eMedicine Specialties > Infectious Diseases > Lower Respiratory Tract Infections

Nursing Home Acquired Pneumonia

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

Updated: Jun 27, 2008

Introduction

Background

Nursing home–acquired pneumonia (NHAP) is defined as pneumonia occurring in a resident of a chronic care facility or nursing home. NHAP is one of the most common infectious diseases in chronic care facilities and is a significant cause of mortality and morbidity among residents of such facilities. NHAP more closely resembles community-acquired pneumonia (CAP) than nosocomial pneumonia (NP).

NP occurs when the pathogen is distributed in a hospital setting, resulting in a subsequent infection. Aerobic gram-negative bacilli, including Pseudomonas aeruginosa, cause NPs. Staphylococcus aureus (eg, methicillin-susceptible S aureus [MSSA] and methicillin-resistant S aureus [MRSA]) infection is not a significant cause of CAP, NP, or NHAP. The presence of P aeruginosa and other aerobic gram-negative bacilli defines the NP group. Because NHAP is caused by CAP-associated pathogens and not NP-associated pathogens, NHAP is considered diagnostically and therapeutically synonymous to CAP. Patients with NHAP have the same length of hospital stay as patients with CAP. Physicians, therefore, approach the treatment strategy for NHAP and CAP in a similar way and with similar empiric antibiotic coverage.

Table 1. Comparison of Characteristics of Nursing Home–Acquired Pneumonia, Community-Acquired Pneumonia, and Nosocomial Pneumonia 

Pathophysiology

The pathophysiology of NHAP is the same as the pathophysiology of CAP. NHAP may result when a patient aspirates oropharyngeal contents into one or more lung segments or lobes. NHAP may also occur if a distant focus of infection hematogenously disseminates to the lungs.

Aspiration pneumonia, whether community-acquired or acquired in a nursing home, results microbiologically from aspirated anaerobic oropharyngeal flora. Hundreds of species of oropharyngeal anaerobes may be cultured from patients with aspiration pneumonia. However, oropharyngeal anaerobes are not like Bacteroides fragilis, which is the primary anaerobe below the diaphragm and is sensitive to nearly all antibiotics. Patients with CAP or NHAP do not require specific anti– B fragilis coverage. In aspiration pneumonia, the location of the lung lesion is related to the position of the patient at the time of aspiration. Because most patients are supine when they aspirate, most lung infiltrates observed on chest radiographs and most aspiration pneumonia occur in segments of the right lung.

If aspiration occurs when patients are lying on their right side, the pulmonary infiltrates most likely involve the right upper lobe. If patients are lying on their left side, the most likely location of the infiltrates is the left upper lobe. If patients are supine and the aspiration is massive, bilateral infiltrates involving multiple lung segments or lobes are possible and may produce a radiologic appearance indistinguishable from left ventricular failure or acute respiratory distress syndrome. 

Table 2. Radiographic Patterns in Aspiration Pneumonia

Hematogenously acquired pneumonia is not common among patients with CAP or NHAP. Hematogenously acquired pneumonia presents with bilateral symmetrical perihilar infiltrates, as opposed to the localized segmental or lobar distribution characteristic of pneumonia acquired via primary inhalation.

The degree of impaired lung function resulting from NHAP depends on the extent of aspiration and the patient's preexisting physiologic and anatomic lung function. The histologic changes in lung parenchyma resulting from NHAP are the same as those observed resulting from CAP (ie, no cavitation, necrosis, or blood vessel invasion). As with CAP, resolving NHAP restores the lung function that existed prior to acquiring pneumonia.

Frequency

United States

NHAP is one of the most common causes of infection in chronic care facilities and is one the most significant infection-related causes of mortality and morbidity in such facilities.

International

NHAP is a common cause of infection in chronic care facilities.

Mortality/Morbidity

• NHAP is one of the most important infection-related causes of mortality and morbidity in chronic care facilities.

Race

• No race predilection exists.

Sex

• No sex predilection exists.

Age

• By definition, most patients in chronic care facilities and nursing homes are elderly; therefore, NHAP is a disease that primarily afflicts elderly individuals.
• NHAP is less common in chronic care or rehabilitation facilities that have smaller populations of elderly individuals.

