Pneumonia

(Community-Acquired Pneumonia; CAP; Bronchopneumonia)

Pronounced: Noo-MO-NEE-yah by Michelle Badash, MS Definition | Causes | Risk Factors | Symptoms | Diagnosis | Treatment | Prevention En Espaol (Spanish Version) More InDepth Information on This Condition Definition Pneumonia is an infection of the lungs. It affects the lower respiratory tract. This includes small bronchi (airways) and air sacs in the lungs. Development of Pneumonia in the Air Sacs of the Lungs

The normal exchange of gases is interrupted by the build up of fluids.

2011 Nucleus Medical Media, Inc.

Causes There are three main causes:

Bacterial pneumoniacaused by bacteria, most commonly Streptococcus pneumoniae Viral pneumoniacaused by a virus Atypical bacterial pneumoniaoften called "walking pneumonia," but can cause a more serious or potentially fatal pneumonia

Other causes of pneumonia include:

Fungal infections, such as infections that are common in people with AIDS

Pneumonias are sometimes described by where it was acquired and how you were exposed to it:

Community-acquired pneumoniaacquired in the community (eg, at school, work, gym) Nosocomial pneumoniaacquired during a hospitalization o Can be very dangerous, especially for patients on a ventilator Aspiration pneumoniahappens when a foreign matter (often stomach content) is inhaled

Aspiration

2011 Nucleus Medical Media, Inc.

Risk Factors Factors that increase your chance of pneumonia include:

Age: 65 or older Flu or other respiratory illness Chronic illness, such as heart or lung disease Stroke (aspiration pneumonia due to difficult swallowing) Weakened immune system caused by AIDS or chemotherapy Chronic bronchitis Malnutrition Pregnancy Infants and very young children Alcohol or drug abuse Smoking Chronic exposure to certain chemicals (eg, work in construction or agriculture)

Symptoms Symptoms of pneumonia may include some or all of the following:

Bacterial Pneumonia
Fever Shaking chills Cough that produces green, yellow, or rust-colored mucus Chest pain Profuse sweating Fever Chills

Viral Pneumonia

Atypical Pneumonia
Fever, often low-grade Chills Coughing; may be violent at times; produces white mucus Possible nausea or vomiting Weakness

Dry cough Headache Muscle pain

Bluish color of the nails or lips due Bluish color of the nails or lips due to diminished oxygen in the blood to diminished oxygen in the blood Confused mental state Weakness

Diagnosis The doctor will ask about your symptoms and medical history. A physical exam will be done. Diagnosis is based on symptoms and listening to your chest. Tests may include:

Chest x-raya test that uses radiation to take pictures of structures inside the body, in this case the chest CT scana type of x-ray that uses a computer to make pictures of structures inside the chest Blood tests Bronchoscopydirect examination of airways Sputum culturetesting mucus coughed up from deep in the lungs Pulse oximetrymeasures the amount of oxygen in the blood Arterial blood gasmeasures oxygen, carbon dioxide, and acid in the blood

Treatment Treatment of pneumonia depends on:

Type of pneumonia Severity of symptoms Other factors

Common treatment approaches include:

For bacterial pneumoniaantibiotics For viral pneumoniaantiviral medicines may be prescribed for young children and people with weakened immune systems o Note: Antibiotics are ineffective for treating viral pneumonia.

Atypical pneumoniaantibiotics

It is very important to take the medicine as prescribed. Stopping medicine early may cause a relapse. It may also create a strain of drug resistant bacteria. General treatment approaches include:

Getting plenty of rest and drinking lots of fluids Eating a healthy diet (includes lots of fruits and vegetables)If you do not get enough vitamin C in your diet, ask your doctor if you should take a supplement (up to 1,000 mg). This may be beneficial for some people. Taking over-the-counter medicines to reduce fever, aches, and cough Being hospitalized (in severe cases)

If you are diagnosed with pneumonia, follow your doctor's instructions.

Prevention Certain vaccines may prevent pneumonia:

Flu shot for people at high risk, particularly the elderly (Pneumonia may be a complication of the flu.) Pneumococcal vaccineGeneral recommendations include: o PCV vaccine series for children o PPSV for adults aged 65 years and older and for younger people who are at high risk for getting infected

Other preventive measures include:

Avoid smoking. Smoke weakens the lungs' resistance to infection. Avoid close contact with people who have the cold or flu. Wash your hands often. This is very important when coming in contact with infected people. Protect yourself on jobs that affect the lungs. Eat a healthy diet. If you do not get enough vitamin C or zinc in your diet, ask your doctor if you should take these supplements. Get adequate rest. Exercise regularly.

RESOURCES: American Academy of Family Physicians http://www.familydoctor.org/ American Lung Association http://www.lungusa.org/ CANADIAN RESOURCES:

The Canadian Lung Association http://www.lung.ca/ Health Canada http://www.hc-sc.gc.ca/

Community-acquired pneumonia (CAP) is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of all ages. CAP often causes problems like difficulty in breathing, fever, chest pains, and a cough. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively (Wikipedia). Community acquired pneumonia is a type of pneumonia that occurred within 48 hours after admission. The nursing goal is the same as pneumonia, combat infection, provide supportive treatment, establishing effective airway and monitor for signs of respiratory distress.

Definition
Pneumonia is an infection of the lung parenchyma. Community-acquired pneumonia refers to pneumonia acquired outside of hospitals or extended-care facilities. Nursing home acquired pneumonia refers to infection acquired in an extended-care facility. Nosocomial pneumonia and hospital-acquired pneumonia describe infections acquired in the hospital setting. The signs and symptoms of acute pneumonia develop over hours to days, whereas the clinical presentation of chronic pneumonia often evolves over weeks to months.
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Prevalence
Despite a broad armamentarium of antimicrobials available to treat the disease, pneumonia remains the seventh leading cause of death in the United States.1 In 2003, the age-adjusted death rate caused by influenza and pneumonia was 20.3 per 100,000 persons. 1 Estimates of the incidence of community-acquired pneumonia range from 4 million to 5 million cases per year, with about 25% requiring hospitalization.2 Nosocomial pneumonia is estimated to occur in 250,000 persons per year, representing about 15% to 18% of all nosocomial infections.3,4
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Figure 1: Click to Enlarge

Microbiology
Streptococcus pneumoniae remains the most commonly identified pathogen in communityacquired pneumonia (Fig. 1). Other pathogens have been reported to cause pneumonia in the community, and their order of importance depends on the location and population studied (Table 1). These include long-recognized pathogens such asHaemophilus influenzae, Mycoplasma pneumoniae, and influenza A, along with newer pathogens such as Legionella species and Chlamydophilia pneumoniae. Other common causes in the immunocompetent patient include Moraxella catarrhalis, Mycobacterium tuberculosis, and aspiration pneumonia. The causative agent of community-acquired pneumonia remains unidentified in 30% to 50% of cases.5 Table 1: Identified Pathogens in Community-Acquired Pneumonia
Pathogen Cases (%)

Streptococcus pneumoniae

20-60

Haemophilus influenzae

3-10

Staphylococcus aureus

3-5

Gram-negative bacilli

3-10

Legionella species

2-8

Mycoplasma pneumoniae

1-6

Chlamydia pneumoniae

4-6

Viruses

2-15

Aspiration

6-10

Others

3-5

Adapted from Mandell LA, Bartlett JG, Dowell SF, et al: Update of practice guidelines for the management of communityacquired pneumonia in immunocompetent adults. Clin Infect Dis 2003;37:1405-1433. 2002 The Cleveland Clinic Foundation.

Previously seen mainly in extended-care facilities and acute-care hospitals, strains of methicillin-resistant Staphylococcus aureus (MRSA) have emerged as prevalent pathogens in community settings.6 Necrotizing pneumonia is a characteristically severe manifestation of these virulent strains. A new human pathogen, severe acute respiratory syndrome (SARS)-associated coronavirus, emerged and spread worldwide in the winter of 2002 to 2003. No cases have been identified since 2004. Data regarding this virus and its associated syndrome, SARS,7 can be found on the SARS page of the website of the Centers for Disease Control and Prevention (CDC), available at http://www.cdc.gov/ncidod/sars. Influenza continues to be a prevalent seasonal disease in the United States, causing considerable morbidity, loss of productivity, and mortality. A strain of H5N1 influenza has spread rapidly through avian flocks in Asia and Europe. Cases of transmission from birds to humans with severe disease have led to international concern about a possible avian influenza pandemic. Readers are encouraged to check the CDC influenza page, available at http://www.cdc.gov/flu/avian/index.htm, for updated prevention and treatment guidelines, as well as the latest epidemiologic information. Other viral causes of respiratory tract infections include parainfluenza virus, adenovirus, human metapneumovirus, herpes zoster virus (HSV), varicella-zoster virus (VZV), and measles. Many pathogens listed as potential agents of bioterrorism are spread by the respiratory route. Among the most likely candidates are Bacillus anthracis, Francisella tularensis, and Yersinia pestis. A more extensive discussion of the agents of bioterrorism can be found elsewhere in this section (Biologic Weapons and the Primary Care Clinician).

