Community-acquired pneumonia in the United Kingdom: a call to action
Chalmers et al. Pneumonia
Community-acquired pneumonia in the United Kingdom: a call to action
James Chalmers 0 1
James Campling 3
Gillian Ellsbury 3
Peter M. Hawkey 2
Harish Madhava 3
Mary Slack 4
0 University of Dundee, Ninewells Hospital and Medical School , Dundee DD1 9SY , UK
1 Division of Molecular & Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School , Dundee DD1 9SY , UK
2 Institute of Microbiology and Infection, University of Birmingham , B15 2TT, Birmingham , UK
3 Pfizer Ltd , Tadworth KT20 7NS , UK
4 School of Medicine, Griffith University , Campus, Gold Coast, QLD 4222 , Australia
Pneumococcal disease has a high burden in adults in the United Kingdom (UK); however, the total burden is underestimated, principally because most cases of community-acquired pneumonia (CAP) are non-invasive. Research into pneumonia receives poor funding relative to its disease burden (global mortality, disability-adjusted life years, and years lived with disability), ranking just 20 out of 25 for investment in infectious diseases in the UK. The current accuracy of data for establishing incidence rates is questionable, and it is a reflection of the paucity of research that much of the background information available derives from nearly 30 years ago. Given the relationship between CAP and mortality (pneumonia accounts for 29,000 deaths per annum in the UK, and 5-15% of patients hospitalised with CAP die within 30 days of admission), and the increasing threat of antimicrobial resistance associated with inappropriate antibiotic prescribing, such neglect of a highly prevalent problem is concerning. In this Call to Action, we explore the poorly understood burden of CAP in the UK, discuss the importance of an accurate diagnosis and appropriate treatment, and suggest how national collaboration could improve the management of an often life-threatening, yet potentially preventable disease.
Antimicrobial resistance; Clostridium Difficile; Community-acquired pneumonia; Immunization; Pneumococcal disease; Pneumonia burden; Pneumonia diagnostics; Pneumonia epidemiology; Streptococcus Pneumoniae
By any measure, pneumonia has a huge impact on the
United Kingdom (UK) and European healthcare systems,
being associated with high rates of hospital admission
and length of stay. Across Europe, annual inpatient care
accounts for healthcare expenditure of €5.7 billion,
outpatient care for €0.5 billion, and medication for €0.2
billion. The reported incidence of invasive
pneumococcal disease (IPD) in the UK is 6.85 per 100,000 annually
]. In addition, 5–15% of patients hospitalised with
community-acquired pneumonia (CAP) will die within
30 days of admission, rising to 30% for those admitted to
the intensive care unit [
]. This is particularly worrying
because pneumonia is responsible for more hospital
admissions and bed days than any other lung disease in the
UK, and results in 29,000 deaths per annum—the third
greatest cause of death from lung disease after chronic
obstructive pulmonary disease (COPD; second greatest
cause) and lung cancer (leading cause). Furthermore, the
UK ranks 21 out of 99 countries for age-standardized
mortality due to pneumonia [
]. CAP also has long-term
implications for subsequent mortality; 1-, 5-, and 7-year
mortality rates in patients who recovered from CAP in
the Netherlands were significantly higher at 17%, 43%,
and 53%, respectively, than the mortality rates seen in
ageand sex-matched population controls (4%, 19%, and 24%).
Malignancy (27%), COPD (19%), and cardiovascular
disease (16%) were the most common causes of death [
Conditions such as cardiovascular disease have seen
mortality rates drop significantly over the past 10 years
] in line with major research initiatives and funding
allocation, but little progress has been observed in
pneumonia epidemiology, pathophysiology, or therapy.
Indeed, in an analysis of UK infectious disease research
funding (1997–2013), pneumonia received poor
investment relative to its disease burden (global mortality,
disability-adjusted life years, and years lived with
disability), ranking just 20 out of 25 infectious diseases
]. In this article, we argue that, despite its obvious
impact and burden, pneumonia is a substantially
underestimated, neglected, and underfunded condition in the
UK. Many possible reasons exist for this unfortunate
position; none of them, we would argue, is acceptable.
