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Semin Respir Crit Care Med 2009; 30(1): 036-045
DOI: 10.1055/s-0028-1119807
© Thieme Medical Publishers

Diagnostic Strategies for Healthcare-Associated Pneumonia

Eva Polverino1 , Antoni Torres1
  • 1Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona–Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)–University of Barcelona (UB)–Ciber de Enfermedades Respiratorias (Ciberes), Barcelona, Spain
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Publication History

Publication Date:
06 February 2009 (online)

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ABSTRACT

The first point of a good diagnostic strategy for healthcare-associated pneumonia (HCAP) is correct classification of patients with specific criteria, as suggested by the last American Thoracic Society/ Infectious Diseases Society of America (ATS/IDSA) guidelines. However, clinical practice and recent literature have suggested new risk factors for multidrug-resistant infection (MRI): the presence of permanent indwelling devices, prior antibiotic use in the last 3 months, chronic and advanced pulmonary diseases (chronic obstructive pulmonary disease, bronchiectasis, etc.), history of alcoholism, and immunosuppression. The clinical presentation in HCAP patients is often unusual (mild respiratory symptoms and frequent extrapulmonary manifestations) due to different factors: advanced age, neurological disorders, and multiple chronic comorbidities. Moreover, HCAP commonly presents a worse clinical course than community-acquired pneumonia, a prolonged length of stay, and a mortality rate close to hospital-acquired pneumonia. Chest radiography and routine laboratory markers (including C-reactive protein) are always needed for clinical evaluation and severity assessment. The clinical use of new biomarkers of infection and sepsis (procalcitonin, etc.) is currently being investigated. Extensive microbiological testing to overcome the high prevalence of MRI in HCAP, including urinary antigens for Legionella and Streptococcus pneumoniae; blood cultures; Gram staining and low respiratory tract secretions (sputum, tracheobronchial aspirate, fibrobronchial aspirate, protected specimen brush, bronchoalveolar lavage); and cultures for aerobic, anaerobic, mycobacterial, and fungal pathogens are recommended, whereas the indication for serology tests for respiratory viruses and atypical pathogens is low. By contrast, the new polymerase chain reaction–based techniques for the rapid identification (2 to 4 hours) of microbial pathogens in respiratory samples (nasopharyngeal swab, bronchoalveolar lavage) seem to be the most innovative future perspective in the diagnostics of HCAP.