Clinical

History

• Patients may complain of fever, cough, chest pain, or rapid respiration.
• Patients with chronic bronchitis are particularly prone to developing pneumonias.
• Patients with aspiration nursing home–acquired pneumonia (NHAP) often have a history of CNS or esophageal disease, or they have a decreased gag reflex that predisposes them to recurrent aspiration.

Physical

• Most, but not all, patients are febrile. Fever, when present, may be high-grade or low-grade.
• Physical findings in the chest include rales over the involved lung segments with or without signs of consolidation or pleural effusion.

Causes

• The most common pathogens that cause NHAP and community-acquired pneumonia (CAP) are S pneumoniae, H influenzae, and M catarrhalis.
• Atypical organisms that cause NHAP are Mycoplasma pneumoniae, Legionella (primarily in chronic care facilities), and C pneumoniae (primarily in elderly residents of nursing homes).
• Overview of NHAP
  • NHAP is a common diagnosis applied upon admission but is the definitive diagnosis in only 33% of patients.
  • Many physicians perform a suboptimal workup for NHAP, omitting sputum Gram stains and culture studies. Blood culture findings are usually negative.
  • The distribution of pathogens observed in NHAP more closely resembles CAP than nosocomial pneumonia (NP).
  • Clinically, NHAP differs from NP in that NHAP is not associated with P aeruginosa, it does not produce cavitation on chest radiographs, and patients generally have a shorter hospital stay. The duration of the hospital stay for a patient with NHAP is the same as for a patient with CAP.
  • The medical conditions most frequently misdiagnosed as NHAP are congestive heart failure (CHF) and chronic obstructive pulmonary disease.
  • Chest radiograph findings in NHAP are useful to rule out CHF. Unilateral segmental or lobar infiltrates are the most common roentgenographic findings in NHAP, as they are in CAP.
  • Fever and leukocytosis are more common in patients with NHAP than in patients with noninfectious mimics of NHAP, but these findings are nonspecific.
  • Noninfectious infiltrates observed on chest radiographs are frequently misdiagnosed as NHAP.
  • Treat NHAP empirically, using the same antibiotics as with CAP, but not as with NP.

Differential Diagnoses

Pleural Effusion
Pulmonary Embolism

Other Problems to Be Considered

Most patients from chronic care facilities who are transferred to acute care hospitals do not have nursing home–acquired pneumonia (NHAP). The most common causes of diagnostic confusion in patients with NHAP are noninfectious cardiac and pulmonary disorders.

CHF is the most common disorder that resembles NHAP in the chronic care facility setting. CHF may represent an exacerbation of preexisting CHF, resulting in increasing shortness of breath for the patient, which mimics the presentation of NHAP.

The clinical presentation of patients in nursing homes who develop asymptomatic acute myocardial infarctions may also mimic the clinical presentation of patients with NHAP. Myocardial infarction may be associated with fever, shortness of breath, and chest pain; all are signs that mimic NHAP.

Many elderly patients are unable to raise sputum, making the absence of a productive cough an inadequate determination to differentiate NHAP and CHF.

Preexisting lung disease, pulmonary emboli, and bronchogenic malignancies mimic NHAP. Collagen vascular diseases affecting the lungs, pulmonary drug reactions, and pulmonary hemorrhage may also mimic NHAP.

Chest radiography is the best study for diagnosing NHAP. Patients with NHAP have a segmental or lobar distribution of infiltrates, as seen on chest radiographs. Patients with CHF have a redistribution of vasculature to the upper lobes, usually accompanied by cardiomegaly. Verify cardiomegaly by physical examination. If CHF is present, it usually is accompanied by an S₃ gallop rhythm.

Preexisting chest radiographs may reveal previous interstitial lung disease that may mimic the appearance of NHAP. Chest radiography is the primary tool for ruling out the mimics of pneumonia and any new or preexisting lung disorders.

Fever that is equal to or greater than 102°F and accompanied by pulmonary symptoms suggests NHAP, especially when accompanied by a productive cough. However, in elderly patients who are the usual residents of chronic care facilities, the febrile response may be blunted. Therefore, the absence of fever or the presence of a low-grade fever is unhelpful in differentiating NHAP from its mimics.

