PNEUMONI JURNAL

Influenza and bacterial pneumonia

Influenza virus A type H1NI is currently causing a smouldering
world-wide outbreak which originated in Mexico. There are pre-
dictions of a major outbreak occurring in the Autumn when the
‘influenza season’ returns to the Northern hemisphere.
A possible scenario similar to that of the 1918/1919 “Spanish
flu” pandemic, which had a very high mortality, frequently affect-
ing previously healthy young individuals, is causing great concern.
There has been considerable interest in the cause of this high death
rate in 1918–1919.
Causes of death in influenza include an overwhelming viral
infection (the influenza virus does enter the blood-stream) – some-
times associated with disseminated intravascular coagulation (DIC)
– myocarditis, encephalitis, and secondary bacterial infection, usu-
ally pneumonia, which can lead to respiratory failure.
A recent paper
[1]
sheds light on the cause of death in the
1918–1919 influenza pandemic. Morens and colleagues at the
United States National Institutes of Health examined stored post-
mortem samples obtained from 58 people who had died of
influenza during the 1918–1919 pandemic. They re-cut tissue sec-
tions and examined them histologically. They also carried out a
literature search for publications reporting the results of pathol-
ogy and microbiology investigations on individuals who died of
influenza during the pandemic.
Morens and colleagues conclude that “
The examination of re-cut
lung tissue sections from 1918-1919 influenza case material revealed,
in virtually all cases, compelling histologic evidence of severe bacterial
pneumonia
”. From their own study, and also their literature search,
they found that
Streptococcus pneumoniae
was the single most
common infecting bacterium.
Streptococcus haemolyticus
(presum-
ably
pyogenes
) was also common as was mixed bacterial infection.
Staphylococcus aureus
was a relatively rare isolate. This latter find-
ing is in contrast to the 1957–1958 ‘Asian’ influenza pandemic when
S. aureus
was the commonest bacterial respiratory pathogen
[2]
.
S.
aureus
, more than 50% of which were meticillin-resistant, was also
found to be the commonest cause of childhood influenza-related
deaths in the United States in the 2003–2004 ‘influenza season’
[3]
.
There is no available cure for influenza although antiviral dugs
such as the neuraminidase inhibitors oseltamivir and zanamivir can
reduce the duration of symptoms of influenza by a day or so, and
may also reduce the severity of complications. The mainstay of the
treatment of influenza complicated by pneumonia must therefore
be antibacterial agents with a spectrum that includes pneumococci
and staphylococci. The possibility of infection caused by meticillin-
resistant staphylococci (MRSA) – both hospital and community
acquired – will be a serious risk.
The time to start antibacterial therapy during the course
of influenza will undoubtedly pose problems. Theoretically, this
should be when there is clinical and X-ray confirmation of pneumo-
nia but this will not be possible in most cases during a pandemic.
Indeed, an abnormal chest X-ray may not signify bacterial pneu-
monia. In a report of 30 patients admitted to hospital in California
with H1N1 influenza up to 17 May 2009, radiographic abnor-
malities were present in 15 of 25 patients X-rayed although
evidence of bacterial super-infection was not found in any of the
30 patients (investigations in some cases included endotracheal
or bronchoalveolar lavage)
[4]
. It has to be assumed that the X-
ray abnormalities were due primarily to the virus infection in this
group of mainly young patients (mean age 27.5 years). Clinicians
cannot therefore necessarily rely on an abnormal chest X-ray, or
the presence of physical signs of pneumonia, to diagnose bacte-
rial pneumonia and commence antibiotics. C-reactive protein (CRP)
may help to differentiate between viral and bacterial pneumonia
[5]
. The decision to commence antibacterial agents will have to be
made on clinical judgement in most cases.
Stockpiling of antibiotics, as with antiviral agents and vaccines,
is required but this will cause problems in terms of availability, cost,
storage and turnover. The antibiotics to be stockpiled for commu-
nity use will depend on national and local guidelines and also the
predominant local pathogens and their sensitivity to antibiotics.
The drugs could include
inter alia
amoxicillin/clavulanate, doxy-
cycline, second and third generation cephalosporins, respiratory
fluoroquinolones, macrolides and co-trimoxazole
[6]
.
Assisted ventilation facilities will also be required. This will
prove difficult as it is likely that a city with a population of around
one million with three or four major hospitals will probably have,
in the absence of an influenza epidemic, a maximum of 10 available
ventilators, and frequently less, on any one day (personal observa-
tion). Four of the 30 Californian H1N1 patients required assisted
ventilation
[4]
. During a pandemic intensive care facilities will be
overwhelmed.
Funding
: None.
Competing interests
: None declared.
Ethical approval
: Not required.
References
[1] Morens DM, Taubenberger JK, Fauci AS. Predominant role of bacterial
pneumonia
as a cause of death in pandemic influenza: implications for pandemic influenza
preparedness. J Infect Dis 2008;198:962–70.
[2] Robertson L, Caley JP, Moore J. Importance of
Staphylococcus aureus
in pneumonia
in the 1957 epidemic of influenza A. Lancet 1958;2:233–6.
0924-8579/$ – see front matter © 2009 Elsevier B.V. and the International Society
of Chemotherapy. All rights reserved.
doi:
10.1016/j.ijantimicag.2009.06.004
294
Editorial / International Journal of Antimicrobial Agents 34 (2009) 293–294
[3] Bhat N, Wright JG, Broder KR, Murray EL, Greenberg ME, Glover MJ, et al.
Influenza-associated deaths among children in the United States, 2003–2004.
N Engl J Med 2005;353:2559–67.
[4] CDC. Hospitalized patients with novel influenza A (H1N1) virus
infection—California, April–May 2009. MMWR 2009;58:1–5.
[5] Cals JWL, Butler CC, Hopstaken RM, Hood K, Dinant G-J. Effect of point of
care
testing for C reactive protein and training in communication skills on antibiotic
use in lower respiratory tract infections. Br Med J 2009;338:b1374.
[6] Gupta RK, George R, Nguyen-Van-Tam JS. Bacterial pneumonia and
pandemic
influenza planning. Emerg Infect Dis 2008;14:1187–92.
A.M. Geddes
Medical School, University of Birmingham, Birmingham, B15 2TT, UK
E-mail address:
a.m.geddes@bham.ac.uk