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Pneumonia

Pneumonia is an acute or chronic inflammation of the parenchyma of the lung. Most cases are due to infection by bacteria or viruses, a few to inhalation of chemicals, fungi, parasites or trauma. Pneumonia is most commonly classified by the area of lung affected: lobar pneumonia, bronchial pneumonia and interstitial pneumonia. The signs and symptoms of pneumonia vary from mild to severe. The most common symptoms of pneumonia include productive cough, fever, dyspnea and chest pain.


Presentation

Individuals with infectious pneumonia generally have a productive cough, sharp pain in between breaths, fever accompanied with shaking chills and an increased respiratory rate. For the elderly, confusion is often the most prominent sign [6]. In children under 5, the typical signs and symptoms are fever, fast or difficult breathing and cough.

Fever is not a specific symptom because it occurs in many other illnesses and may be absent in with more severe conditions or malnutrition. Again, children less than two months old do not present with cough. In severe cases, other symptoms to expect include a blue-tinged skin, decreased thirst, convulsions, constant vomiting, decreased levels of consciousness and temperature always at the extremes.

Both bacterial and viral cases of pneumonia have similar symptoms.

Some causative agents are linked with classic but often non-specific characteristics. For instance pneumonia caused by Klebsiella may have the “currant jelly” symptom or bloody sputum, pneumonia caused by Streptococcus pneumonia is linked with rusty and coloured sputum while Legionella-cuased pneumonia is associated with abdominal pain, diarrhea or confusion.

