Case of pneumococcal (PRSP) bronchitis: Gram staining as the earliest and useful indicator for evaluating the effectiveness of antimicrobial therapy in outpatient.

Abstract

A 75-year-old man was seen in the general practice in our hospital because of fever of 38-39℃, cough and purulent sputa on January 8 th . Six days before visit, he had the chief complaint. The day before, he visited a clinic. The chest X-ray showed no pneumonia shadow suggesting of bronchitis with old tuberculous changes. Azithromycin was administered, but no improvement was seen. The doctor sent him to our hospital. Gram-stained sputum samples showed gram- positive diplococcus, later identified as Streptococcus pneumoniae (PRSP). He was administered two grams of ampicillin for 30 minutes. Gram-stained sputum samples showed smaller or gram-negative pneumococci at the completion of administration of the agent, and a decreased number of extracellular cocci and increased number of phagocyted small and weekly stained cocci at two hours after completion of administration. We estimated the effectiveness of ampicillin and prescribe 2g of amoxicillin hydrate (AMPC) (500mgX4) for 2days followed by 1.5g of AMPC (500mgX3) for the next 5days (till 2/15). He was seen on the 7 th day (2/14) again with no fever, a decreased amount of cough and sputa. The culture of the sputum on the first day (2/8) revealed Streptococcus (PRSP) 3+ resistant to penicillin and ampicillin. But Gram-stained sputum samples showed little number of cocci and we confirmed the effectiveness of ampicillin prescribing no additional antimicrobial agent. He was seen on the 12 th (2/19) to follow up the course, and getting better with little cough having watery sputa. The culture of the sputum on the 7 th (2/14) day revealed no Streptococcus. However, Gram-stained sputum samples showed some extracellular cocci suggesting of pneumococci, and we predicted the coming relapse of bronchitis. We prescribed new ketolide antimicrobial drug telithromycin (TEL,300mgX 2) for 3days. On the 15 th (2/22) he visited our hospital again with no respiratory symptom and Gram-stained sputum samples showed no cocci suggestive of pneumococcus. He recovered from bronchitis. We present here a case in which morphological changes and/or a decreased number of extracellular S. pneumoniae observed in Gram-stained sputum samples obtained after the first administration of antimicrobial agents presented useful information as a reliable therapeutic indicator of the effectiveness of the first administered agent, and follow up check of Gram-stained sputum could prevent the relapse of bronchitis before worsening in outpatient.