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5% in 2008 (p?DDR1 with streptococci of the mitis group [67�C69]. The new, or respiratory, fluoroquinolones such as levofloxacin and moxifloxacin have enhanced activity against pneumococci when compared with the older ones (ciprofloxacin), and have become therapeutic alternatives for the treatment of community-acquired pneumonia in adults, because their spectrum of activity includes S.?pneumoniae, Legionella pneumophila, and other atypical pathogens. Increased use of these antimicrobials has been associated with the emergence of resistance in S.?pneumoniae in both Canada and Spain [70,71]. A multicentre study performed in Europe in 2004�C2005 involving community-acquired respiratory tract infections [72] showed a low level of quinolone resistance in the majority of European countries, with the exception of Poland (4.4%), Finland (6.6%), and Italy (7.2%). Higher rates were also detected in some Asian countries [73], as well as recently in Canada (7.3% in 2006) [74]. In this country, the increase selleck screening library in ciprofloxacin resistance observed between 1998 (0.6%) and 2006 (7.3%) was strongly associated with an increase in fluoroquinolone consumption [74]. In Spain, two nationwide surveillance studies performed in 2002 and 2006 showed a stable rate of ciprofloxacin resistance (2.6% and 2.3%, respectively) [68,69]. There are several reports Selleck Temozolomide of treatment failure with the use of quinolones in the treatment of pneumococcal infection caused by fluoroquinolone-non-susceptible isolates. The risk factors identified in these reports were previous fluoroquinolone use, chronic obstructive pulmonary disease, hospitalization, and living in nursing homes [73]. However, once patients with these risk factors were excluded, the efficacy of levofloxacin in the treatment of pneumococcal pneumonia was proven [75]. To avoid therapeutic failures, it is very important to detect strains with first-step mutations, which usually have low-level ciprofloxacin resistance, with MICs of 4�C8?mg/L, and frequently appear to be levofloxacin-susceptible, with MICs of 1�C2?mg/L [68,69]. These strains could become highly resistant under selective fluoroquinolone pressure. In our experience, the ciprofloxacin breakpoint of 4?��g/mL, suggested by Chen et?al., is the best marker for detecting strains with first-step mutations [68�C70]. These strains, wrongly identified as susceptible, accounted for 2.
