Skip to main content
  • ASM
    • Antimicrobial Agents and Chemotherapy
    • Applied and Environmental Microbiology
    • Clinical Microbiology Reviews
    • Clinical and Vaccine Immunology
    • EcoSal Plus
    • Eukaryotic Cell
    • Infection and Immunity
    • Journal of Bacteriology
    • Journal of Clinical Microbiology
    • Journal of Microbiology & Biology Education
    • Journal of Virology
    • mBio
    • Microbiology and Molecular Biology Reviews
    • Microbiology Resource Announcements
    • Microbiology Spectrum
    • Molecular and Cellular Biology
    • mSphere
    • mSystems
  • Log in
  • My alerts
  • My Cart

Main menu

  • Home
  • Articles
    • Current Issue
    • Accepted Manuscripts
    • COVID-19 Special Collection
    • Archive
    • Minireviews
  • For Authors
    • Submit a Manuscript
    • Scope
    • Editorial Policy
    • Submission, Review, & Publication Processes
    • Organization and Format
    • Errata, Author Corrections, Retractions
    • Illustrations and Tables
    • Nomenclature
    • Abbreviations and Conventions
    • Publication Fees
    • Ethics Resources and Policies
  • About the Journal
    • About JCM
    • Editor in Chief
    • Editorial Board
    • For Reviewers
    • For the Media
    • For Librarians
    • For Advertisers
    • Alerts
    • RSS
    • FAQ
  • Subscribe
    • Members
    • Institutions
  • ASM
    • Antimicrobial Agents and Chemotherapy
    • Applied and Environmental Microbiology
    • Clinical Microbiology Reviews
    • Clinical and Vaccine Immunology
    • EcoSal Plus
    • Eukaryotic Cell
    • Infection and Immunity
    • Journal of Bacteriology
    • Journal of Clinical Microbiology
    • Journal of Microbiology & Biology Education
    • Journal of Virology
    • mBio
    • Microbiology and Molecular Biology Reviews
    • Microbiology Resource Announcements
    • Microbiology Spectrum
    • Molecular and Cellular Biology
    • mSphere
    • mSystems

User menu

  • Log in
  • My alerts
  • My Cart

Search

  • Advanced search
Journal of Clinical Microbiology
publisher-logosite-logo

Advanced Search

  • Home
  • Articles
    • Current Issue
    • Accepted Manuscripts
    • COVID-19 Special Collection
    • Archive
    • Minireviews
  • For Authors
    • Submit a Manuscript
    • Scope
    • Editorial Policy
    • Submission, Review, & Publication Processes
    • Organization and Format
    • Errata, Author Corrections, Retractions
    • Illustrations and Tables
    • Nomenclature
    • Abbreviations and Conventions
    • Publication Fees
    • Ethics Resources and Policies
  • About the Journal
    • About JCM
    • Editor in Chief
    • Editorial Board
    • For Reviewers
    • For the Media
    • For Librarians
    • For Advertisers
    • Alerts
    • RSS
    • FAQ
  • Subscribe
    • Members
    • Institutions
Bacteriology

Barriers to Intravenous Penicillin Use for Treatment of Nonmeningitis Pneumococcal Disease

Jennifer Rosen, Susan Beekmann, Philip Polgreen, Matthew Moore
Jennifer Rosen
1Centers for Disease Control and Prevention, Atlanta, Georgia
2Epidemic Intelligence Service, Office of Workforce and Career Development, Centers for Disease Control and Prevention, Atlanta, Georgia
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: jrosen4@health.nyc.gov zdn4@cdc.gov
Susan Beekmann
3University of Iowa Carver College of Medicine, Iowa City, Iowa
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Philip Polgreen
3University of Iowa Carver College of Medicine, Iowa City, Iowa
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Matthew Moore
1Centers for Disease Control and Prevention, Atlanta, Georgia
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: jrosen4@health.nyc.gov zdn4@cdc.gov
DOI: 10.1128/JCM.01012-10
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

ABSTRACT

Infectious disease physicians were surveyed to determine whether the new penicillin breakpoint change will translate into increased penicillin use and to identify barriers to intravenous (i.v.) penicillin use for pneumococcal infections. The inconvenience of i.v. penicillin may limit its use despite a reduction in numbers of infections considered resistant.

