Clinical and bacteriological implications of macrolide resistance in group A streptococcal pharyngitis.

735 sumed recurrent TB infection. He was treated with co-amoxiclav, and an intercostal drain was inserted to reduce the concomitant pleural effusion. He responded well to therapy, and an acid-fast smear of his sputum confirmed TB; TB therapy (rifampicin, isoniazid, ethambutol and pyrazinamide), as recommended by the South African Department of Health, was commenced. The patient was unable to recall prior fluoroquinolone use. N16 was isolated from a 55-year-old female, with previous renal impairment, admitted with pneumonia. She was treated with cefuroxime and responded well. She had received ciprofloxacin for a urinary tract infection within the previous 10 months of admission. Emergence of these highly resistant Haemophilus species may be the result of several factors. Firstly, in the South African community, there is considered to be a relatively high use of fluoroquinolone antibiotics for the treatment—among other infections—of sexually transmitted diseases and urinary tract infections. Secondly, during the winter of 2001, two new fluoroquinolones (moxifloxacin and gatifloxacin) were licensed for use, widely advertised and recommended in the treatment of community-acquired pneumonia. It should be noted that both of the isolates described in this report were resistant to these new agents. Previous use of a fluoroquinolone has been associated with fluoroquinolone resistance in H. influenzae,3 and it is suggested that prior exposure to a quinolone selected the bacteria described. However, the high-level resistance of both these isolates has been considered previously to be extremely rare, and such strains have not been isolated easily in the laboratory after exposure to the older fluoroquinolones, such as ciprofloxacin and ofloxacin. Therefore, we caution the use of these newer fluoroquinolones, and emphasize the importance of vigilance and surveillance of bacterial species considered previously to be exquisitely susceptible to these agents, so that any changes in the population can be identified quickly and policies put in place to prevent transmission.