Correspondence

Management of Infections Caused by Antibiotic-Resistant Streptococcus pneumoniae

N Engl J Med 1994; 331:1774-1775December 29, 1994

Article

To the Editor:

In their timely review of the management of infections caused by antibiotic-resistant Streptococcus pneumoniae (Aug. 11 issue),1 Friedland and McCracken omit mention of erythromycin and clindamycin as alternative therapy for penicillin-resistant pneumococcal pneumonia once susceptibility data are known. Table 1 of the article indicates that the incidence of resistance to penicillin in the United States is almost the same as the incidence of erythromycin resistance (7 percent and 6 percent, respectively). Recent data from the Centers for Disease Control and Prevention show a similar percentage of pneumococcal strains resistant to each antibiotic, but only 22 percent of penicillin-resistant strains were resistant to erythromycin.2 In another recent study, 80 percent of penicillin-resistant strains in the United States were susceptible to erythromycin.3 Also, Table 2 of the article confirms the relatively low cross-resistance among strains with intermediate resistance. Because most such strains remain susceptible to erythromycin and clindamycin, the authors' emphasis on vancomycin and imipenem for the treatment of sepsis and pneumonia caused by highly penicillin-resistant pneumococci may lead to unnecessary overuse of these two agents. For most cases in the United States, therapy with erythromycin or clindamycin is preferable, after susceptibility has been established. Clindamycin has been almost universally overlooked as a highly effective antipneumococcal agent for the treatment of nonmeningeal infection. Its activity against both penicillin-susceptible and penicillin-resistant pneumococci parallels that of erythromycin,4 and it is better tolerated orally and intravenously. Excessive concern about pseudomembranous colitis has limited its use, despite data that implicate many other antibiotics to the same or a greater degree.5

James J. Rahal, M.D.
New York Hospital Medical Center of Queens, Flushing, NY 11355-5095

5 References

1. 1

   Friedland IR, McCracken GH Jr. Management of infections caused by antibiotic-resistant Streptococcus pneumoniae. N Engl J Med 1994;331:377-382
   Full Text | Web of Science | Medline

2. 2

   Breiman RF, Butler JC, Tenover FC, Elliott JA, Facklam RR. Emergence of drug-resistant pneumococcal infections in the United States. JAMA 1994;271:1831-1835
   CrossRef | Web of Science | Medline

3. 3

   Welby PL, Keller DS, Cromien JL, Tebas P, Storch GA. Resistance to penicillin and non-beta-lactam antibiotics of Streptococcus pneumoniae in a children's hospital. Pediatr Infect Dis J 1994;13:281-287
   CrossRef | Web of Science | Medline

4. 4

   Jacobs MR. Treatment and diagnosis of infections caused by drug-resistant Streptococcus pneumoniae. Clin Infect Dis 1992;15:119-127
   CrossRef | Web of Science | Medline

5. 5

   Anand A, Bashey B, Mir T, Glatt AE. Epidemiology, clinical manifestations, and outcome of Clostridium difficile-associated diarrhea. Am J Gastroenterol 1994;89:519-523
   Web of Science | Medline

To the Editor:

Friedland and McCracken underscore the serious health threat caused by the emergence of antibiotic-resistant S. pneumoniae and conclude, “Until pneumococcal disease can be effectively prevented, we can expect resistant pneumococcal infections to continue to pose therapeutic difficulties.” They discuss treatment but fail to note that a safe and effective vaccine is available to prevent invasive pneumococcal disease.

The Immunization Practices Advisory Committee1 of the Public Health Service recommends the immunization of people 65 years of age and older and others at risk, including adults and children with chronic health conditions, such as cardiovascular or pulmonary disease and diabetes mellitus, and immunocompromised persons, such as those infected with the human immunodeficiency virus and those with cancer. Unfortunately, only about 20 percent of these persons have been vaccinated. Although evidence of the clinical effectiveness of the vaccine in preventing pneumonia is still incomplete, the vaccine does prevent invasive pneumococcal disease, a serious health risk for older adults. It is also cost effective2 and safe, causing few, relatively minor side effects. In addition, its cost is covered by Medicare.

