eMedicine Specialties > Infectious Diseases > Lower Respiratory Tract Infections

Pneumonia, Community-Acquired

Author: Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Contributor Information and Disclosures

Updated: Jul 24, 2009

Introduction

Background

Community-acquired pneumonia (CAP) is one of the most common infectious diseases addressed by clinicians. CAP is an important cause of mortality and morbidity worldwide.

Pathophysiology

CAP is usually acquired via inhalation or aspiration of pulmonary pathogenic organisms into a lung segment or lobe. Less commonly, CAP results from secondary bacteremia from a distant source, such as Escherichia coli urinary tract infection and/or bacteremia. CAP due to aspiration of oropharyngeal contents is the only form of CAP involving multiple pathogens.

Frequency

United States

Patients who require hospital treatment for CAP are typically elderly persons and those with underlying chronic obstructive pulmonary disease (COPD), such as chronic bronchitis (not emphysema). CAP is a common cause of hospital admission, but statistics of patients treated for CAP in the ambulatory setting are difficult to obtain. Overall, the incidence of CAP in 1994 was 170 cases per 10,000 individuals.

International

The prevalence of zoonotic CAPs is higher internationally than in the United States.

Mortality/Morbidity

  • Patients with severe CAP invariably have severe cardiopulmonary disease or diminished or absent splenic function.
  • Mortality and morbidity rates of CAP are highest in elderly patients.

Race

CAP has no racial predilection.

Sex

CAP has no sexual predilection.

Age

CAP is particularly common in elderly adults, with an incidence rate in the United States of 280 cases per 10,000 individuals older than 65 years.

Clinical

History

Patients with community-acquired pneumonia (CAP) due to typical bacterial pathogens present with various pulmonary symptoms, while those with CAP due to atypical pathogens present with a variety of both pulmonary and extrapulmonary symptoms.

  • Patients with bacterial CAP typically present with variable degrees of fever, usually with a productive cough and often with pleuritic chest pain.
  • The clinical presentation of CAP due to atypical pathogens is usually less acute than CAP due to typical bacterial pathogens.
  • CAP due to atypical pathogens may have one or more extrapulmonary features, which is a clue to their presence.
  • Patients with Legionella pneumonia may have a productive or nonproductive cough. In contrast, patients with pneumonia due to Mycoplasma pneumoniae or Chlamydia pneumoniae usually present with a nonproductive cough.
  • With the exception of Legionella pneumonia, chest pain is typically not a feature of CAP due to nonzoonotic atypical pathogens.

Physical

  • Abnormal physical findings are confined to the chest in patients with typical bacterial CAP.
  • Rales are heard upon auscultation of the chest over the involved lobe or segment. If consolidation is present, an increase in tactile fremitus, bronchial breathing, and E to A change may be present.
  • Pleural effusion (usually due to Haemophilus influenzae infection) that is large enough produces signs that are detectable during physical examination. Patients with pleural effusion have decreased tactile fremitus and dullness upon chest percussion. Pleural effusion in a patient with CAP and extrapulmonary manifestations should suggest Legionella infection. Pleural effusion with appropriate epidemiologic history findings, such as contact with a rabbit or deer, may suggest tularemia.
  • Purulent sputum is characteristic of pneumonia caused by typical bacterial pathogens but is typically not a feature of that caused by atypical pathogens, with the exception of Legionnaires disease.
  • Blood-tinged sputum may be found in patients with pneumococcal infections, Klebsiella pneumonia, or Legionella pneumonia.
  • Legionella pneumonia, Q fever, and psittacosis are atypical pneumonias that may present with signs of consolidation. Consolidation is not a feature of pneumonia caused by M pneumoniae or C pneumoniae.
  • Patients with CAP who present with acute heart failure, such as acute myocardial infarction without pre-existing congestive heart failure (CHF), often have normal cardiac silhouettes, bilateral symmetric moist rales, and an S3 gallop rhythm upon auscultation.
  • Severe CAP is caused by the same spectrum of pathogens that cause mild or moderately severe CAP.
    • The severity of CAP is determined by the pre-existing function of the heart, lungs, and spleen.
    • The severity of CAP depends on host factors rather than on the type, number, or virulence of the involved pathogens. However, with all other factors being equal, influenza, severe acute respiratory syndrome (SARS), hantavirus pulmonary syndrome (HPS), and Legionnaires disease are not likely to present as severe CAP.

Causes

  • Typical bacterial pathogens
    • Typical bacterial pathogens that cause CAP include Streptococcus pneumoniae (both penicillin-sensitive and -resistant strains; see Image 1), H influenzae (both ampicillin-sensitive and -resistant strains; see Image 2), and Moraxella catarrhalis (all strains penicillin-resistant; see Image 3). These 3 pathogens account for approximately 85% of CAP cases.

      Gram stain showing <EM>Streptococcus pneumoniae.<...

      Gram stain showing Streptococcus pneumoniae.

      [ CLOSE WINDOW ]
      Gram stain showing <EM>Streptococcus pneumoniae.<...

      Gram stain showing Streptococcus pneumoniae.


      Gram stain showing <EM>Haemophilus influenzae.</E...

      Gram stain showing Haemophilus influenzae.

      [ CLOSE WINDOW ]
      Gram stain showing <EM>Haemophilus influenzae.</E...

      Gram stain showing Haemophilus influenzae.


      Gram stain showing <EM>Moraxella catarrhalis.</EM>

      Gram stain showing Moraxella catarrhalis.

      [ CLOSE WINDOW ]
      Gram stain showing <EM>Moraxella catarrhalis.</EM>

      Gram stain showing Moraxella catarrhalis.