Cough
  • The most common symptoms of pneumonia are: Cough (with some pneumonias you may cough up greenish or yellow mucus, or even bloody mucus) Fever, which may be mild or high Shaking chills Shortness of breath, which may only occur when you climb stairs Additional[lung.org]
  • There are high levels of antibiotic overuse for children with cough/cold in this setting which risks worsening antibiotic resistance.[ncbi.nlm.nih.gov]
  • Again, children less than two months old do not present with cough.[symptoma.com]
  • Children aged 0 to 59 months presenting with cough and/or difficult breathing were recruited from four study hospitals in Ibadan, Nigeria from August 2015 to March 2017.[ncbi.nlm.nih.gov]
  • When to see a doctor See your doctor if you have difficulty breathing, chest pain, persistent fever of 102 F (39 C) or higher, or persistent cough, especially if you're coughing up pus.[mayoclinic.org]
Dry Cough
  • A 67-year-old man was admitted to our hospital complaining of dry cough. Chest computed tomography showed diffuse infiltrates and ground-glass opacities in the bilateral lung fields.[ncbi.nlm.nih.gov]
  • She was admitted to clinic with a 2-week history of dyspnoea, dry cough and fever. Her initial examination showed her to be hypoxic on air with saturations of 77% and left basal crackles.[ncbi.nlm.nih.gov]
  • The clinical symptoms of the patient were dry cough, chills, night sweats and high fevers. Chest computed tomography (CT) scan showed a high-density shadow in the right lung lobe, similar to lobular pneumonia.[ncbi.nlm.nih.gov]
  • A 59-year-old man with a history of chronic obstructive pulmonary disease (COPD) presented with dry cough, low-grade fever, and progressive dyspnea.[ncbi.nlm.nih.gov]
  • Five days after her second treatment with eribulin, she was admitted to our hospital with dyspnea and dry cough.[ncbi.nlm.nih.gov]
Dyspnea
  • A 59-year-old man with a history of chronic obstructive pulmonary disease (COPD) presented with dry cough, low-grade fever, and progressive dyspnea.[ncbi.nlm.nih.gov]
  • She presented with fever, cough, dyspnea and pleuritic chest pain. Chest radiograph showed bilateral infiltrations. Examination of bronchoalveolar lavage fluid revealed significant eosinophilia. She was diagnosed with acute eosinophilic pneumonia.[ncbi.nlm.nih.gov]
  • His slowly progressing cough and dyspnea were accompanied by elevated levels of fibrotic serological markers and an increased reticular shadow on chest computed tomography images.[ncbi.nlm.nih.gov]
  • […] year-old man was treated with nivolumab because of unresectable sinonasal melanoma, he achieved a complete response soon after the initiation of the therapy and a complete response was thereafter maintained for 30 weeks until the patient experienced dyspnea[ncbi.nlm.nih.gov]
  • CASE REPORT We describe the case of a 63-year-old woman who presented with dyspnea, cough, and significant hypoxemia requiring high-flow oxygen supplement with bilateral lung infiltrates, treated with broad-spectrum antibiotics for a presumed diagnosis[ncbi.nlm.nih.gov]
Productive Cough
  • She had started taking the TNFI, golimumab (50 mg/month), 3 years before and developed a productive cough 4 weeks before this admission.[ncbi.nlm.nih.gov]
  • The most common symptoms of pneumonia include productive cough, fever, dyspnea and chest pain.[symptoma.com]
  • Patients with pneumonia usually report a gradual onset of difficulty breathing, along with fever and chills, a productive cough and chest pain associated with the cough.[ems1.com]
  • Many other bacteria may cause bacterial pneumonia including: Group B streptococcus Staphylococcus aureus Group A streptococcus Bacterial pneumonia may have a quick onset and the following symptoms may occur: Productive cough Pain in the chest Vomiting[stanfordchildrens.org]
  • Fever, productive cough, pleuritic chest pain and dyspnea are the most common symptoms. Pregnant women may be at greater risk for morbidity and mortality due to pneumonia because of the immunologic and physiologic changes of pregnancy.[clinicaladvisor.com]
Sputum Production
  • Pneumonia can first feel like a cold or the flu, but will often result in symptoms like a high fever, shaking, chills, and a cough with increased sputum production. The sputum is usually discolored and sometimes bloody.[craighospital.org]
  • Atypical pneumonia : This describes a type of pneumonia that tends to be milder, with little or no sputum production; the chest x-ray may show areas of fluid in the lungs but not in a lobar pattern.[health.harvard.edu]
  • Symptoms of pneumonia may include cough with sputum production, fever , sharp chest pain on inspiration (breathing in), and shortness of breath.[emedicinehealth.com]
  • In very sick people, people with a known problem of the immune system, or when looking for certain unusual organisms, doctors sometimes will obtain sputum samples by giving a vapor treatment that causes the person to cough deeply (inducing sputum production[merckmanuals.com]
Fever
  • Epidemiologic investigations were conducted when a family cluster of severe fever with thrombocytopenia syndrome virus (SFTSV) infection was identified in Shanghai in June 2016.[ncbi.nlm.nih.gov]
  • The authors describe a 60-year-old woman admitted to the hospital for sustained fever, presenting with an alveolar opacity on chest X-ray, with the presumed diagnosis of community-acquired pneumonia and the onset of antibiotics.[ncbi.nlm.nih.gov]
  • Few cases report patients with heart failure, secondary to dilated cardiomyopathy, with high fever. A 23-month-old girl visited the emergency department with high fever, cough, first wheezing episode, chest retraction and tachycardia.[ncbi.nlm.nih.gov]
  • The initial symptoms of viral pneumonia are the same as influenza symptoms: fever, a dry cough, headache, muscle pain, and weakness.[lung.org]