Nursing homeacquired pneumonias are often caused by community-acquired pathogens. However, there is an increased influence of pathogens seen with relatively low frequency in the community, such as S. aureus and gram-negative organisms.
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Pathophysiology
Six mechanisms have been identified in the pathogenesis of pneumonia in immunocompetent adults (Table 2). Inhalation of infectious particles is probably the most important pathogenetic mechanism in the development of community-acquired pneumonia, with particular importance of pneumonia caused by Legionella species and M. tuberculosis. Table 2: Pathogenetic Mechanisms in Pneumonia
Mechanism Frequency

Inhalation of infectious particles

Common

Aspiration of oropharyngeal or gastric contents

Common

Hematogenous deposition

Uncommon

Invasion from infection in contiguous structures

Rare

Direct inoculation

Less common

Reactivation

More common in immunocompromised hosts

2002 The Cleveland Clinic Foundation.

The aspiration of oropharyngeal or gastric contents is the most prevalent pathogenetic mechanism in nosocomial pneumonia, with several contributing factors. Swallowing and epiglottic closure may be impaired by neuromuscular disease, stroke, states of altered consciousness, or seizures. Endotracheal and nasogastric tubes interfere with these anatomic defenses and provide a direct route of entry for pathogens. Impaired lower esophageal sphincter function and nasogastric and gastrostomy tubes increase the risk of

aspiration of gastric contents. Fortunately, aspiration rarely leads to overt bacterial pneumonia. Direct inoculation rarely occurs as a result of surgery or bronchoscopy but may play a role in the development of pneumonia in patients supported with mechanical ventilation. Hematogenous deposition of bacteria in the lungs is also uncommon but is responsible for some cases of pneumonia caused by S. aureus, Pseudomonas aeruginosa, andEscherichia coli. The direct extension of infection to the lung from contiguous areas, such as the pleural or subdiaphragmatic spaces, is rare. Reactivation of pathogens can take place in the setting of deficits of cell-mediated immunity. Pathogens such asPneumocystis jiroveci, Mycobacterium tuberculosis, and cytomegalovirus can remain latent for many years after exposure, with flares of active disease occurring in the presence of immune compromise. Reactivation tuberculosis occasionally occurs in immunocompetent hosts. Once bacteria reach the tracheobronchial tree, defects in local pulmonary defenses can make infection more likely. The cough reflex can be impaired by stroke, neuromuscular disease, sedatives, or poor nutrition. Mucociliary transport is depressed with the aging process, tobacco smoking, dehydration, morphine, atropine, prior infection with influenza virus, and chronic bronchitis. Anatomic changes such as emphysema, bronchiectasis, and obstructive mass lesions prevent the clearance of microbes. Inflammatory cells drawn to infected areas of the pulmonary tree release proteolytic enzymes, altering the bronchial epithelium and ciliary clearance mechanisms and stimulating the production of excess mucus. Community-acquired MRSA strains contain Panton-Valentine leukocidin, a toxin that creates holes in neutrophil cell membranes, releasing chemotactic and inflammatory factors.7 A blunted cellular and humoral immune response can also increase the risk of pneumonia. For example, granulocyte chemotaxis is reduced with aging, diabetes mellitus, malnutrition, hypothermia, hypophosphatemia, and corticosteroids. Granulocytopenia may be caused by cytotoxic chemotherapy. Alveolar macrophages are rendered dysfunctional by corticosteroids, cytokines, viral illnesses, and malnutrition. Diminished antibody production or function can accompany hematologic malignancies such as multiple myeloma or chronic lymphocytic leukemia.
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History and physical examination

Because the clinical syndromes characterizing pneumonic infections caused by various agents often overlap one another and because interobserver variability regarding physical findings of pneumonia is high, the diagnosis of pneumonia can be challenging. A diligent history (Table 3) and physical examination can help narrow the differential diagnosis. In general, typical bacterial pathogens such as S. pneumoniae, H. influenzae, and the enteric gram-negative organisms usually manifest acutely with high fever, chills, tachypnea, tachycardia, and productive cough. Examination findings are localized to a specific lung zone and can include rales, rhonchi, bronchial breath sounds, dullness, increased fremitus, and egophony. In contrast, atypical pathogens such as Mycoplasma, Chlamydophilia, and viruses can manifest in a subacute fashion with fever, nonproductive cough, constitutional symptoms, and absent or diffuse findings on lung examination. Rapid progression of disease to respiratory failure can be seen in severe pneumococcal or Legionella pneumonia. Influenza may be complicated by bacterial pneumonia caused by S. aureus or S. pneumoniae. Table 3: Microbiologic Differential Diagnosis of Pneumonia: Historical Features
History Associated Organisms

Alcoholism

Streptococcus pneumoniae, oral anaerobes, Mycobacterium tuberculosis

Chronic obstructive lung disease (COPD)

S. pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Legionellaspp.

Exposure to bat or bird droppings, construction sites, caves

Histoplasma capsulatum

Exposure to birds

Chlamydia psittaci

Exposure to rabbits

Francisella tularensis

HIV infection

Typical bacterial pathogens, M. tuberculosis, Pneumocystis jiroveci, cytomegalovirus, Cryptococcus spp., Histoplasma spp., Coccidioides spp.

Travel to desert,

Coccidioides spp., Hantavirus (Sin Nombre virus)

southwest United States

Farm exposure

Coxiella burnetii (animals), Aspergillus spp. (barns, hay)

Postinfluenza

S. pneumoniae, S. aureus, Streptococcus pyogenes, H. influenzae

Aspiration

Mixed aerobic, anaerobic

Marijuana smoking

Aspergillus spp.

Anatomic abnormality of lung parenchyma, e.g., bronchiectasis, cystic fibrosis

Pseudomonas aeruginosa, Burkholderia cepacia, S. aureus

Injection drug use

S. aureus, anaerobes, M. tuberculosis, and S. pneumoniae

Obstruction of large airway

Anaerobes, S. pneumoniae, H. influenzae, S. aureus

Incarceration

M. tuberculosis

Neutropenia

Aspergillus spp., Zygomycetes

Asplenia

S. pneumoniae, H. influenzae

Adapted from Mandell LA, Bartlett JG, Dowell SF, et al: Update of practice guidelines for the management of communityacquired pneumonia in immunocompetent adults. Clin Infect Dis 2003;37:1405-1433. 2002 The Cleveland Clinic Foundation.

SARS manifests with high fever and myalgia for 3 to 7 days, followed by a nonproductive cough and progressive hypoxemia, with progression to mechanical ventilation in 20% of cases. This can be distinguished from other viral infections by the higher fever and lack of conjunctivitis, sneezing, rhinorrhea, and pharyngitis. Inhalation anthrax can manifest with

flulike symptoms of myalgia, fatigue, and fever before rapidly progressing to respiratory distress, mediastinitis, meningitis, sepsis, and death. The age of the patient can play an important role in disease presentation. Older patients often have humoral and cellular immunodeficiencies as a result of underlying diseases, immunosuppressive medications, and the aging process. They are more commonly institutionalized with anatomic problems that inhibit the pulmonary clearance of pathogens. The presentation is often more subtle than in younger adults, with more-advanced disease and sepsis, despite minimal fever and sputum production. Extrapulmonary physical findings can provide clues to the diagnosis. Poor dentition and foul-smelling sputum can indicate the presence of a lung abscess with an anaerobic component. Bullous myringitis can accompany infection with M. pneumoniae. An absent gag reflex or altered sensorium raises the question of aspiration. Encephalitis can complicate pneumonia caused by M. pneumoniae or Legionella pneumophila. Cutaneous manifestations of infection can include erythema multiforme (M. pneumoniae), erythema nodosum (C. pneumoniae and M. tuberculosis), or ecthyma gangrenosum (P. aeruginosa).
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Figure 2: Click to Enlarge

Diagnostic and treatment considerations

The composition of the diagnostic workup for pneumonia has been the subject of some disagreement among experts (see later, National Guidelines), but a well-chosen evaluation can support a diagnosis of pneumonia and identify a pathogen.