      • In patients with chronic bronchitis who develop CAP requiring hospitalization, M catarrhalis infection is particularly common.
      • S pneumoniae remains the most common agent responsible for CAP.
    • Importantly, Staphylococcus aureus, Klebsiella pneumoniae, and Pseudomonas aeruginosa are not causes of CAP in typical hosts.
      • S aureus causes CAP in the setting of postviral influenza.
      • K pneumoniae CAP occurs primarily in persons with chronic alcoholism.
      • P aeruginosa is a cause of CAP in patients with bronchiectasis or cystic fibrosis.
    • Other gram-negative pathogens rarely cause CAP.
    • Aspiration pneumonia is caused by the aspiration of oropharyngeal secretions into the lung. The extent of aspiration and lobar distribution of the infiltrates depends on the patient's position at the time of aspiration.
    • Nearly all cases of CAP are due to a single pathogen. Exceptions occur but are rare.
    • Aspiration pneumonia is the only form of CAP caused by multiple pathogens.
  • Atypical pathogens
    • Atypical pneumonias can be divided into zoonotic and nonzoonotic atypical pathogens.
    • Zoonotic atypical pathogens that cause CAP include Chlamydia psittaci (psittacosis), Francisella tularensis (tularemia), and Coxiella burnetii (Q fever).
      • Contact with the appropriate vector is required for these zoonotic pathogens to cause CAP.
      • A history of close contact with a parturient cat or sheep should be sought in patients with suspected Q fever.
      • Psittacosis is preceded by recent close contact with psittacine birds.
      • Patients with tularemia have had recent close contact with deer or rabbits or have recently been bitten by a tick or deer fly.
    • Nonzoonotic atypical pneumonias are caused by Legionella species, M pneumoniae, or C pneumoniae. These 3 pathogens account for approximately 15% of all CAP cases. Legionella species are the most important atypical pathogens that cause CAP.
    • Typical and atypical pneumonias are differentiated based on the pattern of extrapulmonary findings rather than on individual findings.
    • Typical bacterial pneumonias produce few, if any, extrapulmonary findings. In contrast, each atypical pathogen has its own distribution pattern of extrapulmonary organ involvement, which permits an accurate and rapid presumptive clinical diagnosis (see Image 4).

      Clinical diagnostic approach in community-acquire...

      Clinical diagnostic approach in community-acquired pneumonias.

      [ CLOSE WINDOW ]
      Clinical diagnostic approach in community-acquire...

      Clinical diagnostic approach in community-acquired pneumonias.

    • Table 1. Differential Diagnostic Features of Atypical Pneumonias1

      Open table in new window

      [ CLOSE WINDOW ]
      Table


      		Zoonotic Atypical PneumoniasNonzoonotic Atypical Pneumonias
      Key CharacteristicsPsittacosisQ FeverTularemiaMycoplasma
      Pneumonia      		Legionnaires
      Disease      		Chlamydia
      Pneumonia
      Symptoms 
      Mental confusion———±+—
      Prominent headache++————
      Meningismus+————±
      Myalgias++—++—
      Ear pain———±——
      Pleuritic pain———±+—
      Abdominal pain————+—
      Diarrhea———±+—
      Signs 
      Rash±
      (Horder spots)      		——±
      (erythema multiforme)      		±—
      Raynaud phenomenon———±——
      Nonexudative pharyngitis+—±+—+
      Hemoptysis+———+—
      Lobar consolidation±±±±±—
      Cardiac involvement±
      (endocarditis)      		±
      (myocarditis)      		 ±
      (myocarditis/
      heart block/
      pericarditis)      		—
      (endocarditis,
      myocarditis)      		 
      Splenomegaly++————
      Relative bradycardia+±——+—
      Chest Film 
      InfiltratePatchy/
      consolidation      		Patchy/
      consolidation      		Ovid
      bodies      		PatchyPatchy/
      consolidation      		Single
      circumscribed
      lesions
      Bilateral hilar adenopathy——+———
      Pleural effusion——+
      (bloody)      		±
      (small)      		±
      (small/
      moderate)      		±


      		Zoonotic Atypical PneumoniasNonzoonotic Atypical Pneumonias
      Key CharacteristicsPsittacosisQ FeverTularemiaMycoplasma
      Pneumonia      		Legionnaires
      Disease      		Chlamydia
      Pneumonia
      Symptoms 
      Mental confusion———±+—
      Prominent headache++————
      Meningismus+————±
      Myalgias++—++—
      Ear pain———±——
      Pleuritic pain———±+—
      Abdominal pain————+—
      Diarrhea———±+—
      Signs 
      Rash±
      (Horder spots)      		——±
      (erythema multiforme)      		±—
      Raynaud phenomenon———±——
      Nonexudative pharyngitis+—±+—+
      Hemoptysis+———+—
      Lobar consolidation±±±±±—
      Cardiac involvement±
      (endocarditis)      		±
      (myocarditis)      		 ±
      (myocarditis/
      heart block/
      pericarditis)      		—
      (endocarditis,
      myocarditis)      		 
      Splenomegaly++————
      Relative bradycardia+±——+—
      Chest Film 
      InfiltratePatchy/
      consolidation      		Patchy/
      consolidation      		Ovid
      bodies      		PatchyPatchy/
      consolidation      		Single
      circumscribed
      lesions
      Bilateral hilar adenopathy——+———
      Pleural effusion——+
      (bloody)      		±
      (small)      		±
      (small/
      moderate)      		±
    • Although Q fever and psittacosis are associated with relative bradycardia, these zoonotic pneumonias may be excluded by a negative epidemiologic vector contact history finding.
    • If psittacosis and Q fever are eliminated from the diagnostic consideration by history, relative bradycardia in a patient with CAP should suggest Legionnaires disease.
      • Because Legionella pneumonia has its own characteristic pattern of organ involvement, it is readily distinguished from other typical and atypical pathogens (see Image 7).

        This graph outlines a case of <EM>Legionella</EM>...

        This graph outlines a case of Legionella pneumonia, showing characteristics of bradycardia and extrapulmonary involvement. Also shown is an initial lack of response to beta-lactam antibiotics, followed by effective treatment with doxycycline.

        [ CLOSE WINDOW ]
        This graph outlines a case of <EM>Legionella</EM>...

        This graph outlines a case of Legionella pneumonia, showing characteristics of bradycardia and extrapulmonary involvement. Also shown is an initial lack of response to beta-lactam antibiotics, followed by effective treatment with doxycycline.

