Antibiotic strategies for developing countries: experience with acute respiratory tract infections in Pakistan.

The Pakistan program for control of acute respiratory tract infections (ARIs) adopted the standard ARI-case-management strategy of the World Health Organization and recommended co-trimoxazole for the management of nonsevere pneumonia. Reports in that country of high in vitro antimicrobial resistance of Streptococcus pneumoniae and Haemophilus influenzae to co-trimoxazole prompted the program to reevaluate its treatment policy. Two community-based studies during 1991-1993 showed in vivo efficacy of co-trimoxazole in 92% and 91% of children with nonsevere pneumonia. A third double-blind trial showed co-trimoxazole and oral amoxicillin to be equally effective in vivo in cases of nonsevere pneumonia, despite high in vitro resistance. Country-wide surveillance from 1991 to 1994 revealed 78.3%-79.9% in vitro resistance to co-trimoxazole among S. pneumoniae isolates and 59.5%-61.0% among H. influenzae isolates. Co-trimoxazole is still recommended by the Pakistan ARI control program. The fact that amoxicillin is three times more expensive and must be administered more frequently is a big impediment to recommending it as a first-line drug for nonsevere pneumonia.