Factors predicting mortality in invasive pneumococcal disease in adults in Alberta

To define the factors associated with 30-day mortality among adult patients with invasive pneumococcal disease (IPD), we conducted a retrospective review of all cases of IPD in Alberta from 2000 to 2004. We hypothesized that multiple factors would be predictive of such mortality. We also examined the factors predictive of early (within 5 days of admission) mortality. We identified 1154 patients who met our inclusion criteria, 163 (14.1%) of whom died within 30 days. Over half (62.6%) of the deaths occurred within 5 days of admission. Ten factors were independently associated with increased 30-day mortality: 3 comorbidity factors-cancer within 5 years of diagnosis of IPD, diabetes, and cirrhosis; 4 complications-requirement for supplemental oxygen, mechanical ventilation, alteration of mental status, and cardiac arrest; 2 microorganism-related factors-infection with high- or infection with intermediate-mortality serotypes; and 1 treatment-related factor-treatment with a single antibiotic. Age 18-40 years and treatment with 2 antibiotics concurrently were associated with lower 30-day mortality. Comorbid illnesses were not contributory to early mortality (within 5 days of admission); instead, complications (alteration of mental status, requirement for supplemental oxygen, mechanical ventilation, and cardiac arrest) as well as infection with high-mortality serotypes and treatment with a single antibiotic were important. Age 18-40 years, infection with serotypes in the polysaccharide vaccine, and treatment with 2 or more than 2 antibiotics were associated with decreased early mortality. Early mortality accounted for 62.6% of the deaths. In conclusion, we found that mortality in IPD is multifactorial, the factors differ for 5- and 30-day mortality, and mortality is associated with host (age and complications), microorganism (pneumococcal serotypes), and therapeutic factors. Our data indicate that treatment with 2 or more antibiotics effective against Streptococcus pneumoniae should be used to treat IPD.     

Variations in Globin Synthesis in Delta-Beta-Thalassaemia

Peripheral blood globin synthesis studies were done in 11 patients with delta beta-thalassaemia trait, Hb S-delta beta-thalassaemia or delta beta/betao-thalassaemia from two black and two Caucasian families. All patients had elevated Hb F and normal or decreased Hb A2 levels and 10 had family studies confirming the diagnosis. In addition, four unrelated non-thalassaemic patients with elevated Hb F levels also had peripheral blood globin synthesis studies. The beta/alpha specific activity globin synthesis ratios in the three blacks with delta beta-thalassaemia trait were 0.60--1.04. In the four Caucasians with delta beta-thalassaemia traint, the beta/alpha ratios were 0.58--1.02. These results demonstrate a wide range of ratios overlapping those of normal controls (0.99 +/- 0.06). The betas/alpha ratios in three blacks with Hb S-delta beta-thalassaemia ranged from 0.66 to 1.00, similar to those of patients with delta beta-thalassaemia trait. In the black patient with delta beta/betao-thalassaemia, the gamma/alpha ratio was 0.67. The beta/alpha peripheral blood ratios in the four non-thalassaemia patients with elevated Hb F ranged from 1.00 to 1.11, similar to those of normal controls. These studies indicate that a decreased beta/alpha ratio is not an invariable finding in delta beta-thalassaemia in blacks or Caucasian patients and that globin synthesis data alone is insufficient to diagnose definitively heterozygotes for delta beta-thalassaemia or to distinguish this trait from non-thalassaemic haematological disorders associated with a normal percentage of Hb A2 and an elevated level of Hb F.     

Estrogen prevents glucocorticoid-induced apoptosis in osteoblasts in vivo and in vitro.