Streptococcus pneumoniae causes clinical syndromes, including bacteremia, peritonitis, and septic arthritis, and is the most common cause of bacterial meningitis and pneumonia in the United States. Penicillin breakpoints for pneumococcus were originally based on achievable penicillin concentrations in cerebrospinal fluid. However, penicillin achieves greater concentrations in the lungs and blood than in cerebrospinal fluid (1). In January 2008, new penicillin breakpoints for intravenous (i.v.) treatment of pneumococcal infections other than meningitis were published by the Clinical and Laboratory Standards Institute (CLSI) (3, 7). Based on these new breakpoints, many more nonmeningitis pneumococcal infections are now categorized as susceptible to penicillin (2, 7). Increased penicillin use might reduce the need for broader-spectrum antibiotics that increase the potential for antibiotic resistance (6).

Infectious Diseases Society of America (IDSA) guidelines for antimicrobial stewardship programs recommend using culture results to streamline or deescalate empirical antimicrobial therapy to more effectively target the causative pathogen, decrease antimicrobial exposure, and decrease costs (4). Except in an IDSA News article (5) and an updated package insert for i.v. penicillin produced by one manufacturer, the penicillin breakpoint change had not been widely publicized at the time that the survey was conducted. To determine whether the breakpoint change is likely to translate into increased penicillin use and to identify barriers to i.v. penicillin use for the treatment of pneumococcal infections, we surveyed infectious disease physician members of the IDSA Emerging Infections Network (EIN).

On 30 September 2008, 9 months following publication of the new penicillin breakpoints, a questionnaire was distributed via e-mail or facsimile to 1,247 adult and pediatric infectious disease physician members of the EIN and either the IDSA or the Pediatric Infectious Diseases Society. Members subscribe to an e-mail listserv for discussing topics related to the prevention, diagnosis, and treatment of infectious diseases. The 1-page introduction and 2-page self-administered questionnaire (both available upon request) containing 9 multiple-choice questions were developed with input from experts in the field of infectious disease. Topics covered in the questionnaire included awareness of the new penicillin breakpoint change, methods of learning about the breakpoint change, potential for change in prescribing practices, and barriers to i.v. penicillin use. The survey was redistributed to nonresponders twice over 3 weeks. Only respondents who reported that they care for patients with pneumococcal infections were included.

A descriptive analysis was performed on complete responses; denominators for certain questions varied, as not all physicians responded to all questions. Data were analyzed using SAS version 9.2. Comparisons between groups were made by chi-square analysis. P values of <0.05 were considered statistically significant.

A total of 588 responses were received (47% response rate). Characteristics of respondents, including patient population, practice setting, and residence, did not differ significantly from those of nonrespondents. Fifty-nine responses were excluded because the physicians reported that they did not treat patients with pneumococcal infection, leaving a final sample of 529 (42%).

We asked infectious disease physicians how they learned about the penicillin breakpoint change (Table 1). Of the 529 respondents, 82.0% were aware of the breakpoint change at the time of the survey. News reports from the IDSA, reports from clinical microbiology laboratories, and discussions with colleagues were the most common mechanisms for learning about the breakpoint changes. We asked the physicians how they would prefer to learn of similar breakpoint changes in the future. Preferred mechanisms included IDSA News reports, clinical microbiology laboratory reports, and documents published by the CLSI.

We then asked respondents to consider, given the breakpoint change, how likely they were and how likely they believed noninfectious disease physicians were to use i.v. penicillin when treating non-penicillin-allergic patients with pneumococcal infections. Over half of respondents reported that they were more likely to use i.v. penicillin (51.2%), while 11.1% reported that they believed that noninfectious disease physicians were more likely to use penicillin. “Don't know” accounted for 2.3% of responses from infectious disease physicians and 25.7% of responses regarding noninfectious disease physicians.

Table 2 shows infectious disease physician responses regarding reasons why they were unlikely and why they believed noninfectious disease physicians were unlikely to use i.v. penicillin for treating susceptible pneumococcal pneumonia. The most commonly reported barrier to i.v. penicillin use among infectious disease physicians was the frequent dosing schedule. Infectious disease physicians believed that the greatest barriers to i.v. penicillin use among noninfectious disease physicians were clinical improvement after the initial regimen, the convenience of continuing antibiotics that were started empirically, and confusing susceptibility reports.

