From the Guidelines
The Infectious Diseases Society of America (IDSA) guidelines recommend empiric therapy for Streptococcal pneumonia (SP) bacteremia with a macrolide and b-lactam regimen or a fluoroquinolone alone for patients admitted to a hospital ward, and a macrolide or fluoroquinolone plus a b-lactam for patients admitted to the ICU. When considering the management of SP bacteremia, it is essential to prioritize the patient's clinical response, age, and comorbid conditions. The guidelines suggest that for patients with SP bacteremia, monotherapy with a third-generation cephalosporin may be as effective as combination therapy, as shown in a retrospective analysis of Medicare data involving 1700 patients aged 65 years with severe pneumococcal pneumonia 1. However, the decision to continue with combination therapy or switch to a single agent should be determined on an individual basis, taking into account the patient's response to therapy and the presence of any copathogens. Key considerations for treatment include:
- The use of penicillin G or ampicillin for penicillin-susceptible isolates
- The use of cefotaxime, ceftriaxone, or a respiratory fluoroquinolone for penicillin-resistant isolates
- The potential benefits of combination therapy, including reduced mortality and shorter length of stay
- The importance of monitoring patients with follow-up blood cultures to confirm clearance of bacteremia. It is crucial to note that these recommendations are based on the available evidence, including retrospective studies that suggest dual therapy with a macrolide may reduce mortality associated with bacteremic pneumococcal pneumonia 1. Ultimately, a prospective, randomized trial is needed to determine the best regimen for managing SP bacteremia.
From the Research
IDSA Guidelines for Streptococcal Pneumonia (SP) Bacteremia
- The Infectious Diseases Society of America (IDSA) guidelines for the treatment of Streptococcal pneumonia (SP) bacteremia are not explicitly stated in the provided studies, but some studies provide guidance on the treatment of pneumococcal infections 2, 3, 4, 5, 6.
- For severe infections such as bacterial meningitis, the addition of vancomycin to a third-generation cephalosporin is advisable while awaiting laboratory test results, even in areas with low prevalence of penicillin-resistant pneumococci 2.
- Beta-lactam agents can also be a valid choice in the presence of potentially lethal infections such as pneumonia or in the case of penicillin intermediately resistant isolates 2, 4.
- The IDSA recommends the use of a beta-lactam antibiotic (penicillin, aminopenicillin, cefotaxime, or ceftriaxone) administered with a macrolide or a fluoroquinolone agent for adjunctive treatment of infection with potential atypical pathogens 4.
- Vancomycin is the only approved antibiotic that is universally active against multiresistant S. pneumoniae, and its use should be restricted to minimize the emergence of vancomycin-resistant organisms 5, 6.
Treatment Options for SP Bacteremia
- Fluoroquinolones, such as levofloxacin, moxifloxacin, and gatifloxacin, have shown good microbiologic and clinical efficacy against penicillin-resistant pneumococci 2, 3.
- New alternative molecules, such as streptogramins (quinupristin/dalfopristin) and oxazolidinones (linezolid), have been introduced into clinical practice for the therapy of infections caused by penicillin-resistant pneumococci 2.
- Ceftriaxone and cefotaxime have demonstrated good in-vitro activity against penicillin-intermediate and penicillin-resistant S. pneumoniae isolates 5.