A Decade of Advances and Challenges

Many advances and challenges have occurred inthe field of pediatric infectious disease medicineduring the past 10 years. Because this is the 10thanniversary of this column, a summarization of what, inmy opinion, are the most clinically significant developmentsis presented here.

Development of new vaccines, monoclonal antibodies,immunization policies, and guidelines for chemoprophylaxisrepresent impressive advances in preventive infectiousdisease medicine. New vaccines include thoseagainst infections caused by Streptococcus pneumoniae, rotavirus,human papillomavirus, Neisseria meningitides,varicella, influenza, and pertussis.^1,2

As for the contribution of monoclonal antibodies, significantdecreases in morbidity and mortality and associatedrespiratory syncytial virus infection in at-risk infantshave been associated with the widespread prophylacticuse of palivizumab.³ In addition, the implementation ofguidelines aimed at universal prenatal screening and intrapartumprophylaxis has resulted in a dramatic decreasein the incidence of early-onset group B streptococcaldisease among neonates.⁴

We also have witnessed a significant expansion in thefield of molecular diagnostics. Many tests within this category,such as those for Chlamydia trachomatis, Neisseriagonorrhoeae, Enterovirus, herpes simplex virus, HIV, andBartonella henselae infections, are now routinely requestedin most clinical settings. New molecular techniquesalso have resulted in the discovery of pathogens such ashuman metapneumovirus and bocavirus, which now appearto be common causes of pediatric disease.^5,6

One of the most significant achievements from thetherapeutic standpoint has been the ability to use highlyactive antiretroviral therapy effectively in children infectedwith HIV. It has resulted in a significant reduction inmortality in this population. Indeed, in industrializedcountries, the incidence of perinatally acquired HIV infectionhas decreased dramatically because of the use ofhighly active antiretroviral therapy during pregnancy.^7-9Progress also has been made in the development of antiviraltherapy aimed at infections such as influenza,Cytomegalovirus infection, and herpes simplex.

Among new challenges is the growing epidemic ofinfections caused by community-associated methicillinresistantStaphylococcus aureus, which has become themost common bacterial cause of hospitalization in childrenin many areas of the United States. Emergence ofsignificant antibiotic resistance among other commonpediatric pathogens, such as Streptococcus pyogenes, Spneumoniae, and enteric gram-negative organisms, alsohas become a major concern.¹⁰ Although many new antimicrobialshave been developed and licensed for adults,studies aimed at assessing the safety and efficacy of theseagents in children have been lacking, and thus the antibioticarmamentarium in the pediatric population iscurrently not up to par.¹¹ In addition, the success of immunizationprograms has been compromised by the developmentof misconceptions about vaccine administrationin the public sector and a decrease in public awarenessabout the deleterious effects of vaccine-preventablediseases.¹²

New and emerging threats seen during the past decadeinclude the severe acute respiratory syndrome epidemic,a potential new influenza pandemic, and theresurgence of invasive pneumococcal disease in children.Worldwide, elimination of measles and poliomyelitis remainsa challenge, and many developed countries stilllack the resources to effectively treat and prevent pediatricGI infections, tuberculosis, and HIV infection. Nevertheless,new discoveries and technological advances aimed to improve children's healthwill emerge as we address these andother current challenges and, ofcourse, future challenges in the yearsto come.

References:

• Centers for Disease Control and Prevention. Notice to readers recommended childhood immunization schedule-United States, 1998. MMWR. 1998;47:8-12.

• Centers for Disease Control and Prevention. Recommended immunization schedules for persons aged 0-18 years-United States, 2008. MMWR. 2008; 57:Q-1–Q-4.

• Mitchell I, Tough S, Gillis L, Majaesic C. Beyond randomized controlled trials: a “real life” experience of respiratory syncytial virus infection prevention in infancy with and without palivizumab. Pediatr Pulmonol. 2006;41:1167-1174.

• Centers for Disease Control and Prevention. Perinatal group B streptococcal disease after universal screening recommendations-United States, 2003-2005. MMWR. 2007;56:701-705.

• Williams JV, Harris PA, Tollefson SJ, et al. Human metapneumovirus and lower respiratory tract disease in otherwise healthy infants and children. N Engl J Med. 2004;350:443-450.

• Calvo C, García-García ML, Pozo F, et al. Clinical characteristics of human bocavirus infections compared with other respiratory viruses in Spanish children. Pediatr Infect Dis J. 2008; 27:677-680.

• Patel K, Hernán MA, Williams PL, et al; Pediatric AIDS Clinical Trials Group 219/219C Study Team. Long-term effectiveness of highly active antiretroviral therapy on the survival of children and adolescents with HIV infection: a 10-year follow-up study. Clin Infect Dis. 2008;46:507-515.

• Wortley PM, Lindegren ML, Fleming PL. Successful implementation of perinatal HIV prevention guidelines. A multistate surveillance evaluation. MMWR. 2001;50(RR-6):17-28.

• Centers for Disease Control and Prevention. From the Centers for Disease Control and Prevention. Progress toward elimination of perinatal HIV infection-Michigan, 1993-2000. MMWR. 2002;51:93-97.

• McCaskill ML, Mason EO Jr, Kaplan SL, et al. Increase of the USA300 clone among community-acquired methicillin-susceptible Staphylococcus aureus causing invasive infections. Pediatr Infect Dis J. 2007;26:1122-1127.

• Bell EA. Year in review-why only one new antibiotic this year? Infectious Diseases in Children. http://idinchildren.com/200512/pharmconsult.asp. Published 2005. Accessed October 7, 2008.

• Gellin BG, Maibach EW, Marcuse EK. Do parents understand immunizations? A national telephone survey. Pediatrics. 2000;106:1097-1102.