Etiology of Community-Acquired Pneumonia:

Impact of Age, Comorbidity, and Severity

MAURICIO RUIZ, SANTIAGO EWIG, MARIA ANGELES MARCOS, JOSE ANTONIO MARTINEZ,
FRANCISCO ARANCIBIA, JOSEP MENSA, and ANTONI TORRES
Department of Medicine, University of Barcelona, Barcelona, Spain

The aim of this study was to determine the etiology of community-acquired pneumonia (CAP) and
the impact of age, comorbidity, and severity on microbial etiologies of such pneumonia. Overall, 395
consecutive patients with CAP were studied prospectively during a 15-mo period. Regular microbial
investigation included examination of sputum, blood culture, and serology. Sampling of pleural fluid,
transthoracic puncture, tracheobronchial aspiration, and protected specimen brush (PSB) sampling
were performed in selected patients. The microbial etiology was determined in 182 of 395 (46%)
cases, and 227 pathogens were detected. The five most frequent pathogens were Streptococcus pneumoniae (65 patients [29%]), Haemophilus influenzae (25 patients [11%]), Influenza virus A and B (23
patients [10%]), Legionella sp. (17 patients [8%]), and Chlamydia pneumoniae (15 patients [7%]).
Gram-negative enteric bacilli (GNEB) accounted for 13 cases (6%) and Pseudomonas aeruginosa for 12
cases of pneumonia (5%). Patients aged , 60 yr were at risk for an atypical bacterial etiology (odds
ratio [OR]: 2.3; 95% confidence interval [CI]: 1.2 to 4.5), especially Mycoplasma pneumoniae (OR: 5.3;
95% CI: 1.7 to 16.8). Comorbid pulmonary, hepatic, and central nervous illnesses, as well as current
cigarette smoking and alcohol abuse, were all associated with distinct etiologic patterns. Pneumonia
requiring admission to the intensive care unit was independently associated with the pathogens
S. pneumoniae (OR: 2.5; 95% CI: 1.3 to 4.7), gram-negative enteric bacilli, and P. aeruginosa (OR: 2.5;
95% CI: 0.99 to 6.5). Clinical and radiographic features of typical pneumonia were neither sensitive
nor specific for the differentiation of pneumococcal and nonpneumococcal etiologies. These results
support a management approach based on the associations between etiology and age, comorbidity,
and severity, instead of the traditional syndromic approach to CAP. Ruiz M, Ewig S, Marcos MA,
Martinez JA, Arancibia F, Mensa J, Torres A. Etiology of community-acquired pneumonia: impact of age, comorbidity, and severity.
AM J RESPIR CRIT CARE MED 1999;160:397405.

The etiology of adult community-acquired pneumonia (CAP)

has been under constant study in different local settings during the past decade (19). The microbial patterns reported
have differed considerably, depending on the epidemiologic
area studied, the patient population included, and the extent
and nature of the microbiologic techniques used. The knowledge of predominant microbial patterns in CAP, however,
represents the basis for initial decisions about its empirical an-

(Received in original form on August 10, 1998 and in revised form on December 14, 1998)
Supported by the Commisionat per a Universitats i Recerca de la Generalitat de
Catalunya 1997 SGR 00086, Ministerio de Sanidad y Consumo FIS 98/1250, and
IDIBAPS Hospital Clinic Barcelona.
Dr. Ruiz was a 1997 European Respiratory Society (ERS) reserach fellow the Hospital Clnico de la Universidad de Chile, Santiago de Chile, Chile.
Dr. Ewig was a 1997 research fellow from the Medizinische Universittsklinik and
Poliklinik Bonn, Bonn, Germany.
Dr. Arancibia was a 1997 research fellow from the Instituto Nacional del Trax
(INER y CT), Santiago de Chile, Chile.
Correspondence and requests for reprints should be addressed to Dr. Antoni
Torres, Hospital Clnic i Provincial, Servei de Pneumologia i Al.lrgia Respiratoria,
Villaroel 170, 08036 Barcelona. E-mail: atorres@medicina.ub.es
Am J Respir Crit Care Med Vol 160. pp 397405, 1999
Internet address: www.atsjournals.org

timicrobial treatment (10). It therefore appears crucial that

large tertiary care centers determine the peculiar microbial
patterns prevalent in CAP at least in their hospitalized patients with the disease.
Instead of the traditional syndromic approach (i.e., the clinical differentiation of typical and atypical penumonia), recent guidelines of the American Thoracic Society (ATS) for
the initial management of CAP proposed a strategy for its initial empirical treatment based largely on the criteria of age,
comorbidity, and severity of pneumonia, which are thought
to represent the main determinants of microbial etiologies of
CAP (10). This concept was derived from a synopsis of studies
from different areas and with different populations (2, 4, 11
13). However, no study so far has comprehensively determined the impact of these three criteria on microbial etiologies of CAP in a distinct hospital setting.
We therefore conducted a prospective study of the etiology
of CAP in hospitalized patients with such pneumonia, in order
to determine the local microbial spectrum and the influence of
age, comorbidity, and severity of pneumonia on microbial patterns in the disease. We also were interested in the potential
capacity of classical clinical and radiographic features of typical pneumonia to pneumococcal pneumonia as opposed to
nonpneumococcal pneumonia.

