Optimal treatment of pneumonia plays a critical role in temporary medicine regarding morbidity and mortality [
According to treatment guidelines, applications of antibiotics or other specific agents are strongly recommended. The aim of these standard treatments is to eliminate the causative agent (bacteria, viruses or mycoides, etc.) [
However, data on treatment efficacy in pneumonias including complementary and alternative medicine (CAM)—in particular anthroposophic medicine (AM)—are limited.
The aim of the presented study is to evaluate the treatment experience in applying anthroposophic medicine on a specialized and experienced unit with focus on the treatment of pneumonia.
Patients with proven diagnosis of community-acquired pneumonia (CAP), according to current guidelines [
Chart review was carried out focusing on the following parameters: initial clinical symptoms, radiologic features, blood sample tests, and clinical followup. Clinical data were retrospectively reviewed based on the hospital records including medical history and on results from the contributing radiologists and laboratory.
According to current guidelines [
Results of chest X-rays were reviewed by two—and for this case series reevaluated by additional one—independent consultant radiologist(s) who were blinded concerning prior diagnosis but confirming radiological signs of pneumonia.
In order to reduce potential coaffecting circumstances five different groups were differentiated (Figure
Flow chart of the inclusion and exclusion processes. *Other reasons for exclusion: patients with an immunodeficiency (
Group 1 includes patients pretreated with antibiotics before admission to the Department of Homeotherapy; group 2 includes patients with an acute cardiac decompensation and a congestive pneumonia (treatment of heart failure improves usually pneumonia too in these cases); group 3 includes patients in palliative care. All other patients were defined as the
Pneumonia severity index (PSI) was applied in order to indicate the severity level of pneumonia, divided into five risk classes [
Point scoring system by Fine et al. [
Demographics | Points assigned |
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If male | +Age (yr) |
If female | +Age (yr) − 10 |
Nursing home resident | +10 |
Comorbidity | |
Neoplastic disease | +30 |
Liver disease | +20 |
Congestive heart failure | +10 |
Cerebrovascular disease | +10 |
Renal disease | +10 |
Physical exam findings | |
Altered mental status | +20 |
Pulse ≥ 125/minute | +20 |
Respiratory rate > 30/minute | +20 |
Systolic blood pressure < 90mm Hg | +15 |
Temperature < 35°C or ≥40°C | +10 |
Lab and radiographic findings | |
Arterial pH < 7.35 | +30 |
Blood urea nitrogen ≥ 30 mg/dL (9 mmol/liter) | +20 |
Sodium < 130 mmol/liter | +20 |
Glucose ≥ 250 mg/dL (14 mmol/liter) | +10 |
Hematocrit < 30% | +10 |
Partial pressure of arterial O2 < 60 mm Hg | +10 |
Pleural effusion | +10 |
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As shown in Table
In case of missing classification data, only the available information were incorporated into risk assessments. Consecutively, in these cases the patient was classified at a lower risk category and therefore rather understaged. The amount of missing data was documented.
Patients were informed about different treatment options available and about the estimation of the treating physician, whether antibiotics were needed or not. Treatments were carried out only in agreement with the patients (informed consent). The individualized treatments were evaluated gathering information on which anthroposophic drugs and external medical applications like compresses, packs, and poultices each patient received or if the patients were treated with antibiotics and/or antipyretics. The finding process for each individual patient is based on a holistic perspective on man and earth according to the view point of anthroposophic medicine.
For follow-up evaluation the number of leukocytes, the CRP level, the course of body temperature as well as the need for treatment on ICU, and the 30-day mortality in hospital were documented.