The ability of estrogen to prevent glucocorticoid-induced apoptosis in osteoblasts was studied both in vitro and in vivo. Glucocorticoid treatment for 72 h produced a dose-dependent increase in the number of apoptotic cells, determined by acridine orange/ethidium bromide staining, with a maximal response of 31+/-2% and 26+/-3% with 100 nM corticosterone in primary rat and mouse osteoblasts, respectively. Simultaneous administration of varying concentrations of 17beta-estradiol and 100 nM corticosterone decreased apoptotic osteoblasts in a dose-dependent manner, with a maximal decrease of 70% with 0.01 nM 17beta-estradiol. Terminal deoxynucleotidyltransferase-mediated deoxy-UTP-biotin nick end labeling also demonstrated glucocorticoid-induced DNA fragmentation that was inhibited by estrogen. Estrogen was shown to inhibit apoptosis induced by lipopolysaccharide treatment. As early as 6 h, Western blots demonstrated a dose-dependent decrease in the Bcl-2/Bax ratio, which reached a minimum of 0.18 in osteoblasts treated with 1000 nM corticosterone for 72 h. This reduction in Bcl-2/Bax was abolished by treating osteoblasts simultaneously with 17beta-estradiol, but not with 17alpha-estradiol. In 7-day-old mice, administration of varying concentrations of dexamethasone for 72 h resulted in a dose-dependent increase in the number of apoptotic osteoblasts as demonstrated by in situ terminal deoxynucleotidyltransferase-mediated deoxy-UTP-biotin nick end labeling staining of calvaria. A maximum of 22+/-1% apoptotic osteoblasts on the bone surface was found with 1 mg/kg BW dexamethasone compared with 2+/-1% in vehicle-treated mice. Injection of varying concentrations of 17beta-estradiol (0.5-5 mg/kg BW), but not 17alpha-estradiol, with 1 mg/kg dexamethasone produced a dose-dependent decrease in the number of apoptotic osteoblasts to 5+/-1% with 5 mg/kg 17beta-estradiol. Thus, glucocorticoid-induced apoptosis of osteoblasts may be prevented at least in part by 17beta-estradiol.     

Pulmonary sporotrichosis in Oklahoma in susceptibilities in vitro

Six cases of pulmonary sporotichosis were observed in 2 institutions in Oklahoma City, Okla. Three of the patients were treated with iodides with or without surgery. Although one patient required a second course of iodides, the patients have remained well after at least 34 months of follow-up. Three patients treated with amphotericin B, single course as well as multiple courses, and other antifungal agents (hydroxystilbamidine and miconazole) have all relapsed. These cases and a reviewed of more than 40 cases of pulmonary sporotrichosis susceptibilities of Sporothrix schenckii that we observed in vitro suggest that amphotericin B is not an effective agent for the treatment of pulmonary sporotrichosis. It is our opinion that the treatment of choice for pulmonary sporotrichosis is a supersaturated solution of potassium iodide. If the patient is allergic to the medication or fails to respond, then a combination of amphotericin B plus flucytosine may be tried.     

Prediabetes in rural and urban children in 3 states in Mexico

The authors studied the frequency, distribution, and factors associated with prediabetes (fasting glucose, 100-125 mg/dL) in rural and urban children from San Luis Potosí, León, and Querétaro in central Mexico. Family history, somatometry, and levels of fasting insulin, glucose, and lipids were collected in 1238 children 6 to 13 years of age. The authors found no cases of type 2 diabetes and a 5.7% frequency of prediabetes. The group with prediabetes had higher homeostasis model assessment of insulin resistance scores and total cholesterol and high-density lipoprotein cholesterol levels. Prediabetes was more frequent in León, with similar distribution in rural and urban children. The frequency of insulin resistance was 24.1%, with higher figures in urban groups and in San Luis Potosí. In multivariate analysis, prediabetes was associated with insulin resistance and residence in León. The authors concluded that in central Mexico the frequency of prediabetes is significant, and it is associated with insulin resistance and a geographic location, but not with obesity or urban vs rural dwelling.     

Changes in renal function in essential hypertension

Studies of renal hemodynamics, plasma renin activity (PRA), plasma aldosterone, and water and sodium excretion were performed in 171 patients with essential hypertension and 61 normotensive subjects. The para-amino hippurate clearance (C_PAH) was usually normal or moderately reduced in those with benign hypertension and markedly depressed in those with malignant hypertension. The PAH extraction ratio was normal or slightly reduced in the patients with benign hypertension and moderately impaired in those with low C_PAH indicating that a disproportionate decrease in cortical flow occurred only in the latter. The c_pah did not correlate Inversely with the mean blood pressure in the patients with benign hypotension. Reexamination of untreated patients after an average of 28 $\text{1}\text{2}$ months revealed a decrease in renal plasma flow but no further increase in blood pressure. These findings suggest that in uncomplicated hypertension the increase in blood pressure is not caused by renal circulatory disturbances.PRA was unrelated to renal hemodynamics in benign hypertension. In malignant hypertension, it was inversely correlated with the renal plasma flow. Under mild loading with isotonic saline solution, the fractional water excretion correlated with the blood pressure. Sodium excretion was neither related to the blood pressure nor to the estimated peritubular oncotic pressure, but correlated inversely with plasma aldosterone. These observations provide no support for the causative role of a primary disturbance in sodium excretion in essential hypertension.     

Studies of tuberculosis in man in relation to infection in cattle.

A study has been made in Sweden to investigate whether the risk of tuberculous infection and its trend with time in man in different areas were related to varying prevalences of tuberculous infection in cattle. It was found that the level of the infection risk in man was related to the prevalence of tuberculous infection in cattle, varying from 3-4 per cent in 1935 at age 15 in counties with less than 2 per cent infected cattle to 5-8 per cent in counties with 20 per cent infected cattle or more. However, the downward trend to the risk of infection with time was not to found be associated with the prevalence of tuberculous infection in cattle. The correlation between the risk of infection in man and the prevalence of infection in cattle in the 24 Swedish counties was positive and highly significant (+0-79). The relationship between cattle tuberculosis and tuberculosis in man was further studied by correlating infection in cattle with tuberculosis mortality and morbidity in man. The correlation with mortality was negative and highly significant (-0-77), i.e. counties with little cattle tuberculosis had a high tuberculosis mortality in man, and vice versa. There were similar large negative correlations with measures of tuberculosis incidence. When variations between the counties in relevant environmental factors, namely capital, urbanization and overcrowding, were taken into account, a strong positive association remains between the prevalence of infected cattle and the risk of tuberculous infection in man, but the associations with tuberculous mortality and morbidity, though they remain negative, become weaker. It is suggested that the probable explanation of these findings is the long-term protection against adult infection with human tubercle bacilli conferred by bovine infection in childhood.     

Hemoglobin F in primary myelofibrosis and in myelodysplasia

Our study investigated two groups of adult patients with established diagnoses of primary myelofibrosis (21 patients) and myelodysplastic syndromes (MDS) (21 patients). The objective was to assess fetal hemoglobin (HbF) concentration and to investigate correlations with organomegaly and extramedullary hematopoiesis and with the level of anemia and blood transfusion requirement. In all patients, the diagnosis was confirmed by histopathological examination. Patients with myelofibrosis were investigated by ferrokinetics using 59Fe. The percentage of marrow sideroblasts was assessed in patients with refractory anemia with ringed sideroblasts. Increased values of HbF were found to occur both in patients with myelofibrosis and with MDS, although a higher incidence and higher concentrations were evident in patients with myelofibrosis. Statistically significant increases in HbF concentration were found when there was accompanying organomegaly, as compared to patients without this feature. The average HbF concentration in both groups of patients under study was twice as high in cases with as in those without marrow fibrosis. The difference was statistically significant. Increased HbF levels appear to correlate with extramedullary hematopoiesis. HbF concentration did not correlate with the level of anemia or with requirement for blood transfusion.     

Changes in lipid metabolism in chronic hepatitis C

AIM: To investigate the relationship between certain biochemical parameters of lipid metabolism in the serum and steatosis in the liver. METHODS: The grade of steatosis (0-3) and histological activity index (HAI, 0-18) in liver biopsy specimens were correlated with serum alanine aminotransferase (ALT), total cholesterol and triglyceride levels in 142 patients with chronic hepatitis C (CH-C), and 28 patients with non-alcoholic fatty liver disease (NAFLD) without hepatitis C virus (HCV) infection. The serum parameters were further correlated with 1 797 age and sex matched control patients without any liver diseases. RESULTS: Steatosis was detected in 90 out of 142 specimens (63%) with CH-C. The ALT levels correlated with the grade of steatosis, both in patients with CH-C and NAFLD (P<0.01). Inserting the score values of steatosis as part of the HAI, correlation with the ALT level (P<0.00001) was found. The triglyceride and cholesterol levels were significantly lower in patients with CH-C (with and without steatosis), compared to the NAFLD group and to the virus-free control groups. CONCLUSION: Our study confirms the importance of liver steatosis in CH-C which correlates with lower lipid levels in the sera. Inclusion of the score of steatosis into HAI, in case of CH-C might reflect the alterations in the liver tissue more precisely, while correlating with the ALT enzyme elevation.     

