Risk for patients contracting pneumonia increases threefold when treated with pantoprazole

According to researchers at Wake Forest University School of Medicine, a popular stomach-acid reducer used to prevent stress ulcers in critically ill patients needing breathing machine support increases the risk of those patients contracting pneumonia threefold.

Hospital-acquired pneumonia is the leading cause of infection-related deaths in critically ill patients. It increases hospital stays by an average of seven to nine days, cost of care, and the risk of other complications.

"As best we can tell, patients who develop hospital-acquired pneumonia or ventilator-acquired pneumonia have about a 20 to 30 percent chance of dying from that pneumonia," said senior study author David L. Bowton, M.D., professor and head of the Section on Critical Care in the Department of Anesthesiology. "It's a significant event."

The study, published in a recent issue of CHEST, compared treatment with two drugs that decrease stomach acid: ranitidine, marketed under the name ZantacTM, and pantoprazole, marketed under the name ProtonixTM or PrilosecTM.

Both drugs decrease stomach acid, but the newer pantoprazole is considered more powerful and has become the drug of choice in many hospitals.

However, in the analysis of 834 patient charts, the researchers found that hospitalized cardiothoracic surgery patients treated with pantoprazole were three times more likely to develop pneumonia.

"We conducted this study, in part, because we thought we were seeing more pneumonias than we were used to having," said study co-author Marc G. Reichert, Pharm.D., pharmacy coordinator for surgery at Wake Forest University Baptist Medical Center.

Both acid-reducing drugs can make the stomach a more hospitable place for bacteria to colonize. Patients on breathing machines sometimes develop pneumonia when stomach secretions reflux into the lungs.

Current treatment guidelines to prevent pneumonia recommend raising the head of the bed for patients on breathing machines, which reduces the risk of stomach secretions getting into the lungs.

But the study's findings suggest some other steps could keep critically ill patients from developing ventilator-associated pneumonia.

Doctors should consider whether an acid reducer is needed at all, Bowton said. The occurrence of stress ulcer bleeding has gone down in recent years, perhaps because patients with breathing tubes are fed earlier, and food in the stomach may neutralize or reduce the effects of stomach acid.

Bowton added that in cases where an acid reducer is needed, ranitidine is recommended, given the apparent decreased risk in developing pneumonia.

Doctors should stop using the drug as soon as the risk of bleeding passes - once the patient is off the breathing machine and eating, either on his/her own or through a feeding tube.

Prevention and treatment of pneumonia are critical to reducing child

New World Health Organization data to be published in this week's edition of the Lancet will shed new light on two leading causes of pneumonia, the world's leading killer of children under age 5, both globally and within specific countries. The results, which are the first ever available at the country level, are expected to serve as a clarion call to developing country governments to invest in pneumonia prevention programs.

According to the studies, Streptococcus pneumoniae and Haemophilus influenzae type b [Hib] infections take the lives of an estimated 1.2 million children under age 5 each year. Safe and effective vaccines exist to provide protection against both diseases. However, use of Hib vaccine has only recently expanded to low-income countries and pneumococcal vaccine is not yet included in national immunization programs in the developing world, where children bear the highest risk for pneumonia and where most pneumonia-related child deaths occur.

Streptococcus pneumoniae (Pneumococcal Disease)

Data from the study show that in 2000, there were an estimated 14.5 million cases of pneumococcal disease worldwide, and 826,000 children under 5 years of age died of the disease. Of the 14.5 million pneumococcal cases, 95% were attributable to pneumonia. While the majority of pneumococcal cases (51%) were found in Asia due to the high population, an estimated 54% of pneumococcal deaths occurred in Africa, where the lack of vaccines, a high prevalence of HIV infection and lack of access to medical care contributed to the death toll.

The ten countries with the greatest number and greatest proportion of global pneumococcal cases were in Asia and Africa, and taken together account for 66% of cases worldwide. These countries include India (27%), China (12%), Nigeria (5%), Pakistan (5%), Bangladesh (4%), Indonesia (3%), Ethiopia (3%), Democratic Republic of the Congo (3%), Kenya (2%) and the Philippines (2%).

"In areas of the world where access to quality care is limited, the use of pneumococcal vaccine is particularly necessary to limit disease and save lives," said Thomas Cherian, Coordinator of the WHO Expanded Programme on Immunization. "Implementing pneumococcal vaccine is critical if developing countries are to achieve United Nations Millennium Development Goal 4 for child mortality reduction."

In 2000, only the USA had initiated routine use of pneumococcal vaccine. By August 2008, this expanded to include 24 high and two upper-middle income countries but did not include any from Africa or Asia, the regions with the highest numbers of pneumococcal deaths and cases. According to the study, these 26 countries accounted for less than 0.2% of global childhood pneumococcal deaths in 2000 and the children in these countries, on average, had a 40-fold lower risk of pneumococcal death than the children in countries not yet using the vaccine.