Radiography
A cornerstone of diagnosis is the chest x-ray, which is recommended for diagnosis in every circumstance and usually reveals an infiltrate (Fig. 2) at presentation. However, this finding

may be absent in the dehydrated patient. Also, the radiographic manifestations of chronic diseases such as congestive heart failure, chronic obstructive pulmonary disease (COPD), and malignancy can obscure the infiltrate of pneumonia. Although radiographic patterns are usually nonspecific, they can suggest a microbiologic differential diagnosis (Table 4). Table 4: Radiographic Patterns of Common Etiologic Agents
Chest Radiographic Pattern Pathogen

Focal; large pleural effusion

Usually bacteria

Cavitary

Bacterial abscess, fungi, acid-fast bacilli, Nocardia

Miliary

Acid-fast bacilli, fungi

Rapid progression/multifocal

Legionella spp., Pneumococcus, Staphylococcus

Interstitial

Viruses, Pneumocystis jiroveci, Mycoplasma, Chlamydia psittaci

Mediastinal widening without infiltrate

Inhalation anthrax

2002 The Cleveland Clinic Foundation.

Initial Management: Risk Stratification and Treatment Setting

When community-acquired pneumonia is strongly suspected on the basis of history, physical examination, and chest radiography, the next critical management decision is whether the patient requires hospital admission. Health care budgetary constraints have given rise to a number of studies addressing the need for hospitalization in communityacquired pneumonia. A study by the Patient Outcome Research Team (PORT) investigators has validated a risk scale, now called the pneumonia severity index (PSI), for mortality in community-acquired pneumonia. Point values are assigned to patient characteristics, comorbid illness, physical examination, and basic laboratory findings (Table 5).8 Patients younger than 50 years without comorbid illness or significant vital sign abnormalities (risk class I) were found to have a low risk for mortality. The authors suggested that such

patients might be eligible for outpatient antibiotic therapy without extensive laboratory evaluation. Table 5: Pneumonia Severity Index: Point Assignments in Community-Acquired Pneumonia
Risk Factor Point Value

Age

Men

Age (in yr)

Women

Age (in yr) 10

Nursing home resident

+10

Comorbid Illnesses

Neoplastic disease

+30

Liver disease

+20

Kidney disease

+10

Cerebrovascular disease

+10

Congestive heart failure

+10

Physical Findings

Altered mentation

+20

Tachypnea (>30 breaths/min)

+20

Systolic hypotension (<90 mm Hg)

+20

Body temperature (<35 or >40 C)

+15

Heart rate >125 beats/min

+10

Laboratory and Radiographic Findings

Blood pH (arterial) <7.35

+30

Hypoxemia (arterial Pao2<60 mm Hg or O2 saturation <90%)

+10

Serum urea nitrogen (BUN) >30 mg/dL

+20

Na <130 mEq/L

+20

Blood sugar >250 mg/dL

+10

Anemia (hematocrit <30%)

+10

Pleural effusion

10

Adapted from Kolleff MH, Micek ST: Methicillin-resistant Staphylococcus aureusa new community-acquired pathogen? Curr Opin Infect Dis 2006;19:161-168. 2002 The Cleveland Clinic Foundation.

All others were evaluated with the laboratory tests listed in Table 5 and assigned to risk classes by point totals (Table 6). Those in classes I and II are considered excellent candidates for outpatient oral therapy, assuming no hemodynamic instability, no chronic oxygen dependence, immunocompetence, and the ability to ingest, absorb, and adhere to an oral regimen. Patients in risk class III may be considered for outpatient or brief inpatient therapy, depending on clinical judgment. Patients in risk classes IV and V are recommended for hospital admission. Ultimately, each decision to admit must be individualized.

Table 6: Pneumonia Severity Index: Risk of 30-Day Mortality By Point Total

Risk Class Point Score Mortality (%)

No points assigned

0.1

II

<70

0.6

III

71-90

2.8

IV

91-130

8.2

>130

29.2

Adapted from Kolleff MH, Micek ST: Methicillin-resistant Staphylococcus aureusa new community-acquired pathogen? Curr Opin Infect Dis 2006;19:161-168. 2002 The Cleveland Clinic Foundation.

A slightly less complex scheme is the CRB-65. In this algorithm, patients are felt better served by hospitalization if they they meet more than of the following criteria: confusion, respiratory rate greater than 30 breaths per minute, blood pressure less than 90 mm Hg systolic or 60 mm Hg diastolic, or age older than 65 years.9

Diagnostic Testing
When the patient is not severely ill (ie outpatient treatment or not severely ill in the inpatient setting) and has few risk factors, the consensus guidelines of the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS)10 suggest empirical therapy without extensive laboratory evaluation (Box 1). When identification of a pathogen might change therapy, further studies are indicated (see Box 1). The value of such studies is not uniformly agreed on (see later, National Guidelines). However, pathogen identification has important implications for the breadth of therapeutic antibiotic spectrum, development of resistance, and epidemiology.
Box 1: Diagnostic Testing for Community-Acquired Pneumonia

All patients with suspected pneumonia

Chest radiography Complete blood count Complete metabolic profile Blood gases or pulse oximetry

Severely ill or immunocompromised patients, patients with anatomic lung disease

Sputum Gram stain and culture Blood cultures: two sets before antibiotics Legionella serology, urinary antigen, direct fluorescent antibody testing Pneumococcal urinary antigen testing

Inpatients with appropriate history or physical findings

HIV serology Mycoplasma serology Chlamydia serology Fungal serology SARS-associated coronavirus serology or PCR Stains or cultures for fungi, mycobacteria, Pneumocystis jiroveci Analysis or cultures of pleural or cerebrospinal fluid Nasopharyngeal swab for viral direct fluorescent antibody or other rapid technique Tuberculin skin testing

Deteriorating patient without definitive diagnosis of cause

Bronchoscopy (bronchoalveolar lavage, protected catheter, transbronchial biopsy) Thoracoscopic or open-lung biopsy Radiographically guided transthoracic aspirate Legionella, Chlamydia, Mycoplasma serology Fungal serology Evaluation for congestive heart failure, pulmonary embolus, neoplasm, connective tissue disease

PCR, polymerase chain reaction; PORT, Patient Outcome Research Team; SARS, severe acute respiratory syndrome. Adapted Mandell LA, Wunderink RG, Anzueto A, et al; Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-

acquired pneumonia in adults. Clin Infect Dis 2007;44 Suppl 2:S27-S72. 2004 The Cleveland Clinic Foundation.

A Gram-stained sputum specimen can help focus empirical therapy. Unfortunately, sputum is often difficult to obtain from older patients because of a weak cough, obtundation, and dehydration. Nebulized saline treatments might help mobilize secretions. Nasotracheal suctioning can sample the lower respiratory tract directly but risks oropharyngeal contamination. A sputum specimen reflects lower respiratory secretions when more than 25 white blood cells (WBCs) and fewer than 10 epithelial cells are seen in a low-powered microscopic field.11 Empirical therapy based on a predominant organism in such a specimen is likely to contain appropriate coverage.12 Other stains, such as the acid-fast stain for mycobacteria, modified acid-fast stain for Nocardia, or toluidine blue and Gomori's methenamine silver stains should be used when directed by the history or clinical presentation. Direct fluorescent antibody (DFA) staining of sputum, bronchoalveolar lavage fluid, or pleural fluid can help identify Legionellaspecies. Similarly, DFA testing of nasopharyngeal specimens provides rapid diagnosis of influenza types A and B, as well as other common respiratory viruses such as respiratory syncytial virus, adenovirus, and parainfluenza virus. In an outbreak setting, DFA and other rapid techniques can assist in decision making for therapy and infection control. The sputum culture remains a controversial tool but is useful to help tailor therapy when the patient is severely ill, has a history of structural lung disease or alcohol abuse, has pleural effusion, or has evidence of pneumococcal or Legionellainfection. Culture is particularly helpful for identifying organisms of epidemiologic significance, either for patterns of transmission or resistance. Expectorated morning sputum specimens should be sent for mycobacterial culture when the history is suggestive. Blood cultures can also shed light on a pathogen, and samples should be drawn in severely ill or immunocompromised patients (see later, Outcomes). Pleural or cerebrospinal fluid should be sampled when infections in these spaces are suspected. When these procedures fail to yield a microbiologic diagnosis and when the patient does not respond to empirical antibiotic therapy, more-invasive diagnostic techniques may be indicated. Fiberoptic bronchoscopy allows the use of several techniques for the diagnosis of pneumonia. Bronchoalveolar lavage with saline can obtain deep respiratory specimens for

the gamut of stains and cultures mentioned earlier. Transbronchial biopsy of lung parenchyma can reveal alveolar or interstitial pneumonitis, viral inclusion bodies, and fungal or mycobacterial elements. The protected brush catheter is used to distinguish quantitatively between tracheobronchial colonizers and pneumonic pathogens. A more substantial amount of lung tissue may be obtained for culture and histologic examination by thoracoscopic or open lung biopsy. Because these procedures can carry considerable morbidity, they are usually reserved for the deteriorating patient with a pneumonia that defies diagnosis by less-invasive techniques.