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AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE

METHODS
Patient Population
From October 1996 to December 1997, we prospectively studied 395
consecutive patients with CAP who were admitted to our hospital (an
1,000-bed university teaching hospital). CAP was defined as the presence of symptoms of lower respiratory tract infection, along with a
new infiltrate on chest radiography and no emerging alternative diagnosis during follow-up, in a patient not hospitalized for at least the
previous 72 h. Patients were excluded for severe immunosuppression,
such as manifested by neutropenia (, 1.0 3 109/L), or from human
immunodeficiency virus (HIV) infection, solid-organ or bone-marrow
transplantation, or treatment with steroids in a dosage of . 20 mg
prednisone-equivalent per day for 2 wk or more. Patients with pneumonia as an expected terminal event of a chronic disabling illness, tuberculosis, and postobstructive pneumonia due to lung cancer were
also excluded.

Data Collection
Clinical, radiographic, and laboratory data were recorded on a data
sheet and entered in a computer database. The following data were
recorded on admission: age, gender, smoking and alcohol habits, comorbid illnesses, antimicrobial treatment prior to hospital admission,
duration of symptoms before the diagnosis of pneumonia, clinical
symptoms (body temperature, presence of chills, pleuritic chest pain,
purulent sputum, confusion (i.e., disorientation with regard to person,
place, or time that was not known to result from chronic stupor or
coma), clinical presentation (presence of rhales, respiratory rate,
heart rate, arterial systolic and diastolic blood pressures), results of
blood gas analysis (PaO2, PaCO2, PaO2/FIO2), chest radiographic pattern
(alveolar, interstitial or mixed infiltrate, uni- versus bilateral involvement), leukocyte count, and serum creatinine concentration. At the
clinical endpoints of hospital discharge or death, the following parameters were additionally retrieved: results of microbial investigations,
admission to the intensive care unit (ICU), and in-hospital outcome.
Comorbidities were defined as follows: cardiac comorbid illness:
treatment for coronary artery disease or congestive heart failure, or
presence of valvular heart disease; pulmonary: treatment for asthma
or chronic obstructive pulmonary disease (COPD), or presence of interstitial lung disorders; renal: preexisting renal disease with a documented abnormal serum creatinine level outside the period of the
pneumonia episode; hepatic: preexisting viral or toxic hepatopathy;
disorders of the central nervous system (CNS) presence of symptomatic acute or chronic vascular or nonvascular encephalopathy, with or
without dementia; diabetes mellitus: diagnosis of intolerance to glucose and treatment with oral antidiabetics or insulin; neoplastic illness: any solid tumor active at the time of presentation or requiring
antineoplastic treatment within the preceding year.
Alcohol abuse was defined as the ingestion of an estimated amount
of > 80 g alcohol per day for at least the year before presentation.
Smokers were defined as current smokers of > 10 cigarettes/d during
at least the preceding year.

Microbiologic Evaluation
Regular sampling was done of sputum; blood, for two blood cultures;
and serum for paired serology (at admission and within the 4th and
8th weeks thereafter). Pleural puncture, transthoracic needle puncture, and tracheobronchial aspiration (in mechanically ventilated patients), with flexible fiberoptic bronchoscopy for protected specimen
brush (PSB) sampling and bronchoalveolar lavage (BAL) as additional diagnostic techniques, were used according to the clinical judgment of the physician in charge.
Sputum was Gram stained. Representative sputum originating
from the lower respiratory tract was defined as that containing . 25
granulocytes and , 10 epithelial cells per low power field (lpf) (total
magnification: 3100) (14). Such validated sputum, blood, culture samples, as well as pleural fluid, transthoracic needle aspiration samples,
undiluted and serially diluted tracheobronchial aspirates (TBAS), and
PSB, and BAL fluid (BALF) samples were plated on the following
media: blood-sheep agar, CDC agar, chocolate agar and Sabouraud
agar. Undiluted PSB and BALF samples were also cultured on charcoalyeast-extract agar. Identification of microorganisms was done

VOL 160

1999

according to standard methods (15). Results of quantitative cultures

were expressed as colony-forming units per milliliter (cfu/ml).

Diagnostic Criteria
The etiology of pneumonia was classified as presumptive if a valid
sputum sample yielded one or more predominant bacterial strains.
The etiology was considered definite if one of the following criteria
was met: (1) blood cultures yielding a bacterial or fungal pathogen (in
the absence of an apparent extrapulmonary focus); (2) pleural fluid
and transthoracic needle aspiration cultures yielding a bacterial
pathogen; (3) seroconversion (i.e., a fourfold increase in IgG titers for
Chlamydia pneumoniae (IgG > 1:512), Chlamydia psittaci (IgG > 64),
Legionella pneumophila > 1:128, Coxiella burnetii > 1:80, and respiratory viruses, (i.e. Influenzaviruses A and B, parainfluenza viruses 1
to 3, respiratory syncytial-virus, adenovirus; (4) a single increased IgM
titer for C. pneumoniae > 1:32, C. burnetii > 1:80, and Mycoplasma
pneumoniae (any titer); (5) a single titer > 1:128 or a positive urinary
antigen for L. pneumophila; (6) bacterial growth in cultures of TBAS
> 105 cfu/ml, in PSB > 103 cfu/ml, and in BALF > 104 cfu/ml. Growth
of fungi in respiratory samples was considered diagnostic only in the
presence of a concomitant positive blood culture growing the same microorganism.
Independently of microbiologic results, a diagnosis of probable aspiration was made in cases of witnessed aspiration or in the presence
of risk factors for aspiration (severely altered consciousness, abnormal gag reflex, or abnormal swallowing mechanism) (16).

