Streptococcus pneumoniae is the most important causative agent of community acquired pneumonia (CAP) and is also the main causative agent of otitis media, paranasal sinusitis, and meningitis. Streptococcus pneumoniae usually resides in the nasopharyngeal cavity of normal humans and is mostly non-pathogenic, with only a few virulent. More than 80 serotypes are known, and their main pathogenic substances are podococcal and hemolysin. Streptococcus pneumoniae can often invade the body when the body’s resistance decreases, leading to patient morbidity. Streptococcus pneumoniae pneumonia was formerly known as lobar pneumonia. Each year, Streptococcus pneumoniae infections result in 100,000 to 135,000 hospitalizations for pneumonia, 6 million cases of otitis media, and more than 60,000 invasive cases (including 3,300 cases of meningitis). The incidence of the disease in poor areas has a variable geographic distribution, ranging from 21 to 33 cases per 100,000 population. As one of the first pathogens to be defeated by humans and the most familiar bacterium to our medical practitioners, many people do not take it seriously. I believe most physicians have heard the phrase: “Typical lobar pneumonia is becoming less and less common now that antimicrobial drugs are more commonly used.” This statement is actually not wrong, at least from an imaging point of view. However, this correct understanding tends to make people think less of Streptococcus pneumoniae infections, and we have been told more than once that “pneumonia is the only thing you can treat in respiratory medicine, right? However, in this era of antibacterial drugs, more than 1 million children die each year from Streptococcus pneumoniae infections worldwide. Several issues that are easily overlooked in Streptococcus pneumoniae infections, or that should be taken seriously, include drug resistance, choice of initial treatment, treatment of complications, and vaccine use. The incidence of Streptococcus pneumoniae, one of the most important pathogens of CAP, has been a global trend since 1967 when penicillin-resistant Streptococcus pneumoniae (PRSP) was first reported, and has been of great concern to scholars at home and abroad. The total penicillin resistance rate (resistant + mediated) of Streptococcus pneumoniae in the United States in the 1980s was less than 5%;, all at low levels of resistance, rising rapidly to 17% in the early 1990s; and now exceeds 30%;. Recent ANSORP study results show that the total resistance rate of Streptococcus pneumoniae to penicillin in Asia has been as high as 51.7%;, of which, our neighboring regions including Japan, Korea, Vietnam and other countries have exceeded 60%;, individual countries even up to 90%;. From 1997 to 2000, the rate of Streptococcus pneumoniae insusceptible to penicillin (PNSP) [including penicillin-mediated (PISP) and PRSP] reported in our literature was only 8.8%; -22.5%;. However, recent findings show that PNSP is on a rapid rise and has exceeded 40%; and is mainly dominated by an increase in PISP. 2005 China CHINET bacterial resistance surveillance results showed that PNSP accounted for about 61%;. The analysis of drug resistance of 417 strains of Streptococcus pneumoniae isolated from 9 teaching hospitals in China in 2005-2006 showed that the incidence of PNSP was 47.5%; (PRSP 24.5%;, PISP 23%;). The incidence of PNSP was significantly higher in pediatric patients than in adults. The latest CAP flow survey results for adults showed that PNSP was only 20.3%;, with only 2.9% of high level resistant strains; . In comparison, the resistance rate of Streptococcus pneumoniae to penicillin in China has been increasing in recent years, but overall it is still at a low level. Studies in the United States, Canada and the United Kingdom have shown that the resistance rate of Streptococcus pneumoniae to erythromycin is still below 30% to date; and its resistance is mainly mediated by the mefA gene, with the M-resistant phenotype being more common (low-level resistance to 14- and 15-membered-ring macrolide antibiotics and sensitivity to 16-membered-ring macrolide antibiotics, clindamycin and streptomycin B), so the CAP in these countries guidelines all advocate the use of macrolide antibiotics as first-line agents for empirical treatment. Studies in China have shown that Streptococcus pneumoniae shows a high rate of resistance to macrolide antibiotics. The findings of the Chinese Bacterial Drug Resistance Surveillance Study Group in 2003 showed that the resistance rate of Streptococcus pneumoniae to erythromycin in China has been as high as 73.3%;. In the recently completed CAP flow survey of adults, the resistance rate of Streptococcus pneumoniae to azithromycin was also as high as 75.4%;. In addition, the level of resistance of Streptococcus pneumoniae to macrolide antibiotics in China is also much higher than that of the countries mentioned above, and intrinsic type of resistance mediated by the ermB gene (cMLS, with high levels of resistance to erythromycin and cross-resistance to lincomycins and streptogramins B) is very common . This is another important resistance characteristic that distinguishes Streptococcus pneumoniae from other countries in China . Selection of initial treatment: In the treatment of Streptococcus pneumoniae infection, high doses of penicillin or ampicillin are still effective for low penicillin-resistant Streptococcus pneumoniae (PISP) infection, and cefotaxime, ceftriaxone, and neoquinolones are available for highly penicillin-resistant Streptococcus pneumoniae (PRSP) infection. Our Streptococcus pneumoniae has a high rate of in vitro resistance to macrolide antibiotics, but in vivo efficacy has yet to be further studied. How to choose the initial empirical treatment? In the case of CAP, North American scholars are more accepting of covering both Streptococcus pneumoniae and atypical pneumonia pathogens, such as the newer macrolide antibiotics (e.g., azithromycin and clarithromycin), and our current CAP clinic guidelines include macrolide antibiotics as one of the first-line agents for empiric CAP treatment. For CAP patients with underlying disease or risk factors for DRSP infection, North American and Chinese guidelines recommend treatment with β-lactams + macrolides, or fluoroquinolone antibiotics alone (e.g., levofloxacin, moxifloxacin, and gatifloxacin). And in Europe beta-lactam antibiotics are the preferred treatment drugs. Management of complications: There are many complications of Streptococcus pneumoniae infection, such as middle ear effusion, chronic otitis media, temporary deafness or delayed speech. Even serious complications such as meningitis, endocarditis, and shock occur. In the case of CAP, the most common complication is pleurisy. A new study by British scholar Maskell et al. shows that the causative agent of pleural infections is different from pneumonia, and the choice of antimicrobial drugs for treatment should be different from pneumonia. The researchers performed bacteriological cultures and genetic sequence analysis of pleural effusions from 434 patients with pleural infections. The results showed that about 50% of the causative organisms in community-acquired infections; were streptococci and 20%; contained anaerobic bacteria. The study suggests that the causative organisms of pleural infections are different from pneumonia and therefore the treatment should also be different from pneumonia. Antimicrobial drugs used to treat community-acquired pleural infections should be able to cover both anaerobic and aerobic bacteria. Vaccine use: Vaccination with Streptococcus pneumoniae multivalent English membrane polysaccharide vaccine may reduce its infection and carriage rate. It is recommended for people at high risk for Streptococcus pneumoniae infection, such as children under 2 years of age or older adults. A study in JAMA suggests that pneumococcal vaccination of young children may also help reduce the chance of serious pneumococcal infections in adults by providing protection against seven species of Streptococcus pneumoniae. Prevention of Streptococcus pneumoniae infection may be improved through expanded use of the 23-valent polysaccharide pneumonia vaccine in adults and a recently licensed conjugate vaccine for infants and younger children.