
  • osteomyelitis
  • septic arthritis: infection of  a joint
  • pneumonia: lung infection
  • meningitis: infection of the meninges, which are the protective membranes surrounding the brain and spinal cord

How common are pneumococcal infections?

Non-invasive pneumococcal infections are thought to be quite common, although it is hard to estimate the exact number of cases that occur each year in Wales. This is because infections usually clear up within a few days, so many people do not visit their GP.

One estimate is that there are around 63,000 cases of otitis media associated with pneumococcal infections in England and Wales each year.

Pneumonia is the most common type of invasive pneumococcal infection.  In England and Wales it is estimated that 40,000 people are admitted to hospital for treatment due to pneumonia every year.

Other types of invasive penumococcal infections, such as bacteraemia are less common, with around 5,000 to 6,000 cases reported each year. 

Meningitis is the most serious type of invasive pneumococcal infection and is also the rarest. It is estimated that (in England, for example) only 1 person in every 100,000 develop the condition in any given year.

People with a weakened immune system are most at risk of catching a pneumococcal infection. This may be because:

  • they have a serious health condition, such as HIV or diabetes, that weakens their immune system
  • they are having treatment or taking medication that weakens their immune system, such as chemotherapy

Other at-risk groups include:

  • babies and young children under two years of age
  • adults over 65 years of age
  • people who misuse alcohol

See Pneumococcal infections - causes for a full list of the groups who are at risk of developing a pneumococcal infection.

Cases of invasive pneumococcal infection usually peak in the winter, during the months of December and January.

Pneumococcal infections can be treated with antibiotics.

Pneumococcal vaccinations

There are two different types of pneumococcal vaccination:

  • pneumococcal conjugate vaccine (PCV) - which is given to all children under the age of two as part of their childhood vaccination programme
  • pneumococcal polysaccharide vaccine (PPV)- which is given to all adults who are over 65 years of age, plus others who are at high risk

The PCV protects against 13 types of S. pneumoniae bacteria and the PPV protects against 23 types. It is thought that the PPV is around 50-70% effective at preventing more serious types of invasive pneumococcal infection.

See Pneumococcal vaccination - how it works for more information about these two types of vaccine and Pneumococcal vaccination - when it is used for further details of the high-risk groups that should receive the vaccine.

Outlook

Non-invasive pneumococcal infections are usually mild and go away without the need for treatment.

The outlook for pneumonia in people who are otherwise healthy is good, but the infection can lead to serious complications in people who are very young, very old or have another serious health condition.

Due to the introduction of the PCV in 2002, the number of people dying from complications that arise from pneumonia has fallen to around 7%.

The outlook for other types of invasive pneumococcal infections such as bacteraemia is generally good, although there is about a 1 in 20 chance that bacteraemia will trigger meningitis as a secondary infection.

The outlook for meningitis is poor. One person in ten with the condition will die and one in four will experience complications such as hearing loss, which may be permanent.

Multidrug-resistant Streptococcus pneumoniae (MDRSP)

During the 1990s, the increasing levels of S. pneumoniae that had developed a resistance to three or more types of antibiotics was a major concern. These types of bacteria are known as multidrug-resistant Streptococcus pneumoniae (MDRSP).

One study carried out during that time estimated that as many as one case of pneumococcal infection in five was associated with MDRSP.

MDRSP is a real concern because any infection caused by these resistant bacteria is challenging to treat and carries a higher risk of causing complications.

Thankfully, the introduction of two pneumococcal vaccines (PCV and PPV) led to a drop in MDRSP. Fewer cases of infection meant that antibiotics were used less frequently, and the less an antibiotic is used to kill bacteria the smaller the chance the bacteria will develop resistance to that bacteria.

However, data from 2008-2009 suggest that levels of MDRSP are starting to increase again, particularly a strain known as serotype 19A, which is not covered by the PCV.

The ability for bacteria to become resistant to antibiotics is the reason why GPs are becoming increasingly reluctant to prescribe antibiotics for mild infections.

