MANAGEMENT OF COMMUNITY-ACQUIRED PNEUMONIA

Community-acquired pneumonia is a serious illness and is associated with significant morbidity and mortality. Despite the importance of pneumonia as a medical entity, it is not a reportable disease, and as a result the available statistics on pneumonia are inadequate. Data from the USA suggest that there are approximately 2-4 million cases a year. The overall mortality rate for those patients with community-acquired pneumonia, who require hospitalization, varies between 5% and 22%. In patients over 50 years of age, however, and especially in a nursing home group, the peak mortality rate could reach 40-50%. The most important pathogens are still pneumococci at a frequency of 20-25%, followed by Haemophilus influenzae, Gram-negative bacilli, Staphylococcus aureus, Legionella and, especially in young patients, Mycoplasma and Chlamydia pneumoniae. Of great concern currently is the increasing resistance of pneumococci to penicillin. The figures for penicillin-resistant pneumococci vary enormously: in Spain and Hungary the figure is between 30% and 50%, and in a recent study in the USA 29% of pneumococci from Metropolitan Atlanta area were resistant to penicillin including 7% highly resistant strains. Especially alarming is the fact that approximately 10-30% of these strains are also resistant to other antibiotics such as macrolides, tetracyclines and cephalosporins. The clonal structure of penicillin-resistant pneumococci differs considerably between countries, for example clones of serotypes 6B, 9V and 23F predominate in Spain, whereas most resistant isolates in Hungary are of serotype 19A. The multiresistant serotype 23F clone has also been found in the USA and in South Africa. In the treatment of these resistant pneumococci new fluoroquinolones exhibiting good activity against Gram-positive pathogens could be of major importance in the near future. A strategy has to be developed, however, to address this problem of drugresistant Streptococcus pneumoniae to improve surveillance studies, identify risk factors, increase pneumococcal vaccination and promote rational antimicrobial drug use.