KEYWORDS

HCAP - diagnostic tests - etiology in HCAP

REFERENCES

  • 1 Carratala J, Mykietiuk A, Fernandez-Sabe N et al.. Healthcare-associated pneumonia requiring hospital admission: epidemiology, antibiotic therapy, and clinical outcomes.  Arch Intern Med. 2007;  167 1393-1399
    CrossrefPubMedGoogle Scholar
  • 2 Kollef M H, Shorr A, Tabak Y P, Gupta V, Liu L Z, Johannes R S. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia.  Chest. 2005;  128 3854-3862
    CrossrefPubMedGoogle Scholar
  • 3 Meehan T P, Chua-Reyes J M, Tate J et al.. Process of care performance, patient characteristics, and outcomes in elderly patients hospitalized with community-acquired or nursing home-acquired pneumonia.  Chest. 2000;  117 1378-1385
    CrossrefPubMedGoogle Scholar
  • 4 National Center for Health Statistics .Highlights of Trends in the Health of Older Americans: United States, 1994. Washington, DC; US Department of Health and Human Services 1995
    Google Scholar
  • 5 Reuben D B, Schnelle J F, Buchanan J L et al.. Primary care of long-stay nursing home residents: approaches of three health maintenance organizations.  J Am Geriatr Soc. 1999;  47 131-138
    PubMedGoogle Scholar
  • 6 American Thoracic Society . Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.  Am J Respir Crit Care Med. 2005;  171 388-416
    CrossrefPubMedGoogle Scholar
  • 7 Mody L, Maheshwari S, Galecki A, Kauffman C A, Bradley S F. Indwelling device use and antibiotic resistance in nursing homes: identifying a high-risk group.  J Am Geriatr Soc. 2007;  55 1921-1926
    PubMedGoogle Scholar
  • 8 Seenivasan M H, Yu V L, Muder R R. Legionnaires' disease in long-term care facilities: overview and proposed solutions.  J Am Geriatr Soc. 2005;  53 875-880
    CrossrefPubMedGoogle Scholar
  • 9 Troy C J, Peeling R W, Ellis A G et al.. Chlamydia pneumoniae as a new source of infectious outbreaks in nursing homes.  JAMA. 1997;  277 1214-1218
    CrossrefPubMedGoogle Scholar
  • 10 Berk S L. Bacterial pneumonia in the elderly: the observations of Sir William Osler in retrospect.  J Am Geriatr Soc. 1984;  32 683-685
    PubMedGoogle Scholar
  • 11 Donowitz G R, Cox H L. Bacterial community-acquired pneumonia in older patients.  Clin Geriatr Med. 2007;  23 515-534 , vi
    CrossrefPubMedGoogle Scholar
  • 12 Lim W S, Macfarlane J T. A prospective comparison of nursing home acquired pneumonia with community acquired pneumonia.  Eur Respir J. 2001;  18 362-368
    CrossrefPubMedGoogle Scholar
  • 13 Fernandez-Sabe N, Carratala J, Roson B et al.. Community-acquired pneumonia in very elderly patients: causative organisms, clinical characteristics, and outcomes.  Medicine (Baltimore). 2003;  82 159-169
    CrossrefPubMedGoogle Scholar
  • 14 Metlay J P, Schulz R, Li Y H et al.. Influence of age on symptoms at presentation in patients with community-acquired pneumonia.  Arch Intern Med. 1997;  157 1453-1459
    CrossrefPubMedGoogle Scholar
  • 15 Riquelme R, Torres A, El-Ebiary M et al.. Community-acquired pneumonia in the elderly. clinical and nutritional aspects.  Am J Respir Crit Care Med. 1997;  156 1908-1914
    PubMedGoogle Scholar
  • 16 Marrie T J, Blanchard W. A comparison of nursing home-acquired pneumonia patients with patients with community-acquired pneumonia and nursing home patients without pneumonia.  J Am Geriatr Soc. 1997;  45 50-55
    PubMedGoogle Scholar
  • 17 Roghmann M C, Warner J, Mackowiak P A. The relationship between age and fever magnitude.  Am J Med Sci. 2001;  322 68-70
