The pneumococcal vaccine which is used in children is protein-conjugated with polysaccharides. Pneumococcal capsular polysaccharide vaccine is not effective in children below 2 years of age as the immune system of children below 2 years do not respond to polysaccharide antigens properly. If capsular polysaccharide is conjugated with a protein the immune system responds well to protein-conjugated polysaccharides (antigen).

The protein-conjugated polysaccharides vaccine is recommended among infants and children. The introduction of protein-conjugated polysaccharides vaccine in the year 2000 has caused dramatic reduction of pneumococcal infection among children and infants in many countries. The vaccine is made of 7 serotypes of Streptococcus pneumoniae which cause infection among children commonly.

In one study the protein-conjugated polysaccharides vaccine was found to reduce pneumococcal infection (meningitis) by 98% and otitis media (infection of middle ear) by more then 65%, by the seven serotypes, used in the vaccine.

The incidence of pneumococcal infection among unvaccinated children and adults also declined due the effect of “herd immunity”, which may be due to effects of the protein-conjugate polysaccharides vaccine on nasopharyngeal carriage of vaccine serotypes. Herd immunity is the immunity of a community that develops due to widespread use of vaccines, even among non immunized individuals.

A disadvantage of widespread use of protein-conjugated polysaccharides vaccine is, increased incidence of infection by the serotypes of Streptococcus pneumoniae that are not included in the vaccine and these serotypes are becoming increasingly resistant to antibiotics. But in general there is dramatic decline in the incidence of infection by Streptococcus pneumoniae.

There are two types of vaccines available for prevention of pneumococcal pneumonia. The first is pneumococcal capsular polysaccharide vaccine, used for vaccination of adults and the second pneumococcal vaccine is protein conjugated pneumococcal vaccine, used for immunizing children.

Pneumococcal capsular polysaccharide vaccine is in use since 1980s and is made from capsular polysaccharides of 23 serotypes of Streptococcus pneumoniae which are most prevalent in any community. The vaccine found to be effective in several studies, although the effect decreases with age of the immunized individual and also time from vaccination (the effectiveness of vaccine decreases slowly 5 years after administering the vaccine).

Who should get vaccinated with pneumococcal capsular polysaccharide vaccine?

The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommends the following individuals to be vaccinated with pneumococcal capsular polysaccharide vaccine:

• All individuals aged more then 2 years (two) who are at risk of pneumococcal infection or at risk of developing complication.
• Individuals who underwent spleen removal or have anatomical abnormality in spleen.
• Persons of more then 65 years of age.
• Immunocompromised persons such as multiple myeloma, lymphoma, Hodgkin’s disease, HIV infection, undergone any organ transplantation, individuals who use glucocorticoid regularly etc.
• Individuals with diabetes, chronic lung disease, cardiovascular disease, CSF leakage, cirrhosis, chronic alcoholics, persons with chronic renal insufficiency etc.
• Health care professionals.
• Native Americans and Native Alaskans in USA, as they are at increased risk of developing pneumococcal pneumonia due to genetic predisposition.

Unfortunately the pneumococcal capsular polysaccharide vaccine may not work in the individuals, who need it most, AIDS patients and patients of lymphoma, due to poor IgG responses.

What is the recommendation schedule of vaccine?

The pneumococcal capsular polysaccharide vaccine is recommended in the above mentioned individuals every five years, as the antibody levels decline with time. Although some recommends getting only single booster vaccine after five years.

The most common cause of community acquired pneumonia is pneumococcus and empirical therapy for community acquired pneumonia should always include an antibiotic which is effective against local strains of pneumococcus. But the ideal way of treatment is to start with an antibiotic which is not resistant to local strains and send for blood culture and antibiotic sensitivity test. After the antibiotic sensitivity test report is available, the antibiotic can be changed if required or continued if it is sensitive to the pneumococcus.

Generally antibiotics for treatment of pneumococcal pneumonia can be given by oral route or by parenteral route. Commonly used oral antibiotics are amoxicillin (1 gram every 8 hourly), a quinolone such as levofloxacin (500 mg once a day) and Telithromycin (800 mg once a day). Parenteral treatment of pneumonia can be either by ampicillin (1-2 gram IV or intravenously every 6 hourly), ceftriaxone (1 gram IV once or twice a day), quinolone such as gatifloxacin (400 mg IV every 24 hours), Imipenem (500 mg IV every 6 hourly) etc.

How long pneumococcal pneumonia should be treated?

There is no clear cut guideline for optimal treatment of pneumococcal pneumonia. The duration of therapy is generally guided by the response of the patient to the antibiotic therapy. And in absence of a clear cut guideline most of the doctors treat pneumococcal pneumonia for 5-7 days. Most experienced physician’s advice to start treatment with parenteral therapy, followed by oral antibiotic and observation of the patient for not more than 5 days once fever subsides. In this way duration of treatment do not generally cross 5-7 days.

The aim of treatment:

The main aim of treatment of peptic ulcer is to provide symptomatic relief to the patient in the short term, induce ulcer healing and to prevent relapse in the long run. If H. pylori are found, attempt should be made to eradicate with appropriate antibiotic therapy.

General measures:

 General measures for management of peptic ulcer are avoidance of smoking as it has a causative role in peptic ulcer and also smoking cause delay in ulcer healing. So smoking should be strongly discouraged. Aspirin and other NSAIDs (non-steroidal anti inflammatory drugs) should be avoided as far as possible because of the injurious effect they have on gastric and duodenal mucosa. If NSAIDs are required for pain relief of some other pain like toothache, a selective COX₂-inhibitor NSAID (e.g. valdecoxib, celecoxib etc.) should be given or they can be given with proton pump inhibitor drugs (e.g. omeprazole, pantoprazole etc.) or with prostaglandin analogues like misoprostol. Alcohol should be avoided (although alcohol in moderation does no harm) as well as excess tea and coffee.

Medical Management:

Short term management of peptic ulcer is done with H₂-receptor antagonist (e.g. ranitidine, famotidine etc.), proton pump inhibitor drugs (e.g. omeprazole, pantoprazole, rabeprazole, etc.), sucralfate, and prostaglandin analogues (e.g. misoprostol) or with antacids. All the above mentioned medications are equally effective in treatment of peptic ulcer.

Maintenance therapy is done with proton pump inhibitor drugs (e.g. omeprazole) or with H₂-receptor antagonist like ranitidine (either of the group of drugs is safe and effective in long term maintenance).

Eradication of H. pylori is important if found in biopsy. For eradication of H. pylori 14 day treatment is given with omeprazole 20 mg, metronidazole (or tinidazole) 400 mg and clarithromycine 250 mg (available as kit which contains all 3 medicines). One kit is to be taken 2 times a day for 14 days. Other combination kits are also available where clarithromycine is replaced with amoxicillin 750 mg.

Surgical treatment:

If none of the above mentioned treatment regimens including eradication of H. pylori fails, surgical treatment should be considered. Indication of surgical intervention is strengthened by the younger age of the patient, complications like hemorrhage or perforation of intestine, strong family history of peptic ulcer, frequent relapses, if ulcer is causing obstruction to gastric outflow or produced an hour glass stomach due to fibrosis. There are also patients who do not comply with prolonged medical management, can be treated with elective surgical intervention. But in case of elderly patients surgical operation should be avoided.

Finally every ulcer should be viewed with seriousness, especially long standing gastric ulcer as it can turn malignant although rarely. As peptic ulcer is a common problem in the modern life, it should be appropriately treated and doctor’s advice followed strictly.