Until further research leads to an even better vaccine, more people at risk for pneumococcal infections must be vaccinated with the vaccine that is currently available. Widespread administration of the vaccine could be a singularly effective method for combating the growing threat of antibiotic-resistant S. pneumoniae.

Richard J. Hodes, M.D.
National Institute on Aging, Bethesda, MD 20892

Raymond A. Strikas, M.D.
Centers for Disease Control and Prevention, Atlanta, GA 30333

James C. Hill, Ph.D.
National Institute of Allergy and Infectious Diseases, Bethesda, MD 20892

2 References

1. 1

   Recommendations of the Immunization Practices Advisory Committee: pneumococcal polysaccharide vaccineMMWR Morb Mortal Wkly Rep 1989;38:64-8, 73
   Medline

2. 2

   Sisk JE, Riegelman RK. Cost effectiveness of vaccination against pneumococcal pneumonia: an update. Ann Intern Med 1986;104:79-86
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We agree with Dr. Rahal that erythromycin or clindamycin can be considered for the treatment of pneumococcal infections, including resistant infections. However, available data indicate that therapy with β-lactam antibiotics (e.g., penicillin, ampicillin, amoxicillin, and cefuroxime) is effective for bacteremia and pneumonia due to pneumococci with intermediate penicillin resistance, and there are no data that suggest that alternative agents are more effective. It is also likely that most patients with pneumonia caused by pneumococci that are highly resistant to penicillin will still have a response to intravenously administered penicillin, ampicillin, or selected cephalosporins. In addition, pneumococcal strains that are highly resistant to penicillin are much more likely to be resistant to erythromycin (>50 percent of strains) than Dr. Rahal suggests, although clindamycin resistance is uncommon in the United States, even among pneumococcal strains that are highly resistant to penicillin.1 Therefore, a change in therapy from a β-lactam antibiotic to erythromycin or clindamycin would be advised only in the uncommon situation in which a pneumococcal strain that was highly resistant to penicillin had been isolated, susceptibility to erythromycin or clindamycin had been demonstrated, and the patient had no clinical response to therapy with β-lactam antibiotics.

We support the view of Dr. Hodes and his colleagues that many pneumococcal infections could be prevented by immunization. However, the current pneumococcal polysaccharide vaccine is only 60 to 70 percent effective in adults.2 It is ineffective in children less than two years of age, in whom pneumococcal infections, particularly with resistant strains, are most common. Thus, the current vaccine, even if used more extensively, is unlikely to have a major effect on the incidence of resistant pneumococcal infections. Preliminary results of studies with the new conjugate pneumococcal vaccines indicate that they are immunogenic in infants and young children; however, it is not known whether these vaccines will affect colonization or prevent disease on the basis of serotypes contained in the vaccines. Because 80 to 90 percent of the serotypes that demonstrate penicillin resistance are contained in these vaccines, the hope is that the incidence of disease caused by these organisms will be substantially reduced.

Ian R. Friedland, M.Med.
Baragwanath Hospital, Johannesburg 2013, South Africa

George H. McCracken, Jr., M.D.
University of Texas Southwestern Medical Center, Dallas, TX 75235

2 References

1. 1

   Drug-resistant Streptococcus pneumoniae -- Kentucky and Tennessee, 1993MMWR Morb Mortal Wkly Rep 1994;43:23-5, 31
   Medline

2. 2

   Bolan G, Broome CV, Facklam RR, Plikaytis BD, Fraser DW, Schlech WF III. Pneumococcal vaccine efficacy in selected populations in the United States. Ann Intern Med 1986;104:1-6
   Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   René D. Drumm, Duane C. McBride, Lisa Metsch, J. Bryan Page, Kimberly Dickerson, Beverly Jones. (2003) “The Rock Always Comes First”: Drug Users' Accounts About Using Formal Health Care. Journal of Psychoactive Drugs 35:4, 461-469
   CrossRef