Serologic Testing
Often relegated to retrospective or epidemiologic interest because of delays in testing or reporting, serologic testing for such pathogens as Legionella species, Mycoplasma species, and C. pneumoniae should include sera drawn in the acute and convalescent phases for comparison. A fourfold increase in the immunoglobulin G (IgG) titer suggests recent infection with these organisms. An IgM microimmunofluorescence titer of more than 1:16 is considered diagnostic of C. pneumoniae infection. Infection with SARS-associated coronavirus is most often diagnosed by antibody testing and polymerase chain reaction (PCR) testing. A sensitive enzyme immunoassay has been developed for the detection of L. pneumophila type 1 antigen in urine. Because the antigen persists for up to 1 year after infection, it is difficult to differentiate between past and current infections when using this assay. A urinary assay is also available for detecting S. pneumoniae cell wall polysaccharide. This assay may offer some advantage for the rapid diagnosis of pneumococcal pneumonia in culture-proven or unknown cases, but assay specificity is an ongoing question.

Molecular Techniques
Powerful molecular techniques are now being applied to the early diagnosis of pneumonia. DNA probes have been used to detect Legionella species, M. pneumoniae, and M. tuberculosis in sputum. These probes have excellent sensitivity and specificity but can yield false-positive results. The PCR assay has been used for the early detection of various pathogens that are difficult or slow to culture from sputum specimens, including atypical bacteria, viruses (e.g., influenza), and mycobacteria. Given the large percentage of pneumonia cases for which no microbial cause is identified, it is likely that molecular tools

will eventually be applied to the identification and antimicrobial susceptibility testing of almost all causative agents of pneumonia.
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Summary

The patient's history can help narrow the microbial differential diagnosis. The chest radiograph is the cornerstone of diagnosis. The sputum Gram stain and culture are controversial, but they are still useful for targeting antimicrobial therapy when the patient is severely ill or immunocompromised. Serologic testing is slow and therefore often not useful for real-time diagnosis. Molecular methods are playing an increasing role in identifying difficult-to-culture pathogens. The pneumonia severity index uses history, examination, chest radiograph, and initial laboratory test results to identify low-risk patients for outpatient treatment.

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Antimicrobial treatment
Community-Acquired Pneumonia
Antibiotic therapy for community-acquired pneumonia should always be selected with patient characteristics, place of acquisition, and severity of disease in mind. With concerns about antimicrobial overuse, health care costs, and bacterial resistance increasing, many experts believe that therapy should always follow confirmation of the diagnosis of pneumonia and should always be accompanied by a diligent effort to identify a causative agent (see later, National Guidelines). When a specific pathogen is identified, pathogenspecific therapy can be used (Table 7). Table 7: Pathogen-Specific Therapy for Community-Acquired Pneumonia in Adults
Organism Primary Therapy

Streptococcus pneumoniae,penicillinsusceptible

Penicillin G; amoxicillin

S. pneumoniae, penicillin-resistant

Cefotaxime, ceftriaxone, fluoroquinolone, vancomycin, others, based on susceptibility studies

Haemophilus influenzae

Second- or third-generation cephalosporin, doxycycline, beta-lactam or beta-lactamase inhibitor, azithromycin, TMP-SMX

Moraxella catarrhalis

Second- or third-generation cephalosporin, TMP-SMX macrolide, beta-lactam or beta-lactamase inhibitor

Legionella spp.

Macrolide, tetracycline, fluoroquinolone alone

Mycoplasma pneumoniae

Doxycycline, macrolide

Chlamydia pneumoniae

Doxycycline, macrolide

Anaerobes

Beta-lactam or beta-lactamase inhibitor, clindamycin

Enteric gram-negative bacilli

Third-generation cephalosporin aminoglycoside; carbapenem

Pseudomonas aeruginosa

Aminoglycoside + ticarcillin, piperacillin, mezlocillin, ceftazidime, cefepime, aztreonam, or carbapenem

Staphylococcus aureus, methicillinsusceptible

Nafcillin or oxacillin

S. aureus, methicillin-resistant

Vancomycin or linezolid

Bacillus anthracis

Ciprofloxacin or doxycycline + two of the following: rifampin, vancomycin, penicillin, ampicillin, chloramphenicol, imipenem, clindamycin, clarithromycin

Influenza A, within 48 hr of symptom onset or immunocompromised host

Amantidine, rimantadine, oseltamivir, zanamivir

Influenza B, within 48 hr of symptom onset or immunocompromised host

*

Oseltamivir, zanamivir

For community-acquired methicillin-resistant S. aureus, some clinicians add agents that inhibit toxin production, such as

clindamycin, when susceptibility patterns allow. TMP-SMX, trimethoprim-sulfamethoxazole. Adapted from Mandell LA, Wunderink RG, Anzueto A, et al; Infectious Diseases Society of America; American Thoracic Society: Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44 Suppl 2:S27-S72. 2003 The Cleveland Clinic Foundation.

When a pathogen is yet to be identified, empirical therapy is instituted. A number of expert panels have recommended empirical pneumonia therapy, most prominently IDSA and ATS (Table 8). Table 8: Empirical Antimicrobial Therapy for Community-Acquired Pneumonia In Immunocompetent Adults
Patient, Setting Common Pathogens Empirical Therapy

Outpatients

<60 yr No comorbid diseases

Streptococcus pneumoniae Mycoplasma pneumoniae Chlamydia pneumoniae Haemophilus influenzae Viruses

Macrolide or doxycycline

>65 yr or with comorbid disease or antibiotic therapy within last 3 mo

S. pneumoniae (drugresistant) M. pneumoniae C. pneumoniae H. influenzae Viruses Gram-negative bacilli S. aureus

Macrolide or doxycycline fluoroquinolone* Beta-lactam and macrolide

Inpatients

Not severely ill

S. pneumoniae H. influenzae Polymicrobial Anaerobes S. aureus C. pneumoniae Viruses

Macrolide and cefotaxime or ceftriaxone, or betalactam or beta-lactamase inhibitor; fluoroquinolonealone

Severely ill

S. pneumoniae Legionella spp. Gram-negative bacilli M. pneumoniae Viruses S. aureus

Azithromycin, or fluoroquinolone and cefotaxime, ceftriaxone, or beta-lactam or beta-lactamase inhibitor If P. aeruginosa possibleIV macrolide or fluoroquinolone and aminoglycoside IV, or antipseudomonal quinolone and antipseudomonal beta-lactam If MRSA possible, add vancomycin or linezolid

In the outpatient setting, many authorities prefer to reserve fluoroquinolones (levofloxacin, gatifloxacin, moxifloxacin,

gemifloxacin) for patients with comorbid diseases or risk factors.

In most cases, patients with pneumonias caused by these organisms should be hospitalized. Levofloxacin, gatifloxacin, moxifloxacin. Critically ill patients in areas with significant rates of high-level pneumococcal resistance and a suggestive sputum Gram

stain should receive vancomycin or a newer quinolone pending microbiologic diagnosis.

Piperacillin-tazobactam or ampicillin-sulbactam.

Cefpodoxime, cefuroxime, high-dose amoxicillin, amoxicillin-clavulanate, or parenteral ceftriaxone followed by oral cefpodoxime. **Cefotaxime, ceftriaxone, ampicillin-sulbactam, or high-dose ampicillin Adapted from Mandell LA, Wunderink RG, Anzueto A, et al; Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44 Suppl 2:S27-S72. 2003 The Cleveland Clinic Foundation.

Aspiration Pneumonia
Clindamycin is preferred over penicillin for the treatment of community-acquired aspiration pneumonia because of its superiority for treating oral anaerobes such as Bacteroides melaninogenicus. Amoxicillin-clavulanic acid also provides excellent coverage in this setting. When large-volume aspiration is documented in the hospital, a beta-lactambeta-

lactamase inhibitor combination or the combination of clindamycin and an antipseudomonal agent should be used.

Other Considerations
Anthrax
Suspected or proven inhalation anthrax should be treated with ciprofloxacin or doxycycline and two other agents (see Table 7). Clinical experience has suggested that rifampin may be an important agent in empirical regimens.13

Duration of Therapy
Although few data specifically address the duration of therapy, many cases of pneumonia are adequately treated with 10 to 14 days of antibiotics. Longer courses may be required for certain organisms that cause tissue necrosis, (e.g., Legionellaspp., S. aureus, Pseudomonas aeruginosa), organisms that live intracellularly (e.g., C. pneumoniae), or comorbidities that compromise local (COPD) or systemic (hematologic malignancy) immunity.

