The efficacy of high-dose penicillin G for pneumococcal pneumonia diagnosed based on initial comprehensive assessment at admission: an observational study.

OBJECTIVES: High-dose penicillin therapy is effective in approximately 90% of pneumococcal pneumonia cases diagnosed based on urinary pneumococcal antigen tests or Gram staining at admission. The efficacy of high-dose penicillin therapy for pneumococcal pneumonia diagnosed based on an initial comprehensive assessment comprising a syndromic approach, Gram staining of sputum and urinary pneumococcal antigen testing was investigated. RESULTS: Seventy adult patients diagnosed with pneumococcal pneumonia based on an initial comprehensive assessment and treated with high-dose penicillin G at admission were included. The median patient age was 76.5 years, and 37.1% of the patients were women. The urinary pneumococcal antigen test was positive in 67.1% of all patients, and Gram staining of sputum showed that gram-positive cocci were dominant in 58.6% of the patients. The primary outcome was treatment success based on vital signs until day 6. Treatment with high-dose penicillin G was effective in 87.1% of the patients (95% CI 79.1-95.2%), and the proportion of patients who received other antibiotics because of treatment failure with penicillin G was only 5.7%. The efficacy of high-dose penicillin G treatment for pneumococcal pneumonia diagnosed based on a comprehensive assessment at admission may be comparable to that in previous reports.

Bacteremic pneumococcal pneumonia associated with macrolide failure.

Despite rising rates of macrolide resistance to Streptococcus pneumoniae, the current guidelines for outpatient treatment of community-acquired pneumonia include a macrolide as initial empiric therapy. There have only been a few previously documented cases of macrolide treatment failure in community-acquired pneumonia and there is controversy as to whether macrolide resistance in S. pneumoniae is clinically important. Reported here are two cases of community-acquired pneumonia caused by S. pneumoniae, one of which was fatal, that failed to respond to clarithromycin.

Chlamydophila pneumoniae respiratory tract infection aggravates therapy refractory bronchitis or pneumonia in childhood.

BACKGROUND: Chlamydophila pneumoniae was frequently found in bronchial secretions of children with therapy-refractory bronchitis or pneumonia. It was studied, how the agent modifies the course of disease and what findings are associated with the infection. PATIENTS AND METHODS: Bronchial secretions obtained at bronchoscopy of 428 children were studied for C. pneumoniae infection using polymerase chain reaction with enzyme immunoassay detection. Children tested negative and positive were compared for their clinical findings. RESULTS: C. pneumoniae was found in 143 children (33 %). A C. pneumoniae infection has been found to be associated with a purulent bronchial inflammation (90/143 vs. 144/285, p = 0.02), a Streptococcus pneumoniae co-infection (13/143 vs. 6/285, p = 0.002) and a restrictive disturbance (11/51 vs. 8/93, p = 0.04). Purulent inflammation (Odds ratio 7.9; 95 % confidence interval [CI] 1.6-39.3), 2 co-infections (Odds ratio 14.3; 95 % CI 1.4-144.4) and co-infection with M. pneumoniae (4/4 versus 9/26, p = 0.03; Mantel Haentzel 3.0; 95 % CI 1.1-8.0) were identified as factors more often associated with a restrictive disturbance in children with bronchial C. pneumoniae infection. An adequate antibiotic therapy improved pulmonary function. No association was found for wheezing, eosinophil inflammation of the nasal mucosa, alpha-1 antitrypsin or immunoglobulin deficiency in serum, level of secretory IgA in bronchial mucus, pathological lung scintigram, gastro-esophageal reflux disease, sweat test and other co-infections. CONCLUSIONS: In children with therapy-refractory bronchitis or pneumonia bronchial C. pneumoniae infection was associated with a more severe disease in case of several, mostly bacterial co-infections. Adequate antibiotic therapy for C. pneumoniae infection has been demonstrated to improve pulmonary function.

Ciprofloxacin treatment failure in a patient with resistant Streptococcus pneumoniae infection following prior ciprofloxacin therapy.