Among 324 (61.2%) respondents who reported that their clinical microbiology laboratories report separate susceptibilities for meningitis and nonmeningitis pneumococcal isolates (as recommended by the CLSI), 28 (8.6%) rated laboratory interpretations as confusing. i.v. penicillin use has been encouraged at the institutional level according to 80 (15.1%) respondents.

Although awareness among infectious disease physicians about the 2008 i.v. penicillin breakpoint change for treatment of pneumococcal infections was high, it is likely that many fewer noninfectious disease physicians are aware of the breakpoint change. This is concerning, since most antibiotics are prescribed by noninfectious disease providers. Published reports from professional medical societies might help to increase awareness of the breakpoint changes. Communication via clinical microbiology laboratories and national conferences may also be effective for increasing awareness of penicillin and other antibiotic breakpoint changes in the future.

Approximately half of infectious disease physicians self-reported that they were more likely to treat patients with pneumococcal pneumonia with i.v. penicillin as a result of the change in breakpoints. According to the infectious disease providers surveyed, fewer noninfectious disease physicians were believed to be more likely to treat with i.v. penicillin. Barriers to i.v. penicillin use that are unrelated to concerns over antimicrobial resistance exist, so increasing awareness of breakpoint changes alone is likely insufficient to increase penicillin use.

Standard clinical practices are barriers to i.v. penicillin use. Many patients with pneumococcal pneumonia respond so well to initial empirical antibiotic therapy that by the time susceptibility results are available on the second or third hospital day, the patient has already been switched to oral antibiotics. Many physicians also find it more convenient to continue with empirical regimens than to switch to i.v. penicillin. Some antibiotics chosen for empirical therapy, such as ceftriaxone and fluoroquinolones, have the benefit of once-daily administration.

There are limitations to our evaluation. The response rate was 47%, and the population of EIN members who responded to the survey may not be representative of those who chose not to respond. The survey was limited to infectious disease specialists belonging to a professional medical society, and responses from our survey are not representative of the general population of physicians. Noninfectious disease physicians were not surveyed directly, so responses about this population of physicians may not be accurate. Awareness about the new penicillin breakpoints among infectious disease physicians likely increased following publication of an article, 8 months after the survey was conducted, that described the rationale for revising the breakpoints (7).

Hospitals should ensure that clinicians are aware of the new penicillin breakpoint change for pneumococcal pneumonia. Antimicrobial stewardship programs should include strategies that ensure targeted antimicrobial therapy based on susceptibility results. If penicillin is to be used more often in these programs, steps need to be taken to make penicillin more convenient for clinicians, to provide instructions for penicillin use, and to enhance awareness and education about the importance of using narrow-spectrum agents. Rates of penicillin use in hospitals should be monitored to determine whether penicillin prescribing practices have increased since the breakpoint change and whether this change has had any impact on antibiotic-resistant, health care-associated infections. Penicillin use is unlikely to increase substantially without such interventions.

View this table:
  • View inline
  • View popup
TABLE 1.

Method of learning about new penicillin breakpoints for i.v. treatment of pneumococcal infectionsa

View this table:
  • View inline
  • View popup
TABLE 2.

Reported barriers to i.v. penicillin use for pneumococcal pneumonia treatmenta

FOOTNOTES

    • Received 19 May 2010.
    • Returned for modification 9 June 2010.
    • Accepted 29 June 2010.
  • Copyright © 2010 American Society for Microbiology