Oral and Switch Therapies

The use of oral or switch therapies offers potential reductions in duration of stay, antibiotic administration costs, complications of venous access, and disruption of families and careers. Many antibiotics are well absorbed from the gastrointestinal tract, suggesting the possibility of effective fully oral treatment. Because well-controlled, risk-stratified data comparing oral and intravenous therapies are few, appropriate patient populations and treatment settings for full-course oral therapy have yet to be fully defined. Better data exist for the use of IV to oral switch therapies for the stable patient who has good gastrointestinal and swallowing function and adequate social support.14

Failure to Respond to Initial Therapy

Worsening of clinical status despite adequate antibiotic therapy should trigger a reassessment of the original clinical impression. First, the diagnosis of infection must be questioned. Entities such as cancers, pulmonary edema, pulmonary embolus, pulmonary hemorrhage, connective tissue diseases, or drug toxicity can mimic the clinical and radiographic appearance of pneumonia. Organisms with inherent (e.g., fungi, mycobacterial, P. jiroveci) or acquired (Pseudomonas aeruginosa) resistance to drugs commonly used in pneumonia therapy must also be considered. A secondary infection, such as postinfluenza staphylococcal pneumonia, might prove resistant to initial therapy. The patient might fail to respond for reasons of poor adherence, poor drug absorption, or

drug interaction. Finally, immunodeficiency (e.g., HIV, hematologic malignancy) or anatomic derangement (e.g., COPD, bronchiectasis, neoplasm) can alter the clinical course of pneumonia and treatment.

Discharge Criteria
Criteria for hospital discharge in community-acquired pneumonia are based on common sense. Candidates for discharge should have no more than one of the following poor prognostic indicators: temperature higher than 37.8 C, pulse higher than 100 beats/min, respiratory rate higher than 24/min, systolic blood pressure lower than 90 mm Hg, oxygen saturation lower than 90%, and inability to maintain oral intake.
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Summary

Antibiotic therapy for community-acquired pneumonia should always be selected with patient characteristics, place of acquisition, severity of disease, and local resistance patterns in mind. Antimicrobial therapy should be narrowed whenever a pathogen is identified. Most pneumonias, with some exceptions, can be cured with 10 to 14 days of antibiotic therapy. Switching to oral therapy is possible and desirable once the patient stabilizes. Failure to respond to initial therapy should raise questions of diagnosis, treatment adherence, and antimicrobial resistance.

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Prevention
Immunization against influenza and increasingly resistant pneumococci can play a critical role in preventing pneumonia, particularly in immunocompromised and older adults. The influenza vaccine is formulated and administered annually. The Centers for Disease Control and Prevention (CDC) recommends that vaccines be offered to persons older than 50 years, residents of extended-care facilities, and patients who have chronic heart and lung disorders, chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression.15 The pneumococcal vaccine has been shown to be 60% to 70% effective in immunocompetent patients. Side effects are rarely serious and consist of local pain and

erythema, which occur in up to 50% of recipients. The CDC recommends that vaccines be offered to all persons 65 years of age or older, those at increased risk for illness and death from pneumococcal disease because of chronic illness, those with functional or anatomic asplenia, and immunocompromised persons.16 Patients who are immunosuppressed by chronic disease or treatment might not have sustained titers of protective antibody and should be considered for revaccination after 6 years. Residual immunity against Bordetella pertussis wanes over time, leading to transmission from older adults to other adults and infants. Because secondary bacterial pneumonia occurs in a significant number of cases of pertussis, the ACIP (Advisory Committee on Immunization Practices) has recommended that the tetanus-diphtheria-acellular pertussis (Tdap) vaccine replace the tetanus-diphtheria (Td) vaccine in the adult immunization schedule.17 The emergence of SARS, with significant spread in hospitals, forced an extensive reassessment of respiratory infection control in many institutions. Measures to prevent the spread of SARS-associated coronavirus include close attention to cough hygiene, hand hygiene, contact precautions, and respiratory droplet precautions.
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National guidelines
A number of expert bodies have developed guidelines for the diagnosis and management of community-acquired pneumonia. The most often cited are the guidelines of IDSA and ATS.2 Thoughtful and comprehensive, these guidelines provide recommendations for the evaluation and treatment of the patient with community-acquired pneumonia driven by data, when available. Recommendations are classified by strength of supporting data; recommendations formed on the basis of opinion rather than data are identified. There is support for the use of the PSI and CRB scoring systems for risk stratification. Treatment recommendationsare closely aligned with prior guidelines from the individual organizations. Compromise has been reached between the two organizations regarding the diagnostic evaluation of community-acquired pneumonia. Concerns of drug resistance and epidemiologic tracking have been noted, as have been concerns about lack of sensitivity and specificity in microbiologic testing. The resulting recommendations minimize testing for uncomplicated cases of pneumonia, allowing more extensive testing for sicker patients.

Guidelines for the home care of pneumonia have been published. These seek to ensure the administration of well-tolerated antimicrobial therapy and ongoing professional evaluation. 18 When new respiratory pathogens emerge or major flares of well-known respiratory diseases occur, information develops quickly and guidelines are altered on a real-time basis. In such situations, the websites of the CDC, World Health Organization, IDSA, and state and local health departments often contain updated authoritative information and guidelines to assist the practitioner.
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Outcomes and performance measures

Pneumonia-related outcomes have been measured in several areas. In the area of microbiology, Metlay and colleagues have noted that patients with pneumococci not susceptible to penicillin are more likely to develop suppurative complications than patients infected with susceptible isolates.19 Overall, pneumococcal pneumonia has been shown by Fine and associates to carry a mortality rate of 12%.20 This level of mortality is exceeded only by Legionella species among community-acquired pathogens. Several pathogens more associated with long-term care facilities, including P. aeruginosa(61%) and S. aureus (32%), carry substantially higher mortality. Samples for blood cultures drawn within 24 hours of hospital admission have been associated with improvement in 30-day mortality.21 Antibiotic therapy initiated within 4 hours of hospital admission has been shown to improve mortality and length of hospital stay in all pneumonia patients.5,22 Adherence to the IDSA guidelines for antimicrobial therapy improves mortality in patients with community-acquired pneumonia in intensive care units.23 With regard to site of care, the PORT data have suggested a less than 1% risk of 30-day mortality for pneumonia sufferers falling into risk classes I and II of the pneumonia severity index, suggesting the possibility of outpatient care for this group. A home hospital model of care with daily home physician visits can reduce the duration of acute care and overall treatment costs in older patients.24 IV-to-oral switch therapy has been shown to yield no significant reduction in outcome when the switch is instituted after clinical stability. 12 The Centers for Medicare and Medicaid Services are moving forward with pay-forperformance measures, including certain parts of the IDSA/ATS practice guidelines, as a means of promoting hospital quality. Among the measures adopted are assessment of oxygenation, screening for pneumococcal vaccination, blood cultures before first antibiotic

dose, assessment for smoking cessation, antibiotics within 4 to 6 hours of arrival at the hospital, and correct choice of antibiotics.
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References
1. Hoyert DL, Heron MP, Murphy SL, Kung HC. Deaths: Final data for 2003. Natl Vital Stat Rep. 2006, 54: (13): 1-120. 2. American Thoracic Society. Guidelines for the initial management of adults with community-acquired pneumonia: Diagnosis, assessment of severity, and initial antimicrobial therapy. Am J Resp Crit Care Med. 2001, 163: 1730-1754. 3. Wiblin RT, Wenzel RP. Hospital-acquired pneumonia. Curr Clin Top Infect Dis. 1996, 16: 194-214. 4. Bassin AS, Niederman MS. New approaches to prevention and treatment of nosocomial pneumonia. Semin Thorac Cardiovasc Surg. 1995, 7: 70-77. 5. Mandell LA, Bartlett JG, Dowell SF, et al: Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis. 2003, 37: 1405-1433. 6. Kolleff MH, Micek ST. Methicillin-resistant Staphylococcus aureusa new community-acquired pathogen? Curr Opin Infect Dis. 2006, 19: 161-168. 7. Peiris JS, Yuen KY, Osterhaus AD, Stohr K. The severe acute respiratory syndrome. N Engl J Med. 2003, 349: 2431-2441. 8. Fine MJ, Auble TE, Yealy DM, et al: A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997, 336: 243-250. 9. Lim WS, van der Eerden MM, Laing R, et al: Defining community acquired pneumonia severity on presentation to hospital: An international derivation and validation study. Thorax. 2003, 58: (5): 377-382. 10. Mandell LA, Wunderink RG, Anzueto A, et al: Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007, 44: (Suppl 2): S27S72. 11. Murray PR, Washington JA. Microscopic and bacteriologic analysis of expectorated sputum. Mayo Clin Proc. 1975, 50: 339-344. 12. Gleckman R, DeVita J, Hibert D, et al: Sputum gram stain assessment in community-acquired bacteremic pneumonia. J Clin Microbiol. 1988, 26: 846-849.

13. Centers for Disease Control and Prevention. Update: Investigation of bioterrorismrelated anthrax and interim guidelines for exposure management and antimicrobial therapy, October 2001. MMWR Morb Mortal Wkly Rep. 2001, 50: 909-919. 14. Cassiere HA, Fein AM. Duration and route of antibiotic therapy in patients hospitalized with community-acquired pneumonia: Switch and step-down therapy. Semin Resp Infect. 1998, 13: 36-42. 15. Centers for Disease Control and Prevention. Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2005, 54: (RR-08): 1-40. 16. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1997, 46: (RR-08): 1-24. 17. Centers for Disease Control and Prevention. Vaccines and preventable diseases: Combined Tdap vaccine. Available at http://www.cdc.gov/vaccines/vpd-vac/combovaccines/DTaP-Td-DT/tdap.htm(accessed March 9, 2009) 18. Ramsdell J, Narsvage GL, Fink JB, et al: Management of community-acquired pneumonia in the home. Chest. 2005, 127: 1752-1763. 19. Metlay JP, Hofmann J, Cetron MS, et al: Impact of penicillin susceptibility on medical outcomes for adult patients with bacteremic pneumococcal pneumonia. Clin Infect Dis. 2000, 30: 520-528. 20. Fine MJ, Smith MA, Carson CA, et al: Prognosis and outcomes of patients with community-acquired pneumonia. A meta-analysis. JAMA. 1996, 274: 134-141. 21. Arbo MDJ, Snydman DR. Influence of blood culture results on antibiotic choice in treatment of bacteremia. Arch Intern Med. 1994, 154: 2641. 22. Houck PM, Bratzler DW, Nsa W, et al: Timing of antibiotic administration and outcomes for Medicare patients hospitalized with pneumonia. Arch Intern Med. 2004, 164: 637-644. 23. Bodi M, Rodriguez A, Sole-Violan J, et al: Antibiotic prescription for communityacquired pneumonia in the intensive care unit: Impact of adherence to Infectious Diseases Society of America guidelines on survival. Clin Infect Dis. 2005, 41: 17091716. 24. Leff B, Burton L, Mader SL, et al: Hospital at home: Feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005, 143: 798-808.
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Suggested Readings

American Thoracic Society. Guidelines for the initial management of adults with community-acquired pneumonia: Diagnosis, assessment of severity, and initial antimicrobial therapy. Am J Resp Crit Care Med. 2001, 163: 1730-1754. Cassiere HA, Fein AM. Duration and route of antibiotic therapy in patients hospitalized with community-acquired pneumonia: Switch and step-down therapy. Semin Resp Infect. 1998, 13: 36-42. Centers for Disease Control and Prevention. Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2005, 54: (RR-08): 1-40. Centers for Disease Control and Prevention. Prevention of pneumococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1997, 46: (RR-08): 1-24. Centers for Disease Control and Prevention. Update: Investigation of bioterrorismrelated anthrax and interim guidelines for exposure management and antimicrobial therapy, October 2001. MMWR Morb Mortal Wkly Rep. 2001, 50: 909-919. Fine MJ, Auble TE, Yealy DM, et al: A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997, 336: 243-250. Fine MJ, Smith MA, Carson CA, et al: Prognosis and outcomes of patients with community-acquired pneumonia. A meta-analysis. JAMA. 1996, 274: 134-141. Houck PM, Bratzler DW, Nsa W, et al: Timing of antibiotic administration and outcomes for Medicare patients hospitalized with pneumonia. Arch Intern Med. 2004, 164: 637-644. Mandell LA, Bartlett JG, Dowell SF, et al: Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis. 2003, 37: 1405-1433. Mandell LA, Wunderink RG, Anzueto A, et al: Infectious Diseases Society of America; American Thoracic Society: Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007, 44: (Suppl 2): S27S72. Peiris JS, Yuen KY, Osterhaus AD, Stohr K. The severe acute respiratory syndrome. N Engl J Med. 2003, 349: 2431-2441.

Community-acquired pneumonia
From Wikipedia, the free encyclopedia

Community-acquired pneumonia (CAP) is a term used to describe one of several diseases in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of all ages. CAP often causes problems like difficulty in breathing, fever, chest pains, and a cough. CAP occurs because the areas of the lung which absorb oxygen(alveoli) from the atmosphere become filled with fluid and cannot work effectively. CAP occurs throughout the world and is a leading cause of illness and death. Causes of CAP include bacteria, viruses, fungi, and parasites. CAP can be diagnosed by symptoms and physical examination alone, though x-rays, examination of the sputum, and other tests are often used. Individuals with CAP sometimes require treatment in a hospital. CAP is primarily treated with antibiotic medication. Some forms of CAP can be prevented by vaccination.[1]
Contents
[hide]

1 Signs and symptoms 2 Cause

o o o o

2.1 Infants 2.2 Children 2.3 Adults 2.4 Risk factors

3 Pathophysiology 4 Diagnosis 5 Treatment

o o o o

5.1 Newborns 5.2 Children 5.3 Adults 5.4 Hospitalize

6 Prognosis 7 Complications
o o o

7.1 Sepsis 7.2 Respiratory failure 7.3 Pleural effusion and empyema

7.4 Abscess

8 Epidemiology 9 Prevention 10 References

[edit]Signs

and symptoms

Symptoms of CAP commonly include:

problems breathing coughing that produces greenish or yellow sputum a high fever that may be accompanied with sweating, chills, and uncontrollable shaking sharp or stabbing chest pain rapid, shallow breathing that is often painful

Less common symptoms include:

the coughing up of blood (hemoptysis) headaches (including migraine headaches) loss of appetite excessive fatigue blueness of the skin (cyanosis) nausea vomiting diarrhea joint pain (arthralgia) muscle aches (myalgia)

The manifestations of pneumonia, like those for many conditions, might not be typical in older people. They might instead experience:

new or worsening confusion hypothermia falls*

Additional symptoms for infants could include:

being overly sleepy yellowing of the skin (jaundice) difficulties feeding[2]

[edit]Cause There are over a hundred microorganisms which can cause CAP. The most common types of microorganisms are different among different groups of people. Newborn infants, children, and adults are at risk for different spectrums of disease causing microorganisms. In addition, adults with chronic illnesses, who live in certain parts of the world, who reside in nursing homes, who have recently been treated withantibiotics, or who are alcoholics are at risk for unique infections. Even when aggressive measures are taken, a definite cause for pneumonia is only identified in half the cases. [edit]Infants Newborn infants can acquire lung infections prior to being born either by breathing infected amniotic fluid or by blood-borne infection across the placenta. Infants can also inhale (aspirate) fluid from the birth canal as they are being born. The most important infection in newborns is caused by Streptococcus agalactiae, also known as Group B Streptococcus or GBS. GBS causes at least 50% of cases of CAP in the first week of life.[3] Other bacterial causes in the newborn period include Listeria monocytogenes and tuberculosis. Viruses can also be transferred from mother to child; herpes simplex virus is the most common and life-threatening, but adenovirus, mumps, and enterovirus can also cause disease. CAP in older infants reflects increased exposure to microorganisms. Common bacterial causes include Streptococcus pneumoniae,Escherichia coli, Klebsiella pneumoniae, Moraxella catarrhalis, and Staphylococcus aureus. A unique cause of CAP in this group isChlamydia trachomatis, which is acquired during birth but which does not cause pneumonia until 24 weeks later. Maternally-derived syphiliscan be a cause of CAP in this age group. Common viruses include respiratory syncytial virus (RSV), metapneumovirus, adenovirus,parainfluenza, influenza, and rhinovirus. RSV in particular is a common source of illness and hospitalization.[4] Fungi and parasites are not typically encountered in otherwise healthy infants. [edit]Children

For the most part, children older than one month of life are at risk for the same microorganisms as adults. However, children less than five years are much less likely to have pneumonia caused by Mycoplasma pneumoniae, Chlamydophil pneumoniae, or Legionella pneumophila. In contrast, older children and teenagers are more likely to acquire Mycoplasma pneumoniae and Chlamydophila pneumoniae than adults.[5] [edit]Adults The full spectrum of microorganisms is responsible for CAP in adults. Several important groups of organisms are more common among people with certain risk factors. Identifying people at risk for these organisms is important for appropriate treatment.

Viruses Viruses cause 20% of CAP cases. The most common viruses are influenza, parainfluenza, respiratory syncytial virus, metapneumovirus, and adenovirus. Less common viruses causing significant illness include chicken pox, SARS, avian flu, and hantavirus.[6]

Atypical organisms The most common bacterial causes of pneumonia are the so-called atypical bacteria Mycoplasma pneumoniae and Chlamydophila pneumoniae. Legionella pneumophila is considered atypical but is less common. Atypical organisms are more difficult to grow, respond to different antibiotics, and were discovered more recently than the typical bacteria discovered in the early twentieth century.

