Articles, Blog

Public Health Impact of Pneumonia

November 21, 2019


Hello and thank you so much for joining us
here in Health Professional Radio. I’m your host, Neal Howard. Our guest is Dr. Andy Shorr. He’s joining us on the program to talk about
the public health impact of pneumonia and also the need for additional antibiotics and
treatment options to be available. Welcome to the program today Dr. Shorr. Thank you so much. Thanks for taking the time. Give our listeners a bit about your medical
background if you would. Sure. I’m an Academic Pulmonary and Critical Care
Physician. I run the Pulmonary and Critical Care Division
and the MICU at MedStar Washington Hospital Center at the Washington DC and I am a Professor
of Medicine at Georgetown. Was this something that you pursued as soon
as you got in the med school or have you always been interested in this field? What is it that led you to this? By about third or fourth year in medical school,
I knew I pretty much like taking care of sick people and through that kind, directed me
to its pulmonary critical care. We’ve all been hearing about the severity
of this year’s flu season. But let’s talk about the public health impact
of pneumonia. We haven’t heard a lot about that in the
news. Is that something that’s being under-covered
or is it something that so normal that we’re not hearing much about it. I think you’re correct. I think there’s a lot of complacencies when
it comes to community-acquired bacterial pneumonia or CAP. When we talk about community-acquired pneumonia,
Osler identified it as the captain of death, a long time ago over a hundred years ago. In fact, Osler himself, the father of modern
internal medicine died of community-acquired pneumonia. It’s a huge problem and it hasn’t got
a lot of attention. In fact, we haven’t had really new interventions
for community-acquired pneumonia short of vaccination in the last two or three decades. We actually haven’t moved the needle in
terms of mortality for community-acquired pneumonia in about 30 years. This remains a really rubbish severe problem
and whether it’s a de novo problem when the patient just comes in with community-acquired
pneumonia or as routine in this flu season where certain bacteria are leading to superinfection
after influenza. It’s really a challenge, especially since
our armamentarium is limited and we’re seeing risks since pattern changed for the common
pathogens in community-acquired pneumonia. It’s kind of viewed as the price of doing
business, yet I can tell you as an intensivist, I’ve had people who were otherwise healthy,
who are young died of pneumococcal shock and pneumococcal septic shock, that’s still
a challenge and a problem. We still need newer tools and newer options
in our toolkit to address it. From an antibiotic perspective, there’s
been a lot of focus on agents other than fluoroquinolone or cephalosporins and macrolides and we’re
finally stirring disease. Some of the fruit of that kind of, come to
fruition in terms of these efforts that we’re finally getting newer drugs in the clinical
trials, so to actually evaluate them as the new options for community-acquired pneumonia. MRSA got a lot of attention two decades ago
and now we have all these tools for MRSA, but MRSA, so resistant to staph aureus is
actually under decline. We’ve got a lot of attention focused on
highly resistant gram-negative such as Carbapenem-resistant Enterobacteriaceae or CRE, now in the US. We have basically two and perhaps soon three,
four or five agents who are going to be approved for CRE. The number of patients who died from CRE infections
each year is really quite small compared to the number of people who died of community-acquired
pneumonia every year. Does this seem to affect children as much
as adults or is it more prevalent in older people? I know it’s common but who is more at risk
and are we focusing on that population a bit more? Certainly. I’m not a pediatrician so I can’t speak
to all the pediatric issues but we definitely think of community-acquired pneumonia as a
disease of the young and then of the old. But the point is, it can affect anyone and
I think any pulmonary critical care physician, any infectious disease physician or anybody
who work from hospital medicine can tell you stories of also the young person, mid-30s
or 40s whose only risk factor for pneumonia is they have a kid in daycare. They come in with severe community-acquired
pneumonia then end up common to it. We certainly think of it as having two pieces
of incidence but the burden is actually distributed pretty evenly in terms of access, mortality
and things of that nature. Do you think that the age gaps or the difference
in age have anything to do with the current treatments being less effective than they
need to be? No. I think the reason we see these differences
is really because of host immune system issues and also exposure issues. Those are really what’s driving it. I don’t think, novel antibacterial vaccine,
other that were something, other than a vaccination is really gonna treat that. I think vaccination is key and we’ve certainly
seen as the better pneumococcal vaccinations are used to children affects on herd immunity
so that the burden of certain strains of pneumococcus are going down on adults because we’re just
getting a herd immunity effect. Nonetheless, kind of like any balloon, you
squeeze it at one side and it contracts but on the other side, it expands. We’re seeing other strains of pneumococcus
still devoid. When you think of what pneumococcus is becoming
resistant to, you think about macrolide resistance, you’re beginning to see lots of issues in
terms of the choices we have for antibiotic and our need for new ones. Do we have anything on the near horizon in
development that is going to benefit as even more? I am not sure if we can claim benefits of
even more short of randomized control of trials that’ll really show that. But there are a couple of drugs in clinical
development for community-acquired pneumonia. There’s minocycline which is a tetracycline-based
antibiotic that’s been studied in community-acquired pneumonia and it’s under regulatory review
right now. There’s a whole new class of drugs called
pleuromutilin which has been used in animals but not in humans ever and the drug in that
class is Lefamulin and that’s being studied in community-acquired pneumonia. They’ve got one clinical trial that has
been done and the second one should be finishing up very quickly. So hopefully we’ll have pipeline data. I think clinicians all of a sudden are going
to have to wake up from their slumber of complacency where they only know one way to treat community-acquired
pneumonia and reevaluate the new tools as they become available to decide how they’re
going to fit in armamentarium. Because if you keep using the same antibiotics
over and over again, not only you’re going to create resistance eventually, you’re
also going to potentially exposed to patients who risk for, say death or potentially with
quinolone side effects that are related to fluoroquinolones that are getting a lot of
attention in both the medical and lead press right now. We’d like to learn some more, where can
we go online and learn some more and possibly some more about MedStar health as well? MedStar certainly has a website for itself
– medstar.org and you can certainly go there and look at the 10 hospital healthcare system
that I’m proud to be a part of. In terms of community-acquired pneumonia,
I think the simple place to start is up to date online. If you just want to learn some high-level
material but I think the best way to really get out at this, there are some excellent
reviews on Medscape and another website and it’s for medical education. They’re really focused on community-acquired
pneumonia that can address us. Thank you for talking with us today and I’m
hoping you’ll return and give us some updates as things develop. Thank you so much. You’ve been listening to Health Professional
Radio. I’m your host, Neal Howard. Transcripts and audio of this program are
available at healthprofessionalradio.com.au and also at hpr.fm. You can subscribe to this podcast on iTunes,
you can listen and download at SoundCloud and be sure and visit our affiliates page
at healthprofessionalradio.com.au.

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