Staphylococcal pneumonia appears to be increasing in frequency and is a particularly important problem in early infancy when the disease tends to be specially severe and may prove fatal. Only early recognition and prompt treatment can reduce the high mortality rate in this age group. A high index of suspicion must exist for this type of pneumonia in any infant who presents with signs or symptoms of infection of the lower respiratory tract and who fails to respond to adequate doses of penicillin or one of the cyclines in a period of 24 to 36 hours. Frequent and careful observations of any such infant to detect the appearance of empyema fluid and, more particularly, tension pneumothorax are vitally important. Once the presence of empyema has been established, prompt and effective drainage with a closed system should, in our opinion, be instituted without delay; it is also our feeling that the local administration of an antibiotic, such as bacitracin, may be useful and we recommend its use in this manner. Chloramphenicol and erythromycin, used together, in an effort to delay the emergence of resistant organisms, are the antibiotics of choice in the treatment of pneumonia due to penicillin-resistant strains of staphylococci.
In view of our experience with this disease, we recommend therapy as follows: All infants with a tentative diagnosis of staphylococcal pneumonia who have not received any prior antibiotic therapy should receive penicillin, erythromycin and chloramphenicol immediately after cultures are obtained; then administration of the antibiotic or antibiotics shown by in vitro tests to be least effective against the strain of staphylococcus causing the disease, is discontinued.
If the patient has been receiving penicillin prior to admission to the hospital and history shows no evidence of response or improvement, one may infer that the organism is pencillin-resistant and chloramphenicol and erythromycin alone are given.
While triple therapy of this condition may not be ideal, the employment of this combination is considered justified until a satisfactory etiologic diagnosis can be obtained or until antibiotic sensitivity tests are completed. Dowling and his colleagues agree with such therapy in principle especially in the treatment of serious staphylococcal infections, and state that antibiotics when used under such circumstances, as outlined above, "should be used in full (italics ours) doses," and we should like to emphasize the importance of this principle.
Satisfactory clinical evidence of antagonism among antibiotics is lacking and most authorities agree that antagonism between antibiotics "is of little or no consequence in the management of human infections." While some admit the possibility that antagonism may exist occasionally, they feel this is a rare phenomenon. When satisfactory evidence becomes available that there is antagonism among these three antibiotics in the treatment of staphylococcal infections, our present recommendations will be altered but until such time the triple combination is urged in view of the fact that this infection progresses extremely rapidly and every hour counts.
Finally, antibiotics must not be discontinued too early, but should be administered for an average period of 2 to 3 weeks after the patient has become afebrile, or until all signs and symptoms of active disease have disappeared.
The use of a potent bactericidal agent such as bacitracin locally may be extremely important in a severely ill infant with empyema. It is our practice at present in patients with empyema to instill 5,000 to 10,000 units of bacitracin at the time of the initial thoracentesis.
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