For
Extending thirty months, 48 patients with “pneumonia” were admitted to the department of Homeotherapy in Heidenheim and treated based on anthroposophic medicine. 26 patients (19 f : 7 m) with a mean age of 65.5 years (19–90 a; SD 19.84) fulfilled the inclusion criteria “community-acquired pneumonia” (see Figure
Comorbidities of all included patients in the case series (
Patients ( |
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Heart failure | 8 |
Cardiac arrhythmias | 4 |
Hypertension | 5 |
Coronary heart disease | 1 |
Myocardial infarction | 1 |
Aneurysm | 1 |
Anaemia | 1 |
Exsiccosis | 1 |
Deep vein thrombosis | 2 |
Pulmonary emphysema | 4 |
Pulmonary fibrosis | 2 |
Chronic obstructive pulmonary disease | 1 |
Dementia | 2 |
Psychiatric illness | 2 |
Alcohol dependency | 1 |
Melanoma | 6 |
Cachexia | 3 |
Thyroid diseases | 4 |
Pancreatic insufficiency | 1 |
Cirrhosis | 1 |
Steatohepatitis | 1 |
Others | 12 |
18 of these patients showed no major comorbidities, which otherwise might mainly influence the course of the pneumonia (such as congestive heart failures, immunodeficiency), and therefore these 18 patients became the main focus for the evaluation of anthroposophic medicine (CAP-study group, see also Figure
Patients of groups 1–5 according to risk class of PSI.
Risk class I | Risk class II | Risk class III | Risk class IV | Risk class V | Total | |
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No. of all patients | 3 | 9 | 6 | 4 | 4 |
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Patients treated with AM after few days antibiotics (group 1) | 2 | 1 | 1 |
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Patient with heart failure and acute decompensation (group 2) | 1 | 1 |
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Palliative care patients (group 3) | 1 | 1 |
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CAP-study group | ||||||
Patients treated with AM alone (group 4) | 3 | 7 | 5 | 1 |
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Patients treated with AM + antibiotics (group 5) | 2 |
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On the whole 494 items could have been evaluated for calculating the PSI while 65 were missing. That counts for a missing data rate of 13.1%, from 0 to 4 data tops per patient (median 2.0). The pO2 and pH value were the most common missing data, followed by respiratory rate and in few cases glucose and blood urea nitrogen.
16/18 patients were treated applying anthroposophic medicine and without the use of antibiotics; in 2/18 patients, antibiotics were applied in addition. The individualized application plan for each patient in regard to anthroposophic medication and treatment is outlined in Table
Individualized application plan for each patient.
Antibiotic | Antipyretic | Arg. m. p. D30 | Echinacea D6 | Ferr. sid. |
Millefolium D4 | Ferr. phos. D6 | Equisetum D20 | Petasites D3 | Prunus spi. D3 | Sticta pulm D3 | Tartarus stibiatus D4 | Bryonia D4 | Gelomyrtol | Carb. bet. D20 | Ginger |
Millefol. |
Cochlearia |
Mustard |
Potatoes |
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Application | s. c. | s. c./p. o. | s. c. | s. c. | s. c. | s. c. | p. o. | p. o. | p. o. | s. c. | p. o. | p. o. | s. c. | Ext. | Ext. | Ext. | Ext. | Ext. | ||
Patient Nr | ||||||||||||||||||||
1 | + | + | + | + | + | |||||||||||||||
2 | + | + | + | + | + | |||||||||||||||
3 | Pretreated | + | + | + | + | + | + | + | + | |||||||||||
4 | + | D15 | + | + | + | + | + | + | + | |||||||||||
5 | + | + | D10 | D10 | + | D6 | + | + | ||||||||||||
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11 | Pretreated | + | + | + | D6 | + | + | + | + | |||||||||||
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13 | Pretreated | + | ||||||||||||||||||
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17 | + | + | D2 | Dil. | + | + | + | + | ||||||||||||
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This table shows the individual therapy plan of each patient. Peroral (p.o.) and subcutaneous medication (s.c.) is outlined as well as external applications (Ext.). We omitted the illustration of convential co-medication. If the applied homeopathic potencies differed from the described in the headline, it was particularly outlined in the table. CAP-study group are bold.
With regard to parameters which indicate efficacy of treatment (in these series
Statistical analysis of CRP course.
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This table shows the statistical analysis of CRP decrease from the initial to the second and third value and from the second to the third value.
