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THE NEED FOR MORE INTELLIGENT USE OF STREPTOMYCIN IN MANAGEMENT OF PULMONARY TUBERCULOSIS
906
AMERICAN COLLEGE OF CHEST PHYSICIANS
Dec., 19.9
pounds in experimental tuberculosis in mice was recently reported by Donovick and Bernstein (Am. Rev. Tuberc., 60:539, October 1949). Tuberculosis physicians in the United states will await with interest results of further laboratory and clinical investigation of these compounds. Karl H. Pfuetze, M.D., Chairman Benjamin P. Potter, M.D., Vice-Chairman Sumner S. Cohen, M.D., Secretary Alfred Goldman, M.D. Manuel Albertal, M.D. Oscar Auerbach, M.D. J. George Lang, M.D. Emil Bogen, M.D. Arnold Shamaskin, M.D. Edward Dunner, M.D. Henry C. Sweany, M.D. Carl W. Tempel, Col. B. L. Freedlander, M.D. John V. Thompson, M.D.
Editorials. THE NEED FOR MORE INTELLIGENT USE OF STREPTOMYCIN IN MANAGEMENT OF PULMONARY TUBERCULOSIS In January 1944, SChatz, Bugie and Waksman reported their discovery of streptomycin. Less than a year later, in the autumn of 1944, enough laboratory work and animal experiments had been done to justify the cautious use of the drug in humans suffering from miliary, meningeal or far advanced pulmonary tuberculosis. Shortly thereafter patients with a less hopeless prognosis were treated. Soon it became evident that streptomycin was a useful drug in the treatment of tuberculosis. Like other valuable drugs, streptomycin has its limitations as well as its assets and early clinical investigators of the drug were quick to point out that streptomycin was not a "cure all" for tuberculosis and that it was not a substitute for other proved procedures, such as bed rest and collapse therapy. It was early emphasized in regard to pulmonary tuberculosis that the best end-results would be obtained using streptomycin as an adj.unct to other therapeutic measures. It is now five years since streptomycin was first used in clinical tuberculosis. During this period a wealth of valuable information has been added to our knowledge of the drug to guide physicians in its intelligent use. In spite of the vast amount of knowledge accumulated and the numerous splendid papers written, there is still abundant evidence to indicate that use of streptomycin is too often abused. In many instances the life of the patient may be
Volume XVI
COMMITI'EE REPORT
907
jeopardized by injudicious use of the drug tn the over-all management of the case. The occurrence of streptomycin-resistant tubercle bacilli is undoubtedly the chief stumbling block in the use of the drug and this factor must constantly be borne in mind by the physician treating tuberculosis. Since present evidence clearly indicates that streptomycin-resistant organisms occur in a majority of patients who have received streptomycin for a period of two to three months or longer it is imperative that the optimum time for the use of the drug be carefully determined in each case. Procedures such as pneumothorax and thoracoplasty and particularly pulmonary resection are most often effective when timed properly .in relation to the administration of the drug. The advent of dihydrostreptomycin which lessens the occurrence and severity E>f toxic side effects, has not changed the picture as regards the phenomenon of drug-resistance. During the past year several investigators have reported that the appearance of streptomycin-resistant organisms can be considerably delayed in a majority of the patients under study by the administration of para-aminosalicylic acid (PAS) in combination with streptomycin. These preliminary reports are encouraging and if they are sustained by further investigation, it may be hoped that our treatment of certain cases can be modified and improved by such combined therapy. The work of Tempel and Dye regarding intermittent dosage schedules of streptomycin as reported in this issue of "Diseases of the Chest" is also encouraging. In view of the fact that within a short period of five years streptomycin has become universally accepted as an invaluable aid in the treatment of the various forms of tuberculosis, it seems appropriate at this time to comment on the tremendous achievement of those who have had a share in developing the present knowledge of this drug. Surely this accomplishment is a monument to all the groups, organizations and drug firms, who have worked together in such close and active cooperation, pooling their experience, resources and results to accumulate so much information in such a short time. This experience in the clinical evaluation of streptomycin should serve as a splendid example of what can be accomplished by cooperative effort. Surely this same fine spirit of cooperation, if continued will insure a rapid and thorough clinical evaluation of any new and promising antituberculosis agents which may be discovered in the future. KARL H. PFUETZE, M.D., F.C.C.P., Chairman Committee on Chemotherapy and Antibiotics.
