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Introduction: antimicrobial resistance among pediatric respiratory tract and nosocomial pathogens
Introduction: Antimicrobial Resistance Among Pediatric Respiratory Tract and Nosocomial Pathogens Scott F. Dowell, MD, MPH
A
ntimicrobial resistance has been the subject of increasing concern to pediatricians over the past decade, and it remains a major focus of both clinical and research activities for pediatric infectious disease specialists. Reviews of the subject are numerous, touching on different aspects of treatment, including the purported utility of a range of newer antimicrobial agents, prevention, and control. Since the last issue of Seminars in Pediatric Infectious Diseases focused on antimicrobial resistance among bacterial pathogens in 1996, some gratifying progress has been made, particularly in the areas of prevention and control. This issue is structured to highlight the major challenges to pediatricians as a result of the spread of antimicrobial resistance and to examine progress in the control of resistance. Antimicrobial resistance among pathogens in two major categories is covered: community-acquired infections of the respiratory tract and infections acquired in health care settings. For each category, an article from leading clinician teachers highlights the challenges posed by antimicrobial resistance, and it is paired with an article from the relevant public health authorities focusing on critical aspects of prevention and control. The appropriate control measures for antimicrobial resistance are very different for different pathogens, and the approach to control depends primarily on the mode of spread of the pathogen. For example, to focus on legislation regulating the addition of antimicrobial agents to chicken feed makes no sense if the organism of concern is methicillin-resistant Staphylococcus aureus, although such an approach might well be effective at reducing the burden of disease from fluoroquinolone-resistant Campylobacter jejuni. For respiratory tract pathogens such as Streptococcus pneumoniae and Haemophilus influenzae that are spread from child to child in the community, the primary approach to control antimicrobial resistance has been to reduce the underlying antimicrobial pressure by promoting more judicious use of antibiotics. Nosocomial pathogens, such as imipenem-resistant Acinetobacter baumanii or vancomycin-resistant Staphylococcus aureus, are controlled best by improving hospital infection control and institutional antibiotic use policies. The challenges of reducing the burden of antimicrobial resistance in food-borne pathogens such as Campylobacter
© 2004 Elsevier Inc. All rights reserved. 1045-1870/04/1501-0002$30.00/0 doi:10.1053/j.spid.2004.01.002
spp. will be addressed in the subsequent issue, as will such interesting special topics as the economic importance of the National Committee for Clinical Laboratory Standards breakpoint, the use of vaccines as tools to control resistance, and the special challenges posed by antimicrobial resistance in less wealthy countries. A great deal has changed since 1996 in the area of antimicrobial resistance among respiratory tract and nosocomial pathogens. Pediatricians have been forced to contend with increasingly frequent resistance among common respiratory pathogens such as the pneumococcus and now the emergence of strains of highly resistant nosocomial pathogens such as vancomycin-resistant S. aureus. Even pediatricians who rarely confront the most highly resistant
Seminars in Pediatric Infectious Diseases, Vol 15, No 1 ( January), 2004: pp 3-4
3
4
Scott F. Dowell
nosocomial pathogens in their office practices have had to adjust to the movement of methicillin-resistant S. aureus, formerly confined to the hospital setting, to the community. In response, researchers and pharmaceutical corporations have produced, at an increasing pace, new therapeutic agents, including some that are welcome additions to previously available classes of agents and others that are “metoo” drugs, angling to use concerns over antimicrobial resistance to carve out a new market niche. In addition to keeping pace with the bewildering number of newly resistant pathogens and new agents, pediatricians have been told they are at the front lines of the battle against resistance, and they have been urged repeatedly to assume more responsibility for judicious prescribing, careful handwashing, and encouraging hospital antimicrobial use policies.
