Guest: Dr. Andy Shorr, MD
Presenter: Neal Howard
Guest Bio: Andrew Shorr, MD, MPH, is Associate Director of Pulmonary and Critical Care Medicine and Chief of the Pulmonary Clinic at MedStar Washington Hospital Center in Washington, DC. In addition, he is Associate Professor of Medicine, Clinician Scholar Track, at Georgetown University, Washington, DC. A prolific author, Dr. Shorr has published more than 140 original investigations plus numerous peer-reviewed articles, literature reviews, book chapters, editorials, case reports, and letters. In addition, he serves as a reviewer, editorial board member, and editorial advisory board member for several peer-reviewed journals, including Chest, Critical Care Medicine, Clinical Infectious Diseases, Annals of Internal Medicine, as well as for the Pulmonary section of Medscape.
Segment Overview: Dr. Andy Shorr, MD, discusses the public health impact of pneumonia and the need for additional antibiotics and treatment options.
Health Professional Radio – The Public Health Impact of Pneumonia
Neal Howard: Hello and thank you so much for joining us here in Health Professional Radio. I’m your host Neal Howard. Our guest is Dr. Andy Shorr. He’s joining us on the program to talk about the public health impact of pneumonia and also the need for additional antibiotics and treatment options to be available. Welcome to the program today Dr. Shorr.
Dr. Andy Shorr: Thank you so much.
N: Thanks for taking the time. Give our listeners a bit about your medical background if you would.
S: Sure. I’m a Academic Pulmonary and Critical Care Physician. I run the Pulmonary and Critical Care Division and the MICU at MedStar Washington Hospital Center at the Washington DC and I am a Professor of Medicine at Georgetown.
N: Was this something that you pursued as soon as you got in the med school or have you always been interested in this field? What is it that led you to this?
S: By about third or fourth year in medical school, I knew I pretty much like taking care of sick people and through that kind, directed me to it’s pulmonary critical care.
N: We’ve all been hearing about the severity of this year’s flu season. But let’s talk about the public health impact of pneumonia. We haven’t heard a lot about that in the news. Is that something that’s being under covered or is it something that so normal that we’re not hearing much about it.
S: I think you’re correct. I think there’s a lot of complacency when it comes to community-acquired bacterial pneumonia or CAP. When we talk about community-acquired pneumonia, Osler identified it as the captain of death, a long time ago over a hundred years ago. In fact, Osler himself, the father of modern internal medicine died of community-acquired pneumonia. It’s a huge problem and it haven’t got a lot of attention. In fact, we haven’t had really new interventions for community-acquired pneumonia short of vaccination in the last two or three decades. We actually haven’t moved the needle in terms of mortality for community-acquired pneumonia in about 30 years. This remains a really rubbish severe problem and whether it’s a de novo problem when the patient just comes in with community-acquired pneumonia or as routine in this flu season where certain bacteria are leading to superinfection after influenza. It’s really a challenge, especially since our armamentarium is limited and we’re seeing risks since pattern changed for the common pathogens in community-acquired pneumonia. It’s kind of viewed as the price of doing business, yet I can tell you as an intensivist, I’ve had people who were otherwise healthy, who are young died of pneumococcal shock and pneumococcal septic shock, that’s still a challenge and a problem. We still need newer tools and newer options in our tool kit to address it. From antibiotic perspective, there’s been a lot of focus on agents other than fluoroquinolone or cephalosporins and macrolides and we’re finally stirring disease. Some of the fruit of that kind of, come to fruition in terms of these efforts that we’re finally getting newer drugs in the clinical trials, so to actually evaluate them as the new options for community-acquired pneumonia. MRSA got a lot of attention two decades ago and now we have all these tools for MRSA, but MRSA, so resistant to staph aureus is actually under decline. We’ve got a lot of attention focused on highly resistant gram-negative such as Carbapenem-resistant Enterobacteriaceae or CRE, now in the US. We have basically two and perhaps soon three, four or five agents who are going to be approved for CRE. The number of patients who died from CRE infections each year is really quite small compared to the number of people who died of community-acquired pneumonia every year.
N: Does this seem to affect children as much as adults or is it more prevalent in older people? I know it’s common but who is more at risk and are we focusing on that population a bit more?
S: Certainly. I’m not a pediatrician so I can’t speak to all the pediatric issues but we definitely think of community-acquired pneumonia as a disease of the young and then of the old. But the point is, it can affect anyone and I think any pulmonary critical care physician, any infectious disease physician or anybody who work from hospital medicine can tell you stories of also the young person, mid-30s or 40s who’s only risk factor for pneumonia is they have a kid in daycare. They come in with severe community-acquired pneumonia then end up common to it. We certainly think of it as having two piece of incidence but the burden is actually distributed pretty evenly in terms of access, mortality and things of that nature.
N: Do you think that the age gaps or the difference in age has anything to do with the current treatments being less effective than they need to be?
S: No. I think the reason we see these differences is really because of host immune system issues and also exposure issues. Those are really what’s driving it. I don’t think, novel antibacterial vaccine, other that were something, other than a vaccination is really gonna treat that. I think vaccination is key and we’ve certainly seen as the better pneumococcal vaccinations are used to children affects on herd immunity so that the burden of certain strains of pneumococcus are going down on adults, because we’re just getting a herd immunity effect. Nonetheless, kind of like any balloon, you squeeze it at one side and it contracts but on the other side it expands. We’re seeing other strains of pneumococcus still devoid. When you think of what pneumococcus is becoming resistant to, you think about macrolide resistance, you’re beginning to see lots of issues in terms of the choices we have for antibiotic and our need for new ones.
N: Do we have anything on the near horizon in development that is going to benefit as even more?
S: I am not sure if we can claim benefits of even more short of randomized control of trials that’ll really show that. But there are couple of drugs in clinical development for community-acquired pneumonia. There’s minocycline which is a tetracycline based antibiotic that’s been studied in community-acquired pneumonia and it’s under regulatory review right now. There’s a whole new class of drugs called pleuromutilin which have been used in animals but not in humans ever and the drug in that class is Lefamulin and that’s being studied in community-acquired pneumonia. They’ve got one clinical trial that has been done and the second one should be finishing up very quickly. So hopefully we’ll have pipeline data. I think clinicians all of a sudden are going to have to wake up from their slumber of complacency where they only know one way to treat community-acquired pneumonia and reevaluate the new tools as they become available to decide how they’re going to fit in armamentarium. Because if you keep using the same antibiotics over and over again, not only you’re going to create resistance eventually, you’re also going to potentially exposed to patients who risks for, say death or potentially with quinolone side effects that are related to fluoroquinolones that are getting a lot of attention in both the medical and lead press right now.
N: We’d like to learn some more, where can we go online and learn some more and possibly some more about MedStar health as well?
S: MedStar certainly has a website for itself – medstar.org and you can certainly go there and look at the 10 hospital healthcare system that I’m proud to be a part of. In terms of community-acquired pneumonia, I think the simple place to start is up to date online. If you just want to learn some high level material but I think the best way to really get out at this, there‘s some excellent reviews on Medscape and another website and it’s for medical education. They’re really focused on community-acquired pneumonia that can address us.
N: Thank you for talking with us today and I’m hoping you’ll return and give us some updates as things develop.
S: Thank you so much.
N: You’ve been listening to Health Professional Radio. I’m your host Neal Howard. Transcripts and audio of this program are available at healthprofessionalradio.com.au and laso at hpr.fm. You can subscribe to this podcast on iTunes, you can listen and download at SoundCloud and be sure and visit our affiliates page at healthprofessionalradio.com.au.