This a strategic post about pneumonia. By strategic I mean I hope to clarify what it
is and how to prevent it. This is not
about diagnosing and treating it. Most
people reading this blog either don’t need to know that or know a lot more than
me about it. Instead, I hope to address three things – misinformation about it,
barriers in the modern healthcare system to acute care, and how to prevent it.
My focus will be on community acquired pneumonia (CAP). It is a term I am very familiar with dating
back 40 years to med school and my medical internship. As an intern I carried
around my copy of Sanford’s antimicrobial therapy and the relevant section of
Phantom Notes which was basically an outline of the leading Internal Medicine
text at the time. Thirty percent of the
people I admitted to the hospital had some kind of pulmonary problem. Depending on who you read chronic obstructive
pulmonary disease (COPD) is as high as the third leading cause of death
worldwide. Exacerbations of COPD were
very common reasons for hospital and ICU admission.
CAP by definition is acquired in the community and not in a
hospital setting. It can be cause by a
range of microorganisms and host factors.
It can also develop in people with no known risk factors. Conventional
wisdom used to be that the lung was sterile territory but now we know that it
contains a low biomass microbiome consisting of bacterial, viral, and fungal
elements that are there via microaspiration of mouth contents. Local physiological changes can occur to
change the microbiome, or pathogens can be inhaled that establish primary
infections (1). Certain lung diseases
like COPD and asthma can also lead to selective proliferation of elements of
the microbiome.
The ability of the lung to repair itself after injury or
infection is controversial. Some research suggested that the lung was
permanently changed by infection. One
example would be the association of asthma with previous rhinovirus infection.
More recent work suggests there is room for optimistic if the regenerative
capacity of the lung can be activated (2).
My motivation for this post was a clinical trial I read in
the New England Journal of Medicine. It
was about treating CAP in Africa. The
research question was whether adding glucocorticoids to antibiotic treatment as
usual would improve outcomes. That study
quotes the mortality of CAP as 25-30%. The study was conducted in Kenya. 2,180 patients were randomized to standard
care versus glucocorticoids. All
patients were admitted to a hospital and CAP was defined as “the presence of at
least two of the following signs and symptoms for less than 14 days: cough,
fever, dyspnea, hemoptysis, chest pain, or crackles on chest examination.” Imaging was not a criterion for study
entrance because it was not available in many settings. They were started on the protocol within 48
hours of admission. Glucocorticoids were provided for free as one of five
glucocorticoids in bioequivalent doses for a total of 10 days (including after
discharge) in addition to standard care (6 mg of dexamethasone, 160 mg of
hydrocortisone, 30 mg of methylprednisolone, 50 mg of prednisolone, or 50 mg of
prednisone). Standard care was
antibiotic therapy per World Health Organization (WHO) guidelines (beta lactam
and macrolide antibiotics). Exclusion criteria are available in the paper.
30-day mortality was the primary endpoint in an
intent-to-treat analysis. To get to the
treatment population a total of 46,224 patients were screened. Of the 2,180 patients mortality was 530
(24.3%) at 30 days. 246 of 1089 (22.6%)
were in the glucocorticoid group and 284 of 1091 (26.0%) in the glucocorticoid
group. That translates to a hazard ratio
of 0.84. The authors explain the
limitations (comorbid illnesses – HIV, hypertension) and advantages (large N,
lower media age) of their study. That
seems like a slight reduction in mortality for the intervention, but the
authors point out that several other studies had better result up to a 50%
reduction in mortality with glucocorticoids and it is a low tech readily
available intervention.
In looking at the side effects of glucocorticoids Pulmonary tuberculosis and hyperglycemia
were the most common adverse effects in the glucocorticoid treated group. Pulmonary tuberculosis and acute kidney
injury were the most common adverse effects in the standard care group.
There are
characteristic patterns of pneumonia by pathogen based on the immune
response. Bacterial infections elicit an
infiltration of neutrophils into the alveolar space in a pattern of lobar or
bronchopneumonia that results in an exudate of dead cells and phagocytes in the
alveolar space. Viral infections cause
an interstitial pattern of inflammation with lymphocytic cell infiltrates. Identification of the pathogen is largely
done on a clinical basis due to difficulty identifying the pathogens. Indirect methods can be used like determining
acute and convalescent phase antibodies to specific viruses. Both types of
infection compromise normal physiology and can lead to hypoxia and in the case
of bacteria secondary infections like meningitis.
