CDC: Be wary of resistant strep in HIV-infected
Base empiric regimens on local prevalence
Clinicians caring for people with HIV/AIDS should be aware of the potential for antibiotic resistance when treating presumptive pneumococcal infections, the Centers for Disease Control and Prevention advises. The CDC recommends that clinicians base their decisions about empiric antibiotic therapy for presumptive pneumococcal infections on local prevalence data.
Unlike methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE), which initially emerged as nosocomial infections, penicillin-resistant S. pneumoniae (PRSP) and penicillin-nonsusceptible S. pneumoniae (PNSP) infections are primarily community-acquired, the CDC notes.
"Therefore, to understand the impact of this disease in the community, population-based surveillance data need to be collected at the local and state levels," the CDC states. "In addition, these data should be sent to CDC for aggregation at the national level to assist in monitoring the scope and magnitude of PNSP."
S. pneumoniae was uniformly susceptible to penicillin until 1987. However, there has been increased identification of PNSP since then in the United States. In addition, PNSP is becoming less susceptible to other antimicrobial drugs, including tetracycline, erythromycin, extended-spectrum cephalosporins, and chloramphenicol. Some isolates are susceptible only to vancomycin.
Because of the emergence of PNSP, the New York City Department of Health amended the health code in December 1994 to require reporting of PNSP to monitor the local prevalence of resistance to penicillin. Surveillance findings from the department’s data for 1995 indicate that the highest case rates were among children under four years old. Among adults aged 20 years to 44 years with PNSP infections, 71.4% also were HIV-infected.
Confirmed cases with isolates from normally sterile sites were investigated by medical record reviews to determine the clinical presentation, underlying medical conditions (including HIV-infection status), and hospitalization and antibiotic use within the preceding six months. In 1995, a total of 282 PNSP cases were reported to NYC health officials by hospital and commercial laboratories (rate: 3.9 cases per 100,000 population). Of the 282 people with PNSP, 130 (46.1%) had invasive illness with PNSP isolates from normally sterile sites. Chart reviews for 125 of the 130 patients indicated that the major sites of infection were blood (79.2%), tracheal aspirate (12.8%), and cerebrospinal fluid (8.%). Of the 125 invasive cases reviewed, eight (6.4%) were fatal. During the six months preceding illness onset, 43 (34.4%) patients with invasive disease had been hospitalized, and 54 (43.2%) had received antibiotic therapy. Of the 125 patients with invasive illness whose charts were reviewed, 52 (41.6%) were HIV-seropositive or had AIDS. Other underlying medical conditions included pulmonary disease, cardiovascular disease, cancer, and diabetes, the CDC reported.
Reference
1. Centers for Disease Control and Prevention. Surveillance for penicillin-nonsusceptible Streptococcus pneumoniae New York City, 1995. MMWR 1997; 46:297-299.
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