    CrossrefPubMedGoogle Scholar
  • 18 Niederman M S, Brito V. Pneumonia in the older patient.  Clin Chest Med. 2007;  28 751-771 , vi
    CrossrefPubMedGoogle Scholar
  • 19 Marik P E, Kaplan D. Aspiration pneumonia and dysphagia in the elderly.  Chest. 2003;  124 328-336
    CrossrefPubMedGoogle Scholar
  • 20 Groher M E. Managing dysphagia in a chronic care setting: an introduction.  Dysphagia. 1990;  5 59-60
    CrossrefPubMedGoogle Scholar
  • 21 Kayser-Jones J, Pengilly K. Dysphagia among nursing home residents.  Geriatr Nurs. 1999;  20 77-82
    CrossrefPubMedGoogle Scholar
  • 22 Vergis E N, Brennen C, Wagener M, Muder R R. Pneumonia in long-term care: a prospective case-control study of risk factors and impact on survival.  Arch Intern Med. 2001;  161 2378-2381
    CrossrefPubMedGoogle Scholar
  • 23 Kikuchi R, Watabe N, Konno T, Mishina N, Sekizawa K, Sasaki H. High incidence of silent aspiration in elderly patients with community-acquired pneumonia.  Am J Respir Crit Care Med. 1994;  150 251-253
    CrossrefPubMedGoogle Scholar
  • 24 Feldman C. Pneumonia in the elderly.  Clin Chest Med. 1999;  20 563-573
    CrossrefPubMedGoogle Scholar
  • 25 Waterer G W, Kessler L A, Wunderink R G. Delayed administration of antibiotics and atypical presentation in community-acquired pneumonia.  Chest. 2006;  130 11-15
    CrossrefPubMedGoogle Scholar
  • 26 Metersky M L, Sweeney T A, Getzow M B, Siddiqui F, Nsa W, Bratzler D W. Antibiotic timing and diagnostic uncertainty in Medicare patients with pneumonia: is it reasonable to expect all patients to receive antibiotics within 4 hours?.  Chest. 2006;  130 16-21
    CrossrefPubMedGoogle Scholar
  • 27 Meehan T P, Fine M J, Krumholz H M et al.. Quality of care, process, and outcomes in elderly patients with pneumonia.  JAMA. 1997;  278 2080-2084
    CrossrefPubMedGoogle Scholar
  • 28 Houck P M, Bratzler D W, Nsa W, Ma A, Bartlett J G. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia.  Arch Intern Med. 2004;  164 637-644
    CrossrefPubMedGoogle Scholar
  • 29 Kollef M H, Morrow L E, Baughman R P et al.. Healthcare-associated pneumonia (HCAP): a critical appraisal to improve identification, management, and outcomes–proceedings of the HCAP Summit.  Clin Infect Dis. 2008;  46(Suppl 4) S296-S334
    CrossrefPubMedGoogle Scholar
  • 30 El Solh A A, Sikka P, Ramadan F, Davies J. Etiology of severe pneumonia in the very elderly.  Am J Respir Crit Care Med. 2001;  163 645-651
    PubMedGoogle Scholar
  • 31 Martinez-Moragon E, Garcia F L, Serra S B, Fernandez F E, Gomez B A, Julve P R. Community-acquired pneumonia among the elderly: differences between patients living at home and in nursing homes.  Arch Bronconeumol. 2004;  40 547-552
    PubMedGoogle Scholar
  • 32 Micek S T, Kollef K E, Reichley R M, Roubinian N, Kollef M H. Healthcare-associated pneumonia and community-acquired pneumonia: a single-center experience.  Antimicrob Agents Chemother. 2007;  51 3568-3573
    CrossrefPubMedGoogle Scholar
  • 33 Mandell L A, Wunderink R G, Anzueto A et al.. 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
    CrossrefPubMedGoogle Scholar
  • 34 Menendez R, Cavalcanti M, Reyes S et al.. Markers of treatment failure in hospitalised community acquired pneumonia.  Thorax. 2008;  63 447-452
    CrossrefPubMedGoogle Scholar
