Aspa Javier, Rajas Olga, de Castro Felipe Rodríguez
Universidad Autónoma de Madrid, Servicio de Neumología, Hospital Universitario de la Princesa, Madrid, Spain.
Expert Opin Pharmacother. 2008 Feb;9(2):229-41. doi: 10.1517/14656566.9.2.229.
Streptococcus pneumoniae has been consistently shown to represent the most frequent causative agent of community-acquired pneumonia (CAP) and pneumococcal antibiotic resistance towards different families of antibiotics continues to be a much-debated issue. Microbial resistance causes a great deal of confusion in choosing an empirical treatment for pneumonia and this makes it necessary to know which factors actually determine the real impact of antimicrobial resistance on the outcome of pneumococcal infections. Several different aspects have to be taken into account when analyzing this matter, such as the study design, the condition of the patient at the time of diagnosis, the choice of the initial antimicrobial regimen (combination or monotherapy) and the pharmacokinetic/pharmacodynamic variables of the chosen antibiotic. It is generally accepted that in the treatment of beta-lactam-resistant pneumococcal infections, the use of standard antipneumococcal beta-lactam agents is unlikely to impact negatively on the outcome of CAP when appropriate agents are given in sufficient doses. As a general rule, for infections with penicillin-sensitive strains, penicillin or an aminopenicillin in a standard dosage will be effective; in the cases of strains with intermediate resistance, beta-lactam agents are still considered appropriate treatment although higher dosages are recommended; finally, infections with isolates of high-level penicillin resistance should be treated with alternative agents such as the third-generation cephalosporins or the new antipneumococcal fluoroquinolones. In areas of high prevalence of high-level macrolide resistance, empirical monotherapy with a macrolide is not optimal for the treatment of hospitalised patients with moderate or moderately-severe CAP. Fluoroquinolones are considered to be excellent antibiotics in the treatment of pneumococcal CAP in adults, but their general recommendation has been withheld due to fears of a widespread development of resistance. Most international guidelines recommend combination therapy (beta-lactam plus a macrolide) for the treatment of hospitalised patients with CAP.
肺炎链球菌一直被证明是社区获得性肺炎（CAP）最常见的病原体，肺炎球菌对不同抗生素家族的耐药性仍是一个备受争议的问题。微生物耐药性在选择肺炎的经验性治疗时造成了很大的困惑，这使得有必要了解哪些因素实际上决定了抗菌药物耐药性对肺炎球菌感染结局的真正影响。在分析这个问题时，必须考虑几个不同的方面，如研究设计、诊断时患者的状况、初始抗菌治疗方案的选择（联合治疗或单药治疗）以及所选抗生素的药代动力学/药效学变量。一般认为，在治疗对β-内酰胺耐药的肺炎球菌感染时，当给予足够剂量的合适药物时，使用标准的抗肺炎球菌β-内酰胺类药物不太可能对CAP的结局产生负面影响。一般来说，对于青霉素敏感菌株感染，标准剂量的青霉素或氨基青霉素将是有效的；对于中度耐药菌株，β-内酰胺类药物仍被认为是合适的治疗方法，尽管建议使用更高的剂量；最后，对高水平青霉素耐药菌株的感染应使用替代药物治疗，如第三代头孢菌素或新型抗肺炎球菌氟喹诺酮类药物。在高水平大环内酯类耐药率高的地区，对于中度或中度重症CAP住院患者，使用大环内酯类进行经验性单药治疗并非最佳选择。氟喹诺酮类药物被认为是治疗成人肺炎球菌CAP的优秀抗生素，但由于担心耐药性的广泛发展，其一般推荐已被保留。大多数国际指南推荐联合治疗（β-内酰胺类加一种大环内酯类）用于治疗CAP住院患者。
