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Objective: To provide recommendations for the management of community-acquired pneumonia and the surveillance of drug-resistant Streptococcus pneumoniae (DRSP)., Methods: We addressed the following questions: (1) Should pneumococcal resistance to beta-lactam antimicrobial agents influence pneumonia treatment? (2) What are suitable empirical antimicrobial regimens for outpatient treatment of community-acquired pneumonia in the DRSP era? (3) What are suitable empirical antimicrobial regimens for treatment of hospitalized patients with community-acquired pneumonia in the DRSP era? and (4) How should clinical laboratories report antibiotic susceptibility patterns for S pneumoniae, and what drugs should be included in surveillance if community-acquired pneumonia is the syndrome of interest? Experts in the management of pneumonia and the DRSP Therapeutic Working Group, which includes clinicians, academicians, and public health practitioners, met at the Centers for Disease Control and Prevention in March 1998 to discuss the management of pneumonia in the era of DRSP. Published and unpublished data were summarized from the scientific literature and experience of participants. After group presentations and review of background materials, subgroup chairs prepared draft responses, which were discussed as a group., Conclusions: When implicated in cases of pneumonia, S pneumoniae should be considered susceptible if penicillin minimum inhibitory concentration (MIC) is no greater than 1 microg/mL, of intermediate susceptibility if MIC is 2 microg/ mL, and resistant if MIC is no less than 4 microg/mL. For outpatient treatment of community-acquired pneumonia, suitable empirical oral antimicrobial agents include a macrolide (eg, erythromycin, clarithromycin, azithromycin), doxycycline (or tetracycline) for children aged 8 years or older, or an oral beta-lactam with good activity against pneumococci (eg, cefuroxime axetil, amoxicillin, or a combination of amoxicillin and clavulanate potassium). Suitable empirical antimicrobial regimens for inpatient pneumonia include an intravenous beta-lactam, such as cefuroxime, ceftriaxone sodium, cefotaxime sodium, or a combination of ampicillin sodium and sulbactam sodium plus a macrolide. New fluoroquinolones with improved activity against S pneumoniae can also be used to treat adults with community-acquired pneumonia. To limit the emergence of fluoroquinolone-resistant strains, the new fluoroquinolones should be limited to adults (1) for whom one of the above regimens has already failed, (2) who are allergic to alternative agents, or (3) who have a documented infection with highly drug-resistant pneumococci (eg, penicillin MIC > or =4 microg/mL). Vancomycin hydrochloride is not routinely indicated for the treatment of community-acquired pneumonia or pneumonia caused by DRSP.

Fever patterns were studied prospectively in 200 consecutive patients referred for infectious disease consultation and retrospectively in 204 patients with selected infectious or noninfectious diseases. Most patients had remittent or intermittent fever, which, when due to infection, usually followed diurnal variation. Hectic fever occurred less commonly but was observed in patients with all categories of infectious or noninfectious diseases. Although hectic fevers were seen more frequently in patients who had documented bacteremia, there were many nonbacteremic subjects who had this pattern and others without this pattern who had bacteremia. Sustained fever nearly always occurred in patients with Gram-negative pneumonia or CNS damage, although some patients with these diseases had other patterns as well. Our data suggest that, with the possible exception of sustained fever in Gram-negative pneumonia or CNS damage, the fever pattern is not likely to be helpful diagnostically.

Vertebral osteomyelitis is still a diagnostic problem. Nonspecific symptoms (low-grade fever, malaise, and weight loss) may dominate. Specific infections may be suggested by the history, and the diagnosis may be reinforced by a transient response to antibiotics. The patient may have symptoms resulting from a secondary paravertebral abscess. Even with fever, back pain, and point tenderness over the vertebral column, the correct diagnosis may not be considered. Predisposing conditions include drug addiction, instrumentation of the infected urinary tract, bacteremia from other causes, or previous back surgery. Diagnosis is made by roentgenographic studies and isolation of the causative organism from blood cultures or from the infected area. Staphylococcus aureus is the most common pathogen, although other microorganisms may be responsible. Intensive intravenous antibiotic treatment appears to be curative, without surgical debridement, external stabilization, or porlonged oral administration of antibiotics.

Vertebral osteomyelitis due to Staphylococcus aureus was suppressed by not cured by optimal therapy with nafcillin sodium; cure eventually was achieved by treatment with cefazolin sodium and gentamicin sulfate. This is vivo result correlated with in vitro observations that showed that the infecting organism was inhibited but not killed by prolonged incubation with nafcillin or cefazolin; killing was readily achieved in vitro by adding subinhibitory concentrations of gentamicin. Bacterial tolerance in this case appeared to be responsible for the failure of vertebral osteomyelitis to be cured by accepted therapy with beta-lactam antibiotics.

Twenty-eight pressure sores were evaluated prospectively. Osteomyelitis was reported histologically in nine of 28 bones and pressure-related changes were reported in 14 bones. Roentgenograms suggested the presence of osteomyelitis in four instances of histologically proved osteomyelitis. Technetium Tc 99m medronate bone scans were highly sensitive, showing increased uptake in all cases of osteomyelitis; however, increased uptake also occurred commonly in uninfected bones due to pressure-related changes or other noninfectious causes. Cultures of bone biopsy samples usually disclosed anaerobic bacteria, gram-negative bacilli, or both. The diagnosis of osteomyelitis must be considered if a pressure sore does not respond to local therapy. If the technetium Tc 99m medronate uptake is increased in the involved area, or roentgenographic findings are abnormal, the diagnosis can only be made with certainty by histologic examination of bone. Antibacterial treatment should be selected based on the results of bone culture.

Acute bilateral suppurative parotitis developed in two patients with documented cirrhosis of the liver while they were in the hospital. Gram's stain and culture of purulent material obtained from the orifice of Stensen's duct disclosed Haemophilus influenzae as the sole isolate. Both patients were treated successfully with local care and antibiotics. To our knowledge, with one possible exception, infection of the parotid gland due to this organism has not been described previously.

The clinical manifestations of sepsis may be flagrant or subtle. Awareness of the signs and symptoms of sepsis allows early recognition and prompt, appropriate management. The clinical presentation, relative frequency, and current pathophysiologic understanding of the manifestations of sepsis are reviewed. Special emphasis is placed on the cardiopulmonary manifestations, which are examined in a temporal sequence of preshock, early shock, and late shock states. While therapy for the underlying infection (such as antibiotics and drainage of abscesses) is often sufficient, therapy for the specific manifestations of sepsis may also be necessary. Guidelines for therapy for these manifestations of sepsis are given.