'Microerosions' in rectal biopsies in Crohn's disease

Small (less than 1 mm), superficial erosions ('microerosions') have been observed stereo-microscopically in surface-stained rectal biopsies in Crohn's disease (CD). Biopsy specimens from 97 patients with CD, 225 with ulcerative colitis (UC), and a control material of 161 patients were investigated to define the occurrence and significance of the microerosions. In CD they were found in 13% of specimens, in UC in 5%, and in the control material not at all. In CD they were observed only in patients with colonic involvement and were most frequent (44%) in patients with this site of affection exclusively. Granulomas were identified in 62% of the biopsies with microerosions and by examination of two consecutive biopsies from each of these patients, in 85% indicating a positive correlation. In patients with microerosions and a primary diagnosis of UC, granulomas were found in 38% and by examination of two biopsies in 54%. Patients with granulomas and a few other patients were reclassified as CD, but there still remained some patients with microerosions, who most probably had UC. In conclusion, microerosions are observed mainly in CD with colonic involvement. There is a high incidence of granulomas in biopsy specimens with microerosions. The demonstration of microerosions in a specimen is suggestive of, but probably not diagnostic of, CD.     

Bursting pressure in anastomotic healing in experimentally induced colitis in rats

BACKGROUND: Experimental studies on healing of colonic anastomosis have been thoroughly investigated. However, clinical parameters of the healing process of anastomosis in the inflamed colon has not yet been reported. METHODS: In the present study, healing of anastomosis in trinitrobenzene-sulfonic acid-induced colitis in rats was assessed by measuring the bursting pressure and bursting wall tension. RESULTS: On postoperative day 4, bursting pressure and bursting wall tension were significantly lower (P<0.001) in rats with colitis with or without anastomosis and normal colon with anastomosis, compared with normal colon without anastomosis. On postoperative day 7, bursting pressure and bursting wall tension of normal colon with anastomosis approached that of normal colon without anastomosis. However, bursting pressure and bursting wall tension of rats with colitis with or without anastomosis remained significantly lower (P<0.001) than the latter. Furthermore, unlike rats without colitis in which perforation occurred mostly at the anastomotic line, the bursting site in colitic rats was predominantly away from the anastomotic line. CONCLUSIONS: These results suggest that in surgery for inflammatory bowel disease, it is the adjoining inflamed bowel wall that is vulnerable to be perforated in response to increasing intraluminal pressure rather than the anastomosis that is braced by the sutures.     

Variation in polyol levels in cerebrospinal fluid and serum in diabetic patients

Cerebrospinal fluid (CSF) or CSF and plasma levels of sorbitol, 1,5-anhydroglucitol and myoinositol of diabetic and non-diabetic patients with normal kidney function and of diabetic and non-diabetic patients with impaired kidney function were measured by gas-liquid chromatography. The CSF sorbitol level correlated with the plasma glucose level (p less than or equal to 0.05) in diabetic patients with normal kidney function, having received insulin for less than 12 months. The correlation between CSF sorbitol and plasma glucose levels in patients not dependent on insulin was not significant. Sorbitol was not detected in the plasma. The highest sorbitol levels in CSF were seen in insulin-dependent diabetic patients with impaired kidney function. No rise was seen in non-diabetic uremia. 1,5-anhydroglucitol, normally present in plasma, was absent from CSF and plasma in diabetic patients receiving insulin. In non-diabetic uremic patients, 1,5-anhydroglucitol levels in CSF and plasma were lower than in healthy subjects, but htere was no correlation with plasma glucose levels. The myoinositol level was higher in CSF than in the plasma of both non-diabetic and diabetic patients with normal kidney function. Both plasma and CSF levels were significantly (p less than 0.001) elevated in diabetic as well as in non-diabetic uremic patients, the plasma myoinositol increasing relatively more than the CSF levels. The elevation of plasma myoinositol correlated with the elevation of plasma creatinine and thus also with the impairment of kidney function. Plasma and CSF myoinositol levels were not influenced by the plasma glucose level.     