Recent sporadic and
annual viral pandemics have created a confluence of factors at the hospital
that are best avoided. The first is the
use of broad-spectrum antibiotics. Since
a significant portion of people admitted with viral pneumonia develop hospital
acquired secondary bacterial infections – antibiotics are given
prophylactically to prevent that complication.
Increasing exposure to increasingly potent antibiotics leads to multiple
drug-resistant bacteria. The best
pathway is to avoid getting the respiratory infection in the first place.
The absolute best way
to avoid is vaccinations. Vaccinations
are currently available for influenza, COVID-19 (Sars-CoV-2), respiratory
syncytial virus (RSV), and Streptococcus pneumoniae (pneumococcal pneumonia and
meningitis). They have all been tested
and offer relative protection (rather than absolute) against serious illness,
hospitalization, and death, especially for adults 65+ years of age. Vaccinations have become a mixed bag of
accessibility. On the one hand you can
get them from pharmacies and that is a recent development. On the other had we have an elected
government that has appointed a well known antivaccination promoter as the head
of Health and human Services – Robert F. Kennedy, Jr. So far there have been restrictions on the
COVID vaccination to people who are 65+ or have an underlying health
condition. Since the administration is
apparently making health decision based on politics and ideology many states
and professional organizations are publishing their own guidelines. As an example her is a list of respiratory virus vaccination guidelines
form the American Academy of Family Practice (AAFP). The CDC still has pneumococcal vaccination recommendations
for children less than the age of 5 and adults over the age of 50.
The University of
Minnesota Center for Infectious Disease Research and Policy (CIDRAP) program
has a good brief on the vaccine controversy and chaos introduced by the Trump administration
and the lack of scientific origins at this link.
Apart from vaccinations
risk factor modification should be considered. If you were born and raised in American
culture – it is important to realize that you have been socialized to expect to
get sick in the wintertime. I did not
realize that until I was getting sick 2-3 times a year on the inpatient unit
where I worked. They were viral
illnesses that took 2-3 weeks to recover from.
The building was made in an era where preservation of heat was the primary
design goal. There was minimal
circulation of clean air or filtration.
My suggestions to improve the air quality were ignored. The mini-epidemics were made worse by
admitting people who were ill with respiratory viruses and not using any
precautions to prevent the spread of those viruses. The new personal time off (PTO) policies that
make no distinction between vacation and sick days also lead to increased exposure
to sick employees who would rather work sick than use PTO days for sick
time. Since the COVID pandemic even
outpatient clinics ask questions every time they see you to minimize staff exposure
to respiratory viruses.
Masks work. They must be N95 masks and fit correctly but
there is no doubt that they work. These
days it is common to see political arguments and in the extreme ridicule heaped
on people who use them. Large scale uncontrolled studies are often cited as
evidence that they are a weak intervention.
Thise studies are almost all self report with no measures of actual
adherence to masking. The best studies are done in a lab
that look at filtering virus sized particles and there is no doubt they are
equal to that test.
Risk factor
modification is probably important.
Cardiopulmonary diseases are significant risk factors for pneumonia – so
maintaining the best possible treatment for those conditions is important. Weight control and activity level are also
important. There is ate least on studying
showing that 65+ year olds who maintain high activity levels have better
immunity than those who do not. The
specific dose of exercise for that effect is unknown currently.
Expert advice on
vaccine allergies is an important point. I have personal history of an anaphylactic
reaction to anti-rabies duck embryo vaccine in 1975. For the next 30 years I did not get a single
vaccine against influenza because it was egg based. I had innumerable episodes of viral illness
that was probably influenza and decided to see an immunologist to see if I
could be desensitized to eggs so I could get the flu vaccine. When he conformed that I could eat eggs without
problems he said that I would probably not have any problems with the
vaccine. He was correct and I have not
missed an annual dose since.
Look for respiratory
infection season onset and peaks. They are
typically available through your state public health department and the CDC. When
I notice it – I change my routine to shop at nonpeak hours and wear a mask in
stores. In addition to protection from
the airborne transmission route hand washing is also important. Shopping carts, door handles, and other high
traffic areas are unavoidable areas for direct contact transmission. That may
include being in a public bathroom any time somebody flushes a toilet. Keep in mind that there are number of circulating common cold viruses
that include 4 coronaviruses that can make you very ill.