Streptococcus pneumoniae

Streptococcus pneumoniae is a common bacterial cause of CAP (most common cause in UK). Prior to the development of antibiotics and vaccination, it was a leading cause of death. Traditionally highly sensitive to penicillin, during the 1970s resistance to multiple antibiotics began to develop. Current strains of "drug resistant Streptococcus pneumoniae" or DRSP are common, accounting for twenty percent of all Streptococcus pneumoniae infections. Adults with risk factors for DRSP including being older than 65, having exposure to children inday care, having alcoholism or other severe underlying disease, or recent treatment with antibiotics should initially be treated with antibiotics effective against DRSP.[7]

Hemophilus influenzae

Hemophilus influenzae is another common bacterial cause of CAP. First discovered in 1892, it was initially believed to be the cause of influenza because it commonly causes CAP in people who have suffered recent lung damage from viral pneumonia.

Enteric Gram negative bacteria

The enteric Gram negative bacteria such as Escherichia coli and Klebsiella pneumoniae are a group of bacteria that typically live in the human intestines. Adults with risk factors for infection including residence in a nursing home, serious heart and lung disease, and recent antibiotic use should initially be treated with antibiotics effective against Enteric Gram negative bacteria.

Pseudomonas aeruginosa

Pseudomonas aeruginosa is an uncommon cause of CAP but is a particularly difficult bacteria to treat. Individuals who are malnourished, have a lung disease called bronchiectasis, are on corticosteroids, or have recently had strong antibiotics for a week or more should initially be treated with antibiotics effective against Pseudomonas aeruginosa.[8] Many less common organisms cause CAP. They are typically identified because an individual has special risk factors or after treatment for the common causes has failed. These rarer causes are covered in more detail in their specific pages: bacterial pneumonia, viral pneumonia,fungal pneumonia, and parasitic pneumonia. [edit]Risk

factors

Some people have an underlying problem which increases their risk of getting an infection. Some important situations are covered below: Obstruction When part of the airway (bronchi) leading to the alveoli is obstructed, the lung is not able to clear fluid when it accumulates. This can lead to infection of the fluid resulting in CAP. One cause of obstruction, especially in young children, is inhalation of a foreign object such as a marble or toy. The object is lodged in the

small airways and pneumonia can form in the trapped areas of lung. Another cause of obstruction islung cancer, which can grow into the airways block the flow of air. Lung disease People with underlying lung disease are more likely to develop CAP. Diseases such as emphysema or habits such as smoking result in more frequent and more severe bouts of CAP. In children, recurrent episodes of CAP may be the first clue to diseases such as cystic fibrosisor pulmonary sequestration. Immune problems People who have immune system problems are more likely to get CAP. People who have AIDS are much more likely to develop CAP. Other immune problems range from severe immune deficiencies of childhood such as Wiskott-Aldrich syndrome to less severe deficiencies such ascommon variable immunodeficiency.[9] [edit]Pathophysiology The symptoms of CAP are the result of both the invasion of the lungs by microorganisms and the immune system's response to the infection. The mechanisms of infection are quite different for viruses and the other microorganisms.

Viruses

Viruses must invade cells in order to reproduce. Typically, a virus will reach the lungs by traveling in droplets through the mouth and nosewith inhalation. There, the virus invades the cells lining the airways and the alveoli. This invasion often leads to cell death either through direct killing by the virus or by self-destruction through apoptosis. Further damage to the lungs occurs when the immune system responds to the infection. White blood cells, in particular lymphocytes, are responsible for activating a variety of chemicals (cytokines) which cause leaking of fluid into the alveoli. The combination of cellular destruction and fluid-filled alveoli interrupts the transportation of oxygen into the bloodstream. In addition to the effects on the lungs, many viruses affect other organs and can lead to illness

affecting many different bodily functions. Viruses also make the body more susceptible to bacterial infection; for this reason, bacterial pneumonia often complicates viral CAP.

Bacteria and fungi

Bacteria and fungi also typically enter the lung with inhalation, though they can reach the lung through the bloodstream if other parts of the body are infected. Often, bacteria live in parts of the upper respiratory tract and are constantly being inhaled into the alveoli. Once inside the alveoli, bacteria and fungi travel into the spaces between the cells and also between adjacent alveoli through connecting pores. This invasion triggers the immune system to respond by sending white blood cells responsible for attacking microorganisms (neutrophils) to the lungs. The neutrophils engulf and kill the offending organisms but also release cytokines which result in a general activation of the immune system. This results in the fever, chills, and fatigue common in CAP. The neutrophils, bacteria, and fluid leaked from surrounding blood vessels fill the alveoli and result in impaired oxygen transportation. Bacteria often travel from the lung into the blood stream and can result in serious illness such as septic shock, in which there is low blood pressure leading to damage in multiple parts of the body including the brain, kidney, and heart.

Parasites

There are a variety of parasites which can affect the lungs. In general, these parasites enter the body through the skin or by being swallowed. Once inside the body, these parasites travel to the lungs, most often through the blood. There, a similar combination of cellular destruction and immune response causes disruption of oxygen transportation. [edit]Diagnosis Individuals with symptoms of CAP require further evaluation. Physical examination by a health provider may reveal fever, an increasedrespiratory rate (tachypnea), low blood pressure (hypotension), a fast heart rate (tachycardia), and/or changes in the amount of oxygen in theblood. Feeling the way the chest expands (palpation) and tapping the chest wall

(percussion) to identify dull areas which do not resonate can identify areas of the lung which are stiff and full of fluid (consolidated). Examination of the lungs with the aid of a stethoscope can reveal several things. A lack of normal breath sounds or the presence of crackling sounds (rales) when the lungs are listened to (auscultated) can also indicate consolidation. Increased vibration of the chest when speaking (tactile fremitus) and increased volume of whispered speech during auscultation of the chest can also reveal consolidation.[10]

Pneumonia. Chest x-ray showing increased shadowing in right lung (left side of image). (Source: Center for Disease Control and Prevention.)

X-rays of the chest, examination of the blood and sputum for infectious microorganisms, and blood tests are commonly used to diagnose individuals with suspected CAP based upon symptoms and physical examination. The use of each test depends on the severity of illness, local practices, and the concern for any complications resulting from the infection. All patients with CAP should have the amount of oxygen in their blood monitored with a machine

called a pulse oximeter. This helps determine how well the lungs are able to work despite infection. In some cases, analysis of arterial blood gas may be required to accurately determine the amount of oxygen in the blood. Complete blood count (CBC), a blood test, may reveal extra white blood cells, indicating an infection. Chest x-rays and chest computed tomography (CT) can reveal areas of opacity (seen as white) which represent consolidation. A normal chest x-ray makes CAP less likely; however, CAP is sometimes not seen on x-rays because the disease is either in its initial stages or involves a part of the lung not easily seen by x-ray. In some cases, chest CT can reveal a CAP which is not present on chest x-ray. X-rays can often be misleading, as many other diseases can mimic CAP such as heart problems or other types of lung damage.[11]

Main symptoms of infectious pneumonia

Several tests can be performed to identify the cause of an individual's CAP. Blood cultures can be drawn to isolate any bacteria or fungi in the blood stream. Sputum Gram's stain and culture can also reveal the causative microorganism. In more severe cases, a procedure wherein a flexible scope is passed through the mouth into the lungs (bronchoscopy) can be used

to collect fluid for culture. Special tests can be performed if an uncommon microorganism is suspected (such as testing the urine for Legionella antigen when Legionnaires' disease is a concern). [edit]Treatment CAP is treated by administering an antibiotic which is effective in killing the offending microorganism as well as managing any complications of the infection. If the causative microorganism is unidentified, different antibiotics are tested in the laboratory in order to identify which medication will be most effective. Often, however, no microorganism is ever identified. Also, since laboratory testing can take several days, there is some delay until an organism is identified. In both cases, a person's risk factors for different organisms must be remembered when choosing the initial antibiotics (called empiric therapy). Additional consideration must be given to the setting in which the individual will be treated. Most people will be fully treated after taking oral pills while other people need to be hospitalized for intravenous antibiotics and, possibly, intensive care. In general, all therapies in older children and adults will include treatment for atypical bacteria. Typically this is a macrolide antibiotic such as azithromycin or clarithromycin although a fluoroquinolone such as levofloxacin can substitute.Doxycycline is now the antibiotic of choice in the UK for complete coverage of the atypical bacteria. This is due to increased levels of clostridium difficile seen in hospital patients being linked to the increased use of clarithromycin. [edit]Newborns

Most newborn infants with CAP are hospitalized and given intravenous ampicillin and gentamicin for at least ten days. This treats the common bacteria Streptococcus agalactiae, Listeria monocytogenes, and Escherichia coli. If herpes simplex virus is the cause, intravenousacyclovir is administered for 21 days. [edit]Children Treatment of CAP in children depends on both the age of the child and the severity of his/her illness. Children less than five do not typically receive treatment to cover atypical bacteria. If a child does not need to be hospitalized, amoxicillin for seven days is a common treatment. However, with increasing prevalence of DRSP, other agents such as cefpodoxime will most likely become more popular in the future.[12]Hospitalized children should receive intravenous ampicillin, ceftriaxone, or cefotaxime. According to a recent meta-analysis a 3 days course of antibiotics seems to be sufficient for most cases of mild to moderate CAP in children.[1] [edit]Adults In 2001, the American Thoracic Society, drawing on work by the British and Canadian Thoracic Societies, established guidelines for the management of adults with CAP which divided individuals with CAP into four categories based upon common organisms encountered.[13]

Healthy outpatients without risk factors

This group, the largest, is composed of otherwise healthy patients without risk factors for DRSP, enteric Gram negative bacteria,Pseudomonas, or other less common causes of CAP. The primary microoganisms in this group are viruses, atypical bacteria, penicillin sensitive Streptococcus pneumoniae, and Hemophilus

influenzae. Recommended management is with a macrolide antibiotic such asazithromycin or clarithromycin for seven[2] to ten days.

