Confronting Drug-resistant Pneumococci

Termed “Captain of the Men of Death” in 1901 by Sir William Osler in the fourth edition of his renowned text, The Principles and Practice of Medicine [1], lobar pneumonia was a dreaded disease in the early years of this century, with case fatality rates from untreated illness of the order of 30% to 35% [2]. Despite significant advances in therapy, first with the introduction of type-specific anticapsular pneumococcal serum, followed a quarter-century later by sulfapyridine and other sulfonamides, it was only after the publication in 1944 of the report of Tillett and colleagues [3] of the treatment of pneumococcal pneumonia with penicillin that professional attitudes toward this and other pneumococcal infections underwent a profound change. With the advent of penicillin used in doses of 40 000 to 100 000 units daily for 4 to 5 days to treat either bacteremic or nonbacteremic pneumococcal pneumonia, case fatality rates decreased to 5% to 8%, and a previously potentially fatal disease affecting persons of all ages came to be regarded as one of little gravity. This attitude was furthered by declining recognition of the pneumococcus in hospital laboratories as they abandoned routine typing of the organism, no longer a requisite in designing therapy. Even the necessity of examining respiratory secretions of adults with pneumonia was questioned in the 1950s [4].

Had we lived in a culture with a greater awareness of history, the sense of security engendered by the initial success with penicillin might have been tempered by earlier events. Optochin, a drug related to quinine, was used briefly in the second decade of this century to treat pneumococcal infection until its ocular toxicity forced its abandonment. Reports of pneumococci showing increased resistance to optochin recovered from mice treated experimentally with this drug appeared in 1912 [5], and …