Management of community-acquired pneumonia in the era of pneumococcal resistance - A report from the Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group

Objective: To provide recommendations for the management of community-acqui red pneumonia and the surveillance of drug-resistant Streptococcus pneumoni ae (DRSP). Methods: We addressed the following questions: (1) Should pneumococcal resi stance to beta-lactam antimicrobial agents influence pneumonia treatment? ( 2) What are suitable empirical antimicrobial regimens for outpatient treatm ent of community-acquired pneumonia in the DRSP era! (3) What are suitable empirical antimicrobial regimens for treatment of hospitalized patients wit h community-acquired pneumonia in the DRSP era! and (4) How should clinical laboratories report antibiotic susceptibility patterns for S pneumoniae, a nd what drugs should be included in surveillance if community-acquired pneu monia is the syndrome of interest? Experts in the management of pneumonia a nd the DRSP Therapeutic Working Group, which includes clinicians, academici ans, and public health practitioners, met at the Centers for Disease Contro l and Prevention in March 1998 to discuss the management of pneumonia in th e era of DRSP. Published and unpublished data were summarized from the scie ntific literature and experience of participants. After group presentations and review of background materials, subgroup, chairs prepared draft respon ses, which were discussed as a group. Conclusions: When implicated in cases of pneumonia, S pneumoniac should be considered susceptible if penicillin minimum inhibitory concentration (MIC) is no greater than 1 mu g/mL, of intermediate susceptibility if MIC is 2 m u g/ Int, and resistant if MIC is no less than 4 mu g/mL. For outpatient tr eatment of community-acquired pneumonia, suitable empirical oral antimicrob ial agents include a macrolide leg, erythromycin, clarithromycin, azithromy cin), doxycycline (or tetracycline) for children aged 8 years or older, or an oral beta-lactam with good activity against pneumococci (eg, cefuroxime axetil, amoxicillin, or a combination of amoxicillin and clavulanate potass ium). Suitable empirical antimicrobial regimens for inpatient pneumonia inc lude an intravenous beta-lactam, such as cefuroxime, ceftriaxone sodium, ce fotaxime sodium, or a combination of ampicillin sodium and sulbactam sodium plus a macrolide. New fluoroquinolones with improved activity against 5 pn eumoniae can also be used to treat adults with community-acquired pneumonia . To limit the emergence of fluoroquinolone-resistant strains, the neu fluo roquinolones should he limited to adults (1) for whom one of the above regi mens 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 greater than or equal to 4 mu g/mL). Vancomycin hydrochlor ide is not routinely indicated for the treatment of community-acquired pneu monia or pneumonia caused by DRSP.