Amoxicillin-non-susceptible Streptococcus pneumoniae causing invasive pneumonia: serotypes, clones, and clinical...

Amoxicillin is one of the most commonly used antibiotics to treat pneumococcal infections. We analyzed the epidemiology and clinical impact of amoxicillin non-susceptibility in invasive pneumococcal pneumonia. This is an observational study based on prospectively collected data at Bellvitge University Hospital (Barcelona, Spain) from 1994 to 2020. Isolates were tested for antibiotic susceptibility, serotyped, and genotyped. Clinical characteristics and 30 day mortality were evaluated using independent Cox proportional hazards models. We analyzed 1,663 episodes. While the proportion of isolates susceptible to amoxicillin increased from 72.9% (1994-2001) to 91.4% (2016-2020), the proportion of isolates with MIC > 2 mg/L remained stable (4.8% and 5.3%, respectively). A single lineage (GPSC6; serotypes 9V, 14, and 11A) accounted for 56.5% of non-susceptible strains. High McCabe scores (ultimately fatal: HR 2.87 [2.10-3.92] and rapidly fatal: HR 4.98 [3.50-7.09]), along with parameters linked to disease severity such as leukopenia (HR 2.14 [1.63-2.82]), shock (HR 3.47 [2.63-4.57]), respiratory failure (HR 4.26 [2.63-6.89]), and bilobar pneumonia (HR 1.44 [1.09-1.90]), were associated with 30 day mortality. The risk of mortality was higher in episodes treated with amoxicillin than with third-generation cephalosporins (HR 1.81 [1.28-2.56]), especially in episodes with amoxicillin MIC > 2 mg/L (HR 6.14 [1.65-22.80]). Amoxicillin therapy was not associated with increased mortality in patients with a non-fatal McCabe score (HR 1.49 [0.62-3.55]), but it was in the ultimately fatal/rapidly fatal group (HR 1.97 [1.34-2.90]). In addition to the crucial importance of host factors in the outcome of invasive pneumococcal pneumonia, our data indicate that amoxicillin yields poorer outcomes compared to third-generation cephalosporins, particularly in patients with a worse prognosis.