Streptococcus pneumoniae is the leading cause of
community-acquired pneumonia in the UK and Europe
]. The results of a recent systematic review [
that (i) vaccine-type pneumococcal disease still has a
high burden in UK adults, and (ii) the total burden of
pneumococcal disease in the UK is underestimated,
principally because most cases of CAP are non-invasive.
Given the relationship between CAP and mortality, and
the increasing threat of antimicrobial resistance (AMR)
associated with inappropriate antibiotic prescribing, this
neglect of a highly prevalent problem is concerning.
Here, we explore the poorly understood burden of
CAP in the UK, discuss the importance of an accurate
diagnosis and appropriate treatment, and suggest how
national collaboration could improve the management
of an often life-threatening, yet potentially preventable
Community-acquired pneumonia is an immediate and growing concern
Pneumonia disproportionately affects older people [
with an overall CAP incidence of approximately 7.99/
1000 person-years in patients aged 65 years or older, and
a doubling of incidence between individuals aged 65–69
and 85–89 years, according to 1997–2011 data from the
UK Clinical Practice Research Datalink, associated with
the Hospital Episode Statistics (HES) database [
that the UK population is aging (it is estimated that 23%
will be aged ≥65 years by 2035 vs. 17% in 2010) [
economic burden of caring for elderly patients with
pneumonia can only increase in the absence of steps to
minimize the incidence of the disease [
Pneumonia and lower respiratory tract infections are
major causes of morbidity and mortality among those
aged 65 years or older [
], and CAP in the elderly can
aggravate underlying comorbidities (e.g. cardiovascular
disease, renal disease, liver disease, and malignancy) with
serious consequences [
]. Furthermore, long-term
quality of life is substantially affected by CAP, and
pneumococcal pneumonia increases the risk of
pneumoniarelated mortality three-fold versus non-pneumococcal
pneumonia in elderly patients [
Given the growing burden of disease, mechanisms to
reduce societal- and healthcare-associated costs must be
a priority. Prevention aside, the identification of
individuals who could be managed in the outpatient setting
could not only virtually eliminate hospital costs but also
decrease risk of infection with potentially resistant
nosocomial bacteria [
]. However, a study by Woodhead
et al. [
] (1987), conducted almost 30 years ago, was
the last to investigate the relative proportions of patients
with CAP accessing primary and secondary care in the
UK. This study found that 22% of CAP was treated in
hospital, with the remainder treated in primary care
]. For the UK National Health Service (NHS),
avoiding emergency admissions is a major concern due to the
high costs versus other forms of care; however, most
clinical commissioning groups (formerly known as
primary care trusts) still have high rates of emergency
Increased socioeconomic deprivation is associated with
increased incidences of both CAP and lower respiratory
tract infection. Regional variations exist; rates of CAP in
the UK are approximately 70% higher in the most
deprived quintile (North England) than in the least
deprived quintile (London and South East coast) [
Finally, CAP has an indirect socioeconomic impact;
the same historical cohort study [
] mentioned above
found that approximately half of patients in employment
required more than two weeks off work. Data are lacking
on the current effect of pneumonia on work days lost to
CAP in the UK. In Europe, this cost is estimated to be
€3.6 billion annually [
How are policy makers and healthcare funders making informed decisions?
CAP is a cause for serious concern, yet it is largely
ignored in the political and healthcare arenas. This
situation could reflect a lack of understanding of the extent
of the problem. The current accuracy of data for
establishing incidence rates is questionable; we believe the
statistics quoted above are an underestimate. This view
is supported by data from other developed countries
(see Fig. 1). It is a reflection of the paucity of research
that much of the UK background information available
derives from nearly 30 years ago.