Statistics
Results are expressed as means 6 SD. Continuous variables were compared by using Students t test; categorical variables were compared
by using the chi-square test or Fishers exact test where appropriate.
The most frequent pathogens, as well as grouped etiologies (atypical viral pathogens; atypical bacterial pathogens (excluding Legionella
sp.); atypical viral and bacterial pathogens (again excluding Legionella
sp.); nonpneumococcal, nonatypical pathogens; gram-negative enteric
bacilli (GNEB) and Pseudomonas aeruginosa; and undetermined etiology (for definitions see Table 2), were tested for an association with
age (less or more than 60 yr), smoking habit, alcohol abuse, comorbid
illnesses as defined earlier, and severe pneumonia (requiring ICU admission) by using chi-square tests with odds ratios (ORs) and 95%
confidence intervals (CIs). Multivariate analysis was applied by using
stepwise forward logistic regression.
To discriminate pneumococcal and nonpneumococcal pneumonia
(and excluding mixed etiologies), sensitivities and specificities of clinical and radiographic features of typical pneumonia (i.e., eight criteria
overall, including acute onset , 72 h, fever > 398 C, chills, pleuritic
chest pain, purulent sputum, rhales, leukocytosis > 12 3 109/L, and alveolar infiltrates) were calculated according to standard formulas.
The overall accuracy of combined criteria was evaluated with receiver
operating characterictic (ROC) curves, which were constructed by
plotting sensitivity against 1 2 specificity at different numbers of criteria fulfilled (from one of eight to eight of eight).
All reported p values are two-tailed. The level of significance was
set at 5%.

RESULTS
Patient Descriptives

The 395 patients (260 male and 135 female) had a mean age of
68 6 18 yr. Twenty-three patients (6%) were admitted from a
nursing home. Clinical symptoms and radiographic patterns,
as well as comorbid illnesses, are summarized in Table 1. The
mean duration of symptoms before the diagnosis of pneumonia was 5 6 5 d. Sixty-two patients (16%) had received antimicrobial pretreatment prior to hospital admission for pneumonia. Seventy-six percent of patients (n 5 301) had at least one
comorbid illness, with pulmonary comorbidity the most frequent comorbid condition (45%). Vital-sign abnormalities at
admission, as defined by Fine and coworkers (23), were present
in 242 (61%) patients, and included respiratory rate > 30/min
in 187 patients (47%), systolic blood pressure , 90 mm Hg in

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Ruiz, Ewig, Marcos, et al.: Etiology of CAP

nine (2%), heart rate > 125 beats/min in 40 (10%), confusion

in 96 (24%), and body temperature > 408 C in 10 (3%) and
, 358 C in one. Respiratory failure (PaO2/FIO2 , 250) was present
in 142 of 395 (36%) patients. Sixty-four patients (16%) required ICU admission, and 37 of these required mechanical
ventilation (9%). Nineteen patients (5%) died.
Microbial Etiology of CAP

A microbial etiology could be determined in 182 of the 395

(46%) patients. It was presumptive in 65 of 395 (16%) and
definite in 117 of 395 (30%) cases. Mixed infections were
present in 41 (10%) patients (37 [9%] with two pathogens and
four [1%] with three pathogens) (Table 2).
Overall, 227 pathogens were detected, of which 72 (32%)
were detected by sputum examination (presumptively diagnostic) and 155 (68%) were detected by other techniques (definitely diagnostic). S. pneumoniae constituted 65 of the 227
pathogens (29%), and was the most frequent pathogen. The
second to fifth most frequent pathogens were Hemophilus influenzae (n 5 25, 11%), influenza viruses A and B (n 5 23, 10%),
Legionella sp. (n 5 17, 8%), and C. pneumoniae (n 5 15, 7%),
respectively. With regard to grouped pathogens, atypical bacterial pathogens (excluding Legionella sp.) accounted for 41 of
the 227 pathogens detected (18%), viral pathogens for 39 of
the 227 (17%), and nonpneumococcal, nonatypical microorganisms for 65 of the 227 (29%). The last-named group included 13 (6%) GNEB and 12 (5%) P. aeruginosa, respectively
(Table 2).
Mixed infections were present in 41 (23%) of the 182 patients in whom a microbial etiology was determined. Of these,

TABLE 1
DESCRIPTIVES OF CLINICAL AND RADIOGRAPHIC
PRESENTATION AND COMORBID ILLNESSES IN 395 PATIENTS
WITH COMMUNITY-ACQUIRED PNEUMONIA
n (%)
Symptoms
Acute onset, duration of symptoms < 72 h
Fever > 39 C
Chills
Dyspnea
Cough
Purulent sputum
Pleuritic chest pain
Rhales
Leukocytosis > 12 3 109/L
Leukopenia , 4.0 3 109/L
Radiographic patterns
Alveolar infiltrates
Mixed alveolar 1 interstitial infiltrates
Interstitial
Bilateral infiltrates
Comorbidities
None
One
Two
Three
Four
Five
Cardiac
Pulmonary
Renal
Hepatic
Central nervous system
Diabetes mellitus
Neoplastic conditions
Alcohol abuse
Current cigarette smokers

