Aging Begins at 30

Pneumococcal Vaccine Not Used Enough

Community acquired pneumonia (not acquired in hospital) is common and costs the United States $20 billion annually for treatment and lost wages. Hospitalization is responsible for about 96% of this cost and one third of cases need admission. Pneumonia is the sixth most common cause of death in America.

Patients with pneumonia cough up sputum and breathe about 28 times a minute instead of 18. They may have chest pain, worse with deep breathing or coughing. Symptoms can be less obvious in the elderly. Overall less than 1% die, but 18% of the elderly and 25% with bacteria in the bloodstream die. About 66% of all pneumonia patients can be treated at home with oral antibiotics. The rest need hospitalization for injectable antibiotics (of those 15% are in intensive care).

Yearly influenza vaccination can prevent many cases; especially the elderly, diabetics, or chronic lung or heart disease patients. It gives 60% protection, but only 65% get the vaccine. Pneumococcal vaccine once or twice in a lifetime reduces the risk from the most common fatal bacterial pneumonia by 63%. Only 45% of the elderly get this. They should get it to avoid a possibly lethal hospitalization.

Patients over 65 or with diseases like diabetes, alcoholism, or cancer should usually be admitted. Poor lung function, low blood pressure, altered mental status, or infection spreading beyond the lungs require hospitalization. Low arterial oxygen, anemia, kidney failure, multiple lung-lobe involvement, or pus in the chest cavity also lead the doctor to admit. More than 90% of pneumonia deaths occur in the elderly.

The pneumococcus, a bacterium, is responsible for about a third of community pneumonia cases. Various viruses cause 20%. Legionella, a very small bacterium, caused pneumonia at the American Legion meeting in Philadelphia in 1976. It causes 10% (varying regionally). Gut bacteria such as Klebsiella or E.Coli cause 7%, and Hemophilus causes 6%. Several other organisms such as mycoplasma or chlamydia also can cause pneumonia. In nearly one third or more of patients no causative organism is found.

Patients with pneumonia need their sputum examined microscopically for organisms and cultured. Those sick enough to be hospitalized need a blood culture. All require a chest x-ray. This can be difficult in a nursing home. We need more mobile x-ray units. Newer methods like DNA probes or fluorescent microscope identification may make diagnosis easier.

The pneumococcus can develope penicillin resistance (3% in the US and Canada, 15% in Spain, and even higher resistance about 30% in South Africa and Hungary). More resistance occurs in nursing homes, in HIV-positive patients, alcoholics, and patients treated with penicillin within 3 months. Doctors must know current antibiotic resistance rates in the area and hospital.

Choosing antibiotics can be difficult, but starting them within 8 hours of arrival lowers mortality. Currently in our area, if a causative organism is seen in a stained sputum smear we know which antibiotic to start. Usually next day cultures will confirm the organism and antibiotic resistance or sensitivity. While awaiting confirmation, outpatients with pneumococcus get a modified penicillin orally. Hemophilus patients get cefuroxime orally and Staphylococcus aureus patients get nafcillin. If a sputum stain is not available the outpatient gets an oral erythromycin derivative.

Hospital patients get injectable penicillin in high doses for pneumococcus, cefuroxime for Hemophilus, and nafcillin for S. aureus (a penicillin cousin resistant to breakdown). Patients with gut-derived bacteria get cephalosporin (another penicillin cousin) with or without an aminoglycoside (such as tobramycin).

In the ICU the pneumococcus is more invasive and penicillin resistant so patients get an injectable cephalosporin or if allergic to pennicillin get cefotaxime (or ceftriaxone) and erythromycin by injection.

Pneumonia can be a life and death struggle. Proper vaccination prevents many dramatic battles.

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See related Patient Topics Immune System/AIDS, Immunization/Vaccination, Infections, Lungs and Breathing or Pneumonia.

See related Provider Topics Immune System/AIDS, Immunization/Vaccination, Infections, Lungs and Breathing or Pneumonia.

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