Clinicians Biosecurity Network

CBN Report: Antibiotics to Treat Pneumonia: An Overlooked Essential Element of Pandemic Preparedness

By Eric Toner, M.D., September 1, 2006

In a review article in the May issue of Lancet Infectious Disease[1], 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 minority.

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.

Today, much of pandemic preparedness is focused on H5N1. Of the 240 human cases so far, almost all have had pneumonia, and there have been no reported cases of known bacterial suprainfection. However, in the clinical setting many, if not most, of the patients have been treated empirically with antibiotics since it is difficult to rule out the possibility of bacterial involvement. This same clinical dilemma will be faced by clinicians during the next pandemic. Therefore, it seems likely that most influenza patients sick enough to seek medical care, particularly if they require hospitalization, will be administered antibiotics.

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[2]. 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[3]. Thus, there is a potential 10-fold surge in demand for antibiotics to cover pneumonia in a relatively compressed timeframe.

For a variety of reasons, U.S. hospitals have experienced frequent shortages of common antibiotics in recent years [4]. 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.

While much 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[5]. 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.