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www.elsevier.com/locate/micinf
Review
Abstract
Multi drug resistant Streptococcus pneumoniae constitute a major public health concern worldwide. In this review we discuss how the
transformable nature of the pneumococcus, in parallel with antimicrobial induced stress, contributes to the evolution of antimicrobial resistance;
and how the introduction of the pneumococcal conjugate vaccine has affected the situation.
2012 Institut Pasteur. Published by Elsevier Masson SAS. All rights reserved.
Keywords: Streptococcus pneumoniae; Evolution; Antimicrobial resistance; Beta-lactams; Fluoroquinolones; Macrolides
1. Introduction
Streptococcus pneumoniae (the pneumococcus) causes
a spectrum of diseases ranging from the relatively mild otitis
media to the life threatening meningitis, pneumonia and
septicemia. Invasive pneumococcal disease (IPD) is defined by
the isolation of pneumococci from normally sterile sites, i.e.
pleural fluid, blood and cerebrospinal fluid. Colonization of
the nasopharynx by S. pneumoniae is a prerequisite for IPD
and also an important step in the development of antimicrobial
resistance because it provides the environment for genetic
recombination and the exchange of genetic material between
pneumococci and other commensal streptococci [1]. In
developed countries half of children are colonized at least
once before they reach their first birthday, while in developing
countries the pneumococcal carriage rate is much higher [2].
Despite the availability of appropriate antimicrobial chemotherapy, the burden of pneumococcal disease in developing
countries has changed very little over the last century [3].
Pneumococcal disease is responsible for 1.6 million deaths
annually, one million of which are children under five in the
developing world [4]. The introduction of penicillin in 1940 led
to a rapid reduction in the morbidity and mortality associated
with pneumococcal disease, however, widespread consumption
and over prescription contributed to the emergence of penicillin
resistance in the 1960s [5]. Today antimicrobial resistant pneumococci constitute a major public health concern; this is in large
part due to the dissemination of multi drug resistant (MDR)
clones [6]. The introduction of the heptavalent pneumococcal
conjugate vaccine (PCV7) was heralded as an important strategy
in the reduction of antimicrobial resistance. The vaccine targets
the cells polysaccharide capsule the structure of which, for each
strain, takes one of 92 different forms and it is this variation
which is reflected in the traditional serotyping scheme; the PCV7
vaccine includes the seven polysaccharides most frequently
associated with disease and more recent vaccines have increased
the valency. In the USA, PCV7 has successfully reduced the
incidence of IPD and antimicrobial resistance in vaccine serotypes; however this has been paralleled by an increase in the
incidence of IPD caused by non-vaccine serotypes amongst
which antimicrobial resistance in increasing, particularly serotype 19A [7]. The introduction of conjugate vaccines with
1286-4579/$ - see front matter 2012 Institut Pasteur. Published by Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.micinf.2012.01.012
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