150 (38)
106 (27)
163 (41)
272 (69)
306 (78)
239 (61)
128 (32)
312 (79)
235 (60)
6 (2)
302 (77)
86 (22)
7 (2)
74 (19)
94 (24)
174 (44)
104 (26)
18 (5)
4 (1)
1
70 (18)
178 (45)
25 (6)
30 (8)
43 (11)
68 (17)
37 (9)
45 (11)
88 (22)

only one apparent pathogen was covered by the initial empiric

antimicrobial treatment in 19 instances (46%). Pathogens not
covered included: viruses (n 5 13), M. pneumoniae (n 5 1),
C. burnetii (n 5 2), and P. aeruginosa (n 5 3).
Twenty-eight patients (7%) had suspected aspiration pneumonia. The etiology in seven cases of this subgroup (25%) included Legionella sp., C. pneumoniae, and C. burnetii in one
case each, Escherichia coli in three cases (including one case
of mixed infection with Enterococcus faecalis), and Klebsiella
pneumoniae in one case.
The etiology was determined in seven of 23 (30%) patients
with nursing-homeacquired pneumonia, and included S. pneumoniae (n 5 3), H. influenzae (n 5 2), E. coli (n 5 1), and E. coli
and E. faecalis (n 5 1). Both infections with E. coli were blood
culture-positive. Aspiration pneumonia occured in four of the

TABLE 2
ETIOLOGY OF COMMUNITY-ACQUIRED
PNEUMONIA IN THE NON-IMMUNOSUPPRESSED
HOST REQUIRING HOSPITALIZATION

Patients

Pathogens

Pathogens
Definite/
Presumptive

Etiology

n (%)

n (%)

Streptococcus pneumoniae
Legionella pneumophila
Atypical bacterial agents
Chlamydia pneumoniae
Chlamydia psittaci
Mycoplasma pneumoniae
Coxiella burnetti
Atypical viral agents
Influenza virus A
Influenza virus B
Parainfluenza virus 1
Parainfluenza virus 2
Parainfluenza virus 3
Adenovirus
Respiratory syncytial virus
Nonpneumococcal, nonatypical agents
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
Streptococcus viridans
Streptococcus mitis
Enterococcus faecalis
GNEB 1 Pseudomonas aeruginosa
GNEB (not classified)
Escherichia coli
Klebsiella pneumoniae
Serratia sp.
Proteus sp.
Pseudomonas aeruginosa
Opportunistic agents
Candida albicans
Mixed infections*

39 (21)
14 (8)
26 (14)
9 (5)
2 (1)
9 (5)
6 (3)
26 (14)
10 (6)
6 (3)
2 (1)
2 (1)
3 (2)
2 (1)
1 (1)
19 (10)
11 (6)
2 (1)
5 (3)

1 (1)

16 (9)
1 (1)
4 (2)
2 (1)
1 (1)
1 (1)
7 (4)
1 (1)
1 (1)
41 (23)

65 (29)
17 (8)
41 (18)
15 (7)
2 (1)
13 (6)
11 (5)
39 (17)
16 (17)
7 (8)
4 (2)
2 (1)
3 (1)
2 (1)
5 (2)
39 (17)
25 (11)
4 (2)
7 (3)
1 (1)
1 (1)
1 (1)
25 (11)
1 (1)
8 (4)
2 (1)
1 (1)
1 (1)
12 (5)
1 (1)
1 (1)

30/35
17
41

Total

182

227

39

15/24
6/19
1/3
5/2
1/0
1/0
1/0
12/13
0/1
6/2
2/0
1/0
1/0
2/10
1/0
1/0
155/72

*Mixed infections included: S. pneumoniae 1 Legionella sp. 1; S. pneumoniae 1 C.

pneumoniae 1; S. pneumoniae 1 Mycoplasma pneumoniae 2; S. pneumoniae 1 C. burnetii
1; S. pneumoniae 1 Influenza virus A 4; S. pneumoniae 1 Parainfluenza virus 1; S. pneumoniae 1 respiratory syncytial virus 3; S. pneumoniae 1 H. influenzae 6; S. pneumoniae
1 M. catarrhalis 1; S. pneumoniae 1 S. aureus 1; S. pneumoniae 1 Pseudomonas aeruginosa 2; Legionella sp. 1 C. pneumoniae 1; Legionella sp. 1 S. aureus 1; C. pneumoniae 1
respiratory syncytial virus 1; C. pneumoniae 1 H. influenzae 1; M. pneumoniae 1 Influenza virus A 1; M. pneumoniae 1 H. influenzae 1; Influenza virus A 1 H. influenzae 1; Influenza virus B 1 H. influenzae 1; C. burnetti 1 E. coli 1; C. burnetti 1 P. aeruginosa 2;
E. coli 1 H. influenzae 1; E. coli 1 E. faecalis 1; E. coli 1 P. aeruginosa 1; S. pneumoniae 1
H. influenzae 1 C. pneumoniae 1; S. pneumoniae 1 H. influenzae 1 Parainfluenza virus 1
1; S. pneumoniae 1 H. influenzae 1 M. catarrhalis 1; C. pneumoniae 1 C. burnetii 1 S.
viridans 1.

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AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE

23 (17%) patients, with a trend toward more frequent occurence than in patients with domestically acquired pneumonia (p 5 0.07).
Diagnostic Yield of Different Techniques

Sputum was collected from 243 patients, of whom 130 provided a valid sample. Blood cultures were achieved for 261 patients, and serologic samples were taken from 363 patients
(single samples in 159 cases and paired samples in 204). In the
remaining patients, these regular investigations were not done
because of inability to cooperate (sputum), early death, patient noncomplicance (paired serology), and collection errors.
Serology was done significantly less often in patients with no
comorbidity (p , 0.0001) and in the subgroup of patients with
CNS disorders (p , 0.01). In addition, TBAS were obtained
from 31 patients, pleural fluid from 29, and transthoracic puncture specimens from five patients. PSB and BAL were performed in 10 patients each.
Noninvasive techniques had yields of 53% (sputum), 13%
(blood culture), 45% (serology), and 58% (TBAS). Pleural
fluid produced a yield of 14%, transthoracic puncture of 20%.
and PSB and BAL of 30% and 20%, respectively (Table 3).