      • Some signs and symptoms are more important than others and can be expressed in a weighted diagnostic point system, which is highly accurate in assisting the clinician with determining a clinical diagnosis of Legionnaires disease (see Table 3).
    • Table 2. Relative Bradycardia

      Open table in new window

      [ CLOSE WINDOW ]
      Table
      Determination and Evaluation of Relative Bradycardia
      Inclusive criteriaThe patient must be an adult (>12 y).
      The patient must have a fever >101°F.
      The pulse must be taken while the patient’s temperature is elevated.
      Exclusive criteriaThe patient has normal sinus rhythm without arrhythmia, second- or third-degree heart block, or pacemaker-induced rhythm.
      Patient must not be receiving a beta-blocker, verapamil, or diltiazem.
      Temperature-Pulse Relationships (temperature and corresponding pulse [beats/min])
      Appropriate PulseRelative Bradycardia
      41.1°C/106°F = 150/min<140/min
      40.6°C/105°F = 140/min<130/min
      40.0°C/104°F = 130/min<120/min
      39.5°C/103°F = 120/min<110/min
      38.9°C/102°F = 110/min<100/min
      Causes of Relative Bradycardia
      Infectious causesLegionella infection
      Psittacosis
      Q fever
      Typhoid fever
      Typhus
      Malaria
      Babesiosis
      Leptospirosis
      Yellow fever
      Dengue fever
      Rocky Mountain spotted fever
      Tularemia
      Salmonella infections
      Noninfectious causesBeta-blockers
      CNS lesions
      Lymphomas
      Factitious fever
      Drug fever
      Determination and Evaluation of Relative Bradycardia
      Inclusive criteriaThe patient must be an adult (>12 y).
      The patient must have a fever >101°F.
      The pulse must be taken while the patient’s temperature is elevated.
      Exclusive criteriaThe patient has normal sinus rhythm without arrhythmia, second- or third-degree heart block, or pacemaker-induced rhythm.
      Patient must not be receiving a beta-blocker, verapamil, or diltiazem.
      Temperature-Pulse Relationships (temperature and corresponding pulse [beats/min])
      Appropriate PulseRelative Bradycardia
      41.1°C/106°F = 150/min<140/min
      40.6°C/105°F = 140/min<130/min
      40.0°C/104°F = 130/min<120/min
      39.5°C/103°F = 120/min<110/min
      38.9°C/102°F = 110/min<100/min
      Causes of Relative Bradycardia
      Infectious causesLegionella infection
      Psittacosis
      Q fever
      Typhoid fever
      Typhus
      Malaria
      Babesiosis
      Leptospirosis
      Yellow fever
      Dengue fever
      Rocky Mountain spotted fever
      Tularemia
      Salmonella infections
      Noninfectious causesBeta-blockers
      CNS lesions
      Lymphomas
      Factitious fever
      Drug fever
    • Another clue to Legionnaires disease in a patient with CAP and relative bradycardia is the lack of response to beta-lactam antibiotic treatment. If other causes of relative bradycardia are excluded, this is a clue because it is a constant early finding in Legionnaires disease.
    • Table 3. Modified Winthrop University Hospital Infectious Disease Division's Point System for Diagnosing Legionnaires Disease in Adults1

      Open table in new window

      [ CLOSE WINDOW ]
      Table
      Clinical FeaturesQualifying ConditionsPoint Score
      Temperature >103°F*With relative bradycardia+5
      HeadacheAcute onset+2
      Mental confusion/lethargy*Not drug-induced+4
      Ear painAcute onset-3
      Nonexudative pharyngitisAcute onset-3
      HoarsenessAcute, not chronic-3
      Sputum (purulent)Excluding chronic bronchitis-3
      Hemoptysis*Mild/moderate-3
      Chest pain (pleuritic)Rapidly progressive asymmetrical infiltrates*
      (excluding severe influenza/SARS)      		-3
      Loose stools/watery diarrhea*Not drug induced+3
      Abdominal pain*With or without diarrhea+5
      Renal failure*Acute, not chronic+5
      Shock/hypotension*Not 2° to acute cardiac-5
       /pulmonary causes+5
      SplenomegalyExcluding non-CAP causes-5
      Lack of response to beta lactamsAfter 72 h (excluding viral pneumonias)+5
      Laboratory Features
      Chest radiographyRapidly progressive asymmetrical infiltrates*
      (excluding severe influenza/SARS)      		+3
      ↓ PO2 with ↑ A-a gradient (>35)*(Excluding severe influenza/SARS)-5
      ↓ Na +Acute onset+1
      ↓ PO4 =*Acute onset+5
      ↑ SGOT/SGPT (early mild/transient)*Acute onset+4
      ↑ Total bilirubinOtherwise unexplained+1
      ↑ LDH (>400)*Excluding HIV/PCP-5
      ↑ CPK/aldolaseOtherwise unexplained+4
      ↑ CRP (>30)Acute onset+5
      ↑ Cold agglutinins (≥1:64)Acute onset-5
      ↑ CreatinineAcute onset+2
      Microscopic hematuria*Excluding trauma, BPH, Foley catheter, bladder/renal neoplasms+2
      Likelihood of Legionella Infection
      Total Points>15, Legionella infection very likely


      		5-15, Legionella infection likely


      		<5 Legionella infection unlikely
      Clinical FeaturesQualifying ConditionsPoint Score
      Temperature >103°F*With relative bradycardia+5
      HeadacheAcute onset+2
      Mental confusion/lethargy*Not drug-induced+4
      Ear painAcute onset-3
      Nonexudative pharyngitisAcute onset-3
      HoarsenessAcute, not chronic-3
      Sputum (purulent)Excluding chronic bronchitis-3
      Hemoptysis*Mild/moderate-3
      Chest pain (pleuritic)Rapidly progressive asymmetrical infiltrates*
      (excluding severe influenza/SARS)      		-3
      Loose stools/watery diarrhea*Not drug induced+3
      Abdominal pain*With or without diarrhea+5
      Renal failure*Acute, not chronic+5
      Shock/hypotension*Not 2° to acute cardiac-5
       /pulmonary causes+5
      SplenomegalyExcluding non-CAP causes-5
      Lack of response to beta lactamsAfter 72 h (excluding viral pneumonias)+5
      Laboratory Features
      Chest radiographyRapidly progressive asymmetrical infiltrates*
      (excluding severe influenza/SARS)      		+3
      ↓ PO2 with ↑ A-a gradient (>35)*(Excluding severe influenza/SARS)-5
      ↓ Na +Acute onset+1
      ↓ PO4 =*Acute onset+5
      ↑ SGOT/SGPT (early mild/transient)*Acute onset+4
      ↑ Total bilirubinOtherwise unexplained+1
      ↑ LDH (>400)*Excluding HIV/PCP-5
      ↑ CPK/aldolaseOtherwise unexplained+4
      ↑ CRP (>30)Acute onset+5
      ↑ Cold agglutinins (≥1:64)Acute onset-5
      ↑ CreatinineAcute onset+2
      Microscopic hematuria*Excluding trauma, BPH, Foley catheter, bladder/renal neoplasms+2
      Likelihood of Legionella Infection
      Total Points>15, Legionella infection very likely


