Because infections caused by drug-resistant strains of
Streptococcus pneumoniae are common in Spain (1,2), CDC has
received numerous inquiries about vaccination of travelers to the
1992 Summer Olympics in Barcelona and the 1992 World's Fair in
Seville. Pneumococcal vaccination is recommended for all persons
with risk factors for serious pneumococcal infection (3). However,
CDC does not recommend vaccination of all travelers to Spain
because the incidence of invasive pneumococcal disease among
persons without risk factors is low (4,5). Vaccination does not
appear to prevent nasopharyngeal carriage of vaccine-type strains
(6,7), and there is no evidence that drug-resistant strains are
more virulent than susceptible strains.
In recent years, most pneumococcal infections occurring in
Spain have been caused by strains resistant to at least one
commonly used antimicrobial agent including penicillin,
chloramphenicol, trimethoprim/sulfamethoxazole, or erythromycin.
Rates of high-level penicillin resistance (i.e., minimal inhibitory
concentration greater than or equal to 2 ug/mL) increased from 0%
of strains isolated in 1979 to 13%-15% of strains isolated in
1989-90 (1,2). The level of resistance to other beta-lactam agents
generally parallels the level of resistance to penicillin (8). In
contrast, only one ( less than 0.02%) of more than 5000
pneumococcal isolates submitted to CDC from the United States
during 1979-1987 had a high level of penicillin resistance (9).
Pneumococcal polysaccharide vaccine should be administered to
travelers with risk factors for serious pneumococcal infection,
including those who have undergone splenectomy, those with chronic
medical conditions (e.g., cardiovascular disease, pulmonary
disease, diabetes mellitus, and chronic renal failure) or on
immunosuppressive therapy, persons infected with human
immunodeficiency virus, and all persons aged greater than or equal
to 65 years (3). Physicians should be aware of the possibility of
infections with drug-resistant strains of S. pneumoniae in
travelers returning from Spain.
References
Linares J, Pallares R, Alonso T, et al. Trends in antimicrobial
resistance of clinical isolates of Streptococcus pneumoniae in
Bellvitge Hospital, Barcelona, Spain (1979-1990). Clin Infect Dis
1992;15:99-105.
Fenoll A, Bourgon M, Munoz R, Vicioso D, Casal J. Serotype
distribution and antimicrobial resistance of Streptococcus
pneumoniae isolates causing systemic infections in Spain,
1979-1989. Rev Infect Dis 1991;13:56-60.
ACIP. Recommendations of the Immunization Practices Advisory
Committee: Pneumococcal polysaccharide vaccine. MMWR
1989;38:64-8,73-6.
Breiman RF, Spika JS, Navarro VJ, Darden PM, Darby CP.
Pneumococcal bacteremia in Charleston County, South Carolina. Arch
Intern Med 1990;150:1401-5.
Istre GR, Tarpay M, Anderson M, Pryor A, Welch D, Pneumococcus
Study Group. Invasive disease due to Streptococcus pneumoniae in an
area with a high rate of relative penicillin resistance. J Infect
Dis 1987;156:732-5.
Herva E, Luotonen J, Timonen M, Sibakov M, Karma P, Makela PH.
The effect of polyvalent pneumococcal polysaccharide vaccine on
nasopharyngeal and nasal carriage of Streptococcus pneumoniae.
Scand J Infect Dis 1980;12:97-100.
Douglas RM, Hansman D, Miles HB, Paton JC. Pneumococcal carriage
and type-specific antibody: failure of a 14-valent vaccine to
reduce carriage in healthy children. Am J Dis Child
1986;140:1183-5.
Jacobs MR. Treatment and diagnosis of infections caused by
drug-resistant Streptococcus pneumoniae. Clin Infect Dis
1992;15:119-27.
Spika JS, Facklam RR, Plikaytis BD, Oxtoby MJ. Antimicrobial
resistance of Streptococcus pneumoniae in the United States,
1979-1987: the Pneumococcal Surveillance Working Group. J Infect
Dis 1991;163:1273-8.
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