Infectious Diseases: Annual Review of Significant Publications HOBART A

Postgrad Med J: first published as 10.1136/pgmj.47.548.332 on 1 June 1971. Downloaded from Postgraduate Medical Journal (June 1971) 47, 332-353. ANNUAL REVIEW Infectious Diseases: Annual review of significant publications HOBART A. REIMANN M.D. The Hahnemann Medical College and Hospital ofPhiladelphia, U.S.A. 19102 Introduction disease. Bedsonias, mycoplasmas, Listeria, R. Yearly reviews since 1935 recorded significant burneti and Pn. carinii came to attention as patho- contributions to knowledge about infectious diseases. gens. Inapparent and previously ignored mild attacks On the occasion of this, my thirty-fifth consecutive of disease when included in spectrums of severity, annual review, it is of interest to pause and recall raised the previously reported statistical incidence some of the advances made during that time. and lowered the recorded death-rates of polio- Momentous events included the introduction of myelitis, typhoid, shigellosis, yellow fever, melioi- practical antimicrobic drugs by Domagk, by dosis, cholera and plague. Histoplasmosis and cocci- Fleming and by Waksman; Avery's discovery of dioidomycosis, once regarded as fatal, emerged as DNA and RNA pertinent to microbic genetics; widespread, usually mild diseases. Epidemiologic recognition of autoimmunity and ofvarious globulin measures, vaccines and antimicrobic drugs when and complement components as related to infection; applied alone or in combination, held promise to the development ofelectron microscopy; and several eradicate some infections, but not in the foreseeable future. wars that emphasized exotic diseases. Regarding by copyright. antimicrobics, proper therapy reduced the death- During the past year, antimicrobic therapy, rate of bacterial pneumonias, coccal sepsis, endo- opportunistic, nosocomial and iatrogenic infections carditis, tuberculosis, syphilis, rickettsioses, typhoid received continued attention. The importance of and plague. The incidence of rheumatic fever and animals and birds as reservoirs of microbes was re- mastoiditis lessened. Available antimicrobic drugs affirmed. Vaccines for measles, rubella, influenza, reached the limit of effectiveness. Staphylococci, adenoviral and other infections were further tested Gram-negative bacilli and fungi assumed impor- with variable results. Cholera reappeared in epi- tance as drug-resistant pathogens. Therapeutic use demics. A causal relation of herpes-like virus to and misuse of antimicrobics, immunosuppressive infectious mononucleosis and lymphomas was drugs and corticosteroids brought about diseases proposed. Much interest and many publications http://pmj.bmj.com/ caused by these agents and by resulting opportunistic concerned the Australia antigen and hepatitis. invaders. Despite the importance of infectious diseases, those Influenza virus was the first of many respiro- of other origin dominated interest. Among eighty- viruses subsequently discovered. Viral pneumonias six papers on the 1970 programme of the Association were distinguished from those of bacterial origin. of American Physicians, four dealt primarily with Viruses also proved to be causes of mild dysentery. infections. The advent of Ender's cultural technique aided virology. Vaccines against poliomyelitis, yellow Antimicrobic therapy on October 2, 2021 by guest. Protected fever, measles, mumps, rubella and influenza became Penicillin or ampicillin and streptomycin cured available. Pneumotropic, enterotropic, neurotropic, thirty of thirty-six patients with enterococcal endo- and polytropic viruses were discovered. Cytomegalo- carditis. Adverse reactions affected fifteen, one with virosis, herpes simplex, rubella, and toxoplasmosis fatal enteritis.1 Vancomycin and streptomycin were as well, proved to be congenital infections. The recommended for treating enterococcal endocarditis relation of viruses to cancer and the significance of in patients intolerant to penicillin.2 Cloxacillin virus-like particles in tissues during neoplastic and therapy failed to influence the course of septic systemic diseases entailed much research without lesions.3 Staphylococci increasingly resisted methi- conclusive results. Attempts began to find antiviral cillin.4 Among twenty-one tested agents, ampicillin, drugs and to determine the role of interferon in penicillin and vancomycin in that order were most infections. active against Group D Streptococci.5 Gentamicin Insecticides controlled vector-borne malaria, ty- successfully controlled serious infections caused by phus, leishmaniasis, sandfly fever and several neural E. coli and Enterobacter. Those caused by Proteus viroses. Prompt rehydration made cholera a benign and Pseudomonas were less responsive.6 Gentamicin Postgrad Med J: first published as 10.1136/pgmj.47.548.332 