  • 35 Seppa Y, Bloigu A, Honkanen P O, Miettinen L, Syrjala H. Severity assessment of lower respiratory tract infection in elderly patients in primary care.  Arch Intern Med. 2001;  161 2709-2713
    CrossrefPubMedGoogle Scholar
  • 36 Nylen E S, Snider Jr R H, Thompson K A, Rohatgi P, Becker K L. Pneumonitis-associated hyperprocalcitoninemia.  Am J Med Sci. 1996;  312 12-18
    CrossrefPubMedGoogle Scholar
  • 37 Christ-Crain M, Muller B. Biomarkers in respiratory tract infections: diagnostic guides to antibiotic prescription, prognostic markers and mediators.  Eur Respir J. 2007;  30 556-573
    CrossrefPubMedGoogle Scholar
  • 38 Christ-Crain M, Muller B. Procalcitonin and pneumonia: is it a useful marker?.  Curr Infect Dis Rep. 2007;  9 233-240
    CrossrefPubMedGoogle Scholar
  • 39 Ip M, Rainer T H, Lee N et al.. Value of serum procalcitonin, neopterin, and C-reactive protein in differentiating bacterial from viral etiologies in patients presenting with lower respiratory tract infections.  Diagn Microbiol Infect Dis. 2007;  59 131-136
    CrossrefPubMedGoogle Scholar
  • 40 Christ-Crain M, Jaccard-Stolz D, Bingisser R et al.. Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial.  Lancet. 2004;  363 600-607
    CrossrefPubMedGoogle Scholar
  • 41 Christ-Crain M, Stolz D, Bingisser R et al.. Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: a randomized trial.  Am J Respir Crit Care Med. 2006;  174 84-93
    CrossrefPubMedGoogle Scholar
  • 42 Levy M M, Fink M P, Marshall J C et al.. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.  Intensive Care Med. 2003;  29 530-538
    CrossrefPubMedGoogle Scholar
  • 43 Kruger S, Ewig S, Marre R et al.. Procalcitonin predicts patients at low risk of death from community-acquired pneumonia across all CRB-65 classes.  Eur Respir J. 2008;  31 349-355
    CrossrefPubMedGoogle Scholar
  • 44 Harbarth S, Holeckova K, Froidevaux C et al.. Diagnostic value of procalcitonin, interleukin-6, and interleukin-8 in critically ill patients admitted with suspected sepsis.  Am J Respir Crit Care Med. 2001;  164 396-402
    CrossrefPubMedGoogle Scholar
  • 45 Christ-Crain M, Morgenthaler N G, Stolz D et al.. Pro-adrenomedullin to predict severity and outcome in community-acquired pneumonia.  Crit Care. 2006;  10 R96
    CrossrefPubMedGoogle Scholar
  • 46 Christ-Crain M, Morgenthaler N G, Struck J, Harbarth S, Bergmann A, Muller B. Mid-regional pro-adrenomedullin as a prognostic marker in sepsis: an observational study.  Crit Care. 2005;  9 R816-R824
    CrossrefPubMedGoogle Scholar
  • 47 Struck J, Uhlein M, Morgenthaler N G et al.. Release of the mitochondrial enzyme carbamoyl phosphate synthase under septic conditions.  Shock. 2005;  23 533-538
    PubMedGoogle Scholar
  • 48 Waterer G W, Wunderink R G. The influence of the severity of community-acquired pneumonia on the usefulness of blood cultures.  Respir Med. 2001;  95 78-82
    CrossrefPubMedGoogle Scholar
  • 49 Glerant J C, Hellmuth D, Schmit J L, Ducroix J P, Jounieaux V. Utility of blood cultures in community-acquired pneumonia requiring hospitalization: influence of antibiotic treatment before admission.  Respir Med. 1999;  93 208-212
    CrossrefPubMedGoogle Scholar
  • 50 Metersky M L, Ma A, Bratzler D W, Houck P M. Predicting bacteremia in patients with community-acquired pneumonia.  Am J Respir Crit Care Med. 2004;  169 342-347
    CrossrefPubMedGoogle Scholar
