Læknablaðið - 15.01.1996, Page 21

LÆKNABLAÐIÐ 1996; 82
9
Faraldsfræði penicillín ónæmra
pneumókokka
Karl G. Kristinsson
Kristinsson KG
Epidemiology of Penicillin Resistant Pneumococci
Læknablaðið 1996; 82; 9-19
Penicillin resistant and multiresistant pneumococci
have become common all over the world. Pneumo-
cocci resistant to cefotaxime and ceftriaxone have
only become established in the USA, Spain and
South Africa, although recently such strains have
been described in the UK. Resistance to cefotaxime
and ceftriaxone may spread faster than penicillin
resistance. With 6-lactam resistant and multiresis-
tant pneumococci, the choice of antimicrobials is
reduced to a single class of antimicrobials, the glyco-
peptides.
Penicillin resistant pneumococci were introduced in
Iceland in 1988, and had gained 20% incidence in
pneumococcal infections in 1993. This rapid spread
was associated with serogroups 6, 19 and 23, of
which serotype 6B (multiresistant) was by far the
most prevalent. During this period the incidence of
penicillin resistant pneumococci remained low in the
other Nordic countries. Since the practice of med-
icine is very similar in these countries, it was impor-
tant to search for epidemiological clues that would
explain the difference. The following risk factors
have been shown to be important in epidemiological
studies conducted in Iceland: most Icelandic chil-
dren attend day-care centres, where they have nu-
merous contacts with children with respiratory tract
infections during the long winter months. Antimi-
crobial usage was high in children attending day care
centres. The popularity of the sulpha-trimethoprim
combination in Iceland may also be important, as it
was shown to be an independent risk factor.
Total use of antimicrobial agents declined in Iceland
in the years 1991-1993 following a propaganda cam-
paign against misuse and legislative changes that
Fyrirspumir og bréfaskriftir; Karl G. Kristinsson, sýklafræði-
deild Landspítalans, pósthólf 1465, 121 Reykjavík. Tölvu-
póstur: karl@rsp.is.
Lykilorð: Pneumococci, epidemiology, penicillin, resistan-
ce, multiresistance.
increased the cost of the antimicrobials for patients.
The antimicrobial use in day-care centres was signif-
icantly reduced from 1992 to 1995. In 1994 the in-
cidence of penicillin resistant pneumococci de-
creased to 17% (from 20% in 1993). Hopefully re-
duction in antimicrobial use will continue and
contribute to further lowering of resistance levels.
Key words: Pneumococci, epidemiology, penicillin, resist-
ance, multiresistance.
Correspondence: Karl G. Kristinsson, Department of Clin-
ical Microbiology, Landspítalinn, The National University
Hospital, 101 Reykjavík, lceland. E-mail: karl@rsp.is.
Ágrip
Penicillín ónæmir og fjölónæmir pneumó-
kokkar hafa náð að breiðast út um allan heim,
og hafa náð mikilli útbreiðslu á sumum stöð-
um. Cefótaxím og ceftríaxón ónæmi hjá pneu-
mókokkum hefur til þessa aðeins náð fótfestu í
Bandaríkjunum, Spáni og Suður Afríku, en
nýlega var þannig stofnum þó lýst í Bretlandi.
Hætta er á því að það kunni að breiðast hraðar
út en penicillín ónærnið. Þegar pneumókokkar
eru bæði fjölónæmir og ónæmir fyrir öllum
þ-laktamlyfjunum er aðeins einn lyfjaflokkur
eftir með góða verkun, glýkópeptíð (vankó-
mýcín).
Penicillín ónæmir pneumókokkar komu
fyrst fram á Islandi í desember 1988, og höfðu
þeir náð 20% nýgengi í pneumókokkasýking-
um árið 1993. Þessi hraða útbreiðsla tengdist
aðeins þremur hjúpgerðum, 6,19 og 23, en af
þeim var hjúpgerð 6B (fjölónæm) langalgeng-
ust. A sama tíma hélst nýgengi penicillín
ónæmra pneumókokka lágt á hinuni Norður-
löndunum. Þar sem lækningar eru iðkaðar
nánast á sama hátt á Norðurlöndunum, skipti
miklu máli að kanna hvaða þættir ættu mestan
þátt í þessari hröðu útbreiðslu á íslandi. Inn-
lendar rannsóknir hafa sýnt að ákveðnir
áhættuþættir vega þungt, en þeir helstu eru: a)
Dagvistun á leikskólum, þar sem börnin dvelja