  • The most common symptoms of pneumonia include productive cough, fever, dyspnea and chest pain.[symptoma.com]
Chills
  • The clinical symptoms of the patient were dry cough, chills, night sweats and high fevers. Chest computed tomography (CT) scan showed a high-density shadow in the right lung lobe, similar to lobular pneumonia.[ncbi.nlm.nih.gov]
  • Chills iStock/George Clerk Patients with pneumonia often report teeth-chattering chills that cannot be remedied. Chills are a sign of fever and that the body is working overtime to regulate temperature.[rd.com]
  • Individuals with infectious pneumonia generally have a productive cough, sharp pain in between breaths, fever accompanied with shaking chills and an increased respiratory rate. For the elderly, confusion is often the most prominent sign.[symptoma.com]
  • […] nia \ nu̇-ˈmō-nyə , nyu̇- \ : an acute disease that is marked by inflammation of lung tissue accompanied by infiltration of alveoli and often bronchioles with white blood cells (such as neutrophils) and fibrinous exudate , is characterized by fever, chills[merriam-webster.com]
  • The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing. A variety of organisms, including bacteria, viruses and fungi, can cause pneumonia.[mayoclinic.org]
Malaise
  • The elderly may present with mainly systemic complaints of malaise, fatigue, anorexia and myalgia. Young children may present with nonspecific symptoms or abdominal pain.[patient.info]
  • Initially, these patients experience fever with chills, cough, shortness of breath, headache, muscle pain, and malaise , all of which may subside in a day if there is no further exposure.[britannica.com]
  • These patients may present with fever, cough, headache, malaise and erythema nodosum.[clinicaladvisor.com]
  • The following may also occur: dyspnoea sharp chest pain worsening cough fever/chills Tachycardia pleuritic chest pain headaches malaise muscle pains cyanosis due to poorly oxygenated blood loss of appetite rapid breathing wheezing or grunting during breathing[physio-pedia.com]
  • Some people develop a mild flu-like syndrome with low-grade fever, malaise, headache , and muscle aches. In extremely rare cases, some may develop the neurologic syndrome known as Guillain-Barré syndrome.[emedicinehealth.com]
Hypoxemia
  • CASE REPORT We describe the case of a 63-year-old woman who presented with dyspnea, cough, and significant hypoxemia requiring high-flow oxygen supplement with bilateral lung infiltrates, treated with broad-spectrum antibiotics for a presumed diagnosis[ncbi.nlm.nih.gov]
  • She was emergently admitted to our hospital due to the worsening exertional dyspnea and severe hypoxemia.[ncbi.nlm.nih.gov]
  • One week after admission, she developed fever, dyspnea, hypoxemia, tachycardia, and increased serum C-reactive protein level.[ncbi.nlm.nih.gov]
  • Additional tests that may be helpful include pulse oximetry to indicate hypoxemia even in a well appearing pregnant woman.[clinicaladvisor.com]
Anorexia
  • The elderly may present with mainly systemic complaints of malaise, fatigue, anorexia and myalgia. Young children may present with nonspecific symptoms or abdominal pain.[patient.info]
  • Sometimes people who have pneumonia have digestive symptoms such as nausea, diarrhea, and loss of appetite (anorexia). Symptoms vary even more in infants and older people. Fever may not occur.[merckmanuals.com]
Vomiting
  • Aspiration pneumonia Aspiration pneumonia occurs when you inhale food, drink, vomit or saliva into your lungs.[mayoclinic.org]
  • Vomiting – not just vomiting from a big coughing fit, but vomiting even in between coughing fits. Blue color around the lips and face – from lack of oxygen.[askdrsears.com]
  • They may seem weak, vomit, or have diarrhea. Less common symptoms include abdominal pain and a stiff neck.[babycenter.com]
  • Drug or excessive alcohol use: Drinking too much alcohol or using drugs is another risk factor for pneumonia because you may aspirate food, drink, or vomit into your lungs while you're under the influence.[verywell.com]
  • Symptoms may include: Fever Chest or stomach pain Decrease in appetite Chills Breathing fast or hard Vomiting Headache Not feeling well Fussiness The symptoms of pneumonia may resemble other problems or medical conditions.[stanfordchildrens.org]
Loss of Appetite
  • Early symptoms are similar to flu symptoms, which include: Fever Dry cough Headache Sore throat Loss of appetite Muscle pain Additional symptoms about a day later: High fever Cough with mucus Shortness of breath Cleveland Clinic News & More Cleveland[my.clevelandclinic.org]
  • The most common signs and symptoms are: cough fevers , sweating and shivering difficulty breathing or rapid breathing feeling generally tired and unwell loss of appetite Check your symptoms with healthdirect’s Symptom Checker for advice on when to seek[healthdirect.gov.au]
  • […] of appetite, low energy, and fatigue Confusion, especially in older people Symptoms also can vary, depending on whether your pneumonia is bacterial or viral.[lung.org]
  • Fever, sweating and shivering, loss of appetite and a rapid heartbeat are all also symptoms. Less common symptoms include coughing up blood, headaches, tiredness, feeling or being sick, wheezing, muscle pain and confusion.[thesun.co.uk]
  • Other symptoms include shortness of breath, rapid-shallow breathing, chest pain, headache, excessive fatigue, and/or loss of appetite.[craighospital.org]
Diarrhea
  • Nina Martin Updated India Press Release: IVAC 2018 Pneumonia & Diarrhea Progress Report Report finds inequity may slow progress in preventing child pneumonia and diarrhea deaths.[stoppneumonia.org]
  • They may seem weak, vomit, or have diarrhea. Less common symptoms include abdominal pain and a stiff neck.[babycenter.com]