      		5-15, Legionella infection likely


      		<5 Legionella infection unlikely

      *Otherwise unexplained (acute and associated with pneumonia)
    • In typical hosts, CAP does not present with shock. If CAP presents with shock, look for impaired or absent splenic function. Disorders and therapies associated with impaired splenic function include the following:2
    • CAP that presents with shock in the absence of conditions associated with hyposplenism should prompt an evaluation for mimics of pneumonia that manifest as pulmonary infiltrates on chest radiography, fever, leukocytosis, and hypotension, such as acute myocardial infarction or acute pulmonary embolism.
    • If CAP manifests as shock without evidence of hyposplenia, acute myocardial infarction, or acute pulmonary embolism, consider an exacerbation of pre-existing cardiopulmonary disease that presents with hypotension and coronary insufficiency with hypoxemia or emphysema.
  • Nonpulmonary pathogens that have been known to cause CAP include the following:

More on Pneumonia, Community-Acquired

Overview: Pneumonia, Community-Acquired
Differential Diagnoses & Workup: Pneumonia, Community-Acquired
Treatment & Medication: Pneumonia, Community-Acquired
Follow-up: Pneumonia, Community-Acquired
Multimedia: Pneumonia, Community-Acquired
References
[ CLOSE WINDOW ]

References

  1. Cunha BA. Cunha BA (ed). Pneumonia Essentials. 2nd Ed. Royal Oak, MI: Physicians Press; 2008:pp. 55-63.

  2. Cunha BA. Strategies for managing severe community-acquired pneumonia. J Crit Illness. 1997;12:711-21.

  3. Acar J. Broad- and narrow-spectrum antibiotics: an unhelpful categorization. Clin Microbiol Infect. Aug 1997;3(4):395-396. [Medline].

  4. Ahkee S, Smith S, Newman D, Ritter W, Burke J, Ramirez JA. Early switch from intravenous to oral antibiotics in hospitalized patients with infections: a 6-month prospective study. Pharmacotherapy. May-Jun 1997;17(3):569-75. [Medline].

  5. Ailani RK, Agastya G, Ailani RK, Mukunda BN, Shekar R. Doxycycline is a cost-effective therapy for hospitalized patients with community-acquired pneumonia. Arch Intern Med. Feb 8 1999;159(3):266-70. [Medline].

  6. Alvarez-Lerma F, Torres A. Severe community-acquired pneumonia. Curr Opin Crit Care. Oct 2004;10(5):369-74. [Medline].

  7. Alves dos Santos JW, Torres A, Michel GT, de Figueiredo CW, Mileto JN, Foletto VG Jr. Non-infectious and unusual infectious mimics of community-acquired pneumonia. Respir Med. Jun 2004;98(6):488-94. [Medline].

  8. Anzueto A, Niederman MS, Pearle J, Restrepo MI, Heyder A, Choudhri SH. Community-Acquired Pneumonia Recovery in the Elderly (CAPRIE): efficacy and safety of moxifloxacin therapy versus that of levofloxacin therapy. Clin Infect Dis. Jan 1 2006;42(1):73-81. [Medline].

  9. [Guideline] Armitage K, Woodhead M. New guidelines for the management of adult community-acquired pneumonia. Curr Opin Infect Dis. Apr 2007;20(2):170-6. [Medline].

  10. Baril L, Astagneau P, Nguyen J, Similowski T, Mengual X, Beigelman C. Pyogenic bacterial pneumonia in human immunodeficiency virus-infected inpatients: a clinical, radiological, microbiological, and epidemiological study. Clin Infect Dis. Apr 1998;26(4):964-71. [Medline].

  11. Bartlett JG. Diagnostic test for etiologic agents of community-acquired pneumonia. Infect Dis Clin North Am. Dec 2004;18(4):809-27. [Medline].

  12. Bartlett JG, Breiman RF, Mandell LA, File TM Jr. Community-acquired pneumonia in adults: guidelines for management. The Infectious Diseases Society of America. Clin Infect Dis. Apr 1998;26(4):811-38. [Medline].

  13. Bartlett JG, Mundy LM. Community-acquired pneumonia. N Engl J Med. Dec 14 1995;333(24):1618-24. [Medline].

  14. Becker SL. Outpatient management of HIV-related pneumonia. Ann Intern Med. Dec 1 1996;125(11):938-9. [Medline].

  15. Berk SL. From Micrococcus to Moraxella. The reemergence of Branhamella catarrhalis. Arch Intern Med. Nov 1990;150(11):2254-7. [Medline].

  16. Blasi F, Tarsia P. Value of short-course antimicrobial therapy in community-acquired pneumonia. Int J Antimicrob Agents. Dec 2005;26 Suppl 3:S148-55. [Medline].

  17. Boersma WG, Daniels JM, Löwenberg A, Boeve WJ, van de Jagt EJ. Reliability of radiographic findings and the relation to etiologic agents in community-acquired pneumonia. Respir Med. May 2006;100(5):926-32. [Medline].

  18. Bonoan JT, Cunha BA. Staphylococcus aureus as a cause of community-acquired pneumonia in patients with diabetes mellitus. Infect Dis Clin Pract. 1999;8:319-21.

  19. Bordon J, Peyrani P, Brock GN, et al. The Presence of Pneumococcal Bacteremia does not Influence Clinical Outcomes in Patients with Community-acquired Pneumonia. Chest. 133;133:618-624.

  20. Boschini A, Smacchia C, Di Fine M, Schiesari A, Ballarini P, Arlotti M. Community-acquired pneumonia in a cohort of former injection drug users with and without human immunodeficiency virus infection: incidence, etiologies, and clinical aspects. Clin Infect Dis. Jul 1996;23(1):107-13. [Medline].

  21. Boselli E, Breilh D, Rimmelé T, Djabarouti S, Saux MC, Chassard D. Pharmacokinetics and intrapulmonary diffusion of levofloxacin in critically ill patients with severe community-acquired pneumonia. Crit Care Med. Jan 2005;33(1):104-9. [Medline].

  22. Boulware DR, Daley CL, Merrifield C, Hopewell PC, Janoff EN. Rapid diagnosis of pneumococcal pneumonia among HIV-infected adults with urine antigen detection. J Infect. Oct 2007;55(4):300-9. [Medline].

