Pneumonia: The big chill for seniors

Here’s a question for all you health trivia buffs:

  • What infection will cause more deaths this year among older Canadians than any of its rivals?

If your answer is AIDS or hepatitis, guess again. The correct answer is in fact pneumonia. An infection of the lung, pneumonia varies from a mild walking form of infection to a life-threatening illness. Most cases are acquired in the community, hence the term, Community Acquired Pneumonia (CAP).

Caused either by a virus or bacteria, the most common forms of CAP are due to streptococcus pneumoniae and hemophilus influenzae. Some people simply feel ill, experiencing a cough and fever, while others complain of fatigue, chest and/or back pain. Still others notice a heavy feeling in the chest or difficulty breathing.

If sick enough to require medical attention, some patients may find themselves confused by their doctor’s diagnosis. They may say: “You have pneumonia, but there’s no point in giving an antibiotic because it’s due to a virus infection.”

Doctors’ dilemma
Pneumonia certainly poses a challenge for physicians. It’s often difficult, if not impossible, to distinguishetween bronchitis and pneumonia. Even conducting tests of a patient’s sputum may not pinpoint the precise cause of pneumonia. For instance, cultures may grow several different bacteria and viruses, making it possible to identify the cause in only 50 per cent of cases.

But the $64,00 question: which one’s causing the trouble? This presents an obvious dilemma for any doctor. After all, before prescribing a treatment, they’re supposed to know what’s causing the trouble.

If an antibiotic is prescribed when the pneumonia is caused by a virus, you may as well flush the medication down the toilet. Also, there’s a chance you may be given an antibiotic that’s ineffective against particular strains of bacteria. Again, it’s a bit of a gamble.

Dr. Lionel Mandell, professor of medicine at McMaster University, in Hamilton, Ontario, and a world expert on pneumonia and antibiotic resistance, worries that too many people with sinusitis, pharyngitis and bronchitis are being prescribed antibiotics inappropriately.

And because of this frequent and questionable use, too many bacteria have become resistant to antibiotics.

Risk of mutation
The traditional way to treat pneumonia was the ‘stepped’ approach whereby doctors would initially prescribe weaker antibiotics. If the less potent antibiotic failed, they would then order a stronger one. The theory behind this: why use an elephant gun to shoot a mouse?

The problem is that all too often doctors don’t know whether they’re actually shooting a mouse or an elephant. If it’s an elephant and they’re using a small calibre rifle, it won’t harm him. In fact, it allows this bacterial elephant to mutate and become even stronger.

This is what concerns Mandell, who says, “The longer the bacteria are in the body, the greater the risk of mutation.” This is why he claims it’s better to use powerful antibiotics such as Levofloxacin (Levaquin) right off the bat in a very sick patient. The logic: dead bacteria can’t mutate.

Doctors are now using ‘severity of illness scores’ to determine the best antibiotic for a particular case of pneumonia, and deciding which patients require hospital treatment.

Risk of complications
The rule of thumb for those at risk is to see their doctor if any symptoms whatsoever suggest the presence of pneumonia. The sooner pneumonia is treated, the less the risk of complications. This is particularly true if a patient suffers from heart, kidney or other chronic diseases.

Today, it’s unfortunate that too many 50-plus Canadians give little regard to the risks of pneumonia. If they experience the symptoms and ignore them, the pneumonia could cause moderate to severe complications, with the risk of death becoming as high as 25 per cent.

And health costs would be greatly reduced if everyone over 65 received an annual influenza vaccination, as well as a pneumococcal vaccination at least once in a lifetime.
Dr. W. Gifford-Jones is the pen name of Ken Walker, M.D., who practises medicine in Toronto.