Infect Chemother.  2010 Aug;42(4):223-229. 10.3947/ic.2010.42.4.223.

Comparison of Clinical Characteristics of Pneumococcal and non-Pneumococcal Streptococcal Pneumonia

• Jo YM
• Song JY
• Choi WS
• Heo JY
• Noh JY
• Kim WJ
• Cheong HJ

• KMID: 1457382
• DOI: http://doi.org/10.3947/ic.2010.42.4.223

Abstract

BACKGROUND
Although Pneumococcal (SPN) pneumonia is the most common cause of community-acquired pneumonia, non-pneumococcal streptococcal (NSPN) pneumonia is also frequently reported. However, there are insufficient data on characteristics of NSPN pneumonia which makes it difficult to decide treatment plans or to assess the prognosis.
MATERIALS AND METHODS
Between March 2002 and February 2009, medical records including clinical and epidemiological data on patients aged > or =18 years with community-acquired streptococcal pneumonia were reviewed retrospectively. Clinical characteristics were compared between community-acquired NSPN pneumonia and SPN pneumonia.
RESULTS
During the 7 year study periods, 248 patients were hospitalized with community-acquired streptococcal pneumonia and 30 of them had NSPN pneumonia. There were 12 cases of Streptococcus constellatus, 7 cases of S. anginosus, 4 cases of S. mitis, 3 cases of S. pyogenes, 2 cases of S. oralis, 1 case of S. alactolyticus and 1 case of S. agalactiae. There was no difference in percentage of patients with a chronic underlying disease between SPN and NSPN pneumonia groups. The most common was chronic obstructive pulmonary disease (SPN 29.8%, NSPN 16.7%) followed by diabetes mellitus (SPN 22.0%, NSPN 13.3%). Bacteremia (SPN 7.3%, NSPN 20.0%, P=0.04) and empyema (SPN 1.4%, NSPN 53.3%, P<0.001) were more common in NSPN pneumonia. However, there was no significant difference in the CURB-65 pneumonia severity score and 30-day mortality between the two groups. According to multivariate analysis results, the significant risk factor for NSPN pneumonia was the history of frequent alcohol drinking (Adjusted OR 3.81, 95% CI 1.36 to 10.67).
CONCLUSION
Pneumonia caused by NPSN is more commonly accompanied by bacteremia and empyema compared to SPN pneumonia, but there was no difference in the 30-day mortality between the two groups. NSPN pneumonia should be considered if a patient with a history of chronic alcoholism presents with pneumonia and pleural effusion, especially when Gram positive diplococci is seen in the sputum Gram stain.

Keyword

Community-acquired pneumonia; Pneumococcal pneumonia; Streptococcus

MeSH Terms

Aged
Alcohol Drinking
Alcoholism
Bacteremia
Diabetes Mellitus
Empyema
Humans
Medical Records
Multivariate Analysis
Pleural Effusion
Pneumonia
Pneumonia, Pneumococcal
Prognosis
Pulmonary Disease, Chronic Obstructive
Retrospective Studies
Risk Factors
Sputum
Streptococcus
Streptococcus constellatus

Figure

• 

  Figure 1 Annual cases of Streptococcal pneumonia. SPN, Pneumococcal pneumonia; NSPN, Non-pneumococcal streptococcal pneumonia.

Reference

1. Bartlett JG, Dowell SF, Mandell LA, File TM Jr, Musher DM, Fine MJ. Infectious Diseases Society of America. Practice guidelines for the management of community-acquired pneumonia in adults. Clin Infect Dis. 2000. 31:347–382.

2. Song JH, Oh WS, Kang CI, Chung DR, Peck KR, Ko KS, Yeom JS, Kim CK, Kim SW, Chang HH, Kim YS, Jung SI, Tong Z, Wang Q, Huang SG, Liu JW, Lalitha MK, Tan BH, Van PH, Carlos CC, So T. Asian Network for Surveillance of Resistant Pathogens Study Group. Epidemiology and clinical outcomes of community-acquired pneumonia in adult patients in Asian countries: a prospective study by the Asian network for surveillance of resistant pathogens. Int J Antimicrob Agents. 2008. 31:107–114.