  23. Brown RB. Community-acquired pneumonia: diagnosis and therapy of older adults. Geriatrics. Feb 1993;48(2):43-50. [Medline].

  24. Bruns AH, Oosterheert JJ, Prokop M, Lammers JW, Hak E, Hoepelman AI. Patterns of resolution of chest radiograph abnormalities in adults hospitalized with severe community-acquired pneumonia. Clin Infect Dis. Oct 15 2007;45(8):983-91. [Medline].

  25. Carrie AG, Kozyrskyj AL. Outpatient treatment of community-acquired pneumonia: evolving trends and a focus on fluoroquinolones. Can J Clin Pharmacol. 2006;13(1):e102-11. [Medline].

  26. Chen CY, Chen KY, Hsueh PR, Yang PC. Severe community-acquired pneumonia due to Legionella pneumophila Serogroup 6. J Formos Med Assoc. Mar 2006;105(3):256-62. [Medline].

  27. Chokshi R, Restrepo MI, Weeratunge N, Frei CR, Anzueto A, Mortensen EM. Monotherapy versus combination antibiotic therapy for patients with bacteremic Streptococcus pneumoniae community-acquired pneumonia. Eur J Clin Microbiol Infect Dis. Jul 2007;26(7):447-51. [Medline].

  28. Christensen D, Feldman C, Rossi P, Marrie T, Blasi F, Luna C. HIV infection does not influence clinical outcomes in hospitalized patients with bacterial community-acquired pneumonia: results from the CAPO international cohort study. Clin Infect Dis. Aug 15 2005;41(4):554-6. [Medline].

  29. Cunha BA. Ambulatory community-acquired pneumonia: the predominance of atypical pathogens. Eur J Clin Microbiol Infect Dis. Oct 2003;22(10):579-83. [Medline].

  30. Cunha BA. Antibiotic resistance. Control strategies. Crit Care Clin. Apr 1998;14(2):309-27. [Medline].

  31. Cunha BA. Atypical pneumonias: current clinical concepts focusing on Legionnaires' disease. Curr Opin Pulm Med. 2008;14:183-194.

  32. Cunha BA. Clinical Diagnosis of Legionnaires' Disease. Semin Respir Infect. 1998;13:116-127.

  33. Cunha BA. Clinical Relavance of Penicillin Resistant Streptococcus pneumoniae. Seminars in Respiratory Infectioons. 2002;17:204-214.

  34. Cunha BA. Community-acquired pneumonia. Cost-effective antimicrobial therapy. Postgrad Med. Jan 1996;99(1):109-10, 113-4, 117-9, passim. [Medline].

  35. Cunha BA. Community-acquired pneumonia: reality revisited. Am J Med. Apr 1 2000;108(5):436-8. [Medline].

  36. Cunha BA. Doxycycline re-revisited. Arch Intern Med. May 10 1999;159(9):1006-7. [Medline].

  37. Cunha BA. Elevated serum transaminases in patients with Mycoplasma pneumoniae pneumonia. Clin Microbiol Infect. Dec 2005;11(12):1051-2; author reply 1052-4. [Medline].

  38. Cunha BA. Empiric oral monotherapy for hospitalized patients with community-acquired pneumonia: an idea whose time has come. Eur J Clin Microbiol Infect Dis. Feb 2004;23(2):78-81. [Medline].

  39. Cunha BA. Empiric therapy of community-acquired pneumonia: guidelines for the perplexed?. Chest. May 2004;125(5):1913-9. [Medline].

  40. Cunha BA. Extrapulmonary manifestations of pneumonia. Chest. Sep 1998;114(3):945-6. [Medline].

  41. Cunha BA. Historical, physical and laboratory clues to the diagnosis of pneumonia. In: Karetzky M, Cunha BA, Brandstetter RD, eds. The Pneumonias. New York, NY: Springer Verlag; 1993:. 106-44.

  42. Cunha BA. Intravenous to oral antimicrobial switch therapy of community-acquired pneumonia. Internal Medicine. 1997;18:92-3.

  43. Cunha BA. Legionella pneumonia: The value of clinical and laboratory findings. J Respir Dis. 2005;26:515-6.

  44. Cunha BA. Macrolides, doxycycline, and fluoroquinolones in the treatment of Legionnaire's diseases. Antibiot Clin. 1998;2:117-8.

  45. Cunha BA. Penicillin resistant Streptococcus pneumoniae infections. Internal Medicine. 1999;19:13-19.

  46. Cunha BA. Severe community-acquired pneumonia. J Crit Illness. 1997;12:711-21.

  47. Cunha BA. Severe community-acquired pneumonia. Crit Care Clin. Jan 1998;14(1):105-18. [Medline].

  48. Cunha BA. Severe community-acquired pneumonia: Determinants of severity and approach to therapy. Infect Med. 2005;22:53-8.

  49. Cunha BA. The virtues of doxycycline and the evils of erythromycin. Adv Ther. 1997;14:172-80.

  50. Cunha BA, Shea KW. Emergence of antimicrobial resistance in community-acquired pulmonary pathogens. Semin Respir Infect. Mar 1998;13(1):43-53. [Medline].

  51. Cunha BA. Elevated Serum Transaminases in Mycoplasma pneumoniae Pneumonia. Clin Microbiol Infect. 2005;11:1051-1054.

  52. Cunha BA. Hepatic Involvement in a mycoplasma pneumoniae Community Acquired Pneumonia. J Clin Microbiol. 2003;41:3456-3457.

  53. Cunha BA. Hypophosphatemia: Diagnostic Significance in Legionnaires' Disease. Am J Med. 2006;119:5-6.

  54. Cunha BA. Severe Community-acquired Pneumoniae in the Critical Care Unit. In: Cunha BA (ed). Infectious Disease in Critical Care Medicine. 2nd Ed. New York, New York: Informa Healthcare; 2007:pp. 157-168.

  55. Cunha BA. Intravenous to Oral Antibiotic Switch Therapy. Drugs for Today. 2001;37:311-319.

  56. Cunha BA. Legionella pneumonia: The Value of Clinical and Laboratory Findings. J Respir Dis. 2005;26:515-516.

  57. Cunha BA. The Atypical Pneumonias: Clinical Diagnosis and Importance. Clin Microbiol Infect. 2006;12:12-24.

  58. Cunha BA:. Legionnaires' Disease. In: Rackel ER, Bope ED (eds). Conn's Current Therapy - 2005. 57th ed. Philadelphia, PA: W.B. Saunders; 2005.