In more detail, the recent prospective cohort study of
adults (aged ≥16 years) with CAP admitted to two large
teaching hospitals (acute admission units, hospital wards
and critical care units) in Nottingham, UK, used a
standardized proforma to collect daily information on
patient demographics, clinical information, microbiological
investigations, radiological findings and outcome
]. Inclusion criteria comprised symptoms
suggestive of lower respiratory tract infection (at least one
of breathlessness, cough, sputum, or fever), with new
infiltrates on chest radiography consistent with
pneumonia, and treatment by the admitting clinical team for
CAP. Exclusion criteria were post-obstruction
pneumonia due to lung cancer, active tuberculosis (discharged
from hospital within the preceding 10 days), and
aspiration pneumonia. The overall incidence rates for
patients who were hospitalized with CAP and
pneumococcal CAP over 5 years (2008–2013) were 79.9 and
23.4 cases per 100,000 population, respectively. However,
this study was not strictly designed to determine the
overall incidence of CAP. It did not, for example,
include data for patients (i) who did not consent for study;
(ii) from whom a urine sample was not obtained; (iii)
who were discharged from hospital within 10 days
previously; (iv) who were admitted via a route not involving
acute admission units, hospital wards and critical care
units, or (v) who attended Accident and Emergency
(A&E) but were not admitted. Furthermore, a substantial
discrepancy exists between the number of patients aged
16 years or older and eligible for inclusion in the
Nottingham study (n = 2702) [
] and HES data for the
corresponding population (n = 11,059) [
]; there is also a
large difference in CAP incidence rates from these two
sources. Miscoding of HES data is a well-recognized
limitation of the database, but that notwithstanding, the
four-fold scale of this range is alarming, not least
because it is unclear which of the two values is more
accurate. Such a discrepancy might represent the
difference between, for example, an incidence in
Nottingham of 50,000 and 200,000 CAP cases per annum.
These data together with known, extensive regional
variations associated with socioeconomic deprivation [
and higher European incidence rates (Fig. 1) would tend
to reduce confidence in published UK incidence rates.
HES data are used by Public Health England (PHE) to
help guide policy [
], but the problems outlined above
mean that decisions are based on data which might lack
adequate strength and/or consistency.
A comparison of rates across Europe suggests that the
incidence of CAP is seriously underestimated in the UK
(Fig. 1), lending credence to the suggestion that the
Nottingham study data may represent an incomplete
assessment of the incidence of CAP in the UK, which the HES
data might help to clarify. The authors considered
opinion is that even the latter numbers are likely to be an
underestimate. By considering possible routes via which
patients with CAP access healthcare in the UK (Fig. 2),
it becomes clear that across the country, the capture of
CAP incidence in primary care is difficult, and the
capture of CAP incidence in secondary care is incomplete.
One of the fundamental drivers of this problem is the
lack of a specific ICD-10 (10th revision of the
International Statistical Classification of Diseases and Related
Health Problems) diagnostic code for CAP, with the
result that coding is not complete and patients are spread
across multiple diagnostic codes.
The consequence of underestimating the incidence, and
therefore the importance, of CAP is that its impact on
major healthcare outcomes such as AMR, Clostridium
difficile infection (CDI), healthcare costs and winter
pressures are, in turn, greatly underestimated. Such
incomplete data on the incidence of CAP have major
implications for all involved in healthcare, but particularly
for those responsible for healthcare policy at
governmental and local levels, who base far-reaching decisions on
such information. It is our view that we cannot tackle the
consequences of CAP until we raise the profile of CAP
among the public, policy makers, and research funders.