What about barriers to care in the current healthcare
non-system in the US? There are many
since businesses have taken over health care in the past 40 years. Healthcare is rationed by both businesses and
governments with only a very grudging nod to quality. The most obvious example
is avoidance of the emergency department if you need it. Anyone with previous experience knows about
waits in emergency departments and delays in care. People avoid paramedics and ambulances out of
fear they will be billed for that service.
If you expect that you are ill beyond a typical cold and have additional
warning signs like shortness of breath – seek help immediately. I have given that advice to many people and
it is included in the final paragraph of this AMA
information sheet. Keep in mind
that pneumococcal infection can also cause meningitis which is even a more
significant emergency and those symptoms can include a severe headache and neck
stiffness. Maintain a low threshold for
checking these symptoms out with your primary care physician’s office during
working hours and their call line after hours. But if that is not available or
able to give you an answer call 911 and get a paramedic there in person to
advise you and advocate for you getting timely care. Even in our fragmented healthcare system you
do not have to go it alone.
Finally – you must realize
that the infectious disease space has been infiltrated by many people who do
not belong there. They have mixed
agendas involving politics and health and wellness profits. In some cases, they are just promoting
themselves. Their varies from a kernel
of truth rhetoric (eg. “most people who get this virus do not die”) to
outright lies (eg. “this vaccine has never been adequately tested”). There are many points in between such as “He
died of pneumonia not COVID”. In
outrageous cases they have attacked and threatened public health officials. It is important to recognize who these people
are and why they must be ignored to preserve your interest and that is your personal
health.
That is my overall strategy
to avoid pneumonia. It is most important
as you age into categories where your risk doubles (65+ yrs old) and increases
25-fold (80+ yrs old). I use these strategies
myself and have found them to be very effective. And remember the overall strategy is to avoid
the physical virus or bacteria if at all possible and failing that make sure
your immune system is activated by a vaccination to attack it if you are
infected.
George Dawson, MD, DFAPA
References:
1: Li, R., Li, J. & Zhou, X. Lung microbiome: new
insights into the pathogenesis of respiratory diseases. Sig Transduct Target
Ther 9, 19 (2024). https://doi.org/10.1038/s41392-023-01722-y
2: Ainsworth C. Lung,
heal thyself. Nature. 2026 Jan 29;649:S9 – S11.
3: Lucinde RK,
Gathuri H, Mwaniki P, et al. A Pragmatic Trial of Glucocorticoids for
Community-Acquired Pneumonia. N Engl J Med. 2025 Dec 4;393(22):2187-2197. doi:
10.1056/NEJMoa2507100. Epub 2025 Oct 29. PMID: 41159889; PMCID: PMC12659994.
4: Peyrani P, Arnold
FW, Bordon J, et al. Incidence and mortality of adults hospitalized with
community-acquired pneumonia according to clinical course. Chest.
2020;157(1):34-41.
5: Jain S, Self WH,
Wunderink RG, et al.; CDC EPIC Study Team. Community-acquired pneumonia
requiring hospitalization among U.S. adults. N Engl J Med. 2015;373(5):415-427.
Graphic:
Pages from my trusty copy of Phantom Notes that I used on wards as a medical student. I went back to check to see if community acquired pneumonia was a thing back then and it was not. If you can read it they do discuss where it was acquired under Classification (D3). According to PubMed that term was used just twice in 1981 - but became progressively more popular in the 1990s.
Note also that we have an expanded list of viral pathogens compared with 1981.
Phantom Notes Medicine 79-80 edition copyright Joe D. Glickman, Jr, MD All Rights Reserved.
A Shocking Anecdote about Pneumococcus:
When I was an intern on neurology (1983) I was called down to the emergency department to assess a 70 year old woman for "agitation". That was all they could tell me aside from the fact that her labs and exam were normal. She was unresponsive, groaning softly and rolling form side to side on the bed. I proceeded with my examination and found that she had a stiff neck and pus draining out of her left ear. I called my two senior neurology residents and they came sprinting to the ED. A quick gram stain of the pus showed gram positive cocci and we gave her 1 gram of IV chloramphenicol, did a lumbar puncture and transferred her to the Neurology ICU. She subsequently developed ARDS and required transfer to the medical ICU for respiratory support. She was discharged a month later and was completely deaf as a result of pneumococcal meningitis.