Workup

Laboratory Studies

• Blood cultures
  • Obtain blood cultures from all patients with community-acquired pneumonia (CAP) and nursing home–acquired pneumonia (NHAP).
  • Blood culture findings are usually positive if infection with S pneumoniae or H influenzae is causing the patient's pneumonia.
  • The yield of positive blood cultures in NHAP is lower than in CAP, which may represent a difference in the time each culture was taken. Patients with CAP who are admitted to an acute care facility usually have blood cultures drawn in the emergency room or soon after admission. Patients who are transferred to an acute care hospital from a chronic care facility may not have blood cultures drawn for many hours or days after the onset of pneumonia. These factors may account for the difference in culture yields.
• CBC count
  • Physicians usually obtain blood counts, but these tests are not helpful, because the results are nonspecific.
  • Leukocytosis with a left shift is due to stress to the individual, which may occur with NHAP, an acute myocardial infarction, pulmonary emboli, dehydration, or any cause of stress. Therefore, the clinician should not assume that leukocytosis with a left shift is diagnostic of NHAP.
  • The diagnosis of NHAP rests on excluding the mimics of pneumonia and on the presence of characteristic findings on chest radiographs.
• Sputum staining and culture
  • Stain sputum using a Gram stain and perform culture studies from patients with a productive cough who do not have chronic bronchitis.
  • Physicians cannot interpret sputum culture results from patients with chronic bronchitis because the results usually show normal flora or mixed flora, which is unhelpful to the clinician.
  • For sputum specimens to be useful in determining the etiology of the pneumonia, they must be of good quality and must reflect the lower respiratory tract flora. A poor specimen collection, as evidenced by the presence of epithelial squamous cell contamination and a relative lack of polymorphonuclear neutrophils or multiple organisms, suggests that the specimen is invalid and unreliable.
• Multiple pathogens are not a feature of NHAP. Dual infections are rare in both NHAP and CAP.
• Aspiration pneumonia due to anaerobic pharyngeal flora is the only polymicrobial respiratory tract infection that is considered community- or nursing home–acquired. The presence of a single causative pathogen generally excludes anaerobic aspiration pneumonia in patients with CAP or NHAP.

Imaging Studies

• Chest radiography is the primary tool to differentiate the mimics of pneumonia from NHAP. If the resolution of the chest radiograph is insufficient to differentiate NHAP, consider obtaining a chest CT scan.

Other Tests

• Obtain an ECG and cardiac enzymes in patients who may have a cardiac explanation for their pulmonary symptoms, as evidenced by their history, physical, or chest radiograph findings. ECG and cardiac enzymes are helpful in ruling out silent myocardial infarctions, which are not uncommon in elderly patients.
• Bacterial blood gases or lung scans may be useful in ruling out pulmonary emboli as a cause of the patient's pulmonary symptoms.
• If considering Legionnaires disease, a rare cause of sporadic pneumonia in chronic care facilities, obtain liver function tests.
• Patients presenting with extrapulmonary findings in a chronic care facility may have NHAP caused by C pneumoniae infection. In such patients, C pneumoniae immunoglobulin (Ig) M and IgG titers may be diagnostic. IgA may also help to clarify if a patient is experiencing a relapse or a reinfection with Chlamydia. C pneumoniae infection usually occurs as part of an outbreak and should be readily recognizable in the nursing home setting because the infection occurs in clusters and is characterized by extrapulmonary features that set it apart from the usual bacterial causes of NHAP.

Procedures

• Patients with pleural effusions unrelated to a nephrotic syndrome, uremia, hypoalbuminemia, cirrhosis, or heart failure require diagnostic thoracentesis. Physicians should test the thoracentesis fluid using Gram stain and culture studies as well as pH, glucose, protein, cell count, and differential. This procedure may reveal the causal pathogen if blood culture results are negative and if sputum is not available.

Histologic Findings

Findings include local polymorphonuclear neutrophil infiltration of infected lung areas without cavitation, necrosis, or blood vessel invasion.

Treatment

Medical Care

If the physician suspects nursing home–acquired pneumonia (NHAP) and the mimics of pneumonia can be ruled out, early appropriate empiric therapy is the critical component of medical management. Promptly instituting empiric antimicrobial therapy significantly decreases the likelihood of mortality and morbidity associated with NHAP and community-acquired pneumonia (CAP). Direct antimicrobial coverage against the most likely pathogens (ie, S pneumoniae, H influenzae, M catarrhalis, C pneumoniae).