Reported here is the case of a patient with underlying chronic obstructive pulmonary disease (COPD) in whom ciprofloxacin treatment of a lower respiratory tract infection failed subsequent to ciprofloxacin treatment of an exacerbation of COPD several weeks earlier. During the second course of ciprofloxacin therapy, the patient's condition continued to deteriorate, and she was admitted to the intensive care unit. Bilateral pneumonia was diagnosed. Streptococcus pneumoniae, serotype 11A, resistant to ciprofloxacin was isolated from the sputum. Sequencing revealed a S79F mutation in parC and there was evidence of an efflux pump. The patient improved rapidly after administration of azithromycin and ampicillin/sulbactam. This report of treatment failure due to ciprofloxacin-resistant Streptococcus pneumoniae shows that fluoroquinolones should be avoided when treating patients who have recently received this class of antibiotics.

Gatifloxacin used for therapy of outpatient community-acquired pneumonia caused by Streptococcus pneumoniae.

Gatifloxacin is an advanced-generation fluoroquinolone with demonstrated efficacy and safety as therapy for community-acquired pneumonia (CAP). As part of a phase IV postmarketing surveillance program (TeqCES), 136 outpatients with CAP whose sputum was culture-positive for Streptococcus pneumoniae were enrolled in an open-label trial of oral gatifloxacin 400 mg daily for 7 to 14 days. An antibiogram of isolates showed 100% susceptibility to gatifloxacin (MIC(90) 0.5 micro g/mL) and respective susceptibilities of 67%, 70%, and 80% to penicillin, erythromycin, and tetracycline. Clinical cure was achieved in 95.3% of evaluable patients, including seven patients infected with penicillin-resistant S. pneumoniae (MIC > or =2 micro g/mL). The bacteriologic eradication rate for S. pneumoniae was 94.5%. Diarrhea, nausea, and dizziness, the most common adverse events in CAP patients (<3%), were generally mild to moderate; no serious adverse events were recorded. These results support recommendations to treat CAP, particularly due to S. pneumoniae including multidrug-resistant strains, with the newer 8-methoxy-fluoroquinolone, gatifloxacin.

Treatment of pneumococcal pneumonia.

The emergence of Streptococcus pneumoniae strains with resistance to penicillin, macrolide, and other drugs has made the treatment of pneumococcal infections more complicated. Although resistance to penicillin has had a profound impact on the outcome of meningitis, it has had little impact on the mortality from pneumococcal pneumonia because the serum and pulmonary levels achieved with penicillin (or related drugs) are several times higher than the minimal inhibitory concentration of the strains. Thus, based on current levels of resistance to penicillin and cephalosporin, most patients with mild/moderate pneumococcal pneumonia may respond to oral amoxicillin, and most with severe pneumonia may be successfully treated with intravenous ceftriaxone, cefotaxime, or amoxicillin-clavulanic acid. It is of concern that patients infected with erythromycin-resistant pneumococci may not respond to therapy with a macrolide. In our opinion, except for well-selected patients, imipenem and vancomycin should not be widely used for the treatment of pneumococcal pneumonia. Some new drugs such as the new quinolones may play an important role in the management of pneumonia in the near future.

Clinical characteristics and outcome of children with pneumonia attributable to penicillin-susceptible and penicillin-nonsusceptible Streptococcus pneumoniae.