on 1 June 1971. Downloaded from Annual review 333 was 100 times more active in vitro at pH 8 5 than at penicillin and a sulfonamide for a cold and again for pH 5 against most strains of Gram-negative bacilli. gingivitis; erythromycin for small furuncles; tetra- Concurrent administration of an alkalizing agent cycline for infectious mononucleosis, and penicillin allowed smaller effective amounts of gentamicin and fornonstreptococcal sore throat. None ofthis therapy erythromycin.7 was indicated.30 There is no justification for the use The value of cephalothin, cephaloridine, cephalo- of tetracycline or any other antimicrobic in the glycin and cephalexin was assessed.8 Forty-two prevention or treatment of minor viral respiratory papers about cephalosporins appeared in a supple- tract disease.3' ment (Oct. 1970) of the Postgraduate Medical In seven hospitals, 30 6%° (range 24-75Y4) of Journal. Cephalexin controlled staphylococcal infec- patients received antimicrobic therapy, oftenest on tions ofsoft tissues.9 It was useful for treating urinary the pediatric and surgical services. Probably 62%0 of tract infections in moderately uremic patients.10 these were treated prophylactically. Only 38% of Carbenicillin, 18 g daily, controlled pseudomonal treated patients had recorded evidence of infection.32 bronchial infections." The drug caused improve- Evidently the wastage of antimicrobic drugs con- ment in seven of ten children, but four died. Bacilli tinues unabated. In my own 450-bed hospital the persisted in sputum.12 It was active in vitro against cost of antimicrobics to patients in the past year was many Gram-negative bacilli13 and was useful for $290,000, most ofit unnecessary. Physicians, patients urinary tract infections with Pseudomonas and and third-party payers evidently make little or no Proteus. Bacillary resistance developed rapidly.'4 effort to reduce the misuse. According to two reports, carbenicillin has not fulfilled its promise. Of fifty-five pseudomonal infec- Unwanted effects tions only sixteen were cured. Superinfections often The number of bacteremic patients in Finland's ensued.'5' 16 All of thirty-eight strains of Bacteroides hospital doubled between 1935 and 1953, and almost were sensitive to chloramphenicol representing one doubled again by 1965. Gram-negative bacillary sep- of the few indications for its use.'7 sis increased threefold. That from Pseudomonas by copyright. In a 10-year period no evidence of increasing anti- appeared after 1943 and from Klebsiella-enterobacter microbic-resistance appeared among isolates of E. after 1957, dependent upon the increased use and coli or Klebsiella. Resistance actually declined.'8 ensuing resistance to antimicrobic drugs. Mima, The report is at variance with others wherein resis- Herellea and Serratia appeared as pathogens. tance of the bacilli in question was far greater. Deaths from sepsis increased each year: in 1965 During therapy of mycoplasmal pneumonia, twice as many as in 1953. The mortality rate in 1965 microbic resistance increased greatly to erythromycin equalled that of 1941 before antimicrobics were avail- and to five other antimicrobic drugs as well.19 able. To reverse the trend, unnecessary and improper Erythromycins are the first choice only for myco- use of antimicrobial agents, particularly for prophyl- plasmal infections.20 axis will have to be or In a modified stopped.33 http://pmj.bmj.com/ The value of rifampicin for treating tuberculosis surgical ward, cessation of all antimicrobic therapy was established. It may exceed isoniazid and strepto- reduced the incidence of Klebsiella infections.34 mycin in efficacy because of its rapid action, low Antimicrobic therapy in early childhood may toxicity and oral administration.21 Rifampicin was interfere with the development of immunity against of especial value when the bacilli resisted other H. influenzae and account for the increasing fre- drugs.22 The drug may be of value for leprosy.23 It quency of Type B infections in adults.35 Renal also has antiviral action.24 It reduced the percentage failure, deafness and paralysis accompanied irriga- of meningococcal carriers by 80Y% when given tion of body cavities with antimicrobic drugs for on October 2, 2021 by guest. Protected orally.25 Lincomycin controlled actinomycoses in prophylaxis or therapy.36 Therapy is hazardous in four patients allergic to penicillin.28 Clindamycin, a patients with myasthenia gravis.37 drug of second choice for coccal infections may re- Penicillin given intravenously caused convul- place lincomycin as an oral agent.27 Herrell re- sions.38 Anaphylactoid reactions followed orally viewed the historical development of antimicrobics given ampicillin.39 Exanthems occurred during in- after the first one, pyocyanase, was isolated

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