Increasing clindamycin resistance in group A streptococcus

Abstract

We commend Ahmed Babiker and colleagues1Babiker A Li X Lai YL et al.Effectiveness of adjunctive clindamycin in β-lactam antibiotic-treated patients with invasive β-haemolytic streptococcal infections in US hospitals: a retrospective multicentre cohort study.Lancet Infect Dis. 2021; 21: 697-710Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar for their paper on adjunctive clindamycin for β-haemolytic streptococcal infections from 2000 to 2015, which showed a decrease in mortality for patients with severe group A streptococcal (GAS) infection and added to the literature regarding this disease state. We were concerned that increasing clindamycin resistance in GAS isolates was not discussed in the Article. Between 2011 and 2015, the US Centers for Disease Control and Prevention Active Bacterial Core surveillance programme reported an increase from 8·9% to 13·1% of GAS isolates that were non-susceptible to clindamycin (table).2US Centers for Disease Control and PreventionABCs Bact Facts interactive data dashboard: group A streptococcus.https://www.cdc.gov/abcs/bact-facts-interactive-dashboard.htmlDate: 2021Date accessed: April 11, 2021Google Scholar This rate further increased substantially to 24·2% in 2018.2US Centers for Disease Control and PreventionABCs Bact Facts interactive data dashboard: group A streptococcus.https://www.cdc.gov/abcs/bact-facts-interactive-dashboard.htmlDate: 2021Date accessed: April 11, 2021Google ScholarTableGroup A streptococcus non-susceptibility by calendar year from the US Centers for Disease Control and Prevention Active Bacterial Core surveillance programmeResistance rateNumber of isolates20118·9%1108201211·2%852201312·5%940201413·1%1259201513·1%1404201614·7%1737201721·7%2177201824·2%2281 Open table in a new tab In the study by Babiker and colleagues, approximately 20% of the GAS isolates had susceptibility testing for clindamycin, and a resistance rate of 11·4% was observed.1Babiker A Li X Lai YL et al.Effectiveness of adjunctive clindamycin in β-lactam antibiotic-treated patients with invasive β-haemolytic streptococcal infections in US hospitals: a retrospective multicentre cohort study.Lancet Infect Dis. 2021; 21: 697-710Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar The authors did not mention if this rate included only constitutive resistance or was from combined constitutive and inducible resistance. Although a subgroup analysis in the Article did not show increased mortality in the group with clindamycin-resistant GAS infection, the number of GAS isolates with known clindamycin resistance was low (n=76).1Babiker A Li X Lai YL et al.Effectiveness of adjunctive clindamycin in β-lactam antibiotic-treated patients with invasive β-haemolytic streptococcal infections in US hospitals: a retrospective multicentre cohort study.Lancet Infect Dis. 2021; 21: 697-710Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar Clinicians should be cautious when applying these results in clinical settings where the clindamycin resistance in GAS isolates is more than double what was found in this study. Clinicians need to be aware of the increasing rate of clindamycin resistance in GAS infections and order susceptibility testing when using clindamycin for adjunctive treatment. The effect of clindamycin resistance in invasive GAS infections remains unclear. A murine model found that inhibitory concentrations of clindamycin reduced both the size of skin lesions and activity of virulence factors, even in clindamycin-resistant GAS strains.3Andreoni F Zürcher C Tarnutzer A et al.Clindamycin affects group A streptococcus virulence factors and improves clinical outcome.J Infect Dis. 2017; 215: 269-277PubMed Google Scholar The role of clindamycin concentration at the site of infection, the effect of clindamycin resistance, and the clinical outcomes for patients with clindamycin-resistant GAS strains are yet to be elucidated. In the case of clindamycin-resistant GAS strains, clinicians could consider using linezolid; however, there are few data supporting linezolid use in severe GAS infections.4Bryant AE Bayer CR Aldape MJ McIndoo E Stevens DL Emerging erythromycin and clindamycin resistance in group A streptococci: efficacy of linezolid and tedizolid in experimental necrotizing infection.J Glob Antimicrob Resist. 2020; 22: 601-607Crossref PubMed Scopus (6) Google Scholar BPW reports personal fees from Gilead Sciences, outside of the submitted work. EAS declares no competing interests. Effectiveness of adjunctive clindamycin in β-lactam antibiotic-treated patients with invasive β-haemolytic streptococcal infections in US hospitals: a retrospective multicentre cohort studyReal-world data suggest that increased use of adjunctive clindamycin for invasive iGAS infections, but not iNABS infections, could improve outcomes, even in patients without shock or necrotising fasciitis. Full-Text PDF Clindamycin-resistant Streptococcus pyogenes in Chinese childrenThe Correspondence by Bryan White and Emily Siegrist1 about clindamycin-resistant group A streptococcal infection attracted much attention in the USA. White and Siegrist argued that although the findings from some studies suggest a decrease in mortality from group A streptococcal infections in the USA, serious infections caused by clindamycin non-susceptible invasive group A streptococcus are increasing due to expansion of several emm types.2 Therefore, we hope to provide some information about clindamycin-resistant group A streptococcus in China to compare its prevalence in different areas. Full-Text PDF