Pneumonia in the developing world: Characteristic features and approach to management

Abstract

Community-acquired pneumonia (CAP) is a common cause of morbidity and mortality in adults worldwide, but its epidemiology varies markedly by region. Whilst in high-income countries, the predominant burden of CAP is in the elderly and those with chronic cardiovascular and pulmonary co-morbidity, CAP patients in low-income settings are often of working age and, in sub-Saharan Africa, frequently HIV-positive. Although region-specific aetiological data are limited, they are sufficient to highlight major trends: in high-burden settings, tuberculosis (TB) is a common cause of acute CAP; Gram-negative pathogens such as Klebsiella pneumoniae are regionally important; and HIV-associated opportunistic infections are common but difficult to diagnose. These differences in epidemiology and aetiological profile suggest that modified approaches to diagnosis, severity assessment and empirical antimicrobial therapy of CAP are necessary, but tailored individualized management approaches are constrained by limitations in the availability of radiological and laboratory diagnostic services, as well as medical expertise. The widespread introduction of the Xpert MTB/RIF platform represents a major advance for TB diagnosis, but innovations in rapid diagnostics for other opportunistic pathogens are urgently needed. Severity assessment tools (e.g. CURB65) that are used to guide early management decisions in CAP have not been widely validated in low-income settings and locally adapted tools are required. The optimal approach to initial antimicrobial therapy choices such as the need to provide early empirical cover for atypical bacteria and TB remain poorly defined. Improvements in supportive care such as correcting hypoxaemia and intravenous fluid management represent opportunities for substantial reductions in mortality.

Burden of Community-Acquired Pneumonia and Unmet Clinical Needs

“…In the Asia-Pacific region CAP mortality is estimated between 1.1% and 30% [29]. In low-income countries, mortality tends to be higher, as proved in a study addressing mortality in lowincome countries that showed higher mortality than in high-income countries, reporting a mortality rate of 23% in Cambodia, 19% in Senegal, 18% in Uganda and 16% in the Central African Republic [30].…”

Factors predicting in‐hospital mortality among patients admitted with community acquired pneumonia at a tertiary care hospital Karachi, Pakistan

“…There is variation in patient outcomes globally which can, in part, be attributed to diversity in populations across geographical boundaries, and the lack of tailored management guidelines for local and regional settings. Demographically, CAP patients in low resource settings are often younger and of working age in contrast to developed regions where susceptible patients are elderly with chronic cardiovascular and pulmonary comorbidity . Social and environmental risk factors such as malnutrition, overcrowding and indoor air pollution also exist in addition to classical risk factors that are associated with CAP in high income settings, such as smoking, cardiovascular disease (CVD) and chronic obstructive disease (COPD) …”

“…Demographically, CAP patients in low resource settings are often younger and of working age in contrast to developed regions where susceptible patients are elderly with chronic cardiovascular and pulmonary comorbidity. 5 Social and environmental risk factors such as malnutrition, overcrowding and indoor air pollution also exist in addition to classical risk factors that are associated with CAP in high income settings, such as smoking, cardiovascular disease (CVD) and chronic obstructive disease (COPD). 6,7 It has been observed that early mortality in CAP (<48 hours after admission) is predominantly because of pneumonia related factors, such as septic shock, respiratory failure and multi-organ failure.…”

Evaluation of dynamic thiol/disulfide redox state in community-acquired pneumonia

“…Pneumonia is a common cause of morbidity and mortality in adults worldwide 1. Among all infectious diseases, community-acquired pneumonia (CAP) is a leading cause of death in both the developed and developing worlds 2,3.…”