  • 51 Campbell S G, Marrie T J, Anstey R, Dickinson G, Ackroyd-Stolarz S. The contribution of blood cultures to the clinical management of adult patients admitted to the hospital with community-acquired pneumonia: a prospective observational study.  Chest. 2003;  123 1142-1150
    CrossrefPubMedGoogle Scholar
  • 52 Ramanujam P, Rathlev N K. Blood cultures do not change management in hospitalized patients with community-acquired pneumonia.  Acad Emerg Med. 2006;  13 740-745
    PubMedGoogle Scholar
  • 53 Murray P R, Baron E J, Joergensen J H, Pfaller M A, Yolken R H. Manual of Clinical Microbiology. 8th ed. Washington, DC; American Society for Microbiology 2003
    Google Scholar
  • 54 Wong L K, Barry A L, Horgan S M. Comparison of six different criteria for judging the acceptability of sputum specimens.  J Clin Microbiol. 1982;  16 627-631
    PubMedGoogle Scholar
  • 55 Reimer L G, Carroll K C. Role of the microbiology laboratory in the diagnosis of lower respiratory tract infections.  Clin Infect Dis. 1998;  26 742-748
    CrossrefPubMedGoogle Scholar
  • 56 Fishman J A, Roth R S, Zanzot E, Enos E J, Ferraro M J. Use of induced sputum specimens for microbiologic diagnosis of infections due to organisms other than Pneumocystis carinii .  J Clin Microbiol. 1994;  32 131-134
    PubMedGoogle Scholar
  • 57 Roson B, Carratala J, Verdaguer R, Dorca J, Manresa F, Gudiol F. Prospective study of the usefulness of sputum Gram stain in the initial approach to community-acquired pneumonia requiring hospitalization.  Clin Infect Dis. 2000;  31 869-874
    CrossrefPubMedGoogle Scholar
  • 58 Sanyal S, Smith P R, Saha A C, Gupta S, Berkowitz L, Homel P. Initial microbiologic studies did not affect outcome in adults hospitalized with community-acquired pneumonia.  Am J Respir Crit Care Med. 1999;  160 346-348
    PubMedGoogle Scholar
  • 59 Metlay J P, Fine M J. Testing strategies in the initial management of patients with community-acquired pneumonia.  Ann Intern Med. 2003;  138 109-118
    PubMedGoogle Scholar
  • 60 Fein A M. Pneumonia in the elderly: overview of diagnostic and therapeutic approaches.  Clin Infect Dis. 1999;  28 726-729
    CrossrefPubMedGoogle Scholar
  • 61 Ewig S, Schlochtermeier M, Goke N, Niederman M S. Applying sputum as a diagnostic tool in pneumonia: limited yield, minimal impact on treatment decisions.  Chest. 2002;  121 1486-1492
    CrossrefPubMedGoogle Scholar
  • 62 Musher D M, Montoya R, Wanahita A. Diagnostic value of microscopic examination of Gram-stained sputum and sputum cultures in patients with bacteremic pneumococcal pneumonia.  Clin Infect Dis. 2004;  39 165-169
    CrossrefPubMedGoogle Scholar
  • 63 El Solh A, Pineda L, Bouquin P, Mankowski C. Determinants of short and long term functional recovery after hospitalization for community-acquired pneumonia in the elderly: role of inflammatory markers.  BMC Geriatr. 2006;  6 12
    CrossrefPubMedGoogle Scholar
  • 64 El-Ebiary M, Torres A, González J et al.. Quantitative cultures of endotracheal aspirates for the diagnosis of ventilator-associated pneumonia.  Am Rev Respir Dis. 1993;  148 1552-1557
    PubMedGoogle Scholar
  • 65 El Solh A A, Akinnusi M E, Pineda L A, Mankowski C R. Diagnostic yield of quantitative endotracheal aspirates in patients with severe nursing home-acquired pneumonia.  Crit Care. 2007;  11 R57
    CrossrefPubMedGoogle Scholar
  • 66 Ruiz M, Torres A, Ewig S et al.. Noninvasive versus invasive microbial investigation in ventilator-associated pneumonia: evaluation of outcome.  Am J Respir Crit Care Med. 2000;  162 119-125