TABLE 3
YIELD OF DIFFERENT TECHNIQUES FOR THE ETIOLOGIC
DIAGNOSIS OF COMMUNITY-ACQUIRED PNEUMONIA*
Sputum

Blood
Culture

Serology

TBAS

Pleural
Fluid

243/130 gq
69
77
53

261
35
36
13

159 s/204 p
8 s / 82 p
8 s / 87 p
5 s / 40 p

31
18
20
58

29
4
4
14

Streptococcus pneumoniae
Streptococcus viridans
Streptococcus mitis
Enterococcus faecalis
Staphylococcus aureus
Haemophilus influenzae
Moraxella catarrhalis
Escherichia coli
GNEB (not specified)
Klebsiella pneumoniae
Serratia sp.
Proteus sp.
Pseudomonas aeruginosa
Candida albicans

38

2
20
3
2
1
1

10

22
1
1
1
2
2

1
1

3
4
1
2

Legionella sp.
Chlamydia pneumoniae
Chlamydia psittaci
Mycoplasma pneumoniae
Coxiella burnetii
Influenza virus A
Influenza virus B
Parainfluenza virus 1
Parainfluenza virus 2
Parainfluenza virus 3
Adenovirus
Respiratory syncytial virus

15
15
2
13
11
16
7
4
2
3
2
5

Technique
Number of samples
Number positive
Number of pathogens
Percent positive

Definition of abbreviations: GNEB 5 gram-negative enteric bacilli; TBAS 5 transbronchial aspirates.

* The following techniques were also used: thransthoracic puncture in five cases (two
positive, two pathogens [Streptococcus pneumoniae, Pseudomonas aeruginosa]); protected speimen brush in 10 cases (three positive, four pathogens [St. pneumoniae, Haemophilus influenzae, Escherichia coli, P. aeruginosa); bronchoalveolar lavage in 10 cases
two positive, two pathogens [Candida sp., Serratia marcescens]).

gq 5 good quality.

s 5 single.

p 5 paired.

VOL 160

1999

A pneumococcal etiology of CAP was identified exclusively by sputum testing in 35 (54%) cases, by blood culture in
17 (26%), by pleural fluid in one (2%), by TBAS in six (9%),
and by more than one technique in a further six cases (9%)
(sputum and blood culture in three cases [5%]; and blood culture and pleural fluid; TBAS and PSB; and blood culture,
pleural fluid, and transthoracic puncture in one case each).
Thus, 22 cases (34%) were bacteremic. Legionellosis was diagnosed by serology in 15 of 17 (88%) cases (single results in
three cases and paired results in 12), and by urine antigen testing in two cases (12%). Serologic results were confirmed by a
positive urine antigen result in a further four cases. Most diagnoses of GNEB were based on techniques other than sputum
examination (10 of 13, 77%), whereas P. aeruginosa was detected mainly by sputum examination (10 of 12 cases, 83%).
Ten of 12 patients with P. aeruginosa had COPD, including
one with definite bronchiectasis. Of these, only one patient
had no comorbid illness, but was a heavy cigarette smoker (20
pack-yr). P. aeruginosa was the only pathogen detected in
seven of the 12 patients in whom it was found, whereas five
had mixed infections, with S. pneumoniae as the second pathogen in two cases, C. burnetii as the second pathogen in two
cases, and E. coli as the second pathogen in one case).
The diagnostic yield was not significantly different in 62
patients who had antimicrobial pretreatment from those who
did not. Sputum cultures were equally frequently positive in
both groups (30% versus 29%, p 5 0.88). On the other hand,
blood cultures and pleural fluid were more often positive in
patients without antimicrobial pretreatment (15% versus 7%
[p 5 0.18], and 18% versus 2% [p 5 0.04], respectively). A
converse trend was obvious with regard to serology (23% positive versus 32%, p 5 0.17).
Impact of Age, Comorbidity, and Severity
on Microbial Etiology

An age > 60 yr was not associated with any discernible microbial etiology. However, patients aged , 60 yr significantly
more frequently had CAP caused by atypical bacterial pathogens, especially M. pneumoniae. No association with microbial
etiology could be determined for patients with nursing-home
acquired pneumonia (Table 4).
Patients without comorbid illnesses were also more likely
to have a viral or atypical bacterial etiology. Current cigarette
smokers were more likely to have pneumonia caused by Legionella sp. and C. pneumoniae. Pulmonary and hepatic comorbid illness, as well as alcohol abuse, were significantly associated with CAP due to S. pneumoniae and to mixed infections.
Pulmonary comorbidity predisposed to CAP caused by GNEB
and P. aeruginosa, and particularly the latter. Infections due to
atypical bacterial pathogens, especially C. pneumoniae, were
more frequent in patients with alcohol abuse. CNS disorders
favored aspiration pneumonia. Hepatic comorbidity and alcohol abuse were associated with bacteremic infections, and alcohol abuse was associated with bacteremia due to S. pneumoniae in particular. These associations are listed in Table 4.
In the population aged , 60 yr and without comorbid illnesses, an etiology of the group comprising atypical bacterial
pathogens was more probable (10 of 40 cases [40%]) (OR: 3.5;
95% CI: 1.4 to 8.3; p 5 0.002), and especially pneumonia due
to M. pneumoniae (five of 13 cases [39%]) (OR: 5.9; 95% CI:
1.5 to 21.8; p 5 0.001). In patients aged > 60 yr and having any
comorbidity, there was an association with GNEB (21 of 24
cases [88%]) (OR: 4.4; 95% CI: 1.2 to 23.4; p 5 0.01), and particularly with P. aeruginosa (11 of 12 cases [92%]) (OR: 6.7;
95% CI: 1.0 to 291.4; p 5 0.04).

