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Penicillin-resistant pneumococcus and risk of treatment failure in pneumonia

¹ Faculdade de Saúde Pública, Universidade de São Paulo, Brazil
² Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Brazil
³ Hospital de Niños Elizalde, Buenos Aires, Argentina
⁴ Faculdade de Ciências Médicas da Santa Casa de São Paulo, Brazil
⁵ Hospital Municipal Durand, Buenos Aires, Argentina
⁶ Faculdade de Medicina, Universidade Federal de Minas Gerais, Brazil
⁷ Instituto de Puericultura e Pediatria Martagão Gesteira, Rio de Janeiro, Brazil
⁸ Divisão de Bacteriologia, Instituto Adolfo Lutz, São Paulo, Brazil
⁹ Hospital Infantil Dr. Robert Reid Cabral, Santo Domingo, Dominican Republic
¹⁰ Instituto Materno Infantil de Pernambuco, Recife, Brazil
¹¹ Child and Adolescent Health Unit, Pan American Health Organization, Washington DC, USA

Correspondence to:
Dr Maria Regina Alves Cardoso, Avenue Dr Arnaldo 715, 01246–904 São Paulo, Brazil; rcardoso{at}usp.br

Objective: To determine whether the presence of in vitro penicillin-resistant Streptococcus pneumoniae increases the risk of clinical failure in children hospitalised with severe pneumonia and treated with penicillin/ampicillin.

Design: Multicentre, prospective, observational study.

Setting: 12 tertiary-care centres in three countries in Latin America.

Patients: 240 children aged 3–59 months, hospitalised with severe pneumonia and known in vitro susceptibility of S pneumoniae.

Intervention: Patients were treated with intravenous penicillin/ampicillin after collection of blood and, when possible, pleural fluid for culture. The minimal inhibitory concentration (MIC) test was used to determine penicillin susceptibility of the pneumococcal strains isolated. Children were continuously monitored until discharge.

Main outcome measures: The primary outcome was treatment failure (using clinical criteria).

Results: Overall treatment failure was 21%. After allowing for different potential confounders, there was no evidence of association between treatment failure and in vitro resistance of S pneumoniae to penicillin according to the Clinical Laboratory Standards Institute (CLSI)/National Committee for Clinical Laboratory Standards (NCCLS) interpretative standards (_adjRR = 1.03; 95%CI: 0.49–1.90 for resistant S pneumoniae).

Conclusions: Intravenous penicillin/ampicillin remains the drug of choice for treating penicillin-resistant pneumococcal pneumonia in areas where the MIC does not exceed 2 µg/ml.