Infectious disease emergencies: role of the infectious disease specialist.

The importance of infections for public health has become obvious during the last decades. Examples are emerging infections such as HIV/AIDS and severe acute respiratory syndrome, deliberate release of microorganisms, such as the anthrax episode in the USA, the increasing problems with organisms resistant to antimicrobial treatment, such as methicillin-resistant Staphylococcus aureus, and the threat of a new influenza pandemic with a case fatality rate similar to that in the 1918 outbreak. An effective response to infectious disease emergencies requires careful planning and establishment of resources in advance. The medical specialties involved are clinical microbiology, clinical infectious diseases and epidemiology. Clinical microbiology should include bacteriology, virology, and parasitology; the technical developments during the last 15 years have clearly erased most of the methodological differences between these branches of microbiology. New techniques such as new generations of Polymerase Chain Reaction (PCR), rapid methods for nucleic acid sequence analyses and microarrays have enabled more rapid identification of organisms and provide powerful tools in the epidemiological analysis of an outbreak. The infectious disease specialists are necessary for rapid and adequate clinical diagnoses, optimal use of antimicrobial agents and provision of facilities for containment of patients who may spread the infections. The need for isolation units became acute when many countries prepared themselves for a possible severe acute respiratory syndrome outbreak in Europe. With few exceptions, Europe still lacks epidemiological field forces, and it has been embarrassing to be obliged to call upon the Centers for Disease Control for European outbreaks. Hopefully, this will be corrected with the creation of the European Centre for Disease Prevention and Control (ECDC).

Report of working group 3: specialist training and continuing medical education/professional development in the infection disciplines.

The European Union of Medical Specialists (UEMS) core curricula for training in infectious diseases and medical microbiology are adequate with the exception of one deficiency which is the absence of training in epidemiology, public health and infection control. Infectious disease curricula should include training in HIV, tuberculosis, hepatitis and sexually transmitted diseases. There is a need for a core curriculum in infection control. Infection control should have a basis in both medical microbiology and infectious diseases, and should become a specialty dealing with healthcare hygiene in hospitals, in outpatient clinics and also in institutions for the elderly. In the UK, a specialty training in infection is offered and includes internal medicine, clinical infectious diseases and medical microbiology for a total of 9 years. The UEMS should be contacted about the creation of a single specialty of infection, allowing for various degrees of sub-specialisation in infectious diseases or medical microbiology. It is unlikely that a European board examination validating the training of specialists will become a reality soon. Meanwhile, national systems should be created, documenting the content of the training and evaluating the quality of the training institutions. A medical specialist has a constant need for further education. This is generally a national matter, with requirements varying throughout Europe. It should be possible to accumulate continuing medical education/continuing professional development merits on a European level as well as on a national one. With the expansion of the European Union, it is important that the quality and content of specialist training can be verified and training curricula be harmonised. The UEMS should assist in this, in collaboration with scientific societies such as the ESCMID.

Lack of development of new antimicrobial drugs: a potential serious threat to public health.

Antimicrobial resistance is threatening the management of infections such as pneumonia, tuberculosis, malaria, and AIDS. In the past, resistance could be handled by development of new drugs active against resistant microbes. However, the pharmaceutical industry has reduced its research efforts in infections; genomics has not delivered the anticipated novel therapeutics; new regulatory requirements have increased costs; antibiotic use in common infections-eg, bronchitis and sinusitis-is questioned; and, compared with other drugs, return on investments is lower for antimicrobials. To avoid a serious threat to public health, academia, biotechnology and pharmaceutical industry, regulators, and healthcare providers must find solutions to this problem. Academia should concentrate on technologies to unlock new drug targets, and industry on drug candidates. In addition, regulators and pharmaceutical companies should agree on new clinical-trial designs so that information on therapeutic efficacy is generated in fewer patients-eg, by studying pharmacodynamics of antimicrobials in patients with defined infections.

Relief of symptoms in patients with group A beta-hemolytic streptococcus tonsillopharyngitis: comparison between telithromycin and penicillin V.

This study compared the resolution of symptoms in patients with group A beta-hemolytic streptococcus tonsillopharyngitis treated with 5 d of telithromycin 800 mg once daily, or 10 d of penicillin V 500 mg 3 times daily. At days 3-5 of treatment, the mean improvement in total symptom score was greater with telithromycin than with penicillin V (p = 0.042). Thus, telithromycin provided faster symptom relief than penicillin V.

The Treatment of Severe Group A Streptococcal Infections.

Group A streptococci can cause a variety of diseases ranging from uncomplicated superficial infections to severe systemic infections associated with high morbidity and mortality. Since the late 1980s a drastic resurgence of highly aggressive invasive streptococcal infections, including streptococcal toxic shock syndrome and necrotizing fasciitis, have been noted worldwide. This has prompted intense research in the field and important new information has been gained regarding the pathogenesis and treatment of life-threatening invasive group A streptococcal infections. Exotoxins with superantigenic activities have been identified as central mediators of the systemic effects seen in streptococcal toxic shock syndrome. Novel therapeutic strategies include agents that can inhibit these superantigens, and one promising candidate is intravenous polyspecific immunoglobulin that contains neutralizing antibodies against a wide spectrum of streptococcal superantigens. Intravenous immunoglobulin adjunctive therapy was shown in a case-control study to reduce mortality in patients with streptococcal toxic shock syndrome.