LETTERS TO THE EDITOR

Dear Mr. Editor:

The authors of the study "Prevalence of Streptococcus pneumoniae resistance to penicillin in two hospitals of Caxias do Sul" deserve congratulations for the survey they conducted.⁽¹⁾ However, a few comments should be made.

It is difficult to establish the exact percentage of S. pneumoniae as an etiologic agent of community-acquired pneumonia. It is clear, though, that it does not exceed half of the cases. Pneumococcus fans usually quote Bartlett, who said that pneumococcus was the causal agent in 65% of the cases of community-acquired pneumonia.⁽²⁾

In the Brazilian Consensus on Pneumonia in Immunocompetent Adults,⁽³⁾ the pneumococcus etiology found varies from 6% to 43% in the 22 studies surveyed between 1990 and 1999, including 8,116 patients.

Bartlett actually mentions the meta-analysis made by Fine, published in 1996,⁽⁴⁾ whose primary objective was to evaluate the risk factors for mortality in CAP. In this meta-analysis (that included old and nowadays probably irrelevant studies), the agent was not isolated in 50% of the cases. The authors simply multiplied the rate found by two, assuming that, in the 50% of cases in which no agent was isolated, the etiology was the same as in the cases in which the agent had been isolated, which is questionable. Second-hand quotes should be used carefully, even if made by respected authors. As mentioned in the Brazilian Consensus,⁽³⁾ three recent studies which used PCR on blood and pulmonary punction material found S. pneumoniae as the etiology in about 30% of the cases.

The authors’ conclusion is confusing: "The replacement of penicillin, used empirically in the beginning of treatment, by other drugs efficient against resistant germs, is not justified when the etiologic agent is Streptococcus pneumoniae". If the etiology was determined, the treatment is not empirical. In practice, the agent is not isolated, so that the routine use of a narrow-range agent such as penicillin G is not justified. Besides not covering H. influenzae (the etiologic agent found in approximately 10% of CAP cases), penicillin is ineffective against so-called atypical germs, which account for 1/3 of the cases. Although many of these cases are cured without adequate treatment, failures are frequent, as can be easily seen in the pneumologists’ offices, which are still receiving patients treated with procaine penicillin in emergency rooms (an event that is, however, clearly decreasing).

A recent attempt ⁽⁵⁾ to treat patients with amoxycillin + clavulanic acid (1g 3x a day, to ensure more effectiveness against possibly resistant S. pneumoniae) vs. quinolone, according to the typical or atypical presentation of the disease, showed once more that the results of the meta-analysis made for the SBPT Consensus are correct: the treatment failed in 23% of the group treated with amoxycillin/clavulanate, versus 10% of the group treated with quinolone (p = 0.01). As a rule, the assumption of any etiology is impossible based on clinical and radiological data. The conclusion drawn in the abstract is correct, i.e., that the use of other drugs instead of penicillin to treat pneumococcus pneumonia, as it is occurring in other centers, is not justified. The SBPT Consensus (pg. S11) states that, for pneumococcus strains with intermediate resistance, amoxycillin or cefuroxine remain effective, as does penicillin IV in high doses. So, the Consensus recognizes that intermediate resistance, usually high for pneumococcus in Brazil, is not the main determinant for a change in the regimen. The problem is to assume that pneumococcus alone is relevant as a cause of CAP.

The SBPT Consensus was made public and accepted based on (primary) evidence by AMB (the Brazilian Medical Association), which disclosed it broadly. It can be said that the adoption of these Guidelines changed the conduct for the treatment of CAP in Brazil, which should result in greater therapeutic success.

Carlos Alberto de C. Pereira

Editor of the SBPT Consensus on

Community-Acquired Pneumonia

Current President of SBPT

References

1. Spiandorello WP, Morsech F, Spiandorello FAS. Prevalência de resistência à penicilina do Streptococcus pneumoniae em dois hospitais de Caxias do Sul. J Pneumol 2003;29:15-20.

2. Bartlett JG. Respiratory tract infections. 3th ed. Philadelphia: Lippincott Willians & Wilkins, 2001. p.35.

3. Sociedade Brasileira de Pneumologia e Tisiologia. Consenso brasileiro de pneumonias em indivíduos adultos imunocompetentes. J Pneumol 2001;27(Supl 1):1-40.

4. Fine MJ, Smith MA, Carson CA, Mutha SS, Sankey SS, Weissfeld LA, Kapoor WN. Prognosis and outcomes of patients with community – acquired pneumonia: a meta-analysis. JAMA 1996;275:134-44.

5. Ruiz A, Falguera M, Sacristan O, Vallverdu M, Cabre X, Perez T, et al. Community-acquired pneumonia: usefulness of clinical presentation in the selection of antibiotic. Med Clin 2002;17:641-3.

Replica

We thank Dr. Carlos Alberto de C. Pereira for his comments about our work, which definitely contribute to our joint effort to optimize solutions.