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Ruiz, Ewig, Marcos, et al.: Etiology of CAP

TABLE 4
IMPACT OF AGE, CIGARETTE SMOKING, AND COMORBIDITY ON
MICROBIAL ETIOLOGY OF COMMUNITY-ACQUIRED PNEUMONIA
Number of Patients/
Proportion of Patients
with Corresponding
Etiology
(%)

Odds
Ratio

95% Confidence Interval

p Value

Age, 60 yr
Atypical bacterial pathogens
Mycoplasma pneumoniae

96
16/40 (40)
8/13 (62)

2.3
5.4

1.14.8
1.716.8

0.02
0.004

No comorbidity
Viral or atypical bacterial pathogens

91
25/76 (33)

1.9

88
8/17 (47)
9/15 (60)

3.2
5.6

1.19.5
1.719.6

0.03
0.002

Comorbid conditions/
Microbial Etiology

Current cigarette smokers

Legionella spp.
Chlamydia pneumoniae

1.033.3

0.03

Pulmonary
Streptococcus pneumoniae
Gram-negative enteric bacilli 1
Pseudomonas aeruginosa
Pseudomonas aeruginosa
Mixed infections

178
37/65 (57)

1.7

1.03.1

0.04

17/24 (71)
10/12 (83)
24/41 (59)

3.1
6.3
1.8

1.28.5
1.359.8
0.93.7

0.009
0.007
0.07

Hepatic
Streptococcus pneumoniae
Bacteremia
Mixed infections

30
12/65 (19)
8/34 (24)
8/41 (20)

3.9
4.7
3.6

1.79.1
1.712.5
1.49.4

0.0003
0.002
0.007

Central nervous system disorders

Aspiration

43
17/28 (61)

20.1

7.951.8

, 0.0001

Alcohol abuse
Streptococcus pneumoniae
Bacteremic Streptococcus pneumoniae
Atypical bacterial pathogens
Chlamydia pneumoniae
Mixed infections
Bacteremia

45
14/64 (22)
7/22 (32)
11/40 (28)
7/15 (47)
10/41 (24)
9/34 (27)

2.6
4.0
3.5
7.7
2.9
3.2

1.25.6
1.411.3
1.58.1
2.424.9
1.26.7
1.37.8

0.005
0.008
0.003
0.0006
0.005
0.009

Severe pneumonia (requiring ICU admission) was significantly associated with the pathogens S. pneumoniae and bacteremic S. pneumoniae in particular, and with mixed infections and
bacteremic infections. The association with the GNEB group and
with P. aeruginosa had a comparable ORs of 2.3 in each case, but
failed to reach significance. However, in a multivariate analysis
including these five etiologies, pneumonia due to S. pneumoniae,

and to the GNEB group and P. aeruginosa remained independently associated with severe pneumonia (Table 5).
Association of Microbial Etiology with Death

Mortality was highest in cases of pneumonia due to GNEB (two

of 13 cases, 15%) and P. aeruginosa (one of 12 cases, 8%). It
was 6% (four of 65 cases) for S. pneumoniae, 5% (one of 22

TABLE 5
IMPACT OF SEVERITY OF PNEUMONIA ON MICROBIAL ETIOLOGY

Microbial Etiology

Number of Patients/
Proportion of Patients
with Corresponding
Etiology
(%)

Severe pneumonia (ICU admission)

Univariate
Streptococcus pneumoniae
Bacteremic Streptococcus pneumoniae
Gram-negative enteric bacilli 1
Pseudomonas aeruginosa
Mixed infections
Bacteremia
Multivariate
Streptococcus pneumoniae
Gram-negative enteric bacilli 1
Pseudomonas aeruginosa
Definition of abbreviations: ICU 5 intensive care unit.

Odds
Ratio

95% Confidence Interval

p Value

18/65 (28)
8/22 (36)

2.4
3.2

1.34.4
1.38.1

0.006
0.008

7/24 (29)
12/41 (29)
11/34 (33)

2.3
2.4
2.8

0.86.1
1.15.3
1.26.4

0.09
0.02
0.008

2.5

1.34.7

0.005

2.5

0.996.5

0.05

64

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TABLE 6
SENSITIVITY FOR PNEUMOCOCCAL PNEUMONIA AND SPECIFICITIES FOR
NONPNEUMOCOCCAL ETIOLOGIES (IN %) OF CLASSICAL CRITERIA FOR
TYPICAL PNEUMONIA (EXCLUDING PATIENTS WITH MIXED ETIOLOGIES)
Specificity for Nonpneumococcal Etiologies

Streptococcus
pneumoniae

Legionella sp.