Asthma control in adults in Asia-Pacific

OBJECTIVE: The Asthma Insights and Reality in Asia-Pacific (AIRIAP) survey collected detailed information on asthma severity and management in the urban centres of eight areas of the Asia-Pacific region. This study compared asthma morbidity and management practices in these areas. METHODOLOGY: Following recruitment, face-to-face interviews were completed with 2323 adults with diagnosed asthma, who had current symptoms or were using asthma medication. Comparisons between areas were made for asthma severity, asthma burden and management practices. RESULTS Asthma severity varied significantly between areas (P < 0.01), with Vietnam and mainland China reporting the most cases with severe, persistent symptoms. Severity of asthma was significantly associated with advancing age and a lower level of education in a multivariate analysis (P < 0.001). The total use of acute healthcare for asthma was significantly associated with increased asthma severity. Work absence due to asthma was highest in the Philippines (46.6%) and lowest in South Korea (7.5%). The use of inhaled corticosteroids was associated with age in a non-linear manner. There was significant variation among countries in usage of inhaled corticosteroids, from 1.3% in South Korea to 29.0% in Taiwan (P < 0.00001). A peak flow meter was owned by a total of 7.7% of respondents, and overall, 17.9% of adults had a written action plan for asthma management. CONCLUSIONS: Within the Asia-Pacific region, asthma in adults differs significantly in disease severity, management and treatment according to area of residence. International recommendations on the management of asthma are generally not being followed.     

Prevention of venous thromboembolism in surgery, in laparoscopic surgery, in venous surgery and in urology

The article summarizes published data regarding the prophylaxis of venous thromboembolism in surgery, in laparoscopic surgery, in venous surgery and in urology. In surgical patients with low risk, no specific thromboprophylaxis is needed. Patients with moderate risk levels are the candidates for administration of subcutaneous low molecular weight heparin (LMWH) at doses under 3 400 anti-Xa units a day and patients with increased risk at doses higher than 3 400 anti-Xa units a day during the period of higher risk. In order to decrease the risk of bleeding, a half dose 2 hours prior or 4-6 hours after the operation can be administered. Under the highest risk conditions, there is a recommendation to combine LMWH over 3 400 anti-Xa units with elastic panty-hose or, alternatively, with intermittent pneumatic compression (IPC). At moderate risk levels, subcutaneous administration of unfractionated heparin at the doses of 5 000 units twice a day is also possible and at increased risk levels, a TID administration (LDUH) over the increased risk period. In patients with a significant bleeding risk, the physical method of thromboprophylaxis can be used and pharmacological prophylaxis can set in after the risk of bleeding has passed. Fondaparinux is the alternative to LMWH in people with a history of heparin induced thrombocytopenia over the past three months. The sole use of acetylsalycilic acid is not recommended. While undertaking epidural anaesthesia or analgesia, it is necessary to follow strictly the guidelines of the use of pharmacological thromboprophylaxis. Thromboprophylaxis with LMWH, LDUH, elastic panty-hose or IPC is indicated only in those patients who undergo laparoscopic surgeries and who moreover display the additional thrombosis factors. Patients with additional risk thrombosis factors undergoing major venous reconstructions require prophylaxis with LMWH (or LDUH). Uncomplicated patients undergoing transurethral or other low risk urologic surgery require no specific thromboprophylaxis. If they undergo a major intervention and/or they display additional risk thrombosis factors, they require the administration of LMWH or LDUH. Elastic panty-hose and/or intermittent pneumatic compression have the same indication as in abdominal surgeries.     

HRCT shows variations in appearance in disseminated tuberculosis in adults.

OBJECTIVE: To examine patterns of high resolution computed tomography (HRCT) of lungs of adults with disseminated tuberculosis (TB). DESIGN: Disseminated TB was defined as radiological involvement of all lung lobes. RESULTS: The case series illustrated wide variation in HRCT of disseminated TB. Patterns identified on HRCT included (1) miliary TB (haematogenous dissemination), (2) miliary TB with exudative reaction, (3) bronchogenic spread, (4) miliary TB mixed with bronchogenic spread, and (5) bronchogenic spread with multiple cavity formation. CONCLUSION: The HRCT patterns described allow classification of disseminated TB according to the mechanism of spread (haematogenous and/or bronchogenic) and the degree of local lung involvement (reaction or cavitation).     

Stent implantation in recoarctation of aorta in infant

We present the case of a 12 month-old infant with critical coarctaion of aorta, arch hypoplasia, atrial and ventricular septal defects who underwent interventional treatment with stent implantation due to recoarctation of aorta. In neonatal period the patient went through complete surgical correction. At the age of four months balloon angioplasty of recurrent coractation was conducted. Eight months later the patient was hospitalised with heart failure (HF) symptoms. Clinical and echographic examination confirmed critical stenosis of aortic isthmus. We performed heart catheterisation with stent implantation to transverse and descending arch with immediate reduction of gradient from 45 mm Hg to 0 mm Hg, widening of the isthmus from 2 to 8 mm and gradual regression of HF symptoms. At 3 years of observation the patient has not presented with any signs of recurrence of the stenosis. The child remains free of HF symptoms with arterial hypertension controlled with pharmacotherapy and with good left ventricular function on echocardiographic examination.     

