Penicillin Resistant Pneumococcus

1. Epidemiology
   1. Very serious problem
      1. Pneumococcus infection is common
      2. Otitis Media
      3. Meningitis
   2. Treatment failures common especially in Meningitis
   3. Hot spots of resistance
      1. International
         1. Spain
         2. Hungary
         3. South Africa
      2. United States
         1. Dallas
         2. Memphis
         3. Kansas City
         4. Oklahoma City
   4. High Risk Groups (New York, 1995, n=282)
      1. Children under age 4 (7.5 cases per 100,000)
      2. Children under age 1 (30.3 cases per 100,000)
      3. Adults with Human Immunodeficiency Virus (HIV)
      4. Reference
         1. (1997) MMWR Morb Mortal Wkly Rep, 46:297-9
   5. Day Care Prevalence (multiple U.S. state evaluation)
      1. Nasopharyngeal and middle ear swab: 22-29% PRP
   6. Hospital Prevalence (Minneapolis, MN)
      1. Community Hospitals: 15-22% PRP
      2. Tertiary Care Hospital: 50% PRP
   7. Streptococcus Pneumoniae Resistance Rates (2003)
      1. Highest resistance (19-30%)
         1. Penicillin (21%)
         2. Cephalosporins: Cefprozil, Cefuroxime (23-25%)
         3. Macrolides: All are high resistance (23-28%)
         4. Tetracycline (19%)
         5. Trimethoprim-Sulfamethoxazole (30%)
      2. Lowest resistance rates (<10%)
         1. Amoxicillin-Clavulanate (4%)
         2. Cefepime (<1%)
         3. Ceftriaxone (2%)
         4. Fluoroquinolones: Tequin, Levaquin, Avelox (<1%)
         5. Clindamycin (9%)
         6. Vancomycin (0%)
      3. References
         1. Jones (2003) Diagn Microbiol Infect Dis 46:77-80
2. Risk Factors
   1. Age over 65 years (Odds ratio 3.8)
   2. Within last 3 months, beta-lactam antibiotic - Penicillins, Cephalosporins, carbapenems, and monobactams (Odds Ratio 2.8)
   3. Alcohol Abuse (Odds Ratio 5.2)
   4. Immunosuppression
   5. Multiple comorbid medical conditions
   6. Exposure to day-care attending children
   7. Reference
      1. Fraboni (2012) Board Review Express, San Jose
3. Management: Pneumonia or Sepsis
   1. Intermediate Resistance
      1. Higher Penicillin dosage: 150k-250k U/kg/day
   2. High Resistance
      1. Three drug Combination regimen
         1. Vancomycin (40 mg/kg/day) and
         2. Imipenem and
         3. Rifampin
      2. Two drug combination regimen
         1. Vancomycin
         2. Third generation Cephalosporin (if not resistant)
4. Management: Meningitis
   1. Intermediate Resistance
      1. Vancomycin (60 mg/kg/day) and
      2. Imipenem
   2. High resistance
      1. Vancomycin (60 mg/kg/day) and
      2. Rifampin and
      3. Imipenem
   3. Follow-Up Spinal Tap in 24 hours
5. Management: Otitis Media
   1. Intermediate Resistance
      1. Amoxicillin (75 mg/kg/d)
      2. Clindamycin
         1. No coverage for HaemophilusInfluenzae
         2. No coverage for Moraxella catarrhalis
      3. Cefuroxime
      4. Cefprozil
      5. Cefpodoxime
   2. High Resistance
      1. Base on Tympanocentesis culture
6. Prevention
   1. Pneumococcal Vaccine
      1. Public Health may add to 2 year old Immunizations
      2. Would create herd immunity to some pneumococcus