Course of temperature in group 4 (patients with AM only in the CAP-study group). Figure
Course of CRP in group 4 (patients with AM only in the CAP-study group). CRP value 1–3 days shows the highest CRP level within the first three days, CRP value 4–9 the lowest value within this time span, and CRP before admission value at the end of treatment in hospital.
The mean duration in hospital within the CAP-study group (
On the whole, one patient died for not pneumonia-related reasons (out of palliative care group 3), within the patients who fulfilled the inclusion criteria (groups 1–5,
Complications in comparison to control group (Pneumonia PORT Validation Cohort [
Study series | Control group ( |
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Treated on ICU | 0/26 (0%) | 124/1343 (9.20%) |
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Mortality study series ( |
1/26 (3.8%) | 107/1343 (8%) |
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Mortality with excluded patients ( |
3/48 (6.25%) | 107/1343 (8%) |
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Length of hospital stay.
Risk class I | Risk class II | Risk class III | Risk class IV | Risk class V | |
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Study series ( |
19 | 21 | 9 | 29 | 23 |
Control group ( |
5 | 6 | 7 | 9 | 11 |
CAP-study group: patients with AM treatment only (group 4).
Nr. | Sex | Age | Risk class | Temperature | First day subfebrile temp. | Leukocyte begin | Lc. end | CRP |
CRP |
CRP end | † | Comorbidities | Medical history and findings on admission | Chest X-ray |
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1 | F | 44 | I | 38.2 | 2 | 12.48 | 4.4 | 411 | 66.8 | 6.9 | Pleurisy, hepatitis, burnout syndrome, sinusitis, and vertebral discprotrusion | For some days coughing with fever, temperature up to 40°C. Poor general condition, crackling sounds on the lungs. | Large infiltrate upper left lobe and lower right lobe. |
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2 | F | 40 | I | 39.9 | 7 | Normal |
119 | 16 | 0.1 | Hepatitis, sinusitis, recurringpyelonephritis, and hepatic steatosis | Sore throat and cough for 10 days, one week of fever. Poor general condition, obesity, dyspnea on exertion, chills, and crackling sounds on the lungs. | Infiltrate in the lingula of the left lung. | ||
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3 | M | 19 | I | 39.6 | 3 | 18.71 | 8.27 | 323 | 63.9 | Pleurisy, accompanying hepatitis | Fever up to 41°C. Spastic and crackling sounds on the right side of the lung. Poor general condition. | Large infiltrate upper right lobe. | ||
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4 | F | 75 | II | 39.2 | 10 | 3.80 - | 6.4 | 44.2 | 31.3 | 8.0 | Arterial hypertension, adenoma of thethyroid | Cough and fever 3 days prior to admission. |
Small infiltrate basolateral right. |
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5 | F | 58 | II | 39.2 | 7 | Normal |
113 | 37 | Schizophrenia, recurrent pneumonia | Cough with sputum and dyspnea 5 days prior to admission. Tachydyspnea, cyanosis of the lips, and crackling sounds on the lung. | Infiltrate lower left part of the lung. | |||
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6 | M | 51 | II | 39.7 | 3 | 2.90 | 4.6 | 96.2 | 17.2 | 3.6 | Sinusitis, stomatitis, and dizziness | One week of fever up to 40°C, 2 days of strong cough with sputum. Sinusitis. Poor general condition, crackling sounds on the lungs. | Large infiltrate lower and middle lobes. | |
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7 | F | 48 | II | 38.6 | 2 | 13.41 | 110 | 11.0 | 0.1 | Pleurisy | Fever for one week, up to 39°C. Dry cough. |
Initial: large infiltrate right middle and lower lobes. |
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8 | F | 40 | II | 37.0 | 1 | Normal |
48 | 25.8 | 3.7 | Depression | Cough, exhaustion, and pain in the limbs. Before admission fever, sputum, and dyspnea. | Infiltrate in the middle lobeof the lungs, bilaterally. | ||
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9 | F | 34 | II | 40.0 | 9 | 17.53 | 6.64 | 318 | 254 | 0.1 | Pleurisy, burnout syndrome, and mild hyperthyreosis | One day before admission dry cough, fever up to 39°C. Poor general condition. Reduced breathing sounds. | Infiltrate lower right part of lungs. | |
