Pallares R, Viladrich P F, Liñares J, Cabellos C, Gudiol F
Infectious Diseases Service, Hospital Bellvitge and University of Barcelona, Spain.
Microb Drug Resist. 1998 Winter;4(4):339-47. doi: 10.1089/mdr.1998.4.339.
Over the past three decades, penicillin-resistant pneumococci have emerged worldwide. In addition, penicillin-resistant strains have also decreased susceptibility to other beta-lactams (including cephalosporins) and these strains are often resistant to other antibiotic groups, making the treatment options much more difficult. Nevertheless, the present in vitro definitions of resistance to penicillin and cephalosporins in pneumococci could not be appropriated for all types of pneumococcal infections. Thus, current levels of resistance to penicillin and cephalosporin seem to have little, if any, clinical relevance in nonmeningeal infections (e.g., pneumonia or bacteremia). On the contrary, numerous clinical failures have been reported in patients with pneumococcal meningitis caused by strains with MICs > or = 0.12 microg/ml, and penicillin should never be used in pneumococcal meningitis except when the strain is known to be fully susceptible to this drug. Today, therapy for pneumococcal meningitis should mainly be selected on the basis of susceptibility to cephalosporins, and most patients may currently be treated with high-dose cefotaxime (+/-) vancomycin, depending on the levels of resistance in the patient's geographic area. In this review, we present a practical approach, based on current levels of antibiotic resistance, for treating the most prevalent pneumococcal infections. However, it should be emphasized that the most appropriate antibiotic therapy for infections caused by resistant pneumococci remains controversial, and comparative, randomized studies are urgently needed to clarify the best antibiotic therapy for these infections.
在过去三十年中，耐青霉素肺炎球菌已在全球出现。此外，耐青霉素菌株对其他β-内酰胺类药物（包括头孢菌素）的敏感性也有所降低，并且这些菌株往往对其他抗生素类别耐药，这使得治疗选择更加困难。然而，目前肺炎球菌对青霉素和头孢菌素耐药的体外定义并不适用于所有类型的肺炎球菌感染。因此，目前对青霉素和头孢菌素的耐药水平在非脑膜感染（如肺炎或菌血症）中似乎几乎没有临床相关性（如果有也微乎其微）。相反，已报道许多由最低抑菌浓度（MIC）≥0.12μg/ml的菌株引起的肺炎球菌脑膜炎患者出现临床治疗失败情况，并且除非已知菌株对该药物完全敏感，否则绝不应在肺炎球菌脑膜炎中使用青霉素。如今，肺炎球菌脑膜炎的治疗应主要根据对头孢菌素的敏感性来选择，目前大多数患者可能根据患者所在地区的耐药水平用高剂量头孢噻肟（±）万古霉素进行治疗。在本综述中，我们基于当前抗生素耐药水平，提出一种治疗最常见肺炎球菌感染的实用方法。然而，应该强调的是，针对耐青霉素肺炎球菌引起的感染，最合适的抗生素治疗仍存在争议，迫切需要进行比较性随机研究以明确这些感染的最佳抗生素治疗方法。
