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Resistance of Streptococcus pneumoniae to the fluoroquinolones, doxycycline, and trimethoprim-sulfamethoxazole

Daniel M Musher, MD
Section Editor
Daniel J Sexton, MD
Deputy Editor
Sheila Bond, MD


Streptococcus pneumoniae (pneumococcus) is among the most commonly identified bacterial causes of upper and lower respiratory tract infections including pneumonia, otitis media, acute rhinosinusitis, and acute exacerbations of chronic obstruction pulmonary disease (COPD). However, rates of pneumococcal infections are overall declining, in part due to widespread use of pneumococcal vaccinations [1,2].

The fluoroquinolones (often called quinolones) have been used widely to treat adults with these conditions. In 2016, the US Food and Drug Administration (FDA) stated that the serious adverse effects associated with fluoroquinolones generally outweigh the benefits for patients with acute rhinosinusitis (as well as acute bronchitis and uncomplicated urinary tract infections) who have other treatment options [3]. This safety alert is likely to reduce the indiscriminate use of the fluoroquinolones, thereby preserving the susceptibility of pneumococci. (See "Fluoroquinolones", section on 'Restriction of use for uncomplicated infections'.)

Doxycycline and macrolides/azalides (azithromycin or clarithromycin) are used for empiric treatment of pneumonia in adult outpatients [4], acute exacerbation of COPD [5], and acute bacterial rhinosinusitis [6] as alternative agents for patients with penicillin allergy.

Trimethoprim-sulfamethoxazole (TMP-SMX) was commonly used to treat these conditions from the mid-1970s to the mid-1990s, but this combination drug has largely fallen out of favor because of the high rate of pneumococcal resistance.

Pneumococci were uniformly susceptible to all antibiotics used to treat respiratory tract bacterial infections until outbreaks of infection due to antibiotic-resistant pneumococci occurred in South Africa in the late 1970s [7,8]. Although the responsible organisms were called penicillin-resistant pneumococci, they had acquired genetic material that encoded broad resistance both to penicillin and to other commonly used antibiotics. In the ensuing decades, pneumococcal resistance has arisen in a number of clinically relevant classes of antibiotics.

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Literature review current through: Nov 2017. | This topic last updated: Nov 28, 2017.
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