2019

Pneumonia. Treatment and

Diagnosis

ABDO,DELALALI
9\23\19
Abstract
Pneumonia remains a leading cause of morbidity and mortality despite advances in treatment
and therapy.

Quality of Care for Community-acquired Pneumonia in the

Twenty-First Century
During the twentieth century, improvements in public health infrastructure leading to safer
drinking water and technological advances, including the discovery of antibiotics to treat
bacterial infections and development of vaccines against influenza and Streptococcus
pneumoniae, played important roles in transforming pneumonia from the first to the sixth leading
cause of death in the United States (1). Quality of medical care has further improved the
medical outcomes of patients with this common medical illness over the past 2 decades. Quality
of care can be defined as medical care that is expected to maximize an inclusive measure of
patient welfare (2) and the degree to which health services for individuals and populations
increase the likelihood of a desired outcome and are consistent with current professional
knowledge (3). Based on a conceptual model proposed by Avedis Donabedian (2), quality of
care can be measured using three key dimensions: structure of care (i.e., how medical care is
organized at a health care facility or organizational level), processes of care (i.e., the actual
diagnostic and/or therapeutic services that medical providers carry out as part of patient care),
and outcomes of care (i.e., patient-centered medical outcomes). Improvements at all three
levels of care have been responsible for the decline in CAP-associated mortality.

Fungal Pneumonia Guidelines: The Outcome and the Process

Given the increasing incidence of fungal pneumonia (4), the American Thoracic Society
published guidelines on the treatment of fungal pneumonia in 2011 to summarize the more
recent changes in diagnostic and therapeutic regimens that are clinically relevant to patient care
(5). These guidelines include both common and uncommon fungal pathogens of the lung, the
strength and quality of the available data from which the guidelines were derived, and the
process followed to generate the guidelines. Geographic environment, history of prior antibiotic
use, treatment with immune suppressive agents, and transplantation (e.g., organ or bone
marrow transplantation) are important risk factors for fungal pneumonia. In general, lung biopsy
and culture are required, but less invasive diagnostic modalities are needed.Coccidioidomycosis
is caused by infection by either Coccidioides posadasii or Coccidioides immitis, soil-dwelling
fungi endemic to arid regions of the southwest United States, Mexico, and parts of Central and
South America (7). Like histoplasmosis, most Coccidioides infections are asymptomatic, and the
most susceptible populations include immunosuppressed individuals, including individuals
receiving solid organ transplants (5, 7). Because coccidiomycosis can resemble CAP,
geographic location and travel history are important considerations in making the correct
diagnosis. Again, multiple diagnostic platforms may be required to make the diagnosis, including
fungal culture, serology, and polymerase chain reaction. Fluconazole, itraconazole, and
amphotericin B remain the standard of care, but newer drugs such as voriconazole and
posaconazole may have efficacy against coccidiomycosis.
REFLECTION:
This review of pneumonia in the tropics is based on experience with respiratory infectons in
Papua New Guinea since the 1970s. It discusses ideas, principles, historical aspects of
pneumonia research and the need to work with people in the community. In order to understand
pneumonia in a tropical setng and evaluate new interventons it is essental to study the ecosystem
of the causatve infectons, within the host and the community and between interactng
microorganisms. Vaccines are much-needed preventve tools, and for pneumonia in a highly
endemic setng the preventon of severe and fatal disease takes priority over the preventon of
infecton. In this setng mild infecton plays an important role in preventng severe disease. For
achieving long-term sustainable outcomes, sometmes ‘less is more’. A multpronged approach is
required to control and prevent pneumonia, and in devising new ways of doing so. This includes
appropriate and accessible clinical care, a clean, smoke-free environment, good nutriton and a
range of vaccines. Also required are persistent advocacy from the global scientfc community and
strong engagement with and by the communites that bear the burden of disease. Beter health care
must be pursued in conjuncton with raising literacy rates and reducing poverty.

The following observations and reflections derive from my experiences working with
many creative and committed scientists across a range of disciplines investigating
pneumonia and other tropical infectious diseases at the Papua New Guinea Institute of
Medical Research, of which I was the Director from 1977 to 2000.

One of the first things we learned in our studies of infectious disease in Papua New
Guinea was that to understand an infection we had to investigate the ecosystem in
which it occurred. Later we learned that the results of an intervention depended on the
specifics of the ecosystem in which it was applied.The conjugate pneumococcal
vaccine has not been rolled out yet in Papua New Guinea though a country-wide
program will be established with the 13-valent vaccine in 2014. We know that the
coverage of pathogenic serotypes by the vaccine will be less than in the First World.
We can expect significant replacement infection and disease, probably more than
occurred in Alaskan Native Americans [17]. We do not expect to get herd immunity,
since this can only occur where the community source of infection is the group that
has been immunised, in this case young children. Where, in contrast, the route of
transmission goes the other way, and children are principally infected by adults living
in their household, adults will not be protected by immunising infants