  59. Davis SL, Delgado G Jr, McKinnon PS. Pharmacoeconomic considerations associated with the use of intravenous-to-oral moxifloxacin for community-acquired pneumonia. Clin Infect Dis. Jul 15 2005;41 Suppl 2:S136-43. [Medline].

  60. Davydov L, Ebert SC, Restino M, Gardner M, Bedenkop G, Uchida KM. Prospective evaluation of the treatment and outcome of community-acquired pneumonia according to the Pneumonia Severity Index in VHA hospitals. Diagn Microbiol Infect Dis. Apr 2006;54(4):267-75. [Medline].

  61. de Roux A, Marcos MA, Garcia E, Mensa J, Ewig S, Lode H. Viral community-acquired pneumonia in nonimmunocompromised adults. Chest. Apr 2004;125(4):1343-51. [Medline].

  62. Diederen BM. Legionella spp. and Legionnaires' disease. J Infect. Jan 2008;56(1):1-12. [Medline].

  63. Diederen BM, van Zwet AA, van der Zee A, Peeters MF. Community-acquired pneumonia caused by Legionella longbeachae in an immunocompetent patient. Eur J Clin Microbiol Infect Dis. Aug 2005;24(8):545-8. [Medline].

  64. Donowitz GR. Commentary: are care guidelines useful in community-acquired pneumonia? Value hinges on improving outcomes. Postgrad Med. Oct 2005;118(4):13-4, 17. [Medline].

  65. Dunbar LM, Khashab MM, Kahn JB, Zadeikis N, Xiang JX, Tennenberg AM. Efficacy of 750-mg, 5-day levofloxacin in the treatment of community-acquired pneumonia caused by atypical pathogens. Curr Med Res Opin. Apr 2004;20(4):555-63. [Medline].

  66. Ertapenem versus ceftriaxone for the treatment of community-acquired pneumonia in adults: combined analysis of two multicentre randomized, double-blind studies. Woods GL, Isaacs RD, McCarroll KA, Friendland IR. Journal of American Geriatric Society. 2003;51:1526-1532.

  67. Falguera M, Pifarre R, Martin A, Sheikh A, Moreno A. Etiology and outcome of community-acquired pneumonia in patients with diabetes mellitus. Chest. Nov 2005;128(5):3233-9. [Medline].

  68. File TM. Community-acquired pneumonia. Lancet. Dec 13 2003;362(9400):1991-2001. [Medline].

  69. File TM Jr. Clinical efficacy of newer agents in short-duration therapy for community-acquired pneumonia. Clin Infect Dis. Sep 1 2004;39 Suppl 3:S159-64. [Medline].

  70. Fine MJ, Chowdhry T, Ketema A. Outpatient management of community-acquired pneumonia. Hosp Pract (Minneap). Jun 15 1998;33(6):123-33. [Medline].

  71. Fishbane S, Niederman MS, Daly C, Magin A, Kawabata M, de Corla-Souza A. The impact of standardized order sets and intensive clinical case management on outcomes in community-acquired pneumonia. Arch Intern Med. Aug 13-27 2007;167(15):1664-9. [Medline].

  72. Fogarty CM, Sullivan JC, Chattman MS. Once a day levofloxacin in the treatment of mild to moderate and severe community acquired pneumonia in adults. Infect Dis Clin Pract. 1998;7:400-7.

  73. Frighetto L, Nickoloff D, Martinusen SM, Mamdani FS, Jewesson PJ. Intravenous-to-oral stepdown program: four years of experience in a large teaching hospital. Ann Pharmacother. Nov 1992;26(11):1447-51. [Medline].

  74. Garau J, Calbo E. Community-acquired pneumonia. Lancet. Feb 9 2008;371(9611):455-8. [Medline].

  75. García-Leoni ME, Moreno S, Rodeñó P, Cercenado E, Vicente T, Bouza E. Pneumococcal pneumonia in adult hospitalized patients infected with the human immunodeficiency virus. Arch Intern Med. Sep 1992;152(9):1808-12. [Medline].

  76. Garibaldi RA. Epidemiology of community-acquired respiratory tract infections in adults. Incidence, etiology, and impact. Am J Med. Jun 28 1985;78(6B):32-7. [Medline].

  77. Genné D, Sommer R, Kaiser L, Saaïdia A, Pasche A, Unger PF. Analysis of factors that contribute to treatment failure in patients with community-acquired pneumonia. Eur J Clin Microbiol Infect Dis. Mar 2006;25(3):159-66. [Medline].

  78. Gleckman R, DeVita J, Hibert D, Pelletier C, Martin R. Sputum gram stain assessment in community-acquired bacteremic pneumonia. J Clin Microbiol. May 1988;26(5):846-9. [Medline].

  79. Gleckman RA. Oral empirical treatment of pneumonia. The challenge of choosing the best agent. Postgrad Med. Feb 1 1994;95(2):165-72. [Medline].

  80. Gopal V, Bisno AL. Fulminant pneumococcal infections in 'normal' asplenic hosts. Arch Intern Med. Nov 1977;137(11):1526-30. [Medline].

  81. Gupta SK, Imperiale TF, Sarosi GA. Evaluation of the Winthrop-University Hospital Criteria to Identify Legionella Pneumonia. Chest. 2001;120:1064-1071.

  82. Halm EA, Fine MJ, Marrie TJ, Coley CM, Kapoor WN, Obrosky DS. Time to clinical stability in patients hospitalized with community-acquired pneumonia: implications for practice guidelines. JAMA. May 13 1998;279(18):1452-7. [Medline].

  83. Harrington Z, Barnes DJ. One drug or two? Step-down therapy after i.v. antibiotics for community-acquired pneumonia. Intern Med J. Nov 2007;37(11):767-71. [Medline].

  84. Hoeffken G, Talan D, Larsen LS, Peloquin S, Choudhri SH, Haverstock D. Efficacy and safety of sequential moxifloxacin for treatment of community-acquired pneumonia associated with atypical pathogens. Eur J Clin Microbiol Infect Dis. Oct 2004;23(10):772-5. [Medline].