Viral and
Atypical
Bacterial
Pathogens

39
23
51
56
77
82
54
74

25
50
50
67
50
7
57
14

59
64
50
56
42
17
43
23

Sensitivity
Criteria
Acute onset (duration of
symptoms < 72 h
Fever > 398 C
Chills
Pleuritic chest pain
Purulent sputum
Rhales
Leukocytosis > 12 3 109/L
Alveolar infiltrates

Nonpneumococcal,
Nonatypical
Pathogens*

Etiology
Undetermined

57
77
66
69
15
17
20
31

50
61
61
64
45
21
41
24

* Exluding Legionella sp. but including gram-negative enteric bacilli and Pseudomonas aeruginosa.

cases for bacteremic pneumococcal pneumonia), 8% (one of

13 cases) for M. pneumoniae, 4% (one of 25 cases) for H. influenzae, and 6% (two of 34 cases) for bacteremia. Legionellosis, C. pneumoniae and viral pathogens had no associated mortality. Mortality was 4% (eight of 213 cases) in the group with
CAP of undetermined etiology. One patient with mixed infection (S. pneumoniae and H. influenzae) died despite appropriate initial antimicrobial treatment.
Association of Features of Typical Pneumonia
with Etiologies

The sensitivity of the six clinical features of typical pneumonia, leukocytosis > 12 3 109/L, and alveolar infiltrates for
pneumonia caused by S. pneumoniae was low (ranging from
24% to 82%), and the specificities did not exceed 70% for legionellosis or the viral and atypical bacterial pathogen group
(ranging from 7% to 67%) (see Table 6).
ROC curves showed that in the presence of four of eight
criteria, sensitivity for pneumococcal pneumonia reached 80%
and specificities for legionellosis, viral and atypical bacterial
pathogens, nonpneumococcal, nonatypical pathogens, and undetermined etiologies ranged from 12 to 66%, whereas in the
presence of seven of eight criteria, specificities reached 96 to
100% at the expense of a very low sensitivity (3%) (Figure 1).

DISCUSSION
This study, one of the largest unicenter studies, including 395
consecutive hospitalized patients, provides a comprehensive
insight into the impact of age, comorbidity, and severity on the
etiology of CAP. The main results were that: (1) patients aged
, 60 yr without comorbid illnesses were more likely to have
an etiology comprising viral or atypical bacterial pathogens,
especially M. pneumoniae; (2) pulmonary, hepatic, and CNS
comorbidities, as well as current cigarette smoking and alcohol abuse, all had a significant bearing on distinct etiologic
patterns; (3) severe pneumonia (requiring ICU admission)
was independently associated with the pathogens S. pneumoniae and with the GNEB group and P. aeruginosa; and (4)
whereas age, comorbidity, and severity were strongly associated with the etiology of pneumonia, classical clinical and radiographic features of typical pneumonia were neither sensitive nor specific for the differentiation of pneumococcal and
nonpneumococcal etiologies.

With noninvasive diagnostic techniques used for the majority of patients, the percentage of patients with presumptive
and definite etiologies (46%) was within the range of the expected percentages. This was also true for the diagnostic yields
of the different noninvasive and bronchoscopic techniques.
Likewise, the distributions of the main etiologic groups and
the five most frequent pathogens were comparable to those in
several previous series. S. pneumoniae was unanimously found
to be the leading pathogen in CAP (19). In other recent series, H. influenzae was reported to account for 4 to 11% of episodes (19), influenza viruses A and B for 3 to 8% (1, 2, 68),
Legionella spp. for 2 to 16% (19), and C. pneumoniae for 3 to
18% (4, 69), all of which are well comparable to our frequencies of 11%, 10%, 8%, and 7%, respectively. Nevertheless, we
found an unusually high percentage of viral infections (21%,
including 13 of 39 [33%] cases of mixed viral/bacterial infections, as compared with 9 to 16% in other series [13, 58]),
which may be mainly attributable to the high number of
paired serologies obtained. We also found a relatively high
percentage of GNEB (6%) and of P. aeruginosa (5%) among
the pathogens involved. Only four recent studies had a proportion of . 3% of CAP caused by GNEB (4, 6, 8, 18), with
the highest proportion reaching 9% (18). P. aeruginosa was
reported to account for only 1 to 2% in other series (4, 5, 8, 9),
except for one recent study that reported 5% (6). Whereas in
our study the former etiologies were definite in most (77%)
cases, P. aeruginosa was identified exclusively by sputum examination on 85% of occasions, mostly in patients with COPD
(and bronchiectasis in one patient). Since such patients may
be colonized with P. aeruginosa (19), the etiologic role of this
pathogen in the pneumonia episode may be questioned. However, all 12 patients in whom P. aeruginosa was identified in
our study had a valid sputum sample, and six of the 12 had no
evidence of other pathogens. Thus, it seems prudent to consider the pathogens named here as at least probable pathogens of pneumonia. Similar considerations are applicable to
patients with pneumococcal pneumonia proven only by sputum testing, and with COPD (19).
The impact of age was restricted to an association of
younger age (, 60 yr) with atypical bacterial pathogens, especially M. pneumoniae. This finding is in accord with the findings in several previous studies (7). An association of advanced age with gram-negative pathogens and P. aeruginosa
has been claimed by several authors (10, 31). Although in our

403

Ruiz, Ewig, Marcos, et al.: Etiology of CAP

Figure 1. ROC curves for from one to eight classical clinical and radiographic criteria for typical CAP. The
open square at the right top represents the presence of one criterion, the open square at the left bottom
represents the presence of eight criteria.