Through the GAVI Alliance (www.gavialliance.com), low income countries can access existing and future pneumococcal vaccines with only a small self-financed contribution of as little as US $0.15 per dose. By February 2009, 11 countries had received GAVI Alliance approval for support to introduce pneumococcal conjugate vaccine (PCV), including 8 in Africa and Asia. Two of these, Rwanda and the Gambia, have now initiated the use of PCV in their routine infant immunization schedules.

"If fully rolled out in GAVI-eligible countries, the pneumococcal vaccine could save the lives of more than 440,000 children by 2015," said Dr. Julian Lob-Levyt, CEO of the GAVI Alliance. "We encourage all developing countries to apply for this support as an important first step to saving children's lives."

Haemophilus influenzae type b (Hib)

Findings from the Hib study indicate that in 2000, Hib caused approximately 8.1 million serious illnesses worldwide and caused 371,000 child deaths. As with pneumococcal disease, the greatest burden of Hib disease lies in Asia and Africa. The ten countries with the highest estimated number of Hib deaths in 2000 include India (72,000), Nigeria (34,000), Ethiopia (24,000), Democratic Republic of the Congo (22,000), China (19,000), Afghanistan (14,000), Pakistan (13,000), Bangladesh (12,000), Angola (9,000) and Niger (8,000).

Highly effective and safe protein-polysaccharide conjugate Hib vaccines have been available for almost 20 years. These vaccines have virtually eliminated serious Hib disease in the developed and developing countries in which they are in routine use. Widespread use of Hib vaccines was found to have a significant impact on the burden of Hib disease in the United States and Europe. The study indicates that among children born in 2000, approximately 338,000 Hib cases and 12,500 Hib deaths were averted by Hib vaccination.

The World Health Organization and the GAVI Alliance, which is supporting the Hib Initiative, have been working to expand supplies of Hib vaccine, reduce vaccine cost and assist countries with vaccine introduction. There is substantial regional variability in vaccine use, and the study suggests that expanded use of Hib vaccines could have considerable benefit in reducing child mortality worldwide.

"These estimates provide the missing link for country policy makers seeking justification for investments in lifesaving vaccines," said Anne Schuchat, Director of the National Center for Immunization and Respiratory Diseases at the U.S. Centers for Disease Control and Prevention

Pneumonia Types That Require Hospitalization

The infection and inflammation of the lungs caused by bacteria or viruses is a condition called pneumonia and it is a common type of pulmonary disease. This condition triggers an overproduction of mucus in the respiratory tract. The symptoms shown by this condition vary greatly depending on many factors like the age of the infected person, the ability to fight the infection of the immune system, the overall health or the causes of the infection. People that have a strong immune system are less likely to encounter pneumonia but people that have certain predisposition to respiratory infections or have an impaired immune system are at higher risk of developing pneumonia and complications caused by this disease. Because of this, we can say that old people are at higher risk of developing pneumonia and complications than other adults.

Nowadays, most cases of pneumonia are hospitalized because without a proper care and close monitoring, the condition may aggravate. There are however, many mild cases that don't require hospitalization, which are treated at home. The milder forms of pneumonia are also not as contagious as the severe forms, so it is possible for them not to infect other people. Because of this, some persons receive treatments to follow at home. Some of the cases, like walking pneumonia, don't even require bed resting, so people can continue with their daily activities while following a prescription.

In the close past, doctors have begun reconsidering the unnecessary hospitalizations of those patients because of the high costs and overcrowding. It has been considered for elderly people to avoid hospitalization in case of pneumonia. It was shown in recent studies that old people who live in nursing homes can receive medical treatment for pneumonia in the nursing home and hospitalization is not required anymore. They already benefit the medical care and surveillance. For those reasons put together, the nursing homes residents are considered not to be in need of hospitalization in the mild and uncomplicated forms of pneumonia.

This process will be benefic for both the patients and doctors. Also, the costs can be reduced with up to 1500 dollars for every patient.

A group of Canadian researchers started a study involving the collaboration of 20 nursing homes, to establish the necessity of hospitalization in case of pneumonia for the nursing homes residents. Half of the nursing homes were asked to follow their own rules for medical care and surveillance and the other half was asked to apply a new set of procedures and guidelines in case of patients with pneumonia. When the two groups were confronted with pneumonia cases, they followed the directions and the usual care group has sent the patients to the hospital while the exponential group kept them inside the nursing center.

The exponential group of nursing homes was asked to offer treatment inside the facilities for the residents suffering from pneumonia with stable conditions. Those residents that presented complications or aggravations were sent to hospital. In the referential group of nursing homes, there were 327 cases of pneumonia while the usual group encountered 353 cases. During the study, 10, respectively 22 percents of the cases of pneumonia required hospitalization. The researchers concluded that the residents of the nursing home from both groups had similar responses to the treatment regardless of the medical regimen. The mild cases of pneumonia can thus be treated inside the nursing home, avoiding the unnecessary hospitalizations.

The medical costs can be greatly reduced by the generalization of the appliance of the guidelines set by the Canadian researchers in the matter of unnecessary hospitalization of the pneumonia cases encountered among the nursing home residents. Each year, 70 millions dollars could be spared in Canada and 800 millions dollars in America if the unnecessary hospitalizations would be avoided.