REFERENCES

  1. 1.↵
    Andes, D. 2001. Pharmacokinetic and pharmacodynamic properties of antimicrobials in the therapy of respiratory tract infections. Curr. Opin. Infect. Dis. 14 : 165-172.
    OpenUrlCrossRefPubMedWeb of Science
  2. 2.↵
    Centers for Disease Control and Prevention. 2008. Effects of new penicillin susceptibility breakpoints for Streptococcus pneumoniae—United States, 2006-2007. MMWR Morb. Mortal. Wkly. Rep. 57 : 1353-1355.
    OpenUrlPubMed
  3. 3.↵
    Clinical and Laboratory Standards Institute. 2008. Performance standards for antimicrobial susceptibility testing; eighteenth informational supplement. Approved standard M100-S18. Clinical and Laboratory Standards Institute, Wayne, PA.
  4. 4.↵
    Dellit, T. H., R. C. Owens, J. E. McGowan, Jr., D. N. Gerding, R. A. Weinstein, J. P. Burke, W. C. Huskins, D. L. Paterson, N. O. Fishman, C. F. Carpenter, P. J. Brennan, M. Billeter, and T. M. Hooton. 2007. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin. Infect. Dis. 44 : 159-177.
    OpenUrlCrossRefPubMedWeb of Science
  5. 5.↵
    Infections Diseases Society of America. 2008. Penicillin's back: FDA raises breakpoints for S. pneumoniae pneumonia. IDSA News 18(4). http://www.idsociety.org/newsArticle.aspx?id=11010 .
  6. 6.↵
    MacDougall, C., J. P. Powell, C. K. Johnson, M. B. Edmond, and R. E. Polk. 2005. Hospital and community fluoroquinolone use and resistance in Staphylococcus aureus and Escherichia coli in 17 US hospitals. Clin. Infect. Dis. 41 : 435-440.
    OpenUrlCrossRefPubMedWeb of Science
  7. 7.↵
    Weinstein, M. P., K. P. Klugman, and R. N. Jones. 2009. Rationale for revised penicillin susceptibility breakpoints versus Streptococcus pneumoniae: coping with antimicrobial susceptibility in an era of resistance. Clin. Infect. Dis. 48 : 1596-1600.
    OpenUrlCrossRefPubMedWeb of Science
PreviousNext
Back to top
Download PDF
Citation Tools
Barriers to Intravenous Penicillin Use for Treatment of Nonmeningitis Pneumococcal Disease
Jennifer Rosen, Susan Beekmann, Philip Polgreen, Matthew Moore
Journal of Clinical Microbiology Aug 2010, 48 (9) 3372-3374; DOI: 10.1128/JCM.01012-10

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Print

Alerts
Sign In to Email Alerts with your Email Address
Email

Thank you for sharing this Journal of Clinical Microbiology article.

NOTE: We request your email address only to inform the recipient that it was you who recommended this article, and that it is not junk mail. We do not retain these email addresses.

Enter multiple addresses on separate lines or separate them with commas.
Barriers to Intravenous Penicillin Use for Treatment of Nonmeningitis Pneumococcal Disease
(Your Name) has forwarded a page to you from Journal of Clinical Microbiology
(Your Name) thought you would be interested in this article in Journal of Clinical Microbiology.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Share
Barriers to Intravenous Penicillin Use for Treatment of Nonmeningitis Pneumococcal Disease
Jennifer Rosen, Susan Beekmann, Philip Polgreen, Matthew Moore
Journal of Clinical Microbiology Aug 2010, 48 (9) 3372-3374; DOI: 10.1128/JCM.01012-10
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Top
  • Article
    • ABSTRACT
    • FOOTNOTES
    • REFERENCES
  • Figures & Data
  • Info & Metrics
  • PDF

KEYWORDS

Anti-Bacterial Agents
Health Knowledge, Attitudes, Practice
Penicillins
Physicians
Pneumococcal Infections
Streptococcus pneumoniae

Related Articles

Cited By...

About

  • About JCM
  • Editor in Chief
  • Board of Editors
  • Editor Conflicts of Interest
  • For Reviewers
  • For the Media
  • For Librarians
  • For Advertisers
  • Alerts
  • RSS
  • FAQ
  • Permissions
  • Journal Announcements

Authors

  • ASM Author Center
  • Submit a Manuscript
  • Article Types
  • Resources for Clinical Microbiologists
  • Ethics
  • Contact Us

Follow #JClinMicro

@ASMicrobiology

       

ASM Journals

ASM journals are the most prominent publications in the field, delivering up-to-date and authoritative coverage of both basic and clinical microbiology.

About ASM | Contact Us | Press Room

 

ASM is a member of

Scientific Society Publisher Alliance

 

American Society for Microbiology
1752 N St. NW
Washington, DC 20036
Phone: (202) 737-3600

 

Copyright © 2021 American Society for Microbiology | Privacy Policy | Website feedback

Print ISSN: 0095-1137; Online ISSN: 1098-660X