CBN Report: Antibiotics to Treat Pneumonia: An Overlooked Essential Element of Pandemic Preparedness
By Eric Toner, M.D., September 1, 2006
a review article in the May issue of Lancet Infectious Disease, John Brundage,
M.D. examines the relationship between influenza and bacterial suprainfections
in past pandemics. He points out that the evidence available from the pandemics
of 1918, 1957 and 1968 suggests that the majority of fatal cases of pneumonia
in all three pandemics were associated with positive bacterial cultures,
most commonly with pneumococcus, S. aureus, S. pyogenes, and H. influenzae.
While there were cases that appeared to be purely viral pneumonia, based
on clinical features and negative bacterial cultures, these cases were a
While much has been made
of the fulminant cases of presumed viral pneumonia in 1918, Dr. Brundage’s
research indicates that the majority of pneumonia cases, even in 1918, were
either secondary bacterial pneumonias following an influenza infection or
mixed viral and bacterial pneumonias. In the pre-antibiotic era, these cases
of bacterial pneumonia carried a very high mortality rate; however, with
appropriate antibiotic therapy, many such patients may be saved.
The HHS Pandemic Influenza
Plan assumes that 45 million Americans will seek medical care for influenza
in a severe pandemic, and that 10 million of these will require inpatient
care. Assuming that most of these people receive a course of antibiotics,
there will be a large surge in demand for antibiotics over and above what
is needed for other indications. For comparison, there are typically 4 million
cases of community acquired pneumonia in the U.S. each year and about 1 million
hospital admissions for pneumonia. Thus, there is a potential 10-fold
surge in demand for antibiotics to cover pneumonia in a relatively compressed
For a variety of reasons,
U.S. hospitals have experienced frequent shortages of common antibiotics
in recent years . And due to the adoption of just-in-time supply chains,
many hospitals maintain a stock of only a few days’ worth of antibiotics
(this is particularly true of parenteral forms typically be used for inpatients).
Thus, it is likely that shortages of common antibiotics will occur during
an influenza pandemic.
preparedness effort has focused on the availability of antivirals and vaccines,
there has been little discussion of the need to assure a ready surge supply
of antibiotics. For outpatient management, the Strategic National Stockpile
of 40 million 60-day courses of antibiotics for anthrax prophylaxis is a
resource that could be tapped if needed. The ciprofloxacin and doxycycline
that make up most of the stockpile are reasonable choices for the outpatient
treatment of most adults with community acquired pneumonia. However, this
writer has been unable to substantiate the existence of either stockpiles
of parenteral antibiotics or surge manufacturing capacity adequate to deliver
the volume of parenteral antibiotics that will be needed to treat the numbers
of patients likely to be hospitalized during a severe influenza pandemic.
Dr. Brundage’s research suggests that the extraordinary mortality associated with 1918 pandemic could be significantly reduced by the administration of antibiotics if a similar outbreak were to occur today. This assumes that the antibiotics are available. Pandemic planners at all levels--institutional, local, state and federal--should work to ensure that there will be sufficient amounts of the appropriate antibiotics available when the next pandemic occurs.
Brundage JF. Interactions between influenza and bacterial respiratory pathogens:
implications for pandemic preparedness. Lancet Infect Dis 2006;6:303-12
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