3. Barnham M, Weightman N, Anderson A, Pagan F, Chapman S. Review of 17 cases of pneumonia caused by Streptococcus pyogenes. Eur J Clin Microbiol Infect Dis. 1999. 18:506–509.

4. Gentile JH, Sparo MD, Mercapide ME, Luna CM. Adult bacteremic pneumococcal pneumonia acquired in the community A prospective study on 101 patients. Medicina (B Aires). 2003. 63:9–14.

5. Laupland KB, Gregson DB, Zygun DA, Doig CJ, Mortis G, Church DL. Severe bloodstream infections: a population-based assessment. Crit Care Med. 2004. 32:992–997.

6. Talbot TR, Hartert TV, Mitchel E, Halasa NB, Arbogast PG, Poehling KA, Schaffner W, Craig AS, Griffin MR. Asthma as a risk factor for invasive pneumococcal disease. N Engl J Med. 2005. 352:2082–2090.

7. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM Jr, Musher DM, Niederman MS, Torres A, Whitney CG. Infectious Diseases Society of America. American Thoracic Society. 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.

8. Anevlavis S, Petroglou N, Tzavaras A, Maltezos E, Pneumatikos I, Froudarakis M, Anevlavis E, Bouros D. A prospective study of the diagnostic utility of sputum Gram stain in pneumonia. J Infect. 2009. 59:83–89.

9. Wikler MA. Performance standards for antimicrobial susceptibility testing: 19th informational supplement. 2009. Wayne, PA: CLSI.

10. Chung MH, Shin WS, Kim YR, Kang MW, Kim MJ, Jung HJ, Park SC, Pai H, Choi HJ, Shin HS, Kim EC, Choe KW, Kim S, Peck KR, Song JH, Lee K, Kim JM, Chong Y, Han SW, Lee KM. Etiology of community-acquired pneumonia surveyed by 7 university hospitals. Korean J Infect Dis. 1997. 29:339–359.

11. Woo JH, Kang JM, Kim YS, Shin WS, Ryu JH, Choi JH, Kim YR, Cheong HJ, Uh ST, Park CS, Chung MH, Chung KS, Lee CJ, Ryu J. A prospective multicenter study of community-acquired pneumonia in adults with emphasis on bacterial etiology. Korean J Infect Dis. 2001. 33:1–7.

12. Yamashiro T. Studies on clinical significance of "Streptococcus milleri group" in respiratory infections. Kansenshogaku Zasshi. 1991. 65:1419–1429.

13. Shinzato T, Saito A. The Streptococcus milleri group as a cause of pulmonary infections. Clin Infect Dis. 1995. 21:Suppl 3. S238–S243.

14. Singh KP, Morris A, Lang SD, MacCulloch DM, Bremner DA. Clinically significant Streptococcus anginosus (Streptococcus milleri) infections: a review of 186 cases. N Z Med J. 1988. 101:813–816.

15. Sugihara E, Kido Y, Okamoto M, Koyanagi T, Niizeki T, Hirota N, Minami S, Kinoshita T, Uehara Y, Koga H, Ono N, Rikimaru T, Aizawa H. Clinical features of acute respiratory infections associated with the Streptococcus milleri group in the elderly. Kurume Med J. 2004. 51:53–57.

16. Ahmed RA, Marrie TJ, Huang JQ. Thoracic empyema in patients with community-acquired pneumonia. Am J Med. 2006. 119:877–883.

17. Schugk J, Harjola VP, Sivonen A, Vuopio-Varkila J, Valtonen M. A clinical study of beta-haemolytic groups A, B, C and G streptococcal bacteremia in adults over an 8-year period. Scand J Infect Dis. 1997. 29:233–238.

18. Crum NF, Russell KL, Kaplan EL, Wallace MR, Wu J, Ashtari P, Morris DJ, Hale BR. Pneumonia outbreak associated with group A Streptococcus species at a military training facility. Clin Infect Dis. 2005. 40:511–518.

19. Dolinski SY, Jones PG, Zabransky RJ, Rasansky M. Group C streptococcal pleurisy and pneumonia: a fulminant case and review of the literature. Infection. 1990. 18:239–241.