Ghrelin-induced GH secretion in domestic fowl in vivo and in vitro

Although avian and mammalian species differ significantly in their regulation of GH secretion, preliminary studies have demonstrated in vivo GH responses to ghrelin in chickens, as in mammals. However, the relative potency of ghrelin as a GH-releasing hormone (GHRH) in birds is uncertain, as is its site of action.The intravenous administration of human ghrelin to immature chickens promptly increased the circulating GH concentration (within 10 min), although this was transitory and was only maintained for 20 min. This GH response was dose-related with an EC50 of approximately 3.0 microg/kg, comparable with the reported potency of human GHRH in chickens. When incubated with dispersed pituitary cells, human ghrelin induced dose-dependent GH release over a range of 10(-6) to 10(-9) M, with an EC50 of 7.0 x 10(-8) M, comparable with that induced by human GHRH (EC50 6.0 x 10(-8) M), although it was less effective at doses of 10(-6) to 10(-8) M. This was due to direct effects on pituitary somatotrophs, since human ghrelin increased GH release (determined by the reverse hemolytic plaque assay) from individual pituitary cells. The incubation of these cells with human ghrelin induced a dose-dependent increase in the numbers of somatotrophs secreting GH and in the amount of GH released by each cell. In summary, these results demonstrated that ghrelin is a dose-related GH-releasing factor in chickens with a potency comparable with that induced by human GHRH. The GH-releasing action of ghrelin is due, at least in part, to stimulatory actions on the numbers of somatotrophs induced to release GH and upon the amount of GH released from individual somatotrophs.     

Gender differences in trends in diabetes prevalence from 1993 to 2008 in Taiwan

We examined time trends in the prevalence of diabetes using nationally representative samples, with a focus on gender differences. Data were from the Nutrition and Health Survey in Taiwan (NAHSIT), 1993-1996 (n = 2700), and NAHSIT 2004-2008 (n = 2258). Participants aged 19 years or older with adequate fasting glucose data were included. When needed, rates were standardized to the year 2000 WHO 5-year interval population for comparisons. The prevalence increased significantly in men, whose standardized rate increased from 4.6% to 9.3%. In women, the age standardized prevalence decreased slightly from 7.9% to 6.4%. High triglycerides (≥ 150 mg/dL) was associated with diabetes with odds ratios (OR) of 2.14, and 2.69 (all with p<0.05) in the two surveys. High waist circumference (men ≥ 90 cm; women ≥ 80 cm) was also associated with diabetes with ORs of 2.52, and 1.93 (all with p < 0.05). We recommend the development of innovative health promotion programs targeting not only the general population, but also high risk groups such as men, to further reduce diabetes.     

Antimicrobial Therapy in Community-Acquired Pneumonia in Children

Purpose of Review

Empirical antibiotic therapy remains the cornerstone of treatment in community-acquired pneumonia (CAP). However, the best option for empirical antibiotics for treatment on an ambulatory basis, as well as in those requiring hospitalization, is still unclear. This review tries to answer the question regarding the most appropriate antibiotics in different settings in children with CAP as well as duration of therapy.

Recent Findings

Recent studies have provided insights regarding use of oral antibiotics in children with mild to moderate CAP, and severe CAP with lower chest retractions but no hypoxia. In view of rapidly emerging resistance among various causative pathogens, several new drugs have been currently approved, or are under trial for CAP in children.

Summary

Current knowledge suggests that the choice of antibiotics for ambulatory treatment of CAP is oral amoxicillin with a duration of 3–5 days. Children with CAP with lower chest retractions but no hypoxia can be treated with oral amoxicillin. Severe pneumonia can be treated with intravenous antibiotics consisting of penicillin/ampicillin with or without an aminoglycoside. Several new drugs have been developed and approved for use in CAP caused by multidrug-resistant organisms, but these should be used judiciously to avoid emergence of further resistance. Future research is needed regarding the safety and efficacy of newer drugs in children.