Pneumococci highly resistant to penicillin G [minimum inhibitory concentration (MIC) greater than or equal to 2 mg L(-1)] have become prevalent in many parts of the world since their emergence and spread in the late 1970s. In the USA, such organisms are seen primarily in two populations: infants and children, and adults with AIDS. Surveys in both rural and urban areas have revealed presence of these oganisms, as well as an increasing frequency of Streptococcus pneumoniae strains relatively resistant to penicillin (MIC 0.1-1.0 mg L(-1)-now defined by some as 'intermediate' resistance). Predisposing factors are not yet clear. Prior antimicrobial therapy was given to some of the children and most of the adults who are colonized or infected with resistant strains. Prior or concurrent use of cotrimoxazole prophylaxis for Pneumocystis carinii pneumonia has been frequent in our cases in adults, most of whom had a concurrent diagnosis of AIDS. Children with disease often have a history of long-term prophylaxis with a beta-lactam drug (for sickle cell disease, etc). Many strains are also resistant to newer cephalosporins like cefotaxime and ceftriaxone (MIC greater than or equal to 2 mg L(-1)). The organisms are frequently multi-resistant, with high MIC values common as well for chloramphenicol and variable for tetracycline, macrolides, cotrimoxazole, and fluoroquinolones. Only to vancomycin are the organisms consistently susceptible. These findings raise alarms about the future of pneumococcal disease in both community and nosocomial disease. Increasing prevalence in otitis and pneumonia in children and in community-acquired pneumonia in adults may lead to use of vancomycin as empirical therapy for these clinical situations. This would increase the selective pressure for emergence of vancomycin-resistant organisms, whether S. pneumoniae or others. Moreover, the pneumococcus was a common cause of hospital infection prior to the introduction of penicillin. The potential now exists for nosocomial pneumococcal infection again to become a feared and ominous occurrence.