  85. Howard LS, Sillis M, Pasteur MC, Kamath AV, Harrison BD. Microbiological profile of community-acquired pneumonia in adults over the last 20 years. J Infect. Feb 2005;50(2):107-13. [Medline].

  86. Hsueh PR, Teng LJ, Lee LN, Yang PC, Ho SW, Luh KT. Extremely high incidence of macrolide and trimethoprim-sulfamethoxazole resistance among clinical isolates of Streptococcus pneumoniae in Taiwan. J Clin Microbiol. Apr 1999;37(4):897-901. [Medline].

  87. Hyvernat H, Pulcini C, Carles D, Roques A, Lucas P, Hofman V. Fatal Staphylococcus aureus haemorrhagic pneumonia producing Panton-Valentine leucocidin. Scand J Infect Dis. 2007;39(2):183-5. [Medline].

  88. Iannini PB, Paladino JA, Lavin B, Singer ME, Schentag JJ. A case series of macrolide treatment failures in community acquired pneumonia. J Chemother. Oct 2007;19(5):536-45. [Medline].

  89. Johnson DH, Cunha BA. Atypical pneumonias. Clinical and extrapulmonary features of Chlamydia, Mycoplasma, and Legionella infections. Postgrad Med. May 15 1993;93(7):69-72, 75-6, 79-82. [Medline].

  90. Johnstone J, Marrie TJ, Eurich DT, Majumdar SR. Effect of pneumococcal vaccination in hospitalized adults with community-acquired pneumonia. Arch Intern Med. Oct 8 2007;167(18):1938-43. [Medline].

  91. Jones RN, Sader HS, Fritsche TR. Doxycycline use for community-acquired pneumonia: contemporary in vitro spectrum of activity against Streptococcus pneumoniae (1999-2002). Diagn Microbiol Infect Dis. Jun 2004;49(2):147-9. [Medline].

  92. Kirby BD, Synder KM, Meyer RD, et al. Legionnaires' disease: Clinical features of 24 cases. Ann Intern Med. 1978;89:297-309.

  93. Klimek JJ, Ajemian E, Fontecchio S, Gracewski J, Klemas B, Jimenez L. Community-acquired bacterial pneumonia requiring admission to hospital. Am J Infect Control. Jun 1983;11(3):79-82. [Medline].

  94. Kuriyama T, Williams DW, Yanaglasawa M et al. Antimicrobial susceptibility of 800 anaerobic isolates from patients with dentoalveolar infection to 13 oral antibiotics. Oral Microbiology and Immunology. 2007;22:285-288.

  95. LeGall-Simon EL, Orenstein R. Doxycycline for switch therapy in community-acquired pneumonia. Infect Dis Clin Pract. 1999;8:465-6.

  96. Lodise TP, Kwa A, Cosler L, Gupta R, Smith RP. Comparison of beta-lactam and macrolide combination therapy versus fluoroquinolone monotherapy in hospitalized Veterans Affairs patients with community-acquired pneumonia. Antimicrob Agents Chemother. Nov 2007;51(11):3977-82. [Medline].

  97. Loh LC, Chin HK, Chong YY, Jeyaratnam A, Raman S, Vijayasingham P. Klebsiella pneumoniae respiratory isolates from 2000 to 2004 in a Malaysian hospital: characteristics and relation to hospital antibiotics consumption. Singapore Med J. Sep 2007;48(9):813-8. [Medline].

  98. Maesen FP, Davies BI, van Noord JA. Doxycycline in respiratory infections: a re-assessment after 17 years. J Antimicrob Chemother. Oct 1986;18(4):531-6. [Medline].

  99. Marrie TJ. Empiric treatment of ambulatory community-acquired pneumonia: always include treatment for atypical agents. Infect Dis Clin North Am. Dec 2004;18(4):829-41. [Medline].

  100. Marrie TJ. Experience with levofloxacin in a critical pathway for the treatment of community-acquired pneumonia. Chemotherapy. 2004;50 Suppl 1:11-5. [Medline].

  101. Marrie TJ. Incidence and clinical significance of the most common pathogens in community-acquired pneumonias. Infect Dis Clin Pract. 1997;6(S2):S32-S42.

  102. Marrie TJ. The halo effect of adherence to guidelines extends to patients with severe community-acquired pneumonia requiring admission to an intensive care unit. Clin Infect Dis. Dec 15 2005;41(12):1717-9. [Medline].

  103. Marrie TJ, Huang JQ. Low-risk patients admitted with community-acquired pneumonia. Am J Med. Dec 2005;118(12):1357-63. [Medline].

  104. Marrie TJ, Poulin-Costello M, Beecroft MD, Herman-Gnjidic Z. Etiology of community-acquired pneumonia treated in an ambulatory setting. Respir Med. Jan 2005;99(1):60-5. [Medline].

  105. Marrie TJ, Shariatzadeh MR. Community-acquired pneumonia requiring admission to an intensive care unit: a descriptive study. Medicine (Baltimore). Mar 2007;86(2):103-11. [Medline].

  106. Martinez FJ. Monotherapy versus dual therapy for community-acquired pneumonia in hospitalized patients. Clin Infect Dis. May 15 2004;38 Suppl 4:S328-40. [Medline].

  107. McCormick D, Fine MJ, Coley CM, Marrie TJ, Lave JR, Obrosky DS. Variation in length of hospital stay in patients with community-acquired pneumonia: are shorter stays associated with worse medical outcomes?. Am J Med. Jul 1999;107(1):5-12. [Medline].

  108. McCue JD. Pneumonia in the elderly. Special considerations in a special population. Postgrad Med. Oct 1993;94(5):39-40, 43-6, 51. [Medline].

  109. Niederman MS, Brito V. Pneumonia in the older patient. Clin Chest Med. Dec 2007;28(4):751-71, vi. [Medline].

  110. Ortiz-Ruiz G, Vetter N, Isaacs R, Carides A, Woods GL, Friedland I. Ertapenem versus ceftriaxone for the treatment of community-acquired pneumonia in adults: combined analysis of two multicentre randomized, double-blind studies. J Antimicrob Chemother. Jun 2004;53 Suppl 2:ii59-66. [Medline].

  111. Peterson MW, Hornick DB. Community-acquired pneumonia guidelines: Peering back through the looking glass...clearly?. Am J Med. Nov 15 2004;117(10):799-800. [Medline].

