© 2004 American Thoracic Society
Surviving Pneumonia—Just a Short-Term Lease on Life?Thai Ministry of Public Health and U.S. Centers for Disease Control and Prevention Nonthaburi, Thailand Considering the importance of pneumonia, it is remarkable how little is known about what happens to patients after they recover. Pneumonia is the leading infectious killer worldwide. It was the immediate cause of an estimated 3.9 million deaths in 2002; the number of deaths occurring among patients who recover from an initial episode of pneumonia is not routinely measured (1). With more than a million hospitalizations in the United States each year (2), caring for a relative after an episode of pneumonia is an experience many adults can anticipate during their lifetimes. In this issue of the Journal (pp. 910–914), Waterer and coworkers (3) provide a useful contribution to a growing body of evidence indicating that patients who survive hospitalization for pneumonia can expect a mortality rate that is modestly to substantially increased over the subsequent one to four years. Physicians and families now have the means to reduce this delayed mortality, and the current study should help prompt them to do so more effectively. Other investigators have reported substantially increased mortality after hospitalization for pneumonia (4–8). One of the strengths of the current study is the thorough follow-up. By enrolling patients prospectively and by using social security numbers to rigorously review death records, contact all treating physicians, and trace postal contacts, Waterer and coworkers (3) were able to ascertain the survival status of a remarkable 97% of patients at an average of 3 years after discharge. Compared with a matched cohort of the US population, the observed mortality of 34% was considerably elevated relative to the expected 7% mortality in this time period. When the subset of about half of subjects with no comorbidities was compared with the matched U.S. cohort, mortality among the pneumonia patients was only modestly elevated (see their Table 3: 11% versus 5%, p = 0.03). Other investigators studying larger cohorts have found that mortality is significantly increased among pneumonia survivors, even among those with no preexisting comorbidities (7, 9). Minor limitations of the study by Waterer and coworkers, in addition to the relatively small number of patients, should be kept in mind before translating their results into recommendations. Immune-compromised patients and those with a recent hospitalization were excluded from the analysis—groups that might comprise a substantial proportion of patients with pneumonia in some settings. Despite rigorous tracing of almost all patients, the longest follow-up period was 4 years, leaving the longer-term prognosis unstudied. Still, the average time to death among those who died in this cohort was 435 days, and other investigators have recorded even longer delays (5, 8). It appears that an increased risk of death may persist for several years after an episode of pneumonia. To patients and their families, this argues for continued vigilance, and attention to preventive measures with sustained benefits. Specific features of the pneumonia episode may alert clinicians to focus particular attention on the longer-term prognosis of certain patients. In addition to patients with classic comorbid diseases, such as cardiovascular and cerebrovascular disease, Waterer and coworkers identified patients presenting with altered mental status or anemia as having independently increased medium-term mortality, even in the absence of recognized causes for these findings. Other investigators also have identified these high-risk features (4), and clinicians would do well to scrutinize such patients for underlying disease, counsel their families about the more guarded prognosis, and seek preventive measures that have stood the test of time. It is ironic that William Osler died several years after an episode of pneumonia, and that simple preventive measures available today might have prolonged his life. A father of modern medicine, Osler was also a lifelong student of pneumonia, which he famously labeled "the old man's friend," and "the captain of the men of death" (10). At the time of his first bout with pneumonia he was physically rigorous and his writings and intellect placed him at the pinnacle of his field. The pneumococcus had been described, but there was no vaccine or specific treatment, and it was still believed that influenza was caused by a small bacterium (Loeffler's bacillus—now known as Haemophilus influenzae). After his recovery, Osler continued his lifelong smoking habit and he experienced a series of respiratory illnesses over the subsequent years, eventually contracting an influenza-like illness in October of 1919, and then succumbing to an apparent bacterial superinfection. He was 70 years of age, and despite his own contributions to the diagnosis and treatment of pneumonia, died without benefit of a proper chest radiograph, antimicrobial therapy, or surgical intervention. Thankfully, we can do better for patients today. The prognosis for modern day patients who recover from a first bout of pneumonia may be substantially improved by offering an effective smoking cessation program, influenza vaccine, and pneumococcal vaccine. The most recent guidelines for the management of pneumonia from the U.S. and Canadian infectious disease and thoracic societies already endorse such recommendations, but the implementation remains poor (11, 12). Only 55% of adults 65 years or older reported receiving the pneumococcal vaccine in 2002, and the proportion was even lower among nursing-home residents (38%) and 18- to 64-year-old subjects with high risk conditions (17%) (13, 14). The Advisory Committee on Immunization Practices does not currently identify patients discharged with pneumonia as a separate high-risk category, but the accumulated data argue that this should be reconsidered. Influenza vaccination is clearly effective at reducing pneumonia, hospitalization, and death among the elderly in general (15), and specifically reduces the risk of readmission and death among those with a previous hospitalization for pneumonia (16). Standing orders are an effective means of improving vaccination rates, and are ideally suited to protecting patients being discharged after an episode of pneumonia (13). The new data from Waterer and coworkers should be used by physicians to alert patients and their families that recovery from pneumonia may provide only a short-term lease on a future healthy life. This sobering message may be accompanied by recommendations on proven approaches to moderate the risk. All physicians caring for pneumonia patients should review their institution's standing orders policies, and work to include influenza vaccination, pneumococcal vaccination, and a smoking cessation program in standing discharge orders for patients who have recovered from pneumonia. FOOTNOTES Conflict of Interest Statement: S.F.D. has no declared conflict of interest. REFERENCES
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