Inappropriate antibiotic treatment of communityacquired pneumonia aggravates the development of antimicrobial resistance
Hospitalization for CAP is increasing; from 1998 to
2008, the incidence of CAP-associated admissions in
Oxfordshire (UK) rose by 4.2% per year, accelerating to
8.8% per year from 2009 to 2014 [
]. Trotter et al. [
also showed a marked increase (34%) in pneumonia
hospitalizations between 1997 and 1998 and 2004–2005 in
the UK. Consequently, because antibiotics are most
commonly indicated for respiratory tract infections in
UK hospitals (comprising 31% of prescriptions) [
seems likely that increasing rates of hospital admissions
for CAP will also result in a rise in antibiotic prescribing,
contributing to the development of AMR [
In Europe, AMR has been observed in all pathogens
associated with CAP, including S. pneumoniae, which is
the single most common causative agent isolated [
CDI is strongly associated with broad-spectrum
antibiotic use in CAP and is often nosocomial. [
study  in two Edinburgh hospitals found that (i) all
of the broad-spectrum antibiotics commonly used in
CAP (amoxicillin/clavulanic acid, cephalosporins, and
quinolones) were associated with a high level of risk for
CDI, and (ii) shortened antibiotic treatment duration
can reduce disease incidence, risk of developing AMR,
side effects, length of stay and hospital costs.
Improved antimicrobial stewardship and the
development of novel measures to tackle AMR are urgently
needed. A pathogen-directed antibiotic strategy (e.g. use
of penicillin rather than amoxicillin-clavulanate to treat
likely or confirmed pneumococcal disease) has
demonstrated comparable clinical efficacy to an empirical
broad-spectrum antibiotic strategy in patients with CAP
]. Appropriate treatment with pathogen-directed
antibiotics is likely to help reduce the risk of AMR, but
we lack robust, cost-effective and widely available
diagnostics. A perception exists that antimicrobial-resistant
pathogens are increasing in UK and international CAP
patients, leading to increased use of broad-spectrum
antibiotics. Without prospective studies using modern
diagnostics and determining the true incidence of CAP
and its associated pathogens, antibiotic policies are
reliant on superannuated microbiological data, or
international data that may not be applicable to the UK. A
systematic review has shown that current criteria used
to identify potentially antibiotic resistant pathogens in
the USA are not applicable to UK or European CAP
There is an urgent need to develop rapid, accurate,
point-of-care diagnostics capable of (i) differentiating
between viral and bacterial infections in CAP in the
community setting to minimize unnecessary antibiotic
], and (ii) identifying bacterial infections
to guide pathogen-directed antibiotic treatment.
Pointof-care diagnostics will have added benefit in helping to
establish both the true incidence of CAP and the
understanding of bacterial versus viral burden in the disease.
Initiatives such as the “Longitude Prize” [
] are an
important factor in promoting diagnostic research.
A 2013 Cochrane review [
] has shown that
23valent pneumococcal polysaccharide vaccination
prevents IPD and non-invasive pneumococcal pneumonia,
but does not have an impact on all-cause CAP. It is
essential to increase vaccine coverage (e.g. against the
most common causative agents, S. pneumoniae and
]) to at least prevent IPD and non-invasive
pneumonia, thereby potentially reducing antibiotic use
(including that for treating pneumonia-associated
secondary infection) and minimizing selective pressure
leading to AMR [
]. The WHO Global Action Plan on
Antimicrobial Resistance advocates the development and
use of new or improved vaccines to prevent diseases
becoming problematic due to AMR [
]. Furthermore, the
UK Joint Committee on Vaccinations and Immunisation
(JCVI) has recognized the strategic importance of
immunization in addressing AMR, recommending that
cost-effectiveness analyses of vaccination programs
should include the potential benefits of reduced
antimicrobial use [
Data from the Nottingham study [
], together with
serotype-specific surveillance data for IPD (July to June
from 2002 to 2003 to 2013–2014) collated by Public
Health England, published by Waight et al. [
analyzed for cost effectiveness by Van Hoek et al. [
instrumental in the JCVI decision that 13-valent
pneumococcal conjugate vaccine would not be
universally recommended for those aged 65 years and older in
England. The vaccine is therefore only offered to those
aged 10 years or older who have been identified as being
at particularly high risk of, and high mortality from, IPD
(e.g. those receiving bone marrow transplants, or with