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Symptoms

If you have a pneumococcal infection your symptoms will vary depending on the type of infection that you have. Some common symptoms include:

  • a high temperature (fever) of 38°C (100.4°F) or above
  • chills
  • sweats
  • aches and pains
  • headache
  • a general sense of feeling unwell

When to seek medical advice

You should contact your GP as soon as possible if you:

  • have a constant high temperature that lasts for more than three days
  • cough up mucus that is streaked with blood
  • develop rapid breathing (more than 30 breaths a minute) or chest pains
  • become drowsy or confused
  • experience shortness of breath or other breathing difficulties

You should also contact your GP as soon as possible if:

  • your child is under two years of age and they develop a high temperature
  • your child is over two years of age and their symptoms persist for more than three days

You should also see your GP if you have any of the risk factors that make you more vulnerable to developing a pneumococcal infection. See Pneumococcal infection - causes for more information about risk factors.

When to seek emergency medical advice

The most serious type of pneumococcal infection is bacterial meningitis, which requires immediate admission to hospital for emergency treatment.

Bacterial meningitis has a number of early warning signs that can occur earlier than the other symptoms.

These are:

  • pain in the muscles, joints or limbs, such as in the legs or hands
  • shivering or unusually cold hands and feet
  • blue lips and pale or blotchy skin

As the condition gets worse it may cause:

  • drowsiness
  • confusion
  • seizures or fits
  • an inability to tolerate bright lights, known as photophobia (this is less common in young children)
  • a stiff neck (also less common in young children)
  • a rapid breathing rate
  • a blotchy, red rash that does not fade or change colour when you place a glass against it

The symptoms of bacterial meningitis are different in babies and young children. Possible symptoms include:

  • becoming floppy and unresponsive or stiff with jerky movements
  • becoming irritable and not wanting to be held
  • unusual crying

You should dial 999 immediately to request an ambulance if you suspect that you or someone you know has bacterial meningitis.

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Causes

Streptococcus pneumoniae

There are more than 90 different strains of Streptococcus pneumoniae (S. pneumoniae) and some are much more likely to cause serious infection (virulent) than others.

Each strain of bacteria is classified by the type of complex sugar molecules that make up the outer shell of the bacteria.

Exactly how the outer shell is constructed is one factor that determines how virulent each strain is. Some strains have a weak and flimsy outer shell, which means the bacteria can be easily killed by infection-fighting white blood cells.

Other strains have a very tough outer shell, which makes the bacteria resistant to white blood cells and likely to cause a more serious infection.

It is thought that 8-10 strains are responsible for two-thirds of cases of serious infections in adults and most cases in children.

S. pneumoniae enter the human body through the nose and mouth, and an infection can be spread in the same way as a cold or the flu. This can be through:

  • direct contact, for example, when someone sneezes or coughs, tiny droplets of fluid that contain the bacteria are launched into the air and can be breathed in by others
  • indirect contact, for example, if infected droplets of fluid are transferred from someone's hand to a door handle, someone else who touches the handle may become infected with the bacteria if they then touch their mouth or nose

It is important to emphasise that pneumococcal infections are far less contagious than a cold or the flu. This is because most people’s immune systems are able to kill the bacteria before they have the opportunity to cause an infection.

Outbreaks of pneumococcal infections can sometimes occur in environments where there are many people who have a poorly functioning immune system, such as in children’s nurseries, care homes for the elderly and shelters for people who are homeless.

Risk factors

In most cases, S. pneumoniae bacteria do not cause a problem because the immune system prevents it from moving from the throat to other parts of the body.

However, in those with a weakened immune system, either due to their age or general health, the bacteria can move from the throat to other parts of the body, such as the lungs, the blood or the brain. If this happens, a more serious infection can develop.

Those who are particularly at risk from developing a pneumococcal infection are listed below.

  • Children under two years of age
  • Adults who are over 65 years of age
  • People who have a weakened immune system due to a health condition such as HIV or AIDS.
  • People who are receiving medical treatment that is known to weaken the immune system, such as chemotherapy, or corticosteroids.
  • People who have a history of spleen disease, or dysfunction (the spleen is a organ that filters the blood and plays an important role in fighting infection).
  • People with a chronic respiratory disease, such as chronic obstructive pulmonary disease (COPD).
  • People with coronary heart disease or who have previously had a heart attack.
  • People with chronic kidney disease.
  • People with chronic liver disease.
  • People with diabetes who need to take insulin.
  • People who wear a type of hearing aid that is known as a cochlear implant (people who use these devices have a slightly higher risk of developing meningitis. However, the reasons for this are unclear).
  • People who are addicted to alcohol or regularly misuse alcohol (alcohol misuse is known to weaken the immune system)
  • People who are currently infected by the influenza virus (this applies to both seasonal flu and swine flu)
  • People who smoke cigarettes or other tobacco products
  • People who are living in poverty (many of the factors related to poverty, such as poor diet and living in unhygienic and overcrowded environments, increase a person’s risk of developing a pneumococcal infection)
  • People who have spinal damage, which has resulted in their cerebrospinal fluid (CSF) to leak (CSF is a fluid that surrounds the brain and spine).
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Diagnosis

A number of different diagnostic tests are used to diagnose pneumococcal infections. Which tests you have will depend on your particular symptoms.