• Select antibiotics that have the appropriate spectrum and minimal resistance potential, have excellent adverse effect profiles, are cost effective, and are available in intravenous and oral formulations.
• The duration of therapy usually is 2 weeks, depending on the patient's host defenses and underlying cardiopulmonary status.
• Consider extending antimicrobial therapy for a few days in more severe cases, but do not automatically prolong therapy simply because persisting pulmonary infiltrates are observed on chest radiographs, low-grade fevers are present, or the patient has minimal leukocytosis.
• Antimicrobial therapy may be administered intravenously, but this is frequently a problem in elderly patients in chronic care facilities. The absence of intravenous teams and adequate nursing staff makes intravenous antibiotic administration difficult. Elderly patients frequently have poor venous access, further complicating the problem. Therefore, early appropriate antimicrobial therapy with an oral antimicrobial is ideally suited for the early treatment of pneumonia in chronic care facilities. Such early treatment may prevent the further deterioration of the patient and the progression of the pneumonia. Further weakening of the patient's condition may require transfer to an acute care hospital.
• While some past reports indicated that intramuscular administration of antibiotics is efficacious when intravenous access is not possible, current recommendations indicate that oral antimicrobial therapy is preferred and that physicians should use intravenous therapy instead of intramuscular administration.

Consultations

• Patients with NHAP typically do not require consultations; however, when attempting to rule out mimics of pneumonia in patients who are transferred to acute care facilities, consider obtaining an infectious disease consultation.
• Patients with preexisting lung disorders may benefit from pulmonary consultation.
• Patients with an exacerbation of previous cardiac problems or new cardiac problems will benefit from a cardiac consultation.

Diet

• Patients do not require dietary alterations.

Activity

• Physicians usually advise bed rest for patients with NHAP. When the patient is able to ambulate, recommend a gradual transition to ambulation, as tolerated.

Medication

The goals of pharmacotherapy are to reduce morbidity, to eradicate the infection, and to prevent complications.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting.

Levofloxacin (Levaquin)

Second-generation quinolone. Acts by interfering with DNA gyrase in bacterial cells. For pseudomonal infections and infections resulting from multi-drug–resistant gram-negative organisms. Highly active against gram-negative and gram-positive organisms, including highly penicillin-resistant S pneumoniae.

Dosing

Adult

500 mg PO/IV qd for 7-14 d

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Interactions

Administer antacids 1-2 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; levofloxacin reduces therapeutic effects of phenytoin; probenecid may increase levofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins.

Dosing

Adult

1 g IV q24h

Pediatric

Neonates >7 days: 25-50 mg/kg/d IV/IM; not to exceed 125 mg/d
Infants and children: 100 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d

Interactions

Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Gallbladder sludge (eg, pseudobiliary lithiasis) may require cholecystectomy; associated with non-C difficile diarrhea; adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin

Doxycycline (Vibramycin)

Second-generation long-acting tetracycline. More active than tetracycline against many pathogens, especially S pneumoniae and Legionella. Different adverse effect profile and pharmacokinetics compared to tetracycline. Inhibits protein synthesis, thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Dosing

Adult

100-200 mg PO/IV q12h

Pediatric

<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO/IV in 1-2 divided doses; not to exceed 200 mg/d

Interactions

Bioavailability decreases minimally with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Unsafe in pregnancy

Precautions

Rarely, if ever, causes photosensitivity, but may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Cefepime (Maxipime)

Fourth-generation cephalosporin with good gram-negative coverage. Similar to third-generation cephalosporins but has better gram-positive coverage.

Dosing

Adult

2 g IV q12h

Pediatric

50 mg/kg IV q8h; not to exceed 2 g

Interactions

Probenecid at high dose decreases cefepime clearance; aminoglycosides increase nephrotoxic potential of cefepime

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Adjust dose in severe renal insufficiency; prolonged use of cefepime may predispose patients to superinfection

Follow-up

Further Inpatient Care

• Patients with severe nursing home–acquired pneumonia (NHAP) who are transferred to acute care facilities may require initial intravenous antimicrobial administration. Alternatively, oral antibiotic administration in the acute care facility is acceptable and equivalent to intravenously administered antibiotic therapy.
• Transfer patients to an acute care hospital for reasons other than antibiotic administration (ie, patient represents a problem in differential diagnoses, patient requires oxygen therapy, pulmonary toilet, cardiac adjustment of cardiac drugs). Transferring an NHAP patient to an acute care facility simply to receive intravenous antibiotics is usually not necessary.
• Patients started on intravenous antimicrobial therapy in the nursing home or the hospital should be switched to an equivalent oral antimicrobial therapy after 48-72 hours. After patients are on oral therapy and their cardiopulmonary status stabilizes, transfer them back to the chronic care facility.