20. O'Loughlin RE, Roberson A, Cieslak PR, Lynfield R, Gershman K, Craig A, Albanese BA, Farley MM, Barrett NL, Spina NL, Beall B, Harrison LH, Reingold A, Van Beneden C. Active Bacterial Core Surveillance Team. The epidemiology of invasive group A streptococcal infection and potential vaccine implications: United States, 2000-2004. Clin Infect Dis. 2007. 45:853–862.

21. Fujiki R, Kawayama T, Rikimaru T, Oizumi K. A three-year review of acute respiratory tract infections caused by Streptococcus milleri group. Kansenshogaku Zasshi. 2002. 76:174–179.

22. Bartlett JG, Gorbach SL, Thadepalli H, Finegold SM. Bacteriology of empyema. Lancet. 1974. 1:338–340.

23. Snider GL, Saleh SS. Empyema of the thorax in adults: review of 105 cases. Dis Chest. 1968. 54:410–415.

24. Light RW, Girard WM, Jenkinson SG, George RB. Parapneumonic effusions. Am J Med. 1980. 69:507–512.

25. Willcox MD. Potential pathogenic properties of members of the "Streptococcus milleri" group in relation to the production of endocarditis and abscesses. J Med Microbiol. 1995. 43:405–410.

26. Kitada K, Inoue M, Kitano M. Experimental endocarditis induction and platelet aggregation by Streptococcus anginosus, Streptococcus constellatus and Streptococcus intermedius. FEMS Immunol Med Microbiol. 1997. 19:25–32.

27. Jacobs JA, Stobberingh EE. Hydrolytic enzymes of Streptococcus anginosus, Streptococcus constellatus and Streptococcus intermedius in relation to infection. Eur J Clin Microbiol Infect Dis. 1995. 14:818–820.

28. Shain H, Homer KA, Beighton D. Degradation and utilisation of chondroitin sulphate by Streptococcus intermedius. J Med Microbiol. 1996. 44:372–380.

29. Unsworth PF. Hyaluronidase production in Streptococcus milleri in relation to infection. J Clin Pathol. 1989. 42:506–510.

30. Nagashima H, Takao A, Maeda N. Abscess forming ability of Streptococcus milleri group: synergistic effect with Fusobacterium nucleatum. Microbiol Immunol. 1999. 43:207–216.

31. Shinzato T, Saito A. A mechanism of pathogenicity of "Streptococcus milleri group" in pulmonary infection: synergy with an anaerobe. J Med Microbiol. 1994. 40:118–123.

32. Toyoda K, Kusano N, Saito A. Pathogenicity of the Streptococcus milleri group in pulmonary infections--effect on phagocytic killing by human polymorphonuclear neutrophils. Kansenshogaku Zasshi. 1995. 69:308–315.

33. Kanamori S, Kusano N, Shinzato T, Saito A. The role of the capsule of the Streptococcus milleri group in its pathogenicity. J Infect Chemother. 2004. 10:105–109.

34. Jacobs MR. Streptococcus pneumoniae: epidemiology and patterns of resistance. Am J Med. 2004. 117:Suppl 3A. 3S–15S.

35. Metlay JP, Hofmann J, Cetron MS, Fine MJ, Farley MM, Whitney C, Breiman RF. Impact of penicillin susceptibility on medical outcomes for adult patients with bacteremic pneumococcal pneumonia. Clin Infect Dis. 2000. 30:520–528.

36. Aspa J, Rajas O, Rodríguez de Castro F, Blanquer J, Zalacain R, Fenoll A, de Celis R, Vargas A, Rodríguez Salvanés F, España PP, Rello J, Torres A. Pneumococcal Pneumonia in Spain Study Group. Drug-resistant pneumococcal pneumonia: clinical relevance and related factors. Clin Infect Dis. 2004. 38:787–798.

37. Johansson N, Kalin M, Tiveljung-Lindell A, Giske CG, Hedlund J. Etiology of community-acquired pneumonia: increased microbiological yield with new diagnostic methods. Clin Infect Dis. 2010. 50:202–209.