Some of the tests that may be used to diagnose pneumococcal infections are outlined below.

Physical examination

If a pneumococcal infection is suspected, your GP will listen to your chest with a stethoscope. The fluids that are produced during an invasive pneumococcal infection often cause a distinctive crackling sound.

Blood test

Your blood may be tested for the presence of bacteria. A high number of white, infection-fighting blood cells may indicate the presence of an infection.  The blood sample can be sent to a laboratory so the bacteria that caused the infection can be identified.

X-rays

X-rays may be able to show the presence of fluid in the lung, which would indicate a lung infection.  An X-ray uses radiation to produce images of the inside of the body.

Blood pressure test

You may have a blood pressure test because a serious infection can lead to a drop in blood pressure.

Lumbar puncture test

A lumbar puncture test involves taking a sample of cerebrospinal fluid (the fluid that surrounds the brain and spine) from the base of your spine and checking it for the presence of bacteria.  If the sample contains infection-fighting white blood cells and/or bacteria, it may indicate that you have meningitis.

Urinary antigen test

A urinary antigen test is a relatively new type of test that can be used to help diagnose a pneumococcal infection.

It involves taking a urine sample and then carrying out a technique known as an immunochromatographic assay. This is able to detect the distinctive protein molecules that make up the outer shell of the S. pneumoniae bacteria.

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Treatment

Non-invasive pneumococcal infections

Non-invasive pneumococcal infections, such as sinusitis or bronchitis, will usually clear up within a week without the need for treatment.

Drinking plenty of fluids, getting plenty of rest and taking the over-the-counter (OTC) painkillers, such as paracetamol, should help to relieve your symptoms.

See the topics below for more advice about treating specific types of pneumococcal infections:

  • Bronchitis - treatment
  • Otitis media - treatment
  • Sinusitis - treatment

    Invasive pneumococcal infections

    If you have an invasive pneumococcal infection, such as pneumonia, a decision will be made about whether you are well enough to be treated at home or need to be admitted to hospital.

    Most GPs use a scoring system, known as the CRB-65 score, to assess the potential seriousness of a case of pneumonia.

    • C stands for confusion: if you are mentally confused you may have a more serious infection.
    • R stands for respiratory rate: your respiratory rate is how many breaths you take in a minute. More than 30 breaths a minute may be a sign that your lungs are not working properly.
    • B stands for blood pressure: low blood pressure can be a sign of a more serious infection.
    • 65 indicates whether you are 65 years of age or over: older people are more vulnerable to the effects of infection.

    Each of the above criteria is given a score of either 0 or 1 depending on whether or not it is applicable. This scoring system is explained below.

    • A CRB-65 score of 0 means you have a low risk of complications and can usually be treated at home.
    • A CRB-65 score of 1-2 means you have a medium risk of developing complications and you should have a same-day assessment by an expert in treating pneumonia. Depending on the results of the assessment, you may be treated at home or you may need to be admitted to hospital.
    • A CRB-65 score of 3 or more means you have a high risk of developing complications and you should be admitted to hospital for urgent treatment.

    Hospital admission is also recommended for:

    • any type of invasive pneumococcal infection that has developed in a baby or child less than two years of age
    • all cases of suspected meningitis

    Treatment at home

    If you are being treated at home, you will usually be prescribed a seven-day course of  antibiotics.  An antibiotic called amoxicillin is the preferred choice. If you are allergic to amoxicillin, alternative antibiotics such as doxycycline can be used.

    The most common side effects of the antibiotics used to treat pneumonia are:

    • nausea (feeling sick)
    • vomiting
    • diarrhoea

    These side effects are usually mild.

    Sometimes, doxycycline can make your skin more sensitive to the effects of sunlight. Therefore, you should minimise your exposure to direct sunlight and avoid using sun lamps and sun beds when taking doxycycline.

