6 VIEWS & REVIEWS

Focus on infectious . diseases

Worldwide attention turns to infectious diseases

This month, a concerted effort by 36 medical journals worldwide aims to focus international attention on the subject of emerging and re-emerging infections, reports lAMA, one of the 3 originating journals involved in the global collaboration.I,2 'The problems are worldwide; so must be the perspective and the solutions', say Dr Margaret Winker and Ms Annette Flanagin, who are the senior editor and associate senior editor of lAMA. I They note that infectious disease is now the third leading cause of death in the US.

Attendees of the Workshop to Prevent and Control the Emergence and Spread of Antimicrobial-Resistant Microorganisms in Hospitals* published a consensus statement in lAMA that specifies high-priority strate­gies and actions that they considered would be likely to have a significant impact on reducing antimicrobial resistance, if implemented successfully by hospitals.3

Strategies developed at the Workshop to Prevent and· Control the Emergence and

Spread of AntimicrobiaJ..Resisb Microorganisms in. HOspitals

A. Strategies to optimise the used . antimicrobials in 1he hospilal t. Optimise antimicrobial prophylaxis for operative procedllres~.;./i ... .•.... . ...................... ./ 2. Optimise choice and duration of empirical antimicropial therapy. .. . 3. Improve antimicrobial prescribing practices by ~ducational and administrative means. 4. Establish a system to monitor and provide feedback on the occurrence and impact of antibacterial resistance. S. Define and implementinstltutional or health care delivery system guidelines for irnPortanttypesof antimicrobial use,

B. Strategies for detecting, reporting and preventing transmission of antimicrobial­. resistant micro-organisms 1. Develop a systemto recognise and promptly report significant changes and trends in antimicrobial resistance within the hospital. 2. Develop a system for rapid detection and reporting of resistant microorganisms in individual patients and devise means of ensuring a rapid response by caregivers. . 3. Increaseadherencetorelevanfpoliciesand proc:edures,especia!!y.· handnygiene •. barrier· precautions and environmental· control measures.

. "<4. IncorpQratettlegetection,prevention and control of . antimicrobial resistance .into~nslituti()nal . strategicgoal~ andprovidetbe required resources. 5. D~veloP •. ~rpl~l'l ... for •. id7ntifyin9~lrfln~ferring,i.

.. ·.·.·~iscliargi~gElrld r~.l:ldlTl!ttingpatientsr;olo.llised'"'ith" .~pe~ified.anUmicrobial+resistarrtmicnj..,()rnanisms ..••.•.•..

,:. '.: .. ": ,",,_: ..... : .... :._: ...... ".": : .... _ .. "":_ .. :'_::'.:.:'". ".:::_ ... _" . ..... :_:: ... :.: .. : .... ,.J:; ... :: .. " ... : ....... :., ... :,_._: .... :::

27 Jan 1996 INPHARMA"

Workshop attendees comprised a multidisciplinary group of individuals who were divided into 2 'quality improvement teams' that each developed 5 strategic goals [see box]. It was stressed that individual hospitals should consider these suggestions, but ultimately they should adopt approaches that best suit their local problems, conditions and strategic needs.

A second article published in lAMA presents a strategy from the US Centers for Disease Control and Prevention­sponsored Drug-Resistant Streptococcus pneumoniae (DRSP) Working Group that focuses on minimising the impact ofDRSp'4 The group developed a strategy for surveillance, investigation, prevention, and control of infections due to DRSP that involves the following: • implementing an electronic laboratory-based

surveillance system for reporting invasive DRSP infections and providing clinically relevant feedback to clinicians

• identifying risk factors and outcomes of DRSP infection • increasing pneumococcal vaccination • promoting judicious antimicrobial drug use.

