Future trends in the treatment of serious Gram-positive infections.

Gram-positive organisms are the most common bacterial pathogens that cause diseases in humans, with streptococci and staphylococci occurring most frequently. Immunization has been extremely successful in eradicating some Gram-positive infections, such as diphtheria and tetanus, and relatively successful for pneumococci. Staphylococcus aureus vaccines are under investigation. In terms of antimicrobial susceptibility, some Gram-positive organisms have remained sensitive to most antimicrobials, whereas others, including staphylococci, pneumococci and enterococci, have developed clinically relevant resistance. Extensive exposure to antimicrobials in the hospital setting has caused the spread of clones mainly in the hospital environment, yet multiresistance is now also found in community-acquired diseases. Community-acquired methicillin-resistant S. aureus (CA-MRSA) and resistant pneumococci are the most important examples, but even viridans streptococci are becoming resistant to some antibiotics. Moreover, MRSA and vancomycin-resistant enterococci (VRE) are found in pets and farm animals. Because of these concerns, new antimicrobials have been developed during the past decade, including quinupristin/dalfopristin, linezolid, tigecycline, daptomycin and dalbavancin. Also under investigation are beta-lactams, streptogramins and quinolones with activity against MRSA, penicillin-resistant pneumococci and VRE. Finally, infection-control measures, including the identification of carriers of multiresistant organisms and appropriate isolation, must continue to be implemented.