Pneumonia: A Killer in the Community On one of the hottest days in June 2002, I sat shivering in my office.

It wasn’t from the air conditioning. I felt awful and decided to go home to bed. That was the only smart thing I did until four days later when I finally let my wife drag me to the emergency room in Annapolis. I assumed I just had the flu and would eventually get better. But I didn’t; not until the doctors revived me with intravenous fluids and antibiotics, oxygen, potassium, and morphine. Two days later, I was looking and feeling well enough to be released. I had survived an encounter with community-acquired pneumonia. Pneumonia is the seventh leading cause of death in the United States. There are an estimated 4 to 5 million cases of community-acquired pneumonia annually and about 25 percent of those cases require hospitalization. The term “community-acquired” refers to those cases contracted outside of hospitals and nursing homes. Not only can pneumonia be fatal, it also hurts. It starts suddenly, with a fever and chills, coughing, tachypnea (panting), and tachycardia. All that panting can lead to dehydration, which can make it harder for a physician to hear fluid in your lungs and make a diagnosis of pneumonia. The most common cause of pneumonia is a bacterium called Streptococcus pneumoniae. Fortunately, this bug usually responds to antibiotics, and there are two vaccines available to help reduce the chances of catching it. Other common pneumonia-causing bacteria include Haemophilus influenzae (thought by the physicians of 1918 to cause influenza), Mycoplasma pneumoniae, and the headline-grabbing Legionella pneumoniae. There are other bacteria and

viruses that can cause pneumonia, but in 30-50% of cases the responsible bug is never identified by the hospital. Mine was never identified, but that did not prevent the doctors from treating me

“empirically.” That’s a fancy way of saying, “guess now, give antibiotics, and try to confirm later.” Usually, that approach works quite well, though it certainly helps to know what bugs are out in the community and what antibiotics have worked on past pneumonias. So where does Streptococcus pneumoniae come from? How does it cause disease? Well, it’s communicable. We get it by inhaling infectious particles or droplets ejected into the air by someone already ill or infectious. Lodging deep in the lungs, the bug may evade normal host immune responses or quickly overwhelm a host already weakened by flu, asthma, age, smoking, or other conditions, to start an infection. Interestingly, a recent study of pneumonia patients suggests that the use of certain medications for controlling stomach acid may increase the risk of contracting pneumonia. These so-called proton pump inhibitors and H2-receptor antagonists are widely prescribed for treating ulcers and acid reflux conditions. The author of the study, Robert Laheij in the Netherlands, suggested, “It may be prudent to ensure that acid-suppressive treatments are used sparingly in groups already at high risk of pneumonia.” Those groups include the elderly, and patients with asthma, chronic lung diseases, or weakened immune systems. Pneumonia is a common complication of the flu. So much so that the Centers for Disease Control and Prevention (CDC) report mortality data from pneumonia and influenza as a single number. As of last week, for example, Baltimore reported a total of 750 deaths in 2004 due to pneumonia and influenza. Of course, with a shortage of flu vaccines in the U.S., the number of cases of influenza can be expected to be greater than last year. Consequently, the number of complications—such as pneumonia—can be expected to be greater than last year. In the absence of a flu shot, perhaps

the best thing for some people would be to get vaccinated against pneumonia. It wouldn’t help against the flu but it might keep a subsequent pneumonia at bay. There are two vaccines to prevent pneumonias from Streptococcus pneumoniae. One is the pneumococcal conjugate vaccine (PCV7) for infants and toddlers. The other is called pneumococcal polysaccharide vaccine (PPV). It provides protection against 23 different types of S. pneumoniae bacteria, and is recommended for seniors and children older than two who have chronic health problems. Both provide good protection against pneumonia, meningitis, and bloodstream infections. In 2003, about 68% of Maryland’s adults aged 65 and older got a flu vaccine. Sixty-two percent also got vaccination against pneumonia. The national goal is to have 90% of seniors vaccinated against flu and pneumonia by 2010. The flu goal is off track, but there’s no reason not to try for better pneumonia vaccine coverage rates right now.