Notably, a statistically significant trend in increasing macrolide resistance was seen for serotypes 14 and 19F. However, since both serotypes are BIX 1294 included in the pneumococcal

conjugate vaccines, a future reduction of these serotypes can be expected. The low rate of macrolide nonsusceptibility among isolates not Hedgehog inhibitor serotyped corresponds to the fact, that high resistance levels were a main trigger for initiation of serotyping during the early years of this study, when consistent serotyping of all isolates was not conducted due to excessive costs. In spite of all these observations, because the impact of preventive and therapeutic strategies on pneumococcal evolution not only depends on, but also influences the serotype distribution, when normal temporal [11, 40] and regional [15, 41, 42] variations

of serotype distribution are taken into consideration, future developments remain difficult to predict [32]. Ongoing nationwide surveillance is necessary to observe further developments of pneumococcal macrolide resistance in Germany. Acknowledgements We thank the microbiological laboratories in Germany for their cooperation and for providing the isolates. This study was supported, in part, by Wyeth Pharma GmbH, Germany. References 1. Austrian R: Pneumococcus: the first one hundred years. Rev Infect Dis 1981,3(2):183–189.PubMedCrossRef 2. Musher DM: Infections caused by Streptococcus pneumoniae : clinical spectrum, see more pathogenesis, immunity, and treatment. Clin Infect Dis 1992,14(4):801–807.PubMedCrossRef 3. Reinert RR, Ringelstein A, van der Linden M, Cil MY, Al-Lahham A, Schmitz FJ: Molecular epidemiology of macrolide-resistant Streptococcus pneumoniae isolates in Europe. J Clin Microbiol 2005,43(3):1294–1300.PubMedCrossRef 4. Pallares R, Linares J, Vadillo M, Cabellos C, Manresa F, Viladrich PF, Martin

R, Gudiol F: Resistance to penicillin Protein kinase N1 and cephalosporin and mortality from severe pneumococcal pneumonia in Barcelona, Spain. N Engl J Med 1995,333(8):474–480.PubMedCrossRef 5. Deeks SL, Palacio R, Ruvinsky R, Kertesz DA, Hortal M, Rossi A, Spika JS, Di Fabio JL: Risk factors and course of illness among children with invasive penicillin-resistant Streptococcus pneumoniae . The Streptococcus pneumoniae Working Group. Pediatrics 1999,103(2):409–413.PubMedCrossRef 6. Yu VL, Chiou CC, Feldman C, Ortqvist A, Rello J, Morris AJ, Baddour LM, Luna CM, Snydman DR, Ip M, et al.: An international prospective study of pneumococcal bacteremia: correlation with in vitro resistance, antibiotics administered, and clinical outcome. Clin Infect Dis 2003,37(2):230–237.PubMedCrossRef 7. Clinical Laboratory Standards Institute: Performance standards for antimicrobial susceptibility testing; eighteenth informational supplement. Wayne, PA; 2008. 8.