OBJECTIVE: To compare the clinical characteristics, treatment, and outcome of pediatric patients with pneumonia attributable to isolates of Streptococcus pneumoniae that were either susceptible or nonsusceptible to penicillin. DESIGN: Multicenter, retrospective study. SETTING: Eight children's hospitals in the United States. PARTICIPANTS: Two hundred fifty-four children with pneumococcal pneumonia identified from patients enrolled in the United States Pediatric Multicenter Pneumococcal Surveillance Study during the 3-year period from September 1, 1993 to August 31, 1996. OUTCOME MEASURES: Demographic and clinical variables including necessity for and duration of hospitalization, frequency of chest tube placement, antimicrobial therapy, susceptibility of isolates, and clinical outcome. RESULTS: There were 257 episodes of pneumococcal pneumonia that occurred in 254 patients. Of the 257 isolates, 22 (9%) were intermediate and 14 (6%) were resistant to penicillin; 7 (3%) were intermediate to ceftriaxone and 5 (2%) were resistant to ceftriaxone. There were no differences noted in the clinical presentation of the patients with susceptible versus nonsusceptible isolates. Twenty-nine percent of the patients had a pleural effusion. The 189 (74%) hospitalized patients were more likely to have an underlying illness, multiple lung lobe involvement, and the presence of a pleural effusion than nonhospitalized patients. Fifty-two of 72 hospitalized patients with pleural effusions had a chest tube placed, and 27 subsequently underwent a decortication drainage procedure. Eighty percent of the patients treated as outpatients and 48% of the inpatients received a parenteral second or third generation cephalosporin followed by a course of an oral antimicrobial agent. Two hundred forty-eight of the patients (97.6%) had a good response to therapy. Six patients died; however, only 1 of the deaths was related to the pneumococcal infection. CONCLUSION: The clinical presentation and outcome of therapy did not differ significantly between patients with penicillin-susceptible versus those with nonsusceptible isolates of S pneumoniae. Hospitalized patients were more likely to have underlying illnesses, multiple lobe involvement, and the presence of pleural effusions than patients who did not require hospitalization. In otherwise normal patients with pneumonia attributable to penicillin-resistant pneumococcal isolates, therapy with standard beta-lactam agents is effective.

Combating drug-resistant pneumococcal infections.

Penicillin-resistant pneumococcal strains continue to spread. Some strains are also resistant to other antibiotics, including the cephalosporins. Better utilization of the 23-valent pneumococcal vaccine, which covers the serotypes responsible for 90% of pneumococcal infections, is an important step in combating resistance.

Determination of antibodies to pneumococcal C polysaccharide in patients with community-acquired pneumonia.

The pneumococcal C polysaccharide (PnC) is species specific and believed to be a cell wall component of all capsular types. Antibodies against PnC in human sera have been demonstrated previously, but the question of whether a rise in these antibodies occurs during pneumococcal infections has not been investigated. We used an indirect enzyme-linked immunosorbent assay (ELISA) for the estimation of PnC antibodies in 124 hospital-treated patients with pneumonia. In 3 of 6 patients with pneumococcal bacteremia and in 17 of 44 patients with S. pneumoniae isolated in the blood, sputum, or nasopharynx, a significant rise in antibody levels was recorded, accounting for a sensitivity of 38.6%. Of 35 patients with pneumonia of other known or suspected etiology, 1 gave a positive result, corresponding to a specificity of 97.1%. In addition, 3 of 8 patients with PnC antigen in the sputum as the only etiological finding and 5 of 37 patients with unknown etiology gave positive results. The PnC antibodies did not seem to have any protective capacity against pneumonia caused by pneumococci. The ELISA, in which only one antigen preparation was used, was more simple than other tests in which traditional capsular antigen preparations are used. It might therefore be used as a supplemental method in the diagnosis of pneumococcal pneumonia. The problems involved in expressing serum titers obtained with the ELISA are discussed.

Basilar pneumonia simulating acute appendicitis in children.

Twelve children with acute abdominal pain, which was suspected of being acute appendicitis, were subsequently found to have lower lobe pneumonia. Diagnostic barium enema or operative exploration failed to demonstrate any appendiceal abnormality. The abdominal symptoms and the ileus subsided soon after the initiation of antibiotic therapy. Contrary to common belief, it was observed that left-sided pneumonia is capable of mimicking appendicitis almost as frequently as right-sided pneumonia. Since the likelihood of acute appendicitis accompanying pneumonia is small, operative intervention is rarely indicated and should be undertaken only after careful and intensive investigation.