International prevalence and risk factors evaluation for drug-resistant Streptococcus pneumoniae pneumonia
Introduction
Community acquired pneumonia (CAP) is responsible for more than 3 million annual fatalities worldwide.1, 2 The economic burden of CAP is at a steady cost in excess of 17 billion dollars annually for the United States alone.1, 3 Antibiotic resistance associated with CAP is a growing problem for the medical community, and it is estimated that more than 20,000 people die annually in the United States secondary to infections due to resistant bacteria.4, 5 Streptococcus pneumoniae, the most frequently isolated bacterium during CAP, has increasing resistance to the most commonly prescribed antibiotics, including penicillin, macrolides, and fluoroquinolones, and is referred to as drug-resistant Streptococcus pneumoniae (DRSP).6, 7, 8, 9 Antibiotic resistance is an emergent threat in healthcare systems worldwide and can limit antibiotic efficacy against common pathogens responsible for CAP.10, 11
Geographic variations in the prevalence of DRSP have been recognized in different cohorts in antibiotic surveillance studies.12, 13, 14 A higher prevalence of antibiotic resistant strains of S. pneumoniae has been demonstrated in some European countries, such as Spain.15 Surveillance studies have reported DRSP in up to 35% of S. pneumoniae isolated from different sources (i.e., sputum, blood, cerebrospinal fluid, ear secretions, etc.).16, 17 Risk factors for DRSP infection include older age, recent antibiotic usage, chronic obstructive pulmonary disease (COPD), and nursing home residency; but limited data are available regarding clinically relevant risk factors from larger cohort studies.6, 9, 10, 18 Additionally, the actual prevalence of DRSP-CAP worldwide is unknown, and there is a need to evaluate the global prevalence of DRSP. In this regard, point-prevalence studies are useful to determine the global burden of infectious diseases in a specific time point.19
Our aim was to determine the prevalence of DRSP-CAP and identify specific DRSP risk factors at global, continental, and multinational levels.
Section snippets
Study design
We enrolled adult subjects hospitalized with confirmed CAP in 222 hospitals around the world using a point-prevalence study.20 Subjects were recruited on four days randomly selected by each local investigator during the months between March and June 2015. The University of Texas Health at San Antonio (UT Health San Antonio) functioned as the coordinating centre (IRB# HSC20150184E) and waived the need for informed consent due to the nature of the study. All other associated centres were required
Results
A total of 3193 subjects were enrolled from 54 countries. All subjects had pneumonia confirmed by laboratory findings, radiographic imaging, and microbiological testing that were performed within the first 24 h of hospitalization (Fig. 1). Microbiological testing was obtained from blood (2211/3193 [69%]), sputum (1630/3193 [51%]), pneumococcal urinary antigen (1106/3193 [35%]) and bronchoalveolar lavage (311/3193 [10%]). An etiological pathogen was identified in 1173/3193 (37%) of subjects (
Discussion
This multicentre, international, point-prevalence study showed that S. pneumoniae is the most common pathogen isolated in subjects with CAP. The global prevalence rates of DRSP, MDR, and XDR S. pneumoniae infections in subjects with CAP are 1.3%, 0.2%, and 0.03%, respectively. We identified that DRSP-CAP, penicillin-resistant, macrolide-resistant, and tetracycline-resistant prevalence rates are variable among participating centres, revealing important differences between continents and
Conclusion
The multinational prevalence rate of drug-resistant Streptococcus pneumoniae as the causative agent of CAP in this point-prevalence study is lower than previously reported. Differences in DRSP-CAP prevalence rates exist among continents and countries. Therefore, local treatment guidelines and hospital protocols should be based on local prevalence rates. Lastly, global risk factors independently associated with DRSP-CAP may assist medical professionals to appropriately select antibiotic coverage
CRediT authorship contribution statement
Stefano Aliberti: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Visualization, Writing - original draft, Writing - review & editing. Grayden S. Cook: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Writing - original draft, Writing - review & editing. Bettina L. Babu: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation,
Funding
This project was unfunded. However, Nilam Soni's time is partially funded by the Department of Veterans Affairs, Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative Grant (HX002263-01A1). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Department of Veterans Affairs, nor the United States Government.
Declarations of interest
None.
Acknowledgments
We would like to thank the European Respiratory Society, the World Federation of Societies of Intensive and Critical Care Medicine, the American College of Chest Physicians, the Asociación Latinoamericana de Tórax (ALAT), and the Sociedad Argentina de Infectología (SAI) for their support of this project.
Appendix A: GLIMP investigators
We would like to thank the following study contributors for their valuable collaboration:
Argentina: Patricia Karina Aruj, Department of Internal Medicine, University Hospital Alfredo Lanari, Buenos Aires, Argentina; Silvia Attorri, Hospital Luis Lago maggiore, Mendoza, Argentina; Enrique Barimboim, Hospital Central de Mendoza, Argentina; Juan Pablo Caeiro and María I. Garzón, Hospital Privado Universitario, Córdoba, Argentina; Victor Hugo Cambursano, V.H. Dr Cazaux A. Servicio de Neumologia,
References (35)
- et al.
Community-acquired pneumonia
Lancet
(2015) - et al.
Serotype prevalence and antibiotic resistance in Streptococcus pneumoniae clinical isolates among global populations
Vaccine
(2013) - et al.
Impact of age and comorbidity on cause and outcome in community-acquired pneumonia
Chest
(2013) - et al.
Global initiative for meticillin-resistant Staphylococcus aureus pneumonia (GLIMP): an international, observational cohort study
Lancet Infect Dis
(2016) - et al.
Consensus statement on the adherence to clinical and laboratory standards institute (CLSI) antimicrobial susceptibility testing guidelines (CLSI-2010 and CLSI-2010-update) for enterobacteriaceae in clinical microbiology laboratories in Taiwan
J Microbiol Immunol Infect
(2010) - et al.
Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support
J Biomed Inform
(2009) - et al.
Current concepts in antimicrobial therapy against select gram-positive organisms: methicillin-resistant Staphylococcus aureus, penicillin-resistant pneumococci, and vancomycin-resistant enterococci
Mayo Clin Proc
(2011) - et al.
Pathogenesis, treatment, and prevention of pneumococcal pneumonia
Lancet
(2009) - et al.
Risk factors and pathogenic significance of bacteremic pneumonia in adult patients with community-acquired pneumococcal pneumonia
J Infect
(2013) - et al.
What is the best antimicrobial treatment for severe community-acquired pneumonia (including the role of steroids and statins and other immunomodulatory agents)
Infect Dis Clin North Am
(2013)
Prevalence of penicillin and erythromycin resistance among invasive Streptococcus pneumoniae isolates reported by laboratories in the southern and eastern Mediterranean region
Clin Microbiol Infect
Self-medication with antibiotics in the ambulatory care setting within the Euro-Mediterranean region; results from the ARMed project
J Infect Public Health
Community-acquired pneumonia requiring hospitalization among U.S. adults
N Engl J Med
Clinical practice. Community-acquired pneumonia
N Engl J Med
A new antibiotic and the evolution of resistance
N Engl J Med
How to choose the duration of antibiotic therapy in patients with pneumonia
Curr Opin Infect Dis
Bacteraemia and antibiotic-resistant pathogens in community acquired pneumonia: risk and prognosis
Eur Respir J
Cited by (0)
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See Appendix A for GLIMP investigators.