Abstract
Pandemic influenza planning is well under way across the globe. Antiviral drugs and vaccines have dominated the therapeutic agenda. Far less work has been conducted on stockpiling and planning for deployment of antimicrobial drugs against secondary bacterial pneumonia, a cause of substantial illness and death in previous pandemics and epidemics. In the event of a pandemic, effective antimicrobial drug measures are expected to substantially benefit public health. We address issues regarding use of antimicrobial drugs as stocks of individual agents are diminished and the role of resistance surveillance in informing such policy. Furthermore, vaccination with polysaccharide and conjugate pneumococcal vaccines is considered as part of a pandemic strategy. Most illness and death from influenza are likely to occur in developing countries, where neuraminidase inhibitors and vaccines may be neither affordable nor available; thus, compared with industrialized countries, the benefits of treating bacterial complications in developing countries may be substantially greater.
Highlights
Pandemic influenza planning is well under way across the globe
We discuss the potential role of vaccination against Streptococcus pneumoniae in the context of pandemic influenza
In the United Kingdom, ciprofloxacin is active against all H. influenzae isolates (≈100% of recent UK respiratory tract isolates susceptible; HPA, unpub. data), most methicillin-sensitive S. aureus isolates (≈82%), and atypical organisms. If these bacterial pathogens were known or suspected to predominate in influenzarelated pneumonia associated with a future pandemic, the use of ciprofloxacin might be justified, and agents effective against MRSA would be reserved for severe cases and those with culture-confirmed MRSA (99% of UK respiratory MRSA isolates, most of which are hospital acquired, are quinolone resistant; HPA, unpub. data)
Summary
Pandemic influenza planning is well under way across the globe. Antiviral drugs and vaccines have dominated the therapeutic agenda. Evidence from laboratory, clinical, and epidemiologic studies suggests that bacterial co-infection contributes substantially to the illness and death that occurs in pandemic and seasonal influenza. A retrospective study of influenza-related childhood deaths in the United States in the 2003–04 season found S. aureus to be the most common bacterial agent, accounting for 46% of isolates, >50% of which were methicillin-resistant strains [5]. Surveillance for severe influenza-related S. aureus community-acquired pneumonia in the United States during the 2003-04 season recorded 17 cases (88% methicillin-resistant S. aureus [MRSA]) and 5 deaths (4 with MRSA) and a median age of 21 years [16]; laboratory evidence of influenza infection was available for ≈75%. In the context of emerging community-acquired MRSA skin infection in persons without traditional risk factors, this association has substantial implications for possible emergence of MRSA pneumonia in a future pandemic [19]. These figures are generally consistent with other published data; group A streptococci are a rare but serious cause of community-acquired pneumonia [20] and have been associated with fatal cases of influenza [5]
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