study an age > 60 yr with any comorbid illness was significantly associated with these pathogens, advanced age alone
was not, suggesting that comorbidity rather than age is the
determinating condition predisposing to these etiologies. Accordingly, these etiologies were rare in two recent studies of
CAP in the elderly, ranging between 0 and 5% (21, 22).
Patients without comorbid illnesses were more likely to
have a viral or atypical bacterial etiology. However, given that
serology was done significantly more often in these patients,
this finding must be interpreted with caution.
Smokers were more likely to have CAP caused by Legionella spp. and C. pneumoniae. Whereas smoking has only
recently been described as an independent risk factor for sporadic legionellosis (23), no such association has yet been
shown for pneumonia due to C. pneumoniae.
Pneumococcal pneumonia was significantly associated with
pulmonary and hepatic comorbidities as well as with alcohol
abuse. Although COPD, hepatic cirrhosis, and high alcohol
consumption have all repeatedly been described as risk factors
for CAP (2, 3, 11, 13, 24), they have not been recognized as
having an association with pneumococcal pneumonia. In accord with these findings of our study, hepatic comorbidity and
alcohol abuse were also associated with bacteremia, and alcohol abuse with bacteremic S. pneumoniae pneumonia in particular, suggesting a continuum of local and systemic immunocompromise as underlying the pathogenetic mechanism of this
association. Whereas COPD may predispose to pneumococcal
pneumonia by previous tracheobronchial colonization (19),
hepatopathy may cause an impairment of phagocyte clearance
of invading pathogens. An impairment of several local and

systemic host immune mechanisms in alcoholic individuals,

and especially of lymphocyte functions, has been described
(25, 26). Perhaps even more surprising, but consistent with the
described immunologic alterations, was the finding that infections due to atypical bacterial pathogens, and especially C. pneumoniae, were also associated with alcohol abuse. This finding
has not been reported previously. On the other hand, we could
not confirm a higher incidence of GNEB reported in a smaller
previous study of CAP using a similar definition of alcohol
abuse (24).
Pulmonary comorbidity also predisposed to pneumonia
due to GNEB and P. aeruginosa, probably owing mainly to previous tracheobronchial colonization in COPD (and/or bronchiectasis) (19). We were unable to establish associations of these
pathogens with other conditions, such as diabetes mellitus or
aspiration. As expected, suspected aspiration pneumonia was
strongly associated with CNS disorders. However, this association may have included an overestimate of the true incidence
of aspiration since the diagnosis of aspiration was largely
based on criteria for likely aspiration as a consequence of CNS
disorders. Conversely, because of significantly fewer serologies performed on these patients, atypical pathogens may have
been underestimated.
Because there is no universally accepted definition of severe CAP, it was defined for our study as pneumonia requiring ICU admission. This definition is clearly not irrefutable,
nor does it imply that all patients were severely ill to the same
degree. Nevertheless, it reflects clinical judgment in a specialized center, and the results may therefore well be relevant to
other settings. Severe pneumonia was associated with the patho-

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AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE

gens S. pneumoniae, GNEB, and P. aeruginosa, as well as with

mixed etiologies and bacteremic infections. In multivariate
analysis, CAP due to S. pneumoniae, and to GNEB and P. aeruginosa, was in each case an independent predictor of severity.
These etiologic associations were certainly not due to increased age, since none of these pathogens was associated
with an age > 60 yr. Although there are no studies of risk factors for severe pneumonia with which to compare our results,
several studies of series of patients with severe CAP have
shown S. pneumoniae (27, 28), GNEB (27, 29), P. aeruginosa
(13, 30), and bacteremia (13, 27, 31) to be significant risk factors for death, in accord with our own findings.
In terms of mortality, GNEB had the highest associated
mortality (15%). Pneumonia due to P. aeruginosa had a relatively low mortality (8%) as compared with that of ventilatorassociated pneumonia, which may reach 70% (32). This inconsistency may be explained by differences in severity of comorbidity, bacterial load, and antimicrobial susceptibility. Surprisingly, the mortality from bacteremic pneumococcal pneumonia
was equal to that from noninvasive pneumonia (5% versus
6%), and the mortality associated with bacteremia in general
did not exceed 6%. Others have reported a mortality twice as
high for blood culture-proven pneumococcal pneumonia (3).
One might speculate that the low mortality rates in these bacteremic patients are attributable to a short interval between
onset of symptoms and appropriate antimicrobial treatment.
In any case, these mortality rates must be interpreted with
caution, since both the overall and pathogen-related mortality
rates were generally low.
Single or combined clinical and radiographic features of
typical pneumonia failed to discriminate pneumococcal pneumonia from nonpneumococcal etiologies. This finding corroborates several previous reports (3335). As pointed out by
others, the nature of the host and the immunologic host response most probably have a more important bearing on the
clinical features of pneumonia than does the underlying pathogen. A further important confounder, only rarely considered,
may be that viral etiologies especially may often include undetected mixed infections with S. pneumoniae. Thus, the traditional classification of CAP into typical and atypical pneumonia in order to consistently guide initial empirical antimicrobial
therapy in hospitalized patients is no longer adequate. A remarkable exception may be the rare patient who presents with
the complete pattern of typical clinical and radiographic features of CAP.
In conclusion, given that age, comorbidity, and severity of
pneumonia had strong associations with distinct etiologic patterns of CAP, whereas classical features of typical pneumonia
were neither sensitive for pneumococcal pneumonia nor specific for other etiologies, our study clearly supports a management approach based on these criteria as recommended by the
ATS, rather than on the traditional syndromic approach. This
strategy, together with constant epidemiologic surveys in different hospital settings, and notably a regular, comprehensive
diagnostic workup in the most severe cases of pneumonia,
may offer the most beneficial perspective on the initial management of patients hospitalized with CAP.
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