In this work, we did not intend to study the best therapeutic regimen for the treatment of pneumonia, but only to consider the fact that, in the environment in which the study was carried out, Streptococcus pneumoniae is still not resistant to penicillin, and therefore its substitution by other drugs would not be justified. There are reasons to use other antibiotic regimens, the most important of which is related to the diagnostic uncertainties regarding the etiologic agent, as mentioned by Dr. Carlos Alberto. The identification of the causal agent requires a diagnostic support infrastructure frequently unavailable in medical practice, forcing the physician to establish different diagnostic strategies. Furthermore, there are economic factors which keep the more expensive antibiotics out of the reach of a great part of our population.

Evidence has been brought regarding the different resistance of Streptococcus pneumoniae to penicillin in different regions, and its tendency to increase in time. We wish to convey the opinion that epidemiology applied on segments is more precise than generalization, by showing that the use of a given antibiotic is still acceptable in some cases, whereas, in other cases, it is no longer so. More precisely, when antibiotic resistance is low, the strategy should be to keep it low, whereas, when the resistance is high, the antibiotics to which there is resistance should be changed for others, to which the bacterium is sensitive.

In our environment, we have seen that the use of penicillin has decreased to treat pneumonia in adult patients. The situation is different for pediatric patients, due to the contraindication of quinolone use. A strong argument to explain the little use of penicillin is the increasing number of papers published in the medical literature showing the growing resistance of Streptococcus pneumoniae to this antibiotic. This study, however, showed that high resistance is not yet generalized. It is also considered that some physicians feel that it is easier to use a broad-spectrum drug rather than worrying too much about diagnosing the etiologic agent. However, the opposite is recommended by the Campaign to Prevent Antimicrobial Resistance in Healthcare Settings, conducted by the CDC, that can be accessed on the Internet at: http://www.cdc.gov/drugresistance/healthcare/ha/HASlideSet.pdf. In the particular case of Streptococcus pneumoniae, it can be quickly and frequently visualized by a direct sputum test, if a microbiology laboratory is available, differently from pneumonia of other etiologies.

Which conduct is correct? Probably both of the two proposed conducts are correct, when applied in the proper environment. Therefore, we would like to emphasize the localized role of the epidemiological surveillance of microbial resistance in the strategic decisions regarding treatment and prevention, and also, whenever possible, to try to identify the etiologic agent.

Wilson Paloschi Spiandorello

MD, PhD,

Full Professor of Pneumology

and Thoracic Surgery

Dear Mr. Editor of the JP:

I was very pleased by the modifications you made in the Jornal de Pneumologia: structure of the journal, editorial board, X-ray case, etc.

Following its indexation by Lilacs, Periodica, and the last one by SciElo Brasil, in my opinion, the indexation by Medline would be only natural and should be attempted immediately. To this effect, however, I think and suggest that the name of our journal should be changed from Jornal de Pneumologia (Journal of Pneumology) into "Jornal Brasileiro de Pneumologia" ("Brazilian Journal of Pneumology"). I think this would make the origin of our journal clearer and would give it the stronger and better defined personality of those who have a defined nationality.

Warmest regards and congratulations.

Mauro Zamboni

Hospital do Cancer – INCA/MS

Rio de Janeiro, RJ

Reply

Dear Mauro:

Thank you and the whole Board of the Sociedade Brasileira de Pneumologia e Tisiologia (Brazilian Society of Pneumology and Phthisiology) for the support given to us in order to keep the high editorial level of the Jornal de Pneumologia, as well as in implementing several modifications.

I just came back from a meeting of the Latin American science editors held at Puebla, Mexico, where I represented the JP. It became very clear that the journals from Latin America are underrepresented in Medline. One of the major barriers is the language, and in that regard the Jornal de Pneumologia was mentioned as a possible example to be followed. We chose to translate our online version into English, available in full at the Bireme database – Scientific Electronic Library On-line (SciELO) (www.jornaldepneumologia.com.br), and to keep the printed version in Portuguese. Thereby we hope to increase our international visibility. We will distribute a flyer at international congresses, inviting everybody to access our website and to read our papers.

As for changing the name of the Journal, we will undoubtedly have to hear other opinions. A change of name may – on the short run – make the citation indexes more difficult, but may be a good strategy on the medium and long run.

We searched the SciELO (www.scielo.br), where currently 102 journals are indexed, and found that 48% have the identification "Brazil" or "Brazilian" in their name. Focusing only the journals published in English, 75% have the identification of Brazil in their name. These data suggest that the journals with a greater international focus prefer to be identified as Brazilian.

The Jornal de Pneumologia belongs to all of us, please send us an e-mail ([e-mail]) with your opinion, and the best letters will be published.

Geraldo Lorenzi Filho

Editor of the JP

Publication Dates

• Publication in this collection
  24 Sept 2003
• Date of issue
  June 2003