Use of Pristinamycin for Macrolide-Resistant Mycoplasma genitalium Infection

High levels of macrolide resistance and increasing fluoroquinolone resistance are found in Mycoplasma genitalium in many countries. We evaluated pristinamycin for macrolide-resistant M. genitalium in a sexual health center in Australia. Microbiologic cure was determined by M. genitalium–specific 16S PCR 14–90 days after treatment began. Of 114 persons treated with pristinamycin, infection was cured in 85 (75%). This percentage did not change when pristinamycin was given at daily doses of 2 g or 4 g or at 3 g combined with 200 mg doxycycline. In infections with higher pretreatment bacterial load, treatment was twice as likely to fail for each 1 log₁₀ increase in bacterial load. Gastrointestinal side effects occurred in 7% of patients. Pristinamycin at maximum oral dose, or combined with doxycycline, cured 75% of macrolide-resistant M. genitalium infections. Pristinamycin is well-tolerated and remains an option where fluoroquinolones have failed or cannot be used.

[Antibiotic resistance as a public health problem: the case of genital mycoplasmoses]

Antibiotic resistance is an emerging public health problem especially due to the continuous use of antibiotics that selects more aggressive and resistant species. In the present study the authors determined the antibiotic sensitivity of 128 Mycoplasma hominis strains obtained from urethral swabs of male patients (mean age 36 years). The Mycoplasma IST 2 strip was used to test antibiotic susceptibility: 88% of analysed strains were found to be resistant to erythromycin and azithromycin, 75% to clarithromycin, 50% to ofloxacin and ciprofloxacin, and 12% to tetracycline. All strains were susceptible to josamycin, doxycycline and pristinamycin. Results were comparable to those of a recent study by Savarino-Mattei which also showed high resistance of M hominis to macrolide antibiotics and to ciprofloxacin and susceptibility to tetracyclines. Doxycycline is currently the antibiotic of first choice for treating M hominis infections.

Emergence of a Streptococcus pneumoniae isolate resistant to streptogramins by mutation in ribosomal protein L22 during pristinamycin therapy of pneumococcal pneumonia

OBJECTIVES

The aim of this study was to characterize the mechanism of resistance to macrolides and streptogramins of a Streptococcus pneumoniae strain isolated from blood cultures in an 80-year-old patient suffering from severe pneumonia unsuccessfully treated with pristinamycin.

METHODS

Resistance genes erm(B) and mef(A) were searched for by PCR. Portions of genes for domains V and II of the 23S rRNA (rrl) and genes for ribosomal proteins L4 (rplD) and L22 (rplV) were amplified by PCR from total genomic DNA and sequenced.

RESULTS

Resistance genes erm(B) and mef(A) were not detected. Only mutation in the rplV gene encoding ribosomal protein L22 was detected. The strain contained a six amino acid insertion ((107)KRTAHI(108)) in the C-terminus of the ribosomal protein L22.

CONCLUSIONS

This is the first report of emergence of a pneumococcus resistant to streptogramins by mutation in ribosomal protein L22 during treatment with pristinamycin.

[Efficacy and safety of pristinamycin vs amoxicillin in community acquired pneumonia in adults]

STUDY OBJECTIVE

Evaluation of efficacy and safety of pristinamycin (PRI), compared with amoxicillin (AMX), both at 3 g daily for 7 to 10 days in adults with community-acquired pneumonia (CAP).

PATIENTS AND METHODS

Multinational, randomized, double blind, double dummy clinical trial of non-inferiority was conducted in 399 patients with a CAP.

RESULTS

At inclusion, the mean age was 47.8+/-18.3 years, 24.3% patients were 65 or older. The Fine score was < or =III in 85.4% patients. The bacterial etiology was documented in 34.8% of patients: Streptococcus pneumoniae (48.1%), Mycoplasma pneumoniae (18.6%), Haemophilus influenzae (14.7%), Chlamydia pneumoniae (13.2%), Legionella pneumophila (9.3%). In the clinical per-protocol population, the clinical success rate was 87.6% in each group: 149/170 patients (PRI) and 148/169 (AMX); The 95% confidence interval was [-6.61%; 7.23%]. In modified intend to treat population, the clinical success rate was 79.9% (151/189) in the PRI group and 83.0% (151/182) in the AMX group [CI 95% (-10.87%; 4.69%)]. A satisfactory bacteriological response was observed in 82.3% (51/62) of PRI patients and 88.1% (59/67) of AMX patients. Treatment related adverse events occurred similarly in both groups according to the expected tolerance profile of the two drugs. No serious adverse events in both groups were related to the study drugs.

