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For further information, see CMDT Part 33-03: Pneumococcal Infections

Key Features

Essentials of Diagnosis

  • Productive cough, fever, rigors, dyspnea, early pleuritic chest pain

  • Consolidating lobar pneumonia on chest radiograph

  • Lancet-shaped gram-positive diplococci on Gram stain of sputum

General Considerations

  • The most common cause of community-acquired pyogenic bacterial pneumonia

  • Predisposing factors

    • Alcohol use disorder

    • Asthma

    • HIV infection

    • Sickle cell disease

    • Splenectomy

    • Hematologic disorders

Clinical Findings

Symptoms and Signs

  • High fever, productive cough, occasional hemoptysis, and pleuritic chest pain

  • Rigors may occur initially but are uncommon later in the course

  • Bronchial breath sounds are an early sign


Laboratory Tests

  • Diagnosis requires isolation of the organism in culture, although the Gram stain appearance of sputum can be suggestive

  • Sputum and blood cultures, positive in 60% and 25% of cases of pneumococcal pneumonia, respectively, should be obtained prior to initiation of antimicrobial therapy in patients who are admitted to the hospital

  • A good-quality sputum sample (< 10 epithelial cells and > 25 polymorphonuclear leukocytes per high-power field) shows gram-positive diplococci in 80–90% of cases

  • A rapid urinary antigen test for Streptococcus pneumoniae, with sensitivity of 70–80% and specificity > 95%, can assist with early diagnosis


  • Chest radiograph shows findings of consolidation, often with a lobar distribution, infiltrates, pleural effusion



  • Initial antimicrobial therapy of pneumonia is empiric pending isolation and identification of the causative organism (Table 9–8)


  • Amoxicillin, 750 mg twice daily orally for 7–10 days

  • Cephalosporins may also be used

    • Cefpodoxime, 200 mg orally twice daily

    • Cefdinir, 300 mg twice daily

  • Alternatives include

    • Azithromycin, one 500-mg dose orally on the first day and 250 mg orally for the next 4 days

    • Clarithromycin, 500 mg twice daily orally for 7 days

    • Doxycycline, 100 mg twice daily orally for 7 days

    • Levofloxacin, 750 mg orally for 5–7 days

    • Moxifloxacin, 400 mg orally for 7–14 days

  • Outpatients with high-risk comorbid conditions (such as pulmonary disease, diabetes, cardiac disease, or alcohol use disorder) may benefit from broader combination therapy (eg, amoxicillin/clavulanate or cephalosporin plus doxycycline or a macrolide), unless a fluoroquinolone is chosen for monotherapy


  • Ceftriaxone, 1 g every 24 hours intravenously

  • Azithromycin or doxycycline are typically added for coverage of atypical organisms

  • For a highly penicillin-resistant strain, one of the following may be used:

    • Vancomycin, 1 g every 12 hours intravenously

    • Levofloxacin, 750 mg intravenously or orally once daily

    • Moxifloxacin, 400 mg intravenously or orally once daily

  • Total duration of therapy is not well defined but 5–7 days is appropriate for patients who ...

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