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Pleural effusions developing after initiation of antimicrobial therapy usually are sterile, and thoracentesis need not be performed if the patient is otherwise improving Thoracentesis is indicated for an effusion present prior to initiation of therapy and in the patient who has not responded to antibiotics after 3 4 days Chest tube drainage may be required if pneumococci are identified by culture or Gram stain, especially if aspiration of the fluid is difficult Echocardiography should be done if pericardial effusion is suspected Patients with pericardial effusion who are responding to therapy and have no signs of tamponade may be monitored and treated with indomethacin, 50 mg orally three times daily, for pain In patients with increasing effusion,

Parapneumonic (sympathetic) effusion is common and may cause recurrence or persistence of fever These sterile fluid accumulations need no specific therapy Empyema occurs in 5% or less of cases and is differentiated from sympathetic effusion by the presence of organisms on Gram-stained fluid or positive pleural fluid cultures

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unsatisfactory clinical response, or evidence of tamponade, pericardiocentesis will determine whether the pericardial space is infected Infected fluid must be drained either percutaneously (by tube placement or needle aspiration), by placement of a pericardial window, or by pericardiectomy Pericardiectomy eventually may be required to prevent or treat constrictive pericarditis, a common sequela of bacterial pericarditis Endocarditis should be treated for 4 weeks with 3 4 million units of penicillin G every 4 hours intravenously; ceftriaxone, 2 g once daily intravenously; or vancomycin, 15 mg/kg every 12 hours intravenously Mild heart failure may respond to medical therapy, but moderate to severe heart failure is an indication for prosthetic valve implantation, as are systemic emboli or large friable vegetations as determined by echocardiography

Torpy JM et al JAMA patient page Pneumococcal diseases JAMA 2006 Apr 12;295(14):1730 [PMID: 16609100]

For example, the following declaration defines a method named MyMethod( ) that returns void (that is, it returns no value at all) and takes two parameters (an int and a Button):

Fever, headache, altered mental status Meningismus Gram-positive diplococci on Gram stain of cerebrospinal fluid

The prevalence of penicillin-resistant pneumococci (MIC > 01 mcg/mL) in the United States is approximately 20%, although there is considerable regional variability All blood and cerebrospinal fluid isolates should now be tested for resistance to penicillin Pneumonia caused by intermediately resistant strains (penicillin MIC > 01 mcg/mL but 1 mcg/ mL) generally will respond to high-dose penicillin therapy High-dose penicillin is likely to be effective for infections other than meningitis caused by highly penicillin-resistant strains (MIC > 1 mcg/mL) However, ceftriaxone, 1 g intravenously once daily, or vancomycin, 1 g intravenously every 12 hours, results in a more favorable ratio between serum drug concentration and MIC and may be preferred, especially for immunocompromised patients An extended-release form of amoxicillin-clavulanate (1000 mg-625 mg per tablet) is FDA-approved at a dose of two tablets every 12 hours for 7 10 days for treatment of community-acquired pneumonia, including that caused by penicillin-resistant strains of S pneumoniae with MIC 2 mcg/mL) Fluoroquinolones with enhanced gram-positive activity (eg, levofloxacin 500 mg once daily or moxifloxacin 400 mg once daily) are effective oral alternatives Penicillin-resistant strains of pneumococci often are resistant to multiple antibiotics, including macrolides, trimethoprim-sulfamethoxazole, and chloramphenicol, and susceptibility must be documented prior to their use

Lexau CA et al; Active Bacterial Core Surveillance Team Changing epidemiology of invasive pneumococcal disease among older adults in the era of pediatric pneumococcal conjugate vaccine JAMA 2005 Oct 26;294(16):2043 51 [PMID: 16249418] Siquier B et al; 620 Clinical Study Group Efficacy and safety of twice-daily pharmacokinetically enhanced amoxicillin/clavulanate (2000/125 mg) in the treatment of adults with community-acquired pneumonia in a country with a high prevalence of penicillin-resistant Streptococcus pneumoniae J Antimicrob Chemother 2006 Mar;57(3):536 45 [PMID: 16446376] Talbot TR et al Asthma as a risk factor for invasive pneumococcal disease N Engl J Med 2005 May 19;352(20):2082 90 [PMID: 15901861] Tleyjeh IM et al The impact of penicillin resistance on short-term mortality in hospitalized adults with pneumococcal pneumonia: a systematic review and meta-analysis Clin Infect Dis 2006 Mar 15;42(6):788 97 [PMID: 16477555]

void MyMethod (int firstParam, Button secondParam) { // ... }

S pneumoniae is the most common cause of meningitis in adults Head trauma, with cerebrospinal fluid leaks, sinusitis, and pneumonia may precede it

The onset is rapid, with fever, headache, meningismus, and altered mentation Pneumonia may be present Compared with meningitis caused by the meningococcus, pneumococcal meningitis lacks a rash, and focal neurologic deficits, cranial nerve palsies, and obtundation are more prominent features

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