CONCLUSIONS

In this study, PRI 3 g daily was clinically as effective and well tolerated as AMX 3 g daily, for 7 to 10 days, in PPc, in the treatment of bacterial community-acquired pneumonia.

Traitement des exacerbations de broncho-pneumopathie chronique obstructive (BPCO) par la pristinamycine

BACKGROUND

Pristinamycin is a bactericidal antibiotic whose spectrum covers the main respiratory pathogens including S. pneumoniae poorly sensitive to penicillin. It has not yet been evaluated in short course treatment of acute exacerbations of chronic obstructive bronchitis (AECB).

METHODS

476 patients suffering from an AECB were randomised to either a short course of pristinamycin, 3 G daily for 4 days, or conventional treatment with co-amoxiclav (AAC) 2G daily for 8 days. The duration of follow-up was 6 months.

RESULTS

The clinical success rate at 21 days was the same in both groups at 87.2% and 87.9%, CI95% [-7.0%, 6.0%], in the protocol population (FEV1<80%). Among the 120 patients in whom a bacterial pathogen was isolated at the time of inclusion a satisfactory bacteriological response was obtained in 84.6% of the PRI patients against 78.2% of the AAC patients. The time to relapse was comparable with a relapse rate of 25% reached in 128 days in the PRI group and 125 days in the AAC group. Treatment related side effects occurred in 9.2% of the PRI group and in 10.6% of the AAC group.

CONCLUSION

Pristinamycin 3 G daily for 4 days is as effective and well tolerated as co-amoxiclav 2G daily for 8 days in the treatment of AECB.

[Peroneal nerve palsy induced by anterior tibialis pyomyositis]

A 16-year-old girl from Guadeloup developed paresis of the flexors of the right foot, associated with edema and acute pain located in the upper anterior tibialis muscle. Electromyography confirmed mononeuritis of the right peroneal nerve, with severe reduction of potential amplitude. Computed tomography of the right leg showed a heterogeneous mass involving the upper segment of the anterior tibialis muscle, close to the location of peroneal nerve. Muscle biopsy confirmed pyomyositis. Muscle culture was negative. Paresis improved soon after antibiotic therapy was started.

Three-year outcome in a patient with Staphylococcus lugdunensis discitis

The few reported cases of bone and joint infection by Staphylococcus lugdunensis indicate that the clinical manifestations are severe, the diagnosis elusive, and the treatment difficult. We report a case of lumbar discitis caused by Staphylococcus lugdunensis in a 67-year-old man receiving chemotherapy for stage III IgA lambda multiple myeloma. Treatment was with ofloxacin and pristinamycin for 1 year. Although he started to improve only 5 months after treatment initiation, the outcome was favorable. Follow-up at the time of this writing is 3 years.

[Streptococcus pneumoniae: lack of emergence of pristinamycin resistance]

Since 1997, a few studies have been published suggesting the emergence of clinical isolates of Streptococcus pneumoniae resistant to pristinamycin. Such results were not confirmed by recent studies from different investigators using reference techniques for the determination of susceptibilities, which is in accordance with the low probability of emergence of resistance to this antibiotic in vitro. Discrepancies are encountered with macrolide-resistant strains and may be due to the type of method used for susceptibility testing (agar-diffusion test), the final inoculum used in this technique, or the recent lowering of breakpoint for susceptibility. On the contrary, correlation between reference techniques and commercial galleries using liquid medium is excellent. Despite 35 years of exerting selective pressure, the in vitro activity of pristinamycin remains constant against clinical isolates of S. pneumoniae.