Bacterial respiratory diseases remain a major health problem in children worldwide and are the main reason for medical visits. However, the true incidence, disease burden, and health-care economic impact are not well quantified in most countries. In resource-poor countries, each year millions of children die of pneumonia and the burden of disease is considerable.1–3 In wealthy countries mortality has dramatically decreased, but a high morbidity is still present. North American and European pediatric hospitals are routinely faced with complicated pneumonia, especially with empyema. Bacterial respiratory diseases are also the main reason for the prescription of antibiotics in children <3 years, leading to antibiotic resistance, which is a worldwide concern and priority of the World Health Organization.4 In the last decade, vaccines for the prevention of bacterial respiratory diseases in young children (Haemophilusinfluenzae type b and Streptococcus pneumoniae) have been licensed on one hand, and, on the other hand, many countries and scientific societies have issued guidelines on the diagnosis and management of common bacterial respiratory infections. The profusion of guidelines illustrates the need for rationalizing both diagnosis and the use of antibiotics.5–7 Only a few studies have actually evaluated the impact of the guidelines, although some data are available from the United States and the Netherlands.8–11 The findings in these studies suggest that the guidelines are theoretically accepted, but not necessarily implemented in daily clinical practice.
The concept of watchful waiting for acute otitis media (OM) introduced by most guidelines is often difficult to implement.12–14 Some of the reasons are: (1) the definition and diagnosis of childhood bacterial diseases is often only possible or probable; (2) physicians fear individual complications (the risk of severe complications of acute OM is difficult to assess, even in Western countries), and (3) resistance to behavior modification is very difficult to overcome and most guidelines are very recent.
The current supplement reports on the considerations made on childhood bacterial diseases that were discussed during a Global Master Class that took place in Brussels in March 2008; this was supported by an unrestricted educational grant from GlaxoSmithKline Biologicals. The objectives of this Master Class were to review the epidemiology and pathogenesis, prevention and management of selected childhood bacterial respiratory diseases, review the experience gained in the first decade of pneumococcal conjugate vaccines (PCVs), and find a rationale for future vaccine development and use. The Master Class participants were international experts from different countries with an experience in management of respiratory bacterial disease and expertise of pediatrics, pediatric infectious diseases, otorhinolaryngology, public health, epidemiology, and medical microbiology.
The 4 main respiratory bacteria that have a major impact on diseases worldwide are Neisseria meningitidis, Hib, S. pneumoniae, and nontypeable H.influenzae (NTHi). Altogether, these account for about 75% of the serious bacterial respiratory infections worldwide or respiratory-originated infections and a high proportion of systemic infections in pediatric patients. The Master Class concentrated on S. pneumoniae and NTHi, but one cannot talk about epidemiology, pathogenesis, prevention, or management of these without referring to the experience gained in various aspects of N. meningitidis and H.influenzae b infections in infants and children.
Heptavalent PCV-7 started to be administered to children almost 10 years ago. In this relatively short period considerable experience was gained, some of which provides answers, more of which raises questions. It is for this reason that the Master Class covered the issue of protective correlates associated with PCV-7, as it relates to invasive pneumococcal disease, pneumonia and otitis media.
In “Microbial Interactions in the Respiratory Tract” Murphy et al explain how upper respiratory tract infections are caused by the synergistic and antagonistic interactions of upper respiratory tract viruses and bacterial pathogens and review the interactions between these microorganisms in the pathogenesis of upper respiratory tract infections.
In “Childhood Bacterial Respiratory Diseases: Past, Present, and Future” Nohynek et al examine the causes of global childhood mortality, the distribution of childhood pneumonia mortality and morbidity, the risk factors that affect pneumonia incidence, and the potential effectiveness of available vaccines to reduce the burden of childhood bacterial respiratory diseases. They show that the risk of children aged between 0 and 4 years developing pneumonia is 0.03 episodes per child year in wealthy countries and 0.29 episodes per child year in resource-poor countries. Consequences of childhood pneumonia and its significant morbidity and mortality are preventable by the optimized use of vaccines against measles and pertussis, and expanding the use of Hib and PCVs. The implementation of proven cost-effective interventions that can save millions of lives appears both feasible and of utmost importance and vaccines play a critical role in this regard.
Finally, Pelton and Leibovitz, in “Recent advances in Otitis Media,” examine the epidemiology and pathogenesis of OM, treatment challenges, and prevention strategies with a focus on vaccines, and emphasize that antibacterial therapy should be considered both at the level of the specific individual and that of society.
We believe that this supplement will be informative and contribute in improving the management of childhood respiratory diseases worldwide.
The authors thank Dr. Armine Najand (Medical Education Global Solutions, France) for medical writing and Mr. Yann Colardelle (Medical Education Global Solutions, France) for manuscript coordination. GlaxoSmithKline Biologicals provided editorial assistance and sponsored this supplement.
1.Williams BG, Gouws E, Boschi-Pinto C, et al. Estimates of world-wide distribution of child deaths from acute respiratory infections. Lancet Infect Dis
2.Morris SS, Black RE, Tomaskovic L. Predicting the distribution of under-five deaths by cause in countries without adequate vital registration systems. Int J Epidemiol
3.Bryce J, Boschi-Pinto C, Shibuya K, et al. WHO estimates of the causes of death in children. Lancet
4.WHO/UNICEF. Pneumonia: The Forgotten Killer of Children
. New York, NY: WHO/UNICEF; 2006.
5.American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics.
6.Madhi SA, Albrich W. WHO guidelines for treatment of severe pneumonia. Lancet
7.Oudesluys-Murphy AM, Meuwese-Jongejeugd J. The practice guideline ‘Otitis media with effusion’ (second revision) from the Dutch College of General Practitioners [in Dutch]. Ned Tijdschr Geneeskd.
151:268–269, 2007; author reply 269.
8.Marchisio P, Mira E, Klersy C, et al. Medical education and attitudes about acute otitis media guidelines: a survey of Italian pediatricians and otolaryngologists. Pediatr Infect Dis J
9.Vernacchio L, Vezina RM, Mitchell AA. Management of acute otitis media by primary care physicians: trends since the release of the 2004 American Academy of Pediatrics/American Academy of Family Physicians clinical practice guideline. Pediatrics
10.Reuveni H, Asher E, Greenberg D, et al. Adherence to therapeutic guidelines for acute otitis media in children younger than 2 years. Int J Pediatr Otorhinolaryngol
11.Woolley SL, Smith DR. Acute otitis media in children–there are guidelines but are they followed? J Laryngol Otol
12.Kenna MA. Otitis media and the new guidelines. J Otolaryngol
. 2005;34(Suppl 1):S24–32.
13.Finkelstein JA, Stille CJ, Rifas-Shiman SL, et al. Watchful waiting for acute otitis media: are parents and physicians ready? Pediatrics
14.Spiro DM, Arnold DH. The concept and practice of a wait-and-see approach to acute otitis media. Curr Opin Pediatr