'A comprehensive, effective, and timely public health response to the problem of DRSP is crucial to avoid further loss of ground in this battle', says the working party. * cosponsored by the US Centers for Disease Control and Prevention and the Nationol Foundation for lrifectious Diseases 1. Wmker MA. Infectious diseases: a global approach to a global problem. Journal of the American Medical Association 275: 245-246, 17 Jan 1996 2. Lederbeq>; J. Infection emergent Joumal of the American Medical Association 275: 243-245, 17 Jan 19963. Goldmann DA, et al. Straregies to prevent and control the emergence and spread of antimicrobial-resistant microorg.misms in hospitals: a challenge to hospital leadership. Joumal of the American Medical Association 275: 234-240,17 Jan 1996 4. Jernigan DB. et al Minimizing the impact of drug-resistant Streptococcus pneumoniae (DRSP): a straregy from the DRSP Working Group. Journal of the American Medical Association 275: 206-209, 17 Jan 1996 800314898

Treabnent of penicillin-resistant S. pneumoniae infections

Recommendations for treating Streptococcus pneumoniae infections in children have been formulated by 4 infectious disease specialists from the US and South Africa in response to concern over the emergence of penicillin-resistant strains of S. pneumoniae. The specialists presented their choices of treatment for 4 clinical scenarios of S. pneumoniae infection.

In the treatment of meningitis suspected to be due to S. pneumoniae, the US specialists recommend initial treatment with cefotaxime and vancomycin. In areas where the rate of resistance to cephalosporins is less widespread, the specialists still advocate mono­therapy with cefotaxime or ceftriaxone. Vancomycin can then be added if ~-lactam resistance is suspected on culture.

In the case of acute otitis media that is not responding to amoxicillin or a second line antibacterial, several possibilities emerged. Doubling the dose of amoxicillin, or using amoxicillin in combination with amoxicillinl clavulanic acid, was one option. A second- or third­generation cephalosporin or clindamycin (where the pathogen is known to be S. pneumoniae) was also recommended.

0156·270319611021-00061$01.00° Adis International Limited 1996. All rights reserved

VIEWS & REVIEWS

Pneumonia caused by penicillin-resistant S. pneumoniae can be successfully treated with a second- or third-generation cephalosporin, according to 3 of the specialists consulted.

In the case of bacteraemia due to penicillin­resistant S. pneumoniae, concern was expressed that checks be made to ensure the infection had not spread to a secondary site. Given the scenario of initial treatment with 1M ceftriaxone followed by oral amoxicillin, opinion on continuing therapy was divided. Two specialists suggested continuing amoxicillin while the others recommended using an alternative oral agent. Bradley JS, Kaplan SL, Klugman KP, et al. Consensus: management of infections in children caused by Streptococcus pneumoniae with decreased susceptibility to penicillin. Pediatric Infectious Disease Journal 14: 1037-1041, Dec 1995 800416154

Bestbreahnentforconunurnrl~­acquired pneumonia unclear

Even though the new quinolone sparfIoxacin is a 'reliable' agent for the initial treatment of non-severe community-acquired penumonia. its inappropriate and extensive use could lead to a reduction in its value as a treatment for bacterial infections, according to an editorial in the European Respiratory Journal. The authors say that the older antibacterials, especially the penicillins, are still very effective in the treatment of non-severe community-acquired pneumonia.

Physicians seem to have differing views on the treatment of uncomplicated community-acquired pneumonia. The British Thoracic Society still recommends the use of penicillins; however, the American Thoracic Society recommends the use of macrolides. The authors point out that the increasing use of macrolides over the last decade for the treatment of community-acquired pneumonia has been associated with resistance to erythromycin.

The authors conclude that there is no sufficiently strong reason to withdraw the penicillins from the first-line treatment of non-severe community-acquired pneumonia.

See also Therapy section, this issue,pl3; 800414807

Torres A, Ausina V. Empirical treatment of nonsevere community·acquired pneumonia: still a difficult issue. European Respiratory Journal 8: 1996-1998,

Dec 1995 800414806

0156·270319611021·0007I$Ol.0r!' Adls International Limited 1996. All rights reaervad

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INPHARMA" 27 Jan 1996