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Recommendations Regarding Penicillin-Resistant Pneumococcal Disease -- Spain

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.


  1. 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.

  2. 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.

  3. ACIP. Recommendations of the Immunization Practices Advisory Committee: Pneumococcal polysaccharide vaccine. MMWR 1989;38:64-8,73-6.

  4. Breiman RF, Spika JS, Navarro VJ, Darden PM, Darby CP. Pneumococcal bacteremia in Charleston County, South Carolina. Arch Intern Med 1990;150:1401-5.

  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.

  6. 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.

  7. 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.

  8. Jacobs MR. Treatment and diagnosis of infections caused by drug-resistant Streptococcus pneumoniae. Clin Infect Dis 1992;15:119-27.

  9. 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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