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10 | M | 32 | II | 39.9 | 3 | 17.43 | 4.72 | 320 | 42.8 | 2.1 | Pleurisy, grand mal epilepsy. Recurrent pneumonia | Cough, chest pain on the right side, which got worse in the last few days, plus night sweats and a temperature up to 40.4°C. Poor general condition. Normal breathing. | Infiltrate middle lobes. |
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11 | F | 82 | IIII | 39.0 | 6 | 14.13 | 6.24 | 286 | 60.7 | 7.1 | Chronic progressive respiratory insufficiency due to emphysema, post- tuberculosis condition with sintering of the left-sided lobe of the lungs, and arrhythmia | Poor general condition, bad nutritional state. |
Infiltrate left middle lobes. | |
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12 | F | 67 | III | 38.6 | 2 | 18.47 | 6.64 | 55.6 | 11.4 | Emphysema, chronic fibrosis of the lungs, and neurofibromatosis with cerebral microangiopathy, chronic alcoholism, and cachexia | Cough and sputum, temperature up to 39°C. |
Infiltrate lower right lobe, pronounced emphysema, fibrosis, and cor pulmonale. | ||
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13 | F | 65 | III | 39.2 | 2 | Normal |
6 | 0.3 | 0.3 | Breast cancer, arterial hypertension, and arrhythmia | Fever 1d prior to admission, at admission 39.2°C, dry cough, rare sputum, weakened general condition. Crackling sounds on the lungs. | Infiltrate lower right part of lungs. | ||
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14 | F | 64 | III | 38.9 | 3 | 13.95 | 7.14 | 216 | 30.4 | Chronic heart failure, burn-out syndrome, candidiasis, and pleurisy | One week of coughing without sputum, fever: 39-40°C, initial vomiting. |
Infiltrate lower right lobe. | ||
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15 | F | 31 | III | 39.4 | 5 | Normal |
22.9 | 15.9 | 5.9 | Emphysema, mental retardation, cardiac arrhythmia, mild hyperthyroidism, and mycoplasma pneumonia | One week of cough and fever, drinks little, received intravenous fluids 2 days prior to admission, poor general condition, and cachetic, crackling sounds on the lungs. | Initial: large infiltrate middle and lower lobes right and left lower lobes. |
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16 | F | 71 | V | 38.8 | 6 | Normal |
90.2 | 9.9 | 4.2 | Breast cancer, uterus carcinoma., primary biliary cirrhosis, and current radiotherapy | Cough, sputum. Sinusitis. Poor general condition, breathing sounds on the right side. Crackling sounds on the lungs. | Large infiltrate lower right side of the lung, pleural effusion. |
Sex: F: female; M: male; risk class after Fine et al [
CAP-study group: patients with AM and additionally treated with antibiotics (group 5).
Nr. | Sex | Age | Risk class | Temperature | First day subfebrile temp. | Leukocyte begin | Lc. end | CRP |
CRP |
CRP end | † | Comorbidities | Medical history and findings on admission | Chest X-ray |
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1 | F | 79 | IV | 39.8 | 3 | Normal |
94 | 39.0 | Chronic heart failure, arterial hypertension, acute severe diarrhoea, acute hemorrhagic cystitis, decubitus ulcer (heel and coccygeal), and dehydration | Diarrhoea and fever: 39-40°C, dyspnea. Crackling sounds on the lungs, cyanotic lips. Poor general condition. | Infiltrate retrocardic left, central pulmonary congestion. | |||
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2 | M | 75 | IV | 38.9 | 10 | Normal |
44 | 34.0 | 4.0 | Acute heartattack with aneurysm of the heart during inpatient treatment pancreaticinsufficiency, condition after Billroth II resection of the stomach | 38.9°C 3 days prior admission, shivering and sweating, and cough with sputum. Poor general condition. Dyspnea, crackling sound on the right side of the lungs. | Initial: no infiltrates. Control: infiltrates on the right and left sides. |
Sex: F: female; M: male; risk class after Fine et al [
The CRP level was reduced significantly (
There were no additional complications observed within the presented study.