AMERICAN COLLEGE OF CHEST PHYSICIANS
Dec., 19.9
pounds in experimental tuberculosis in mice was recently reported by Donovick and Bernstein (Am. Rev. Tuberc., 60:539, October 1949). Tuberculosis physicians in the United states will await with interest results of further laboratory and clinical investigation of these compounds. Karl H. Pfuetze, M.D., Chairman Benjamin P. Potter, M.D., Vice-Chairman Sumner S. Cohen, M.D., Secretary Alfred Goldman, M.D. Manuel Albertal, M.D. Oscar Auerbach, M.D. J. George Lang, M.D. Emil Bogen, M.D. Arnold Shamaskin, M.D. Edward Dunner, M.D. Henry C. Sweany, M.D. Carl W. Tempel, Col. B. L. Freedlander, M.D. John V. Thompson, M.D.
Editorials. THE NEED FOR MORE INTELLIGENT USE OF STREPTOMYCIN IN MANAGEMENT OF PULMONARY TUBERCULOSIS In January 1944, SChatz, Bugie and Waksman reported their discovery of streptomycin. Less than a year later, in the autumn of 1944, enough laboratory work and animal experiments had been done to justify the cautious use of the drug in humans suffering from miliary, meningeal or far advanced pulmonary tuberculosis. Shortly thereafter patients with a less hopeless prognosis were treated. Soon it became evident that streptomycin was a useful drug in the treatment of tuberculosis. Like other valuable drugs, streptomycin has its limitations as well as its assets and early clinical investigators of the drug were quick to point out that streptomycin was not a "cure all" for tuberculosis and that it was not a substitute for other proved procedures, such as bed rest and collapse therapy. It was early emphasized in regard to pulmonary tuberculosis that the best end-results would be obtained using streptomycin as an adj.unct to other therapeutic measures. It is now five years since streptomycin was first used in clinical tuberculosis. During this period a wealth of valuable information has been added to our knowledge of the drug to guide physicians in its intelligent use. In spite of the vast amount of knowledge accumulated and the numerous splendid papers written, there is still abundant evidence to indicate that use of streptomycin is too often abused. In many instances the life of the patient may be
Volume XVI
COMMITI'EE REPORT
907
jeopardized by injudicious use of the drug tn the over-all management of the case. The occurrence of streptomycin-resistant tubercle bacilli is undoubtedly the chief stumbling block in the use of the drug and this factor must constantly be borne in mind by the physician treating tuberculosis. Since present evidence clearly indicates that streptomycin-resistant organisms occur in a majority of patients who have received streptomycin for a period of two to three months or longer it is imperative that the optimum time for the use of the drug be carefully determined in each case. Procedures such as pneumothorax and thoracoplasty and particularly pulmonary resection are most often effective when timed properly .in relation to the administration of the drug. The advent of dihydrostreptomycin which lessens the occurrence and severity E>f toxic side effects, has not changed the picture as regards the phenomenon of drug-resistance. During the past year several investigators have reported that the appearance of streptomycin-resistant organisms can be considerably delayed in a majority of the patients under study by the administration of para-aminosalicylic acid (PAS) in combination with streptomycin. These preliminary reports are encouraging and if they are sustained by further investigation, it may be hoped that our treatment of certain cases can be modified and improved by such combined therapy. The work of Tempel and Dye regarding intermittent dosage schedules of streptomycin as reported in this issue of "Diseases of the Chest" is also encouraging. In view of the fact that within a short period of five years streptomycin has become universally accepted as an invaluable aid in the treatment of the various forms of tuberculosis, it seems appropriate at this time to comment on the tremendous achievement of those who have had a share in developing the present knowledge of this drug. Surely this accomplishment is a monument to all the groups, organizations and drug firms, who have worked together in such close and active cooperation, pooling their experience, resources and results to accumulate so much information in such a short time. This experience in the clinical evaluation of streptomycin should serve as a splendid example of what can be accomplished by cooperative effort. Surely this same fine spirit of cooperation, if continued will insure a rapid and thorough clinical evaluation of any new and promising antituberculosis agents which may be discovered in the future. KARL H. PFUETZE, M.D., F.C.C.P., Chairman Committee on Chemotherapy and Antibiotics.