Inpatient & Outpatient Medications

• Physicians typically treat patients with NHAP for 2 weeks. If a few more days of antimicrobial therapy are necessary while the patient is in the hospital or the chronic care facility, use oral formulations.
• Pulmonary infiltrates that do not resolve after 2 weeks of appropriate antimicrobial therapy suggest that the infiltrates are not infectious, and the physician should initiate further diagnostic studies to determine the cause. Pulmonary infiltrates resolve more slowly than their appearance on chest radiographs indicates; however, as long as the infiltrates are resolving and the patient is improving clinically, the patient does not need to remain in the acute care facility until the infiltrates clear from the radiographs. Make certain that the patient's pneumonia is resolving and that they are clinically stabilized before returning them to the chronic care facility.

Transfer

• As long as the pulmonary infiltrates are resolving and the patient is improving clinically, the patient need not remain in the acute care facility until the chest radiographs are clear. Make certain that the patient's pneumonia is resolving and they are clinically stabilized before returning them to the chronic care facility.

Deterrence/Prevention

• Keep patients who are predisposed to aspiration pneumonia in a semiupright position at night.
• Take care when feeding patients who have an empiric gag reflex or neurologic disorder that depresses consciousness or interferes with swallowing.

Complications

• Empyema may complicate pneumonia. Diagnose empyema with thoracentesis and treat patients with appropriate antimicrobial therapy and chest tube drainage.

Prognosis

• Prognosis depends on the host immune system, the patient's preexisting cardiopulmonary reserve status, and the extent of the patient's lobar involvement resulting from the pneumonia.
• Patients who are predisposed to aspiration are at high risk for re-aspiration. The same factors that cause the initial aspiration predispose patients to further episodes of aspiration pneumonia. Treat these patients with the same antibiotics for each episode. The recurrence of pneumonia is not the result of antibiotic failure but the result of the underlying predisposing factors to aspiration.

Miscellaneous

Medicolegal Pitfalls

• Do not assume that all patients with respiratory symptoms and infiltrates on their chest radiographs have pneumonia. Consider that patients may have one of the many mimics of pneumonia before embarking on a course of empiric antimicrobial therapy. If a physician treats a patient with empiric antimicrobial therapy when the patient has a treatable noninfectious cause for his or her pulmonary infiltrates, the patient may suffer because cardiac or noninfectious pulmonary conditions require other, nonantimicrobial, measures.

Special Concerns

• Remember that renal function decreases with age, and most patients in chronic care facilities are elderly; therefore, consider their creatinine clearance rate when calculating antimicrobial dosing.
• The initial dose of renally cleared antibiotics in patients with renal insufficiency is the same as in individuals without renal insufficiency; however, physicians should decrease the maintenance dose in proportion to the degree of renal dysfunction. If using hepatically cleared antibiotics (eg, doxycycline) that primarily have a nonrenal mode of elimination, no dosing adjustment is necessary in elderly patients with impaired renal function.

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Keywords

nursing home–acquired pneumonia, NHAP, pneumonia in chronic care facilities, Streptococcus pneumoniae, S pneumoniae, Haemophilus influenzae, H influenzae, Moraxella catarrhalis, M catarrhalis, Legionella, Chlamydia pneumoniae, C pneumoniae, aspiration pneumonia, chronic bronchitis, CNS disease, esophageal disease, decreased gag reflex, community-acquired pneumonia, CAP, nosocomial pneumonia, NP

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

Wesley W Emmons, MD, FACP, Assistant Professor, Department of Medicine, Thomas Jefferson University; Consulting Staff, Infectious Diseases Section, Department of Internal Medicine, Christiana Care, Newark, DE
Wesley W Emmons, MD, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and International AIDS Society
Disclosure: Nothing to disclose.

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

Managing Editor

Ronald A Greenfield, MD, Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
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CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
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.

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