  112. Plouffe JF Jr. Multiply resistant Streptococcus pneumoniae: Clinical significance and therapeutic implications. P & T. 2000;25:302-11.

  113. Pomilla PV, Brown RB. Outpatient treatment of community-acquired pneumonia in adults. Arch Intern Med. Aug 22 1994;154(16):1793-802. [Medline].

  114. Quintiliani R, Nicolau DP, Nightingale CH. Clinical relevance of penicillin-resistant Streptococcus pneumoniae with particular attention to therapy with ceftizoxime, cefotaxime, and ceftriaxone. Clin Infect Dis Pract. 1996;3(S1):S37-S41.

  115. Quntiliani R, Nightingale C. Transitional antibiotic therapy. Infect Dis Clin Pract. 1994;3(S3):S161-S166.

  116. Ramirez JA. Community-acquired pneumonia in adults. Prim Care. Mar 2003;30(1):155-71. [Medline].

  117. Ramírez JA. Processes of care for community-acquired pneumonia. Infect Dis Clin North Am. Dec 2004;18(4):843-59. [Medline].

  118. Raschilas F, Tigoulet F, Durant R, Blain H, Jeandel C. Ertapanem therapy for community-acquired pneumonia in the elderly. J Am Geriatr Soc. Oct 2004;52(10):1788-9; author reply 1789. [Medline].

  119. Restrepo MI, Mortensen EM, Pugh JA, Anzueto A. COPD is associated with increased mortality in patients with community-acquired pneumonia. Eur Respir J. Aug 2006;28(2):346-51. [Medline].

  120. Ruiz-González A, Falguera M, Nogués A, Rubio-Caballero M. Is Streptococcus pneumoniae the leading cause of pneumonia of unknown etiology? A microbiologic study of lung aspirates in consecutive patients with community-acquired pneumonia. Am J Med. Apr 1999;106(4):385-90. [Medline].

  121. Scalera NM, File TM Jr. How long should we treat community-acquired pneumonia?. Curr Opin Infect Dis. Apr 2007;20(2):177-81. [Medline].

  122. Segreti J, House HR, Siegel RE. Principles of antibiotic treatment of community-acquired pneumonia in the outpatient setting. Am J Med. Jul 2005;118 Suppl 7A:21S-28S. [Medline].

  123. Shea KW, Cunha BA, Ueno Y, Abumustafa F, Qadri SM. Doxycycline activity against Streptococcus pneumoniae. Chest. Dec 1995;108(6):1775-6. [Medline].

  124. Siegel RE, Halpern NA, Almenoff PL, Lee A, Cashin R, Greene JG. A prospective randomized study of inpatient iv. antibiotics for community-acquired pneumonia. The optimal duration of therapy. Chest. Oct 1996;110(4):965-71. [Medline].

  125. Sopena N, Pedro-Botet ML, Sabrià M, García-Parés D, Reynaga E, García-Nuñez M. Comparative study of community-acquired pneumonia caused by Streptococcus pneumoniae, Legionella pneumophila or Chlamydia pneumoniae. Scand J Infect Dis. 2004;36(5):330-4. [Medline].

  126. Strålin K, Holmberg H. Usefulness of the Streptococcus pneumoniae urinary antigen test in the treatment of community-acquired pneumonia. Clin Infect Dis. Oct 15 2005;41(8):1209-10. [Medline].

  127. Torell E, Molin D, Tano E, Ehrenborg C, Ryden C. Community-acquired pneumonia and bacteraemia in a healthy young woman caused by methicillin-resistant Staphylococcus aureus (MRSA) carrying the genes encoding Panton-Valentine leukocidin (PVL). Scand J Infect Dis. 2005;37(11-12):902-4. [Medline].

  128. Troy CJ, Peeling RW, Ellis AG, Hockin JC, Bennett DA, Murphy MR. Chlamydia pneumoniae as a new source of infectious outbreaks in nursing homes. JAMA. Apr 16 1997;277(15):1214-8. [Medline].

  129. Wallace RJ Jr, Musher DM, Martin RR. Hemophilus influenzae pneumonia in adults. Am J Med. Jan 1978;64(1):87-93. [Medline].

  130. Welte T, Petermann W, Schürmann D, Bauer TT, Reimnitz P,. Treatment with sequential intravenous or oral moxifloxacin was associated with faster clinical improvement than was standard therapy for hospitalized patients with community-acquired pneumonia who received initial parenteral therapy. Clin Infect Dis. Dec 15 2005;41(12):1697-705. [Medline].

  131. Wunderink RG, Waterer GW. Community-acquired pneumonia: pathophysiology and host factors with focus on possible new approaches to management of lower respiratory tract infections. Infect Dis Clin North Am. Dec 2004;18(4):743-59, vii. [Medline].

  132. Yoshimoto A, Nakamura H, Fujimura M, Nakao S. Severe community-acquired pneumonia in an intensive care unit: risk factors for mortality. Intern Med. Jul 2005;44(7):710-6. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

community-acquired pneumonia, CAP, bacterial pneumonia, viral pneumonia, pneumococcal pneumonia, Streptococcus pneumoniae pneumonia, S pneumoniae pneumonia, Streptococcus pneumonia, streptococcal pneumonia, Haemophilus influenzae pneumonia, pneumonia, Moraxella catarrhalis pneumonia, M catarrhalis pneumonia, pneumonia, zoonotic pneumonia, pneumonia, pneumonia, Mycoplasma pneumonia pneumonia, pneumonia, pneumonia, Legionnaires disease, tularemia, Q fever, psittacosis, aspiration pneumonia

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Fred A Lopez, MD, Associate Professor and Vice Chair, Department of Medicine, Assistant Dean for Student Affairs, Louisiana State University School of Medicine
Fred A Lopez, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, Infectious Diseases Society of America, and Louisiana State Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Charles V Sanders, MD, Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center
Charles V Sanders, MD is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, Alpha Omega Alpha, American Association for the Advancement of Science, American Association of University Professors, American Clinical and Climatological Association, American College of Physician Executives, American College of Physicians, American Federation for Medical Research, American Foundation for AIDS Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association for Professionals in Infection Control and Epidemiology, Association of American Medical Colleges, Association of American Physicians, Association of Professors of Medicine, Infectious Disease Society for Obstetrics and Gynecology, Infectious Diseases Society of America, Louisiana State Medical Society, Orleans Parish Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southeastern Clinical Club, Southern Medical Association, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD, Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.