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Risk Factors for Multidrug-Resistant Pneumococcal Pneumonia

Aspa, Javier PhD*; Rajas, Olga PhD*; Rodríguez de Castro, Felipe PhD; Torres, Antoni PhD; Blanquer, José PhD§; Zalacain, Rafael MD; Vendrell, Montserrat PhD; Gallego, Miguel PhD#; Puzo, Carmen MD**; Andreu, Felipe PhD††; Menéndez, Rosario PhD‡‡; Martínez, Eva MD§§; Roig, Jordi PhD∥∥; Martín, Juan PhD¶¶; Benítez, José María MD##; Melchor, Rosario PhD***; González, Rocío PhD†††; Tillotson, Glenn PhD‡‡‡on behalf of The Pneumococcal Pneumonia in Spain Study Group

Infectious Diseases in Clinical Practice: November 2008 - Volume 16 - Issue 6 - p 368-375
doi: 10.1097/IPC.0b013e31817eec69
Original Articles

Background: Several patient-related factors for acquisition of penicillin/erythromycin-resistant pneumococcal community-acquired pneumonia (CAP) have been reported. However, risk factors associated with CAP caused by multidrug-resistant Streptococcus pneumoniae (MDRSP) have not been extensively studied.

Methods: From January 1999 to April 2000, a prospective-multicenter study was conducted in 35 Spanish hospitals to determine the risk factors associated with CAP caused by MDRSP. Pneumococci resistant to multiple antimicrobial agents were defined by the presence of intermediate or high-level resistance to penicillin plus intermediate resistance/resistance to ≥2 non-β-lactam agents (erythromycin, tetracycline, vanco mycin, chloramphenicol, or respiratory quinolones).

Results: One hundred forty-two of 638 isolates were found to be MDRSP. The 30-day survival probability was 79.5 and 86.6 for MDRSP-CAP and non-MDRSP-CAP, respectively (P = 0.059). Using multivariate survival analysis, only shock (hazard ratio: 16.4) showed an association with 30-day mortality in MDRSP-CAP. Multivariate analysis showed that asthma (odds ratio [OR], 2.17), HIV infection (OR, 1.97), previous hospital admission (OR, 1.75), nursing home residence (OR, 2.94), and Pneumonia Severity Index (PSI) classes ≥ III (PSI-III, P = 0.008; PSI-IV, P = 0.022; PSI-V, P = 0.005) were significantly associated with MDRSP-CAP.

Conclusions: Pneumonia Severity Index score, asthma, HIV infection, previous hospital admission, and nursing home residence are risk factors for MDRSP in CAP patient.

*Hospital de la Princesa, Madrid; †Hospital de Gran Canaria Dr. Negrín, Las Palmas; ‡Institut Clínic de Pneumología i Cirugía Torácica, Hospital Clínic, Barcelona; §Hospital Clínico de Valencia, Valencia; ∥Hospital de Cruces, Bilbao; ¶Hospital Dr. Josep Trueta, Girona; #CH Parc Taulí; **Hospital Santa Creu i Sant Pau; ††Hospital Germans Trias i Pujol, Barcelona; ‡‡Hospital La Fe; §§Hospital de Sagunto, Valencia; ∥∥Hospital Ntra. Sra. de Meritxell, Andorra; ¶¶Hospital Carlos Haya, Málaga; ##Hospital Virgen Macarena, Sevilla; ***Fundación Jiménez Díaz, Madrid; †††Fundación de Investigación, Unidad de Epidemiología Clínica, Hospital de la Princesa, Madrid, Spain; ‡‡‡Replidyne Inc, Milford, CT; and §§§Grupo TIR, Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, Spain.

This study was designed by an ad hoc Scientific Committee created by the "Sociedad Española de Neumologia y Cirugía Torácica (SEPAR)" through its "Area de Tuberculosis e Infecciones Respiratorias (TIR)." An independent firm (Pharma Consult Madrid) was engaged to carry out the administrative management, the cost of which was paid by AVENTIS. Expenses arising from the study on antibiotic sensitivity of pneumococcal strains and their serotypes, performed in the "Centro Nacional de Microbiología" (Majadahonda, Madrid), were supported by a grant from the Fundación RESPIRA, Fundación Española del Pulmón. Data analysis was carried out by the signatory authors of this manuscript with support of the Red-Respira (RTIC C03/11). The final manuscript was approved by all the named authors, and care was taken to ensure the integrity of the work. All the authors fulfill the authorship criteria and declare no competing interests.

Address correspondence and reprint requests to Javier Aspa, Olga Rajas, Servicio de Neumología, Hospital Universitario de la Princesa, C/Diego de León, 62 28006, Madrid, Spain. E-mail:

© 2008 Lippincott Williams & Wilkins, Inc.