acute or chronic leukaemia) [
determining the efficacy and cost effectiveness of vaccination
programs requires accurate information on the burden of
disease. As noted previously, data on CAP incidence are
poorly captured in the UK, not least because most cases
of CAP are non-invasive [
Call to action
As a first step, we draw attention to pneumonia as an
underestimated, neglected, and underfunded condition
in the UK, and call for all healthcare practitioners,
Prospective, national community study of the true incidence of CAP in primary care
o Incorporating representative centres from each major UK geographical region
Prospective national study of the true incidence of CAP in secondary care
o Involving ~5 representative centres; one in each major UK geographical region
Develop simple, accurate, and affordable point-of-care diagnostic(s) for:
o Differentiating viral vs. bacterial CAP to avoid unnecessary antibiotic use
o Identifying causative pathogen to guide pathogen-directed antibiotic therapy
Role/scale of inappropriate antibiotic prescribing in the treatment of CAP in both primary and
Contribution of inappropriate prescribing in CAP to the development of AMR
Establish the effectiveness of antibiotic stewardship programs in terms of improved CAP
outcomes and reduced AMR
Comprehensive molecular diagnostic studies in patients with CAP to establish the incidence
of antibiotic resistant pathogens and novel approaches to identify those requiring
broadspectrum antibiotic therapies
Institute appropriate vaccination strategy, including groups at risk, according to national
researchers, health planners, and policy makers at both
primary and secondary care level to react swiftly, as
outlined in Table 1. National prospective studies of the true
incidence of CAP in both primary and secondary care
(including reasons for patients being overlooked or lost
to follow-up), immediate review of CAP diagnostic
methods, and effective preventative strategies (e.g.
adequate vaccination programs) are urgently needed to
ensure that all patients (especially the elderly) receive
optimal care and treatment to minimize the impact of
CAP, reduce its medical and socioeconomic burden, and
restrict the development of AMR.
A&E: accident & emergency; AMR: antimicrobial resistance; CAP
IC: community-acquired pneumonia in children; CAP: community acquired
pneumonia; CDI: Clostridium difficile infection; CXR: chest X-ray; GP: general
practitioner; HCAP: healthcare-acquired pneumonia; HES: Hospital Episode
Statistics; ICD-10: International Statistical Classification of Diseases and
Related Health Problems – 10th revision; ICU: intensive care unit;
IPD: invasive pneumococcal disease; JCVI: Joint Committee on Vaccinations
and Immunisation; NHS: National Health Service; NICE: National Institute for
Health and Care Excellence; PHE: Public Health England; WHO: World Health
Dr. James Chalmers, Prof. Peter Hawkey and Prof. Mary Slack received
honoraria from Pfizer in connection with the development of this
manuscript. Pfizer also provided funding for the following: Hospital Episode
Statistics (HES) data processing and analysis by Harvey Walsh Ltd. under an
NHS digital re-use agreement, medical writing support by Richard Watt of
Sudler Medical Communications, and journal publication charges.
Availability of data and materials
The datasets used and/or analysed for the current article are available from
the corresponding author on reasonable request.
All authors were involved in draft content development, and in reading and
approval of the final manuscript.
Ethics approval and consent to participate
Consent for publication
Dr. James Chalmers has received research grant support from AstraZeneca,
Pfizer, GlaxoSmithKline, Boehringer-Ingelheim and Bayer Healthcare and has
participated in advisory boards or lectures for Griffols, AstraZeneca, Pfizer,
Napp, Boehringer-Ingelheim and Bayer Healthcare.
Prof. Peter Hawkey has received support from Pfizer to present at
educational meetings and to attend advisory board meetings, as well as
research funding and/or speaker support from: AstraZeneca, Beckton
Dickinson, Eumedica; MSD, Novartis, Novacta, Roche, Department of Health
UK, NIHR, and PHE. He is also Director of Modus Medica, a medical
Prof. Mary Slack has received personal fees from GSK, Pfizer, AstraZeneca and
Sanofi Pasteur as a speaker at international meetings and as a member of
advisory boards (outside the scope of the submitted work). She has also
worked as a contractor for Pfizer.
James Campling, Gillian Ellsbury and Harish Madhava are full-time employees
of Pfizer; no other conflicts of interest to declare.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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