    CrossrefPubMedGoogle Scholar
  • 67 Ramirez P, Valencia M, Torres A. Bronchoalveolar lavage to diagnose respiratory infections.  Semin Respir Crit Care Med. 2007;  28 525-533
    Article in Thieme ConnectPubMedGoogle Scholar
  • 68 El Solh A A, Aquilina A T, Dhillon R S, Ramadan F, Nowak P, Davies J. Impact of invasive strategy on management of antimicrobial treatment failure in institutionalized older people with severe pneumonia.  Am J Respir Crit Care Med. 2002;  166 1038-1043
    CrossrefPubMedGoogle Scholar
  • 69 El Solh A A, Alhajjhasan A, Ramadan F H, Pineda L A. A comparative study of community- and nursing home-acquired empyema thoracis.  J Am Geriatr Soc. 2007;  55 1847-1852
    CrossrefPubMedGoogle Scholar
  • 70 Murdoch D R. Diagnosis of Legionella infection.  Clin Infect Dis. 2003;  36 64-69
    CrossrefPubMedGoogle Scholar
  • 71 Kupronis B A, Richards C L, Whitney C G. Invasive pneumococcal disease in older adults residing in long-term care facilities and in the community.  J Am Geriatr Soc. 2003;  51 1520-1525
    CrossrefPubMedGoogle Scholar
  • 72 Nuorti J P, Butler J C, Crutcher J M et al.. An outbreak of multidrug-resistant pneumococcal pneumonia and bacteremia among unvaccinated nursing home residents.  N Engl J Med. 1998;  338 1861-1868
    CrossrefPubMedGoogle Scholar
  • 73 Tan C G, Ostrawski S, Bresnitz E A. A preventable outbreak of pneumococcal pneumonia among unvaccinated nursing home residents in New Jersey during 2001.  Infect Control Hosp Epidemiol. 2003;  24 848-852
    CrossrefPubMedGoogle Scholar
  • 74 Phares C R, Russell E, Thigpen M C et al.. Legionnaires' disease among residents of a long-term care facility: the sentinel event in a community outbreak.  Am J Infect Control. 2007;  35 319-323
    CrossrefPubMedGoogle Scholar
  • 75 Falsey A R, Walsh E E. Viral pneumonia in older adults.  Clin Infect Dis. 2006;  42 518-524
    CrossrefPubMedGoogle Scholar
  • 76 File T M. Community-acquired pneumonia.  Lancet. 2003;  362 1991-2001
    CrossrefPubMedGoogle Scholar
  • 77 Lim W S, Macfarlane J T. A prospective comparison of nursing home acquired pneumonia with community acquired pneumonia.  Eur Respir J. 2001;  18 362-368
    CrossrefPubMedGoogle Scholar
  • 78 Falsey A R, Dallal G E, Formica M A et al.. Long-term care facilities: a cornucopia of viral pathogens.  J Am Geriatr Soc. 2008;  56 1281-1285
    CrossrefPubMedGoogle Scholar
  • 79 Tambyah P A, Habib A G, Ng T M, Goh H, Kumarasinghe G. Community-acquired methicillin-resistant Staphylococcus aureus infection in Singapore is usually “healthcare associated”.  Infect Control Hosp Epidemiol. 2003;  24 436-438
    CrossrefPubMedGoogle Scholar
  • 80 Naimi T S, LeDell K H, Como-Sabetti K et al.. Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection.  JAMA. 2003;  290 2976-2984
    CrossrefPubMedGoogle Scholar
  • 81 Nakashima K, Tanaka T, Kramer M H et al.. Outbreak of Chlamydia pneumoniae infection in a Japanese nursing home, 1999–2000.  Infect Control Hosp Epidemiol. 2006;  27 1171-1177
    CrossrefPubMedGoogle Scholar
  • 82 Waites K B, Talkington D F. Mycoplasma pneumoniae and its role as a human pathogen.  Clin Microbiol Rev. 2004;  17 697-728
    PubMedGoogle Scholar
  • 83 Blasi F, Cosentini R, Tarsia P, Capone P, Allegra L. Atypical pathogens and asthma: can they influence the natural history of the disease?.  Monaldi Arch Chest Dis. 2001;  56 276-280
    PubMedGoogle Scholar