    It is very important that you finish your course of antibiotics, even if you start to feel better. Not completing the full course of antibiotics could cause the pneumonia to return.

    Treatment at hospital

    If your symptoms are moderate, you can usually be treated with antibiotic tablets.

    If your symptoms are severe, you will usually be given antibiotics through a drip into your arm. You may also be given fluids to stop you becoming dehydrated, and oxygen to help you breathe.

    Depending on how well you respond to treatment, it may be possible to switch from a drip to antibiotic tablets after a few days.

    Most people who are treated in hospital require a seven-to-ten-day course of antibiotics. The length of time it will take before you are well enough to return home will depend on your general state of health and whether you experience a more serious type of pneumococcal infection, such as meningitis. 

    Follow up

    It is usually recommended that you attend a follow-up examination six weeks after the start of your symptoms. This is to check that the infection has not caused any serious or permanent damage to the affected parts of your body, such as your lungs.

    The follow-up examination usually involves taking a chest X-ray so the state of your lungs can be assessed.

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    Prevention

    Preventing the spread of infection

    You can help to prevent the spread of a pneumococcal infection by taking some simple hygiene precautions. These include:

    • washing your hands regularly and thoroughly, particularly after touching your mouth and nose, and before handling food
    • coughing and sneezing into a tissue, immediately throwing it away, and washing your hands
    • not sharing cups or kitchen utensils with others.

    Pneumococcal conjugate vaccine (PCV)

    All children under the age of two should routinely receive the pneumococcal conjugate vaccine (PCV) as part of their childhood immunisation schedule.

    A first dose of PCV is usually given when a child is between 2-4 months of age, with a second dose given two months later.

    The PCV is entirely safe, although about 1 in 10 children will experience some redness and swelling at the site of the injection, plus symptoms of a mild fever. However, these symptoms will pass quickly.

    Speak to your GP or health visitor if you are not sure whether your child has received their PCV.

    Pneumococcal polysaccharide vaccine (PPV)

    If you are in one of the high-risk groups for developing a pneumococcal infection (see Pneumococcal infections - causes), your GP surgery will contact you to arrange a vaccination. If this is not the case, you should contact your GP to arrange an appointment.

    Healthy adults usually require only one dose of PPV. However, those with weakened immune systems or spleen disorders may require additional booster doses. Your GP will be able to advise you about this.

    After you have had your PPV you may experience some pain and inflammation at the site of the injection. This should only last for between 1-3 days. Less commonly, some people report the symptoms of a mild fever. Again, this should pass quickly.

    See the Health topic about Pneumococcal vaccination for more information and advice.

    Alcohol

    There is an increasing body of evidence to suggest that people who drink an excessive amount of alcohol are a greater risk of developing invasive pneumococcal infections.

    Alcohol is known to suppress some of the the immune system, the body's natural defence system that will attempt to prevent an invasive pneumococcal infection. Therefore, the best way to lower your risk of developing a pneumococcal infection is to ensure that you stick to the recommended daily amounts for alcohol.

    The recommended daily amount of alcohol consumption is 3-4 units for men, and 2-3 units for women. A unit of alcohol is equal to about half a pint of normal strength lager, a small glass of wine, or a pub measure (25ml) of spirits.

    Speak to your GP if you are finding it difficult to moderate your alcohol consumption. Counselling and medication are available for people with an alcohol misuse problem.

    See the Health topic about Alcohol misuse and the Lifestyle & Wellbeing section about Alcohol for more information and advice.

    Smoking

    Smoking is the single biggest risk factor for developing an invasive pneumococcal infection in otherwise healthy adults.

    Research has found that almost 60% of previously healthy people who develop an invasive pneumococcal infection are smokers.

    It is not known exactly why smoking makes a person more vulnerable to an invasive pneumococcal infection. One theory is that the chemicals contained in tobacco smoke disrupt the normal workings of the immune system and make it less efficient.

    As well as reducing your risk of developing an invasive pneumococcal infection, giving up smoking will help reduce your risk of developing other serious health conditions, such as cancer, heart disease and stroke.

    If you want to give up smoking a good first step is to contact Smokers Helpline Wales on 0800 169 0 169 and Stop Smoking Wales on 0800 085 2219.  Stop Smoking Wales hold details of local support services.  These services offer the most effective support for people who want to give up smoking. Studies show you are four times more likely to give up smoking successfully if you do it with the help of the NHS.

    Alternatively, your GP can provide help and advice about quitting.

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