Some welcome news after all this effort is that evidence that the interventions are paying off is accumulating. For the first time in decades, the rate of prescribing antimicrobial agents for community-acquired respiratory tract infections has declined, and concerted efforts in certain centers within the heath care setting have resulted in fewer nosocomial infections and reduced costs. This issue provides an opportunity for some of the leading authorities in the field to update pediatricians on the current problems and also to lay out the solutions that have proven successful in curbing the spread of antimicrobial resistance during the past several years. Scott F. Dowell, MD, MPH Guest Editor
A
ntimicrobial resistance has been the subject of increasing concern to pediatricians over the past decade, and it remains a major focus of both clinical and research activities for pediatric infectious disease specialists. Reviews of the subject are numerous, touching on different aspects of treatment, including the purported utility of a range of newer antimicrobial agents, prevention, and control. Since the last issue of Seminars in Pediatric Infectious Diseases focused on antimicrobial resistance among bacterial pathogens in 1996, some gratifying progress has been made, particularly in the areas of prevention and control. This issue is structured to highlight the major challenges to pediatricians as a result of the spread of antimicrobial resistance and to examine progress in the control of resistance. Antimicrobial resistance among pathogens in two major categories is covered: community-acquired infections of the respiratory tract and infections acquired in health care settings. For each category, an article from leading clinician teachers highlights the challenges posed by antimicrobial resistance, and it is paired with an article from the relevant public health authorities focusing on critical aspects of prevention and control. The appropriate control measures for antimicrobial resistance are very different for different pathogens, and the approach to control depends primarily on the mode of spread of the pathogen. For example, to focus on legislation regulating the addition of antimicrobial agents to chicken feed makes no sense if the organism of concern is methicillin-resistant Staphylococcus aureus, although such an approach might well be effective at reducing the burden of disease from fluoroquinolone-resistant Campylobacter jejuni. For respiratory tract pathogens such as Streptococcus pneumoniae and Haemophilus influenzae that are spread from child to child in the community, the primary approach to control antimicrobial resistance has been to reduce the underlying antimicrobial pressure by promoting more judicious use of antibiotics. Nosocomial pathogens, such as imipenem-resistant Acinetobacter baumanii or vancomycin-resistant Staphylococcus aureus, are controlled best by improving hospital infection control and institutional antibiotic use policies. The challenges of reducing the burden of antimicrobial resistance in food-borne pathogens such as Campylobacter
© 2004 Elsevier Inc. All rights reserved. 1045-1870/04/1501-0002$30.00/0 doi:10.1053/j.spid.2004.01.002
spp. will be addressed in the subsequent issue, as will such interesting special topics as the economic importance of the National Committee for Clinical Laboratory Standards breakpoint, the use of vaccines as tools to control resistance, and the special challenges posed by antimicrobial resistance in less wealthy countries. A great deal has changed since 1996 in the area of antimicrobial resistance among respiratory tract and nosocomial pathogens. Pediatricians have been forced to contend with increasingly frequent resistance among common respiratory pathogens such as the pneumococcus and now the emergence of strains of highly resistant nosocomial pathogens such as vancomycin-resistant S. aureus. Even pediatricians who rarely confront the most highly resistant
Seminars in Pediatric Infectious Diseases, Vol 15, No 1 ( January), 2004: pp 3-4
3
4
Scott F. Dowell
nosocomial pathogens in their office practices have had to adjust to the movement of methicillin-resistant S. aureus, formerly confined to the hospital setting, to the community. In response, researchers and pharmaceutical corporations have produced, at an increasing pace, new therapeutic agents, including some that are welcome additions to previously available classes of agents and others that are “metoo” drugs, angling to use concerns over antimicrobial resistance to carve out a new market niche. In addition to keeping pace with the bewildering number of newly resistant pathogens and new agents, pediatricians have been told they are at the front lines of the battle against resistance, and they have been urged repeatedly to assume more responsibility for judicious prescribing, careful handwashing, and encouraging hospital antimicrobial use policies.
Some welcome news after all this effort is that evidence that the interventions are paying off is accumulating. For the first time in decades, the rate of prescribing antimicrobial agents for community-acquired respiratory tract infections has declined, and concerted efforts in certain centers within the heath care setting have resulted in fewer nosocomial infections and reduced costs. This issue provides an opportunity for some of the leading authorities in the field to update pediatricians on the current problems and also to lay out the solutions that have proven successful in curbing the spread of antimicrobial resistance during the past several years. Scott F. Dowell, MD, MPH Guest Editor