  • 84 Plouffe J F. Importance of atypical pathogens of community-acquired pneumonia.  Clin Infect Dis. 2000;  31(Suppl 2) S35-S39
    CrossrefPubMedGoogle Scholar
  • 85 Blasi F. Atypical pathogens and respiratory tract infections.  Eur Respir J. 2004;  24 171-181
    CrossrefPubMedGoogle Scholar
  • 86 Murdoch D R. Nucleic acid amplification tests for the diagnosis of pneumonia.  Clin Infect Dis. 2003;  36 1162-1170
    CrossrefPubMedGoogle Scholar
  • 87 Kumar S, Wang L, Fan J et al.. Detection of 11 common viral and bacterial pathogens causing community-acquired pneumonia or sepsis in asymptomatic patients using a multiplex reverse transcriptase PCR assay with manual (enzyme hybridization) or automated detection (electronic microarray).  J Clin Microbiol. 2008;  46 3063-3072
    CrossrefPubMedGoogle Scholar
  • 88 Brittain-Long R, Nord S, Olofsson S, Westin J, Anderson L M, Lindh M. Multiplex real-time PCR for detection of respiratory tract infections.  J Clin Virol. 2008;  41 53-56
    CrossrefPubMedGoogle Scholar
  • 89 El Solh A A, Brewer T, Okada M, Bashir O, Gough M. Indicators of recurrent hospitalization for pneumonia in the elderly.  J Am Geriatr Soc. 2004;  52 2010-2015
    CrossrefPubMedGoogle Scholar
  • 90 Greub G, Liaudet L, Wiesel P, Bettschart V, Schaller M D. Respiratory complications of gastroesophageal reflux associated with paraesophageal hiatal hernia.  J Clin Gastroenterol. 2003;  37 129-131
    CrossrefPubMedGoogle Scholar
  • 91 Ruhl C E, Sonnenberg A, Everhart J E. Hospitalization with respiratory disease following hiatal hernia and reflux esophagitis in a prospective, population-based study.  Ann Epidemiol. 2001;  11 477-483
    CrossrefPubMedGoogle Scholar
  • 92 El Solh A A, Pietrantoni C, Bhat A et al.. Colonization of dental plaques: a reservoir of respiratory pathogens for hospital-acquired pneumonia in institutionalized elders.  Chest. 2004;  126 1575-1582
    CrossrefPubMedGoogle Scholar
  • 93 Coulthwaite L, Verran J. Potential pathogenic aspects of denture plaque.  Br J Biomed Sci. 2007;  64 180-189
    PubMedGoogle Scholar
  • 94 Beal M, Chesson A, Garcia T, Caldito G, Stucker F, Nathan C A. A pilot study of quantitative aspiration in patients with symptoms of obstructive sleep apnea: comparison to a historic control group.  Laryngoscope. 2004;  114 965-968
    CrossrefPubMedGoogle Scholar
  • 95 Llombart M, Chiner E, Andreu A L et al.. Prevalence of sleep apnea syndrome in patients with community acquired pneumonia [abstract].  Am J Respir Crit Care. 2007;  175 A702
    PubMedGoogle Scholar
  • 96 King P, Holdsworth S, Freezer N, Holmes P. Bronchiectasis.  Intern Med J. 2006;  36 729-737
    CrossrefPubMedGoogle Scholar
  • 97 Park M A, Li J T, Hagan J B, Maddox D E, Abraham R S. Common variable immunodeficiency: a new look at an old disease.  Lancet. 2008;  372(9637) 489-502
    CrossrefPubMedGoogle Scholar
  • 98 Gudmundsson G, Gross T J. Middle lobe syndrome.  Am Fam Physician. 1996;  53 2547-2550
    PubMedGoogle Scholar
  • 99 Casey K R. Neoplastic mimics of pneumonia.  Semin Respir Infect. 1995;  10 131-142
    PubMedGoogle Scholar

Antoni TorresM.D. Ph.D. 

Pneumology Department, Clinic Institute of Thorax (ICT), Hospital Clinic of Barcelona–Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)–University of Barcelona (UB)–Ciber de Enfermedades Respiratorias (Ciberes)

Villarroel 170, 08036, Barcelona, Spain

Email: atorres@ub.edu

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