RESPIRATORY DISEASES

Health Evidence Bulletins - Wales
Team Leader: Dr Michael Burr Date of completion: 5/3/98

The contents of this bulletin are likely to be valid for approximately one year, by which time significantly new research evidence may become available


8. Pneumonia

(Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation)

The Statements The Evidence
8a. The specific intervention that is most clearly useful in preventing pneumonia is influenza vaccination for vulnerable groupsi.
(Health gain notation - 1 "beneficial")
i. See statement 7a in Chapter 7 ‘Influenza
8b. Pneumococcal vaccine gives good protection against pneumococcal pneumonia (as measured by incidence and duration) in many groups of people. A meta-analysis of randomised controlled trials showed an effect only in low risk patientsi but other evidence suggests that it also confers protection on patients with chronic cardiac or pulmonary disease and on asplenic personsii . One trial suggests that it confers no benefit on non-immunocompromised people over 50 years old who have been previously treated in hospital for community-acquired pneumonia iii. Vaccination is currently recommended for those aged two years or older in whom pneumococcal infection is likely to be more common and/or dangerous and guidance is availableiv.
(Health gain notation - 3 "trade-off between beneficial and adverse effects")
The randomised trials of pneumococcal vaccine have not sufficiently distinguished between different high-risk groups. The vaccine may be effective in those who are relatively immunocompetent rather than in those who are not. There is a need for more focused trials.
i. Fine MJ, Smith MA, Carson CA et al. Efficacy of pneumococcal vaccination in adults: a meta-analysis of randomized controlled trials. Archives of Internal Medicine 1994; 154: 2666-2677
(Type I evidence - meta-analysis);
ii. Butler JC, Breiman RF, Campbell JF et al. Pneumococcal polysaccharide vaccine efficiency. An evaluation of current recommendations. Journal of the American Medical Association 1993; 270 (15): 1826-1831
(Type III evidence - case-controlled study);
iii. Írtqvist ┼, Hedlund J, Burman L-┼ et al. Randomised controlled trial of 23-valent pneumococcal capsular polysaccharide vaccine in prevention of pneumonia in middle-aged and elderly people. Lancet 1998; 351: 399-403
(Type II evidence - randomised controlled trial);
iv. Salisbury DM, Begg NT (eds.)  Immunisation against infectious disease. Department of Health and Others.  London: HMSO, 1996 pp. 168-169
(Type I evidence - systematic review)
8c. Antibiotic treatment for upper respiratory tract infections does not prevent pneumonia in children i.
(Health gain notation - 5"unlikely to be beneficial")

caveat: There is an apparent conflict between accepted clinical practice and the evidence in relation to pneumonia in young children, in that the cause is usually viral, but practitioners are understandably reluctant to risk accusations of neglect by not giving antibiotics.

i. Gadomski AM. Potential interventions for preventing pneumonia among young children: lack of effect of antibiotic treatment for upper respiratory infections. Pediatric Infectious Disease Journal 1993; 12: 115-120
(Type I evidence - systematic review)

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8d. It is unclear as to whether antibiotics are beneficial in the treatment of pneumonia in infants and young children. This condition is usually caused by a virus, and antibiotics are indicated only if there is likely to be secondary bacterial infectioni.
(Health gain notation - 3 "trade-off between beneficial and adverse effects")
Since it is difficult to distinguish between viral and bacterial infection, and young children can deteriorate rapidly, it is good practice to consider antibiotic therapy, particularly in vulnerable groups or if there is any sign of deterioration.
(see Statement e.) ii.
i. Friis B, Andersen P, Bren°e E et al. Antibiotic treatment of pneumonia and bronchiolitis. Archives of Disease in Childhood 1984; 59; 1038-1045
(Type II evidence - randomised controlled trial);
ii. Internal Review Group (see contributors)
(Type V evidence - expert opinion)
8e. Pneumonia thought to be caused by bacteria should be treated with antibiotics. Examination of the sputum with Gram's stain may help in selecting the antibiotic groupsi. The choice of antibiotic should be determined by the likely pathogen (Streptococcus pneumoniae being the commonest) and the known sensitivities of respiratory pathogens in the area. Therapy should be started as soon as the diagnosis is madeii.
(Health gain notation - 1 "beneficial")
i. Pomilla PV, Brown RB. Outpatient treatment of community-acquired pneumonia in adults. Archives of Internal Medicine 1994; 154: 1793-1802
(Type I evidence - systematic review);
ii. British Thoracic Society. Guidelines for the management of community-acquired pneumonia in adults admitted to hospital. British Journal of Hospital Medicine 1993; 49: 346-350
(Type V evidence - expert opinion)
8f. Recommendations for good practice in the prevention and treatment of pneumonia are availablei,ii,iii. i. British Thoracic Society. Guidelines for the management of community-acquired pneumonia in adults admitted to hospital. British Journal of Hospital Medicine 1993; 49: 346-350
(Type V evidence - expert opinion)
ii. Salisbury DM, Begg NT (eds.)  Immunisation against infectious disease. Department of Health and Others.  London: HMSO, 1996
(Type V evidence - expert opinion);
iii. Working Party of the British Committee for Standards in Haematology Clinical Haematology Task Force. Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. British Medical Journal 1996; 312: 430-434
(Type V evidence - expert opinion)
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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk