Antimicrobial therapy issues facing pediatricians

In the field of infectious diseases, the emergence of new pathogens or old diseases in newly recognized forms; changing virulence of pathogens; changing patterns of antimicrobial susceptibility; new diagnostic techniques, drugs or vaccines; changing concepts of chemoprophylaxis; controversies about medical vs. surgical techniques; and the challenge of care of children with infectious diseases within new guidelines of managed care are recently identified areas of change. The increased resistance of Streptococcus pneumoniae to many commonly used antimicrobials and the increased proportion of beta-lactamase-producing nontypable Haemophilus influenzae and Moraxella catarrhalis concern many practitioners. The decreased antibiotic susceptibility of S. pneumoniae is a relatively new phenomenon in the United States. Optimal therapy for mild, moderate or severe pneumococcal disease is dependent on current local susceptibility patterns. Group A streptococci are uniformly susceptible to readily achieved concentrations of all penicillins and cephalosporins. However, recent clusters of cases of rheumatic fever, increased recognition of toxic shock syndrome and bacteremic and localized severe pneumococcal disease have increased concern about the changing ecology of the Streptococcus and the implications for therapy. Finally recognition that many children with acute bacterial otitis media have resolution of disease without use of antimicrobial agents has led to more rigorous study designs for evaluating new drugs. Criteria for choice of antimicrobial agents for acute otitis media in children are based on clinical efficacy determined from studies of sufficient sample size to show differences among the products evaluated, microbiologic efficacy with aspirates of middle ear fluid before therapy and subsequent evaluation based on clinical criteria or repeat aspiration of middle ear fluid to define sterilization by the drug, side effects and toxicity, administrative advantages, acceptability and costs of illness.