Review articleClinical relevance of antimicrobial resistance in the management of pneumococcal community-acquired pneumonia☆
Section snippets
Antibiotic resistance in the community
Bacterial resistance in community-acquired respiratory-tract infections is a serious problem that is increasing at an alarming rate throughout the world, affecting all age groups.7, 8, 9, 10 Streptococcus pneumoniae, one of the main organisms associated with resistance in respiratory-tract infections, has developed multiple resistance mechanisms, and resistant strains, including multidrug-resistant ones, have spread to several regions of the world (Table I). 7, 11 The definitions of antibiotic
Penicillin resistance
Until 1967, all clinical isolates of the pneumococcus were considered uniformly sensitive to penicillin.21 Since that time, reports have appeared regularly in the literature documenting isolates with varying degrees and spectra of antibiotic resistance.22 Many reviews and several studies have been published describing the association between antibiotic resistance and the outcome of pneumococcal pneumonia.22 Although many reports have shown no differences in the outcomes of these infections, an
Evaluation of the consequences of antibiotic resistance
Despite the rapid increase in the prevalence and levels of antimicrobial resistance that have been documented among the isolates that commonly cause community-acquired pneumonia, relatively few controlled studies have revealed clinical failures or increased morbidity and mortality as consequences of this resistance.19, 75 Several reasons have been proposed to explain this discrepancy.19 First, even with the appropriate treatment of relatively mild infections with antibiotic-susceptible
Empiric antibiotic prescribing suggestions in the era of antibiotic resistance
Initial antibiotic therapy of community-acquired pneumonia is of necessity empiric; these infections are severe, with residual mortality, and evidence is beginning to suggest that the outcome of infection is improved by the early initiation of appropriate antibiotic therapy to which the causative organism(s) is susceptible. Because the causative organism is unknown at the outset of an infection, the initial antibiotic therapy is therefore “best guess,” intended to cover the most likely
Conclusions
It is important for the clinician attending a patient with community-acquired pneumonia to be fully aware of the rates of antimicrobial resistance among common respiratory-tract pathogens, such as the pneumococcus, in their communities and, particularly, in their own areas of practice. They should have a thorough knowledge of and search for risk factors for possible infection with antibiotic-resistant isolates.75 Because prior antibiotic exposure is thought to be a major risk factor for
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2010, Journal of Infection and Public HealthCitation Excerpt :The in vitro/in vivo paradox with macrolide group of antibiotics, referring to discordance between reported in vitro resistance and clinical success, has been documented in respiratory infections. Macrolides are commonly prescribed for the management of community-acquired pneumonia in outpatients, with the newer generation macrolides (clarithromycin and azithromycin) often used as monotherapy [21]. However, the high prevalence of erythromycin resistance (37.7%) in S. pneumoniae with predominance of highly resistant strains (MIC ≥64 mg/l) observed in this study is of concern for empiric therapy of community-acquired pneumonia because therapeutic failure with these agents has been reported [18], and many clinicians caution against using these agents as monotherapy in areas with high prevalence of resistance [21].
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The author has acted on the advisory board of pharmaceutical companies marketing antibiotics (Abbott, Aventis, and Bristol-Meyers Squibb), has been reimbursed for lectures sponsored by pharmaceutical companies (Pfizer, Abbott, Bristol-Meyers Squibb, and Glaxo-Smith Kline), and has attended conferences sponsored by pharmaceutical companies (Bristol-Meyers Squibb, Aventis, and Pfizer).