In order to present the data most transparent, each individual course is outlined within Tables
Patients pretreated with antibiotics before admission (group 1).
Nr. | Sex | Age | Risk class | Temperature | First day subfebrile temp. | Leukocyte begin | Lc. end | CRP |
CRP |
CRP end | † | Comorbidities | Medical history and findings on admission | Chest X-ray |
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1 | F | 86 | V | 38.6 | 4 | Normal |
99 | 48 | 29.7 | Dementia, cachexia, exsiccosis, breast cancer, mildhyperthyroidism, and large pleural effusion | Recurrent fever up to 39°C while on antibiotics; multiple pretreated with antibiotics (cephalosporins, quinolone). |
Large pleural effusion, large infiltrate on the right lung. |
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2 | F | 57 | II | 37 | 1 | Normal |
56.0 | 11.4 | 0.0 | Hypothyroidism, hepatitis | Fever, cough with sputum and fatigue 3 d prior to admission. Antibiotic pretreatment of 2 d. |
Infiltrate right upper part of lungs. | ||
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3 | F | 68 | IV | 40.8 | 5 | Normal |
25 | 5.0 | 5.2 | Gastric carcinoma, hypothyroidism | One week of fever, up to 39°C 3 d prior to admission. Antibiotic pretreatment of 3 d (quinolone), no crackling sound on the lungs. | Infiltrate of the lower right segment. | ||
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4 | F | 66 | II | 38.5 | 8 | Normal |
70 | 53.7 | 7.4 | Chronic obstructive pulmonary disease(COPD), coronary heart disease, arterial hypertension, spinal syndromes with paralysis ofthe legs, and chronic heart failure (NYHA II-III) | 2a of COPD with dry cough and dyspnea, temperature up to 38.5°C, and cough for one week prior to admission. Antibiotic pre-treatment of 2 d (cefaclor). |
Infiltration right lower lung. |
Sex: F: female; M: male; risk class after Fine et al. [
Patient with chronic heart failure with acute decompensation (group 2).
Nr. | Sex | Age | Risk class | Temperature | First day subfebrile temp. | Leukocyte begin | Lc end | CRP |
CRP |
CRP end | † | Comorbidities | Medical history and findings on admission | Chest X-ray |
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1 | M | 85 | III | 39.0 | 13 | 13.28 | 71 | 44.5 | 6.1 | Chronic heart failure, deep vein thrombosis, and arterial hypertension | Was admitted with a deep vein thrombosis. Enlarged swollen leg. Crackling sound of the lungs. Temperature 39°C. | Infiltrate on the left side. Enlarged heart, pulmonary vascular congestion. |
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2 | M | 87 | V | 39.0 | 8 | Normal |
53 | 16.0 | <0.1 | Chronic heart failure, rectal carcinoma, Pleuritis calcarea, and deep vein thrombosis | Dyspnea, fever, also thoracic pressure 3 d prior to admission. Poor general condition. Crackling sounds on the right side of the lungs. | Initial: no infiltrate, pleuritis calcarea, increased heart size, and central congestion. |
Sex: F: female; M: male; risk class after Fine et al. [
Palliative care patients (group 3).
