Fatal Meningitis Due to Levofloxacin-Resistant Streptococcus pneumoniae

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Abstract
Because of the rising incidence of respiratory tract infections caused by penicillin-resistant Streptococcus pneumoniae, recommendations for empirical treatment of community-acquired pneumonia include the use of a fluoroquinolone with enhanced activity against S. pneumoniae (such as levofloxacin or trovafloxacin) [1]. The choice of a fluoroquinolone is attractive, since the prevalence of fluoroquinolone resistance among S. pneumoniae isolates has been reported to be as low as 0.3% [2]. Because of this low rate, microbiology laboratories may not routinely test isolates of S. pneumoniae for resistance to the fluoroquinolones, and the Performance Standards for Antimicrobial Susceptibility Testing of the National Committee for Clinical Laboratory Standards [3] lists only erythromycin, penicillin, and trimethoprim-sulfamethoxazole as agents to test primarily and to report. With the widespread use of fluoroquinolones, however, the potential for an increasing rate of unrecognized fluoroquinolone resistance exists. We report our experience with a case of fatal S. pneumoniae bacteremia and meningitis that occurred despite treatment with levofloxacin.