Outpatients with underlying illness and/or risk factors

This group does not require hospitalization; its members either have underlying health problems (such as emphysema or congestive heart failure) or is at risk for DRSP and/or enteric Gram negative bacteria. Treatment is with a fluoroquinolone active against Streptococcus pneumoniae such as levofloxacin or a beta-lactam antibiotic such as cefpodoxime, cefuroxime, amoxicillin, or amoxicillin/clavulanate plus a macrolide antibiotic such as azithromycin or clarithromycin for seven to ten days.[3]

Hospitalized individuals not at risk for Pseudomonas

This group requires hospitalization and administration of intravenous antibiotics. Treatment is with either an intravenous fluoroquinoloneactive against Streptococcus pneumoniae such as levofloxacin or beta-lactam antibiotic such as cefotaxime, ceftriaxone, ampicillin/sulbactam, or high-dose ampicillin plus an intravenous macrolide antibiotic such as azithromycin or clarithromycin for seven to ten days.

Individuals requiring intensive care at risk for Pseudomonas

Individuals being treated in an intensive care unit with risk factors for infection with Pseudomonas aeruginosa require specific antibiotics targeting this difficult to eradicate bacteria. One possible regimen is an intravenous antipseudomonal beta-lactam such as cefepime,imipenem, meropenem, or piperacillin/tazobactam plus an intravenous antipseudomonal fluoroquinolone such as levofloxacin. Another recommended regimen is an intravenous antipseudomonal beta-lactam such as cefepime, imipenem, meropenem, or piperacillin/ tazobactam plus an intravenous aminoglycoside such as gentamicin or tobramycin plus either an intravenous macrolide such azithromycin or an intravenous nonpseudomonal fluoroquinolone such as ciprofloxacin.

For mild to moderate communityacquired pneumonia shorter courses of antibiotics (37 days) seem to be sufficient according to a recent metaanalysis.[1] [edit]Hospitalize Some people with CAP require hospitalization and more intensive care than the majority. In general, a discussion between the individual and his or her health care provider determines the need for hospitalization. Clinical prediction rules, such as the pneumonia severity index andCURB-65 have been developed to help guide the decision.[14] Factors which increase the need for hospitalization include age greater than 65; underlying chronic illnesses; a respiratory rate greater than thirty breaths per minute; a systolic blood pressure less than 90 mmHg; a heart rate greater than 125 per minute; temperature less than 35 or greater than 40C; confusion; and evidence of infection outside the lung. Laboratory results which increase the need for hospitalization include arterial oxygen tension less than 60 mm Hg, carbon dioxide of greater than 50 mmHg, or pH less than 7.35 while breathing room air; hematocrit less than 30%; creatinine greater than 1.2 mg/dl or blood urea nitrogen greater than 20 mg/ dl; white blood cell count less

than 4 10^9/L or greater than 30 10^9/L; and absolute neutrophil count less than 1 x 10^9/L. X-ray findings which increase the need for hospitalization include involvement of more than one lobe of the lung, presence of a cavity, and the presence of a pleural effusion. [edit]Prognosis Individuals who are treated for CAP outside of the hospital have a mortality rate less than 1%. Fever typically responds in the first two days of therapy and other symptoms resolve in the first week. The x-ray, however, may remain abnormal for at least a month, even when CAP has been successfully treated. Among individuals who require hospitalization, the mortality rate averages 12% overall, but is as much as 40% in people who have bloodstream infections or require intensive care.[15] Factors which increase mortality are the same as those which increase the need for hospitalization and are listed above. When CAP does not respond as expected, there are several possible causes. A complication of CAP may have occurred or a previously unknown health problem may be playing a role. Both situations are covered in more detail below. Additional causes include inappropriate antibiotics for the causative

organism (i.e. DRSP), a previously unsuspected microorganism (such as tuberculosis), or a condition which mimics CAP (such as Wegener's granulomatosis). Additional testing may be performed and may include additional radiologic imaging (such as a computed tomography scan) or a procedure such as a bronchoscopy or lung biopsy. [edit]Complications Despite appropriate antibiotic therapy, severe complications can result from CAP, including: [edit]Sepsis Sepsis can occur when microorganisms enter the blood stream and the immune system responds. Sepsis most often occurs with bacterial pneumonia; Streptococcus pneumoniae is the most common cause. Individuals with sepsis require hospitalization in an intensive care unit. They often require medications and intravenous fluids to keep their blood pressure from going too low. Sepsis can cause liver, kidney, and heart damage among other things. [edit]Respiratory

failure

Because CAP affects the lungs, often individuals with CAP have difficulty breathing. If enough of the lung is involved, it may not be possible for a person to breathe enough to live without

support. Non-invasive machines such as a bilevel positive airway pressure machine may be used. Otherwise, placement of a breathing tube into the mouth may be necessary and a ventilator may be used to help the person breathe. [edit]Pleural

effusion and

empyema
Occasionally, microorganisms from the lung will cause fluid to form in the space surrounding the lung, called the pleural cavity. If the microorganisms themselves are present, the fluid collection is often called an empyema. If pleural fluid is present in a person with CAP, the fluid should be collected with a needle (thoracentesis) and examined. Depending on the result of the examination, complete drainage of the fluid may be necessary, often with a chest tube. If the fluid is not drained, bacteria can continue to cause illness because antibiotics do not penetrate well into the pleural cavity. [edit]Abscess Rarely, microorganisms in the lung will form a pocket of fluid and bacteria called an abscess. Abscesses can be seen on an x-ray as a cavity within the lung. Abscesses typically occur in aspiration pneumonia and most often contain a mixture of anaerobic bacteria. Usually antibiotics are able to fully treat

abscesses, but sometimes they must be drained by a surgeon or radiologist. [edit]Epidemiology CAP is a common illness in all parts of the world. It is a major cause of death among all age groups. In children, the majority of deaths occur in the newborn period, with over two million worldwide deaths a year. In fact, the WHO estimates that one in three newborn infant deaths are due to pneumonia.[16] Mortality decreases with age until late adulthood; elderly individuals are particularly at risk for CAP and associated mortality. More cases of CAP occur during winter months than during other times of the year. CAP occurs more commonly in males than females and in blacks than Caucasians. Individuals with underlying illnesses such as Alzheimer's disease, cystic fibrosis, emphysema, tobacco smoking,alcoholism, or immune system problems are at increased risk for pneumonia.[17] [edit]Prevention In addition to treating any underlying illness which can increase a person's risk for CAP, there are several additional ways to prevent CAP.Smoking cessation is important not only for treatment of any underlying lung

disease, but also because cigarette smoke interferes with many of the body's natural defenses against CAP. Vaccination is important in both children and adults. Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae in the first year of life have greatly reduced their role in CAP in children. A vaccine against Streptococcus pneumoniae is also available for adults and is currently recommended for all healthy individuals older than 65 and any adults with emphysema, congestive heart failure, diabetes mellitus,cirrhosis of the liver, alcoholism, cerebrospinal fluid leaks, or who do not have a spleen. A repeat vaccination may also be required after five or ten years.[18] Influenza vaccines should be given yearly to the same individuals as receive vaccination against Streptococcus pneumoniae. In addition, health care workers, nursing home residents, and pregnant women should receive the vaccine.[19] When an influenza outbreak is occurring, medications such as amantadine, rimantadine, zanamivir, and oseltamivir have been shown to prevent cases of influenza.[20] [edit]References This article's citation style may be

unclear. The references used may be made clearer with a different or consistent style of citation, footnoting , or external linking. (July 2011)
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