Nr. | Sex | Age | Risk class | Temperature | First day sub-febrile temp. | Leukocyte begin | Lc end | CRP |
CRP |
CRP end | † | Comorbidities | Medical history and findings on admission | Chest X-ray |
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1 | F | 91 | V | 36 | 1 | Normal level | 49 | † | Renal insufficiency, chronic heart failure with acute decompensation, tachyarrhythmia absoluta, and emphysema of the lungs | No fever, no cough, tachyarrhythmia absolutes (120 heart beats/minute), dyspnea, crackling sound of the lungs, and very poor general state of health (moribund). | Infiltrate lower right lobe. | |||
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2 | M | 90 | IV | 37,4 | 1 | 15.87 | 19.53 | 232.9 | 189 | 192 | Chronic heart failure, acute decompensation, arrhythmia, and cachexia | Patient was already diuretically treated as outpatient for heart failure and acute decompensation. Consecutively developed an electrolyte imbalance (hypokalemia), deterioration of general status since 5 days prior to admission. 90-year-old patient with very weakened general condition and malnutrition, tachycardia (heart rate 120/min), and no increased body temperature. Ever recurring episodes of apnoea. Crackling sound on the lower right side and reduced breath sound on the right. | Large pleural infusion right lower lobe, infiltrate right lower lobe. |
Sex: F: female; M: male; risk class after Fine et al. N. [
From the background of achieving high cure rates, antibiotic therapy for community-acquired bacterial pneumonia is the treatment of choice today. However with increasing resistance to antibiotics, unpleasant adverse effects and not least with rising request of patients to be treated within the scope of an integrative approach, alternative treatment options are under debate. Moreover, available data in this context is limited within the established medical literature. Therefore, the aim of the presented observational case series is to evaluate the experience in treating community-acquired pneumonia (CAP) with anthroposophic medicine (AM) within a highly specialized and well-experienced medical unit. The data of the presented observational case series are documenting the availability of an integrative treatment option for the treatment of CAP in hospital with good and comparable results in certain cases, in the context of such a specialized medical unit. Herewith, the presented study reports on unique data on a very relevant topic. However, due to the retrospective study design, the small number of patients, and a mutually not to be underestimated selection bias, the weight of conclusions for future treatment strategies in bacterial pneumonias is limited. Therefore, controlled prospective trials remain to further clarify the role of integrative medicine in the treatment of pneumonias.
Out of 48 patients with pneumonia, 26 had CAP, and 18 patients out of these were primarily treated with AM (CAP-study group, see Figure
In addition, also multiresistance of pneumonia inducing bacteria has become a rising and challenging issue at present [
With regard to the well-validated classification of CAP into different levels of severity (PSI: pneumonia severity index), 15/18 patients of the CAP-study-group belonged to lower risk classes I–III, and all of these were treated with AM only (Table
Anyhow it is worth to notice that even severe pneumonias might be approachable by applying AM only, as indicated by the patient classified in risk class V. This is in accordance with recently published data reporting a successful treatment course in a case of a 96-year-old female with severe pneumonia, lung abscess, and associated septicemia, treated with AM only (without antibiotic) [
Anthroposophic medicine is based on modern temporary natural science and medicine by aiming to extend these achievements with an additional holistic view on man, earth, and cosmos including the four aspects of elements and therefore intends to search for a specific individual treatment for each patient [
Finally, within the context of the presented data it needs to be pointed out that integrative medicine—and as in the presented case series AM in hospital—needs a great personal effort, due to its time-intense care procedures that call for a high competence, and this might at least partly justify a prolonged hospital stay. At present, the reported data do not allow to indicate the use of anthroposophic medicine in the treatment of CAP in general. But the presented data are encouraging to further evaluate the role of integrative medicine within the treatment of CAP regarding efficacy, security, economy, and sustainability.
This case series contributed towards showing the usefulness of AM in the context with inpatient treatment of CAP. The data shows that it is possible to put selected patients with CAP on a comfortable path of recovery by treating them with AM only. Because health conscious patients in particular opt for CAM, and, in our case AM, we cannot exclude the aspects of a selection bias towards healthier patients in the presented series. Therefore, it would be particularly useful to have a larger sized controlled prospective study on the treatment of pneumonia patients with AM.
All authors declare no conflict of interests.
The authors thank Thomas Ostermann, Ph.D. and M.S., Professor for Research Methodology and Information System in Complementary Medicine, Center of Integrative Medicine, Faculty of Health, Witten/Herdecke University, Germany, for conducting the statistical work and analysis. They also thank Jan-Peter Schenkengel, M.D., Head of the Department of Radiology, Hospital Heidenheim, Teaching Hospital of the University Ulm, for his reevaluation of the X-rays. We do thank Angela Lorenz (Heidenheim) and Stephan Hampe (Berlin) for editorial assistance. And last but by no means not least do we thank all the nurses for their ongoing support and commitment to carry AM forward.