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Special Article |

Management of Community-Acquired Pneumonia in the Era of Pneumococcal Resistance: A Report From the Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group

James D. Heffelfinger, MD; Scott F. Dowell, MD, MPH; James H. Jorgensen, PhD; Keith P. Klugman, MD; Leah R. Mabry, MD; Daniel M. Musher, MD; Joseph F. Plouffe, MD; Alexander Rakowsky, MD; Anne Schuchat, MD; Cynthia G. Whitney, MD, MPH ; and the Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group
Arch Intern Med. 2000;160(10):1399-1408. doi:10.1001/archinte.160.10.1399.
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Objective  To provide recommendations for the management of community-acquired pneumonia and the surveillance of drug-resistant Streptococcus pneumoniae(DRSP).

Methods  We addressed the following questions: (1) Should pneumococcal resistance to β-lactam antimicrobial agents influence pneumonia treatment? (2) What are suitable empirical antimicrobial regimens for outpatient treatment of community-acquired pneumonia in the DRSP era? (3) What are suitable empirical antimicrobial regimens for treatment of hospitalized patients with community-acquired pneumonia in the DRSP era? and (4) How should clinical laboratories report antibiotic susceptibility patterns for, S pneumoniae and what drugs should be included in surveillance if community-acquired pneumonia is the syndrome of interest? Experts in the management of pneumonia and the DRSP Therapeutic Working Group, which includes clinicians, academicians, and public health practitioners, met at the Centers for Disease Control and Prevention in March 1998 to discuss the management of pneumonia in the era of DRSP. Published and unpublished data were summarized from the scientific literature and experience of participants. After group presentations and review of background materials, subgroup chairs prepared draft responses, which were discussed as a group.

Conclusions  When implicated in cases of pneumonia, S pneumoniae should be considered susceptible if penicillin minimum inhibitory concentration (MIC) is no greater than 1 µg/mL, of intermediate susceptibility if MIC is 2 µg/mL, and resistant if MIC is no less than 4 µg/mL. For outpatient treatment of community-acquired pneumonia, suitable empirical oral antimicrobial agents include a macrolide (eg, erythromycin, clarithromycin, azithromycin), doxycycline (or tetracycline) for children aged 8 years or older, or an oral β-lactam with good activity against pneumococci (eg, cefuroxime axetil, amoxicillin, or a combination of amoxicillin and clavulanate potassium). Suitable empirical antimicrobial regimens for inpatient pneumonia include an intravenous β-lactam, such as cefuroxime, ceftriaxone sodium, cefotaxime sodium, or a combination of ampicillin sodium and sulbactam sodium plus a macrolide. New fluoroquinolones with improved activity against S pneumoniae can also be used to treat adults with community-acquired pneumonia. To limit the emergence of fluoroquinolone-resistant strains, the new fluoroquinolones should be limited to adults (1) for whom one of the above regimens has already failed, (2) who are allergic to alternative agents, or (3) who have a documented infection with highly drug-resistant pneumococci (eg, penicillin MIC ≥4 µg/mL). Vancomycin hydrochloride is not routinely indicated for the treatment of community-acquired pneumonia or pneumonia caused by DRSP.

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The relationship between pneumococcal resistance and treatment outcomes for patients with pneumonia. Horizontal lines indicate the current National Committee for Clinical Laboratory Standards (NCCLS) break points.12 Good evidence exists that for Streptococcus pneumoniae strains with penicillin minimum inhibitory concentration (MIC) of up to 1 µg/mL, resistance does not increase the likelihood of treatment failures.2022 For strains with penicillin MICs of 2 and 4 µg/mL, some evidence indicates no increase in pneumonia treatment failures,28,29 whereas other evidence indicates increased mortality22 or complications.2325 Too few patients with pneumonia and pneumococcal isolates with penicillin MICs of no less than 8 µg/mL have been studied to draw appropriate conclusions, but pharmacodynamic considerations indicate theoretical reasons for concern.37 Asterisk indicates no significant difference in outcome between patients infected with strains of intermediate penicillin susceptibility vs penicillin-sensitive strains; S, susceptible; I, intermediate; and R, resistant.

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