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Pneumococcal Disease EU

CME

Pneumococcal Disease: Current Concepts for At-Risk Adults

Physicians: Maximum of 0.75 AMA PRA Category 1 Credit™

Released: August 22, 2024

Expiration: August 21, 2025

CME/CE Information

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Definitions and Burden of Pneumococcal Disease

Let's discuss the burden of pneumococcal disease. First, it is important to understand the difference between noninvasive and invasive pneumococcal disease.

Noninvasive pneumococcal disease refers to infections caused by S. pneumoniae in nonsterile sites, such as pneumococcal otitis media and nonbacteremic pneumococcal pneumonia.1

Invasive pneumococcal disease (IPD), on the other hand, occurs when S. pneumoniae infects typically sterile sites, such as the bloodstream, causing bacteremia, or the meninges, leading to meningitis. Other examples include osteomyelitis and pleural effusions. Differentiating between these types of infections is crucial, especially when considering at-risk individuals.2

The risk of pneumococcal disease follows a U-shaped curve, with children younger than 2 years old and adults older than 65 being particularly vulnerable.2,3  In addition, independent of age, certain chronic conditions increase the risk of pneumococcal disease. These conditions include diabetes, chronic lung diseases like chronic obstructive bronchitis, cardiac conditions, renal insufficiency, and lifestyle factors such as smoking and alcohol abuse.

People with functional or anatomical asplenia, sickle cell disease, HIV, or other immunocompromising conditions (whether due to disease or treatment) are at very high risk.

We categorize individuals with chronic conditions as being at moderate risk, and those who are immunocompromised or asplenic as high risk.

Although pneumococcal infections can occur year-round, the incidence typically peaks during winter months, especially in Europe and other temperate climates, often due to coinfections with respiratory viruses.2,4

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Pneumococcal CAP Among European Adults

Community-acquired pneumonia (CAP) is the most frequent noninvasive pneumococcal disease. A review of literature assessing the incidence of CAP in European adults reveals that incidence rates are quite high, ranging from 68 to 7000 cases per 100,000 people across different age groups and regions in Europe. Of note, the incidence of CAP increases consistently with age.

Although younger individuals are at increased risk of pneumococcal disease, the highest burden of CAP is seen in older adults and those with chronic conditions. When S. pneumoniae pathogen is the cause of CAP, the mortality rate is higher compared to CAP caused by other pathogens. In older patients with pneumococcal pneumonia, the mortality rate is 3 times higher than in those with nonpneumococcal CAP.

Despite the introduction of childhood vaccination in Europe, many cases of pneumococcal CAP are still caused by serotypes covered by the current or previous pneumococcal conjugate vaccines (PCV), such as the PCV13 vaccine.5

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Burden of Pneumococcal Pneumonia Among US Adults

Examining the burden of pneumococcal pneumonia, particularly using data from the United States, we see that the incidence rates of pneumonia increase with age. Specifically, individuals aged 65 years or older have higher incidence rates. In addition, those with more risk factors for pneumococcal disease exhibit higher incidence rates compared to individuals without risk factors.

The table highlights that the incidence rate of pneumococcal pneumonia is elevated in individuals aged 65 years or older, even in those without other risk factors. Moreover, each additional risk factor beyond age further increases the incidence rate. Thus, people with risk factors have higher incidence rates of pneumococcal pneumonia and overall pneumonia.6  

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Pneumococcal Infections Leading to Hospitalizations in France, 2013-2019 

Data from a French study examined pneumococcal infections associated with hospitalization in France, including all-cause pneumonia, noninvasive pneumococcal pneumonia, nonbacteremic pneumococcal pneumonia, pneumococcal bacteremia, and pneumococcal meningitis. The findings showed that the risk of both invasive and noninvasive pneumococcal infections increases with age.

This risk is particularly higher in individuals aged 65 years or older, even without specific risk factors. CAP incidence is nearly 5 times higher in those older than age 65 vs those aged 50 to 64, and 16 times higher vs those aged 18 to 49. In fact, 47% of CAP and other pneumococcal infections occur in people older than age 65 without risk factors.

Having moderate- or high-risk factors further increases the likelihood of noninvasive and invasive pneumococcal infections. Of note, younger individuals with high-risk factors have a higher risk of infection compared to older individuals with low- or moderate-risk factors.

Understanding this association is crucial: the older an individual is and the more risk factors they have—especially high-risk factors—the greater their risk of both noninvasive and invasive pneumococcal infections.7

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IPD Burden in Europe, 2018

When examining the burden of IPD in Europe, the data from various European countries show a U-shaped curve, with higher incidence rates in children younger than 2 years and adults older than 65 years.2,3 In addition, at these extreme ages, invasive pneumococcal infections are more common in males than females.

The map illustrates that the distribution of invasive pneumococcal infections varies by European country, partly due to differences in notification rates. Invasive pneumococcal infections are a significant cause of morbidity and mortality in Europe, as confirmed by data from the European Centre for Disease Prevention and Control (ECDC).4

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Burden of Pneumococcal Infections: Risk Increases With Age and Risk Factors

These data from a retrospective cohort study conducted in the United States also show that the incidence of pneumococcal disease increases with age. Risk increases with age above 49 years.

Among various common disease states associated with a higher risk of pneumococcal disease, chronic kidney disease stands out as being linked to a significantly higher risk for pneumococcal disease across all age groups.6

People aged 50 years and older, especially with certain comorbidities, could benefit from pneumococcal vaccination. 

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Your colleague would like to give pneumococcal vaccine to a 56-year-old patient with hypertension and chronic kidney disease. Is this patient at risk for pneumococcal disease and could they benefit from vaccination? 

Burden of Pneumococcal Infections: People with Immunocompromise

The same study also examined the incidence of invasive and noninvasive pneumococcal infections among individuals with immunocompromising conditions. As with the general population, the incidence increases with age.

The study showed that pneumococcal disease rates were higher among adults aged 65 years or older who were healthy or had a chronic medical condition or immunocompromising condition when compared with younger adults.6  

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Burden of IPD Among Older Adults

A retrospective study conducted in France, which examined adults hospitalized due to IPD, showed that more than 40% of the cases were severe, with most patients experiencing sepsis and/or septic shock.

The study also showed a very high mortality rate during hospitalization, with age being strongly associated with increased mortality risk. Specifically, individuals aged 65 years or older had a significantly higher risk. In addition, the number of comorbidities was an independent risk factor for mortality.

Vaccination showed a beneficial effect on disease outcomes. However, vaccine coverage among hospitalized patients with IPD was found to be very low. Despite this, the pneumococcal conjugate vaccine was shown to reduce mortality due to IPD in this study.8

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