A recent article by Kaplan and colleagues was published in the Journal of Pediatric Infectious Diseases in November 2025 evaluating the pneumococcal serotypes and susceptibility of invasive pneumococcal disease in children.¹ In this article, the authors evaluated pediatric pneumococcal disease in children admitted to 8 hospitals across the United States from 2018 – 2023. These findings help us identify information on which pneumococcal diseases continue to occur despite vaccination, inform current empiric treatment strategies in children and help identify areas for targeted stewardship interventions.

Pneumococcal Disease and Conjugate Vaccine History

To fully understand this article, it is essential to understand the history of the pneumococcal disease and vaccination. Pneumococcal disease has significantly cased invasive infections in young and old as well as those with significant chronic conditions including immunocompromise. The incidence of these infections has been greatly reduced from ~ 25 per 100,000 in late 1990’s to < 10 per 100,000 in 2023.² This reduction has been primarily due to pneumococcal vaccination. In 2010, the pneumococcal conjugate 13 valent vaccine (PCV13) replaced the 7 valent vaccine (PCV7). A key advantage of this broadening was the coverage of serotype 19A, which was a major cause of severe, antibiotic resistant infections in young children.³ More recently, the 15 and 20 valent pneumococcal vaccines (PCV15, PCV20) were recommended for use in children in 2022 and 2023, respectively.^4-7

Study Key Findings

Despite overall numbers of invasive pneumococcal disease decreasing, breakthrough infections (e.g., those caused by PCV13 strains), do occur.  This study found that 30% of the cases were caused by PCV13 strains, particularly pneumonia and mastoiditis.¹. In contrast, infections such as bacteremia, meningitis, peritonitis, and bone and joint infections were more commonly caused by strains not covered by the PCV13 vaccine.¹ It is estimated that up to 23% of the isolates with non-PCV13 strains may be covered by the newer vaccines.¹

Fortunately, non-CNS isolates were reported to have low non-susceptibility rates to both penicillin (4%) and ceftriaxone (3%).  Of those that were resistant, they continued to be primarily caused by serotype 19A.  Concerningly, meningitis isolates that were tested using CNS breakpoints demonstrated higher rates of non-susceptibility with about 40% non-susceptible to penicillin and 10% to ceftriaxone (majority were serotypes 19A and 35B).¹  This suggests there is continued need to use combination empiric therapy for meningitis in children.

Pharmacist Considerations

For pharmacists, these findings reinforce empiric therapy recommendations.  Amoxicillin (or amoxicillin/clavulanate for mastoiditis) remains appropriate for most invasive pneumococcal infections in children (e.g., pneumonia, mastoiditis).  Unfortunately, neither penicillin nor ceftriaxone should be relied upon alone for empiric pneumococcal meningitis treatment, instead vancomycin still should be combined with ceftriaxone.

As broader spectrum PCVs (i.e., PCV15, PCV20) are now commonly used, ongoing surveillance for pneumococcal serotypes and resistances will be important to guide future antibiotic treatment recommendations.

 

References

1. Kaplan SL, Barson WJ, Ling Lin P, et al. Invasive Pneumococcal Disease at Eight Children’s Hospitals in the United States, 2018-2023. Pediatr Infect Dis J. 2025
2. Centers for Disease Control and Prevention. Pneumococcal Disease Surveillance and Trends. Accessed November 11, 2025 https://www.cdc.gov/pneumococcal/php/surveillance/index.html
3. Centers for Disease Control and Prevention (CDC). Licensure of a 13-valent pneumococcal conjugate vaccine (PCV13) and recommendations for use among children – Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep. 2010;59(9):258–261
4. Kobayashi M, Farrar JL, Gierke R, et al. Use of 15-Valent Pneumococcal Conjugate Vaccine Among U.S. Children: Updated Recommendations of the Advisory Committee on Immunization Practices – United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(37):1174–1181
5. American Academy of Family Physicians. Immunization Schedules. Accessed November 13, 2025https://www.aafp.org/family-physician/patient-care/prevention-wellness/immunizations-vaccines/immunization-schedules.html
6. American Academy of Pediatrics, Committee on Infectious Diseases. Red Book : Report of the Committee on Infectious Diseases 2024 – 2027. AAP Immunization Schedule. Accessed November 14, 2025https://publications.aap.org/redbook/resources/15585
7. ACIP Updates: Recommendations for Use of 20-Valent Pneumococcal Conjugate Vaccine in Children – United States, 2023MMWR Morb Mortal Wkly Rep. 2023;72(39):1072

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