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Double jeopardy: Pneumococcal pneumonia following seasonal influenza

Schweon, Steven J. MPh, MSN, RN, CIC, HEM

doi: 10.1097/01.NURSE.0000390682.88018.ef
Department: COMBATING INFECTION
Free

Steven J. Schweon is an infection preventionist at Pleasant Valley Manor Nursing Home in Stroudsburg, Pa. He's also an infection prevention consultant.

SHORTLY AFTER a family get-together, Mrs. Jacob, a 65-year-old woman with no known medical problems, suddenly develops severe myalgia, headache, fatigue, pharyngitis, fever, and chills. She calls her healthcare provider, who tells her to come to his office that same day. He adds that she'll be given a surgical mask to wear upon entering the office and be kept apart from other patients in the waiting room.

At the healthcare provider's office, Mrs. Jacob's oral temperature is 102.0° F; apical heart rate, 110; respiratory rate, 22; and BP, 124/76 mm Hg. Her heart sounds are normal and breath sounds are clear. Based on Mrs. Jacob's signs and symptoms, the healthcare provider suspects seasonal influenza and obtains a nasal-pharyngeal specimen for confirmation. She's prescribed the antiviral agent oseltamivir.

The healthcare provider asks Mrs. Jacob whether she'd received office reminders to obtain both a seasonal influenza and pneumococcal polysaccharide vaccine (PPSV) in October. She replies that she did, but hadn't gotten around to getting them. The healthcare provider doesn't offer PPSV now due to her moderate illness.1 Instead, he asks the nurse to give Mrs. Jacob a PPSV information sheet and set up an appointment to receive the vaccine in 2 weeks.

At home, she improves for 10 days, then her condition worsens. Mrs. Jacob calls her healthcare provider complaining of fever and a productive cough and is referred to the local ED. In triage, her oral temperature is 103.2° F; pulse, 116 beats/minute; respiratory rate, 24 breaths/minute; and BP, 124/82 mm Hg. SpO2 is 90% on room air, and she has right-sided inspiratory crackles and rhonchi on auscultation.

Mrs. Jacob has a gray, anxious appearance and complains of sharp, "stabbing" chest pain, which worsens with inspiration and coughing. Supplemental oxygen is administered, peripheral venous access is established, and she's placed on a cardiac monitor. Blood specimens are obtained for a complete blood cell count, basic metabolic panel, and blood cultures, and a sputum specimen is obtained for Gram stain and culture and sensitivity.

A 12-lead ECG shows sinus tachycardia without signs of myocardial ischemia or infarction. Mrs. Jacob's white blood cell count is 13,000 cells/mm3, and a chest X-ray reveals a right middle lobe pulmonary infiltrate. Mrs. Jacob has no known allergies, and initial empiric antibiotic therapy is begun with I.V. ceftriaxone and azithromycin in the ED. Once culture results are available, antibiotic therapy will be modified to target the identified pathogen(s) and to narrow the spectrum of activity if possible.2

Sputum Gram stain reveals Gram-positive cocci in pairs and chains, and both the sputum and blood cultures are positive for Streptococcus pneumoniae, or pneumococcus. Mrs. Jacob is diagnosed with pneumococcal pneumonia and bacteremia following seasonal influenza. Both culture-antibiotic sensitivity reports reveal the organism is resistant to penicillin but sensitive to ceftriaxone, so the azithromycin is discontinued.

After 4 days her fever dissipates, her clinical status improves, and she's discharged. One week later, she has a follow-up appointment with her healthcare provider, who offers her PPSV. He explains that different pneumococcal strains can cause infection, and infection with one type doesn't protect against another type.3 Mrs. Jacob agrees to be vaccinated.

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Dangerous combination

Secondary bacterial pneumonia is a well-recognized complication following seasonal influenza infection. An estimated 175,000 hospitalizations in the United States each year are due to pneumococcal pneumonia, with mortality at 5% to 7%.4 Pneumococcal bacteremia occurs in 25% to 30% of patients with pneumococcal pneumonia.4 It's most common in neonates and patients age 70 and older. Previous respiratory viral infection with the influenza virus predisposes patients to pneumococcal infection.5 Pneumococcal disease kills more people each year than all other vaccine-preventable diseases combined, with more than half occurring in adults to whom PPSV was recommended.4

Many healthy people are colonized with pneumococcus in their respiratory tract. Respiratory droplets can transmit the organism to others. The CDC recommends standard precautions when caring for a patient with pneumococcal pneumonia. Droplet precautions should be implemented if there's evidence of transmission within a patient-care unit or facility.6

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Recommended vaccines

PPSV doesn't protect against pneumococcal pneumonia.7 Instead, it offers protection against invasive pneumococcal diseases such as bacteremia and meningitis. For this reason, it shouldn't be referred to as the "pneumonia vaccine."7 Recommend PPSV along with a seasonal influenza vaccination to all patients age 65 and over, as well as those who have risk factors for pneumococcal disease (see Who's at risk?).

Another type of pneumococcal vaccine, pneumococcal conjugate vaccine, is recommended for children under age 5. It's not recommended for adults.1

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Patient education

Educate older patients and younger patients with long-term health problems about the importance of receiving both PPSV and seasonal influenza vaccines to help prevent dangerous complications. Use the PPSV Vaccine Information Statement, available at www.immunize.org/vis/pneum3.pdf, to help them understand the vaccine.

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Who's at risk?1

A single dose of PPSV is recommended for anyone ages 2 through 64 with health problems such as:

  • heart disease
  • lung disease
  • sickle cell disease
  • diabetes
  • alcoholism
  • cirrhosis
  • cochlear implants
  • cerebrospinal fluid leaks
  • Hodgkin disease
  • lymphoma or leukemia
  • kidney failure
  • multiple myeloma
  • nephrotic syndrome
  • HIV infection or AIDS
  • damaged or absent spleen
  • organ transplant
  • receiving long-term steroids, certain cancer drugs, or radiation therapy
  • smoking (any adult ages 19 through 64)
  • asthma (any adult ages 19 through 64).

A second dose may be recommended for patients age 65 and older who received their first dose when they were under age 65 and it's been 5 or more years since the first dose. It's also recommended for patients ages 2 through 64 who have a damaged or absent spleen; sickle cell disease; HIV infection or AIDS; cancer, leukemia, lymphoma, or multiple myeloma; nephritic syndrome; an organ or bone marrow transplant; or are taking medications that lower immunity.

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REFERENCES

1. Immunization Action Coalition. Pneumococcal polysaccharide vaccine: what you need to know. October 6, 2009 .
2. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S27–S72.
3. Immunization Action Coalition. Ask the experts. October 2009 .
4. Immunization Action Coalition. Pneumococcus: questions and answers. September 2010 .
5. Mandell GL, Bennett JE, Dolin R. Principles and Practices of Infectious Diseases. 6th ed. New York: Churchill Livingstone; 2004.
6. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. 2007 guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings .
7. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. 11th ed. Washington, DC: Public Health Foundation; 2009.
© 2010 Lippincott Williams & Wilkins, Inc.