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Question 3

https://doi.org/10.1136/adc.2009.171611

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    Can pneumonia caused by penicillin-resistant Streptococcus pneumoniae be treated with penicillin?

    You are looking after a previously healthy 3-year-old girl, who was admitted with radiographically confirmed lobar pneumonia 3 days ago. She was started on intravenous penicillin and remains clinically stable but continues to be febrile. The laboratory informs you that Streptococcus pneumoniae has grown from her blood culture and that the isolate is penicillin-resistant (minimum inhibitory concentration (MIC) 1 μg/ml). You are uncertain whether this has any implications for her clinical course and wonder whether you should change her antibiotic treatment on the basis of this information.

    Structured clinical question

    In a child with pneumonia due to penicillin-resistant Streptococcus pneumoniae [patient], does treatment with penicillin alone [intervention] result in higher morbidity or mortality [outcome]?

    Clinical bottom line

    • In children with pneumonia, infection with penicillin-resistant pneumococci does not result in higher morbidity or mortality compared to infection with penicillin-susceptible strains. (Grade A)

    • High-dose monotherapy with penicillin or ampicillin is effective for the treatment of pneumococcal pneumonia caused by intermediate resistant as well as high-level resistant strains up to a minimum inhibitory concentration (MIC) of 2.0 μg/ml. (Grade B)

    • Infections with high-level resistant pneumococci with an MIC of 4.0 μg/ml or greater should be treated with alternative antibiotics. (Grade D)

    Search strategy and outcome

    Medline was searched via the OVID interface using the following keywords: (pneumococc* OR streptococcus pneumoniae) AND (pneumonia OR sepsis OR bacteraemia OR bacteremia OR septicaemia OR septicemia OR invasive disease) AND (penicillin-resistan* OR penicillin resistan* OR ampicillin-resistan* OR ampicillin resistan*). Limits set: human, English-language. This produced 917 matches, of which seven were relevant (see table 3).1 2 3 4 5 6 7 Searches of additional databases using the same strategy, including the ISI Web of Science (1955 to present; 1108 matches), EMBASE (1980 to present; 671 matches) and Scopus (1950 to present; 358 matches), identified no further publications that had not already been found. All relevant …

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    Footnotes

    • Funding MT is supported by a Fellowship award from the European Society for Paediatric Infectious Diseases and an International Research Scholarship from the University of Melbourne.

    • Competing interests None.

    • Provenance and Peer review Commissioned; externally peer reviewed.

    • V Clifford and M Tebruegge contributed equally and are considered joint first authors.