  • Patients with pneumonia also experience fevers, nausea, diarrhea, loss of appetite, fatigue, and shortness of breath—the severity of which can vary depending on the causative agent and the patient’s overall level of health.[news-medical.net]
  • […] instance pneumonia caused by Klebsiella may have the “currant jelly” symptom or bloody sputum, pneumonia caused by Streptococcus pneumonia is linked with rusty and coloured sputum while Legionella-cuased pneumonia is associated with abdominal pain, diarrhea[symptoma.com]
  • Though these antibiotics can also cause diarrhea, it happens less frequently.[merckmanuals.com]
Abdominal Pain
  • For instance pneumonia caused by Klebsiella may have the “currant jelly” symptom or bloody sputum, pneumonia caused by Streptococcus pneumonia is linked with rusty and coloured sputum while Legionella-cuased pneumonia is associated with abdominal pain[symptoma.com]
  • Less common symptoms include abdominal pain and a stiff neck. Streptococcus pneumoniae is the usual cause, but other bacteria (such as Staphylococcus aureus or Mycoplasma pneumoniae) can cause pneumonia, too.[babycenter.com]
  • Young children may present with nonspecific symptoms or abdominal pain. Signs: tachypnoea, bronchial breathing, crepitations, pleural rub, dullness with percussion.[patient.info]
  • Sometimes a child's only sign may be rapid breathing and often when pneumonia exist in the lower part of the lungs, no breathing problems may be present but rather fever, abdominal pain or vomiting.[physio-pedia.com]
Periodontitis
  • The oral bacteria propagated in the periodontal regions may drop into the lung and increase the risk of pneumonia. We, therefore, investigated the association of tooth loss with mortality from pneumonia in a cohort study of Japanese dentists.[ncbi.nlm.nih.gov]
Chest Pain
  • She presented with fever, cough, dyspnea and pleuritic chest pain. Chest radiograph showed bilateral infiltrations. Examination of bronchoalveolar lavage fluid revealed significant eosinophilia. She was diagnosed with acute eosinophilic pneumonia.[ncbi.nlm.nih.gov]
  • Our patient presented with symptoms of worsening dyspnoea and intermittent chest pain for past 1 month. She reported increased use of e cigarettes during this time period to help her quit smoking.[ncbi.nlm.nih.gov]
  • pain No chest pain or only mild pain No sore throat Sore throat How pneumonia is diagnosed Pneumonia can be difficult to diagnose because the symptoms are very similar to bronchitis, a bad cold or asthma.[beta.nhs.uk]
  • pain, and reduced lung expansion, and is typically caused by an infectious agent (such as a bacterium, virus, or fungus) — see bronchopneumonia , pneumocystis carinii pneumonia , primary atypical pneumonia — compare pneumonitis[merriam-webster.com]
  • He had chest pain and a dry cough for 3 weeks, was dull at the left base clinically, and had left lower zone consolidation on chest radiography. The pneumonia spread despite oral ampicillin and cloxacillin.[ncbi.nlm.nih.gov]
Tachycardia
  • A 23-month-old girl visited the emergency department with high fever, cough, first wheezing episode, chest retraction and tachycardia. The chest X-ray revealed consolidation on the left lower lung field; the cardiothoracic ratio was 60%.[ncbi.nlm.nih.gov]
  • One week after admission, she developed fever, dyspnea, hypoxemia, tachycardia, and increased serum C-reactive protein level.[ncbi.nlm.nih.gov]
  • The following may also occur: dyspnoea sharp chest pain worsening cough fever/chills Tachycardia pleuritic chest pain headaches malaise muscle pains cyanosis due to poorly oxygenated blood loss of appetite rapid breathing wheezing or grunting during breathing[physio-pedia.com]
Cyanosis
  • The following may also occur: dyspnoea sharp chest pain worsening cough fever/chills Tachycardia pleuritic chest pain headaches malaise muscle pains cyanosis due to poorly oxygenated blood loss of appetite rapid breathing wheezing or grunting during breathing[physio-pedia.com]
  • At times, the individual's skin color may change and become dusky or purplish (a condition known as cyanosis) due to their blood being poorly oxygenated.[emedicinehealth.com]
Myalgia
  • The elderly may present with mainly systemic complaints of malaise, fatigue, anorexia and myalgia. Young children may present with nonspecific symptoms or abdominal pain.[patient.info]
Arthralgia
  • Arthralgia and myalgia are often reported. Severe complications include pancreatitis, peritonitis, pericarditis, myocarditis, endocarditis and glomerulonephritis. Signs Vital signs should be checked.[patient.info]
Confusion
  • A patient's mental state may be confused or delirious. The initial symptoms of viral pneumonia are the same as influenza symptoms: fever, a dry cough, headache, muscle pain, and weakness.[lung.org]
  • For the elderly, confusion is often the most prominent sign. In children under 5, the typical signs and symptoms are fever, fast or difficult breathing and cough.[symptoma.com]
  • Seek urgent medical attention if you're experiencing severe symptoms, such as rapid breathing, chest pain or confusion. Who's affected? In the UK, pneumonia affects around 8 in 1,000 adults each year. It's more widespread in autumn and winter.[nhs.uk]
  • He or she also will look for confusion and a purplish hue in your lips, fingernails or hands because these symptoms can indicate that you have low levels of oxygen in your blood.[drugs.com]
Headache
  • The initial symptoms of viral pneumonia are the same as influenza symptoms: fever, a dry cough, headache, muscle pain, and weakness.[lung.org]
  • Headache affects the majority of symptomatic sufferers. Fever is relatively unusual. Symptoms may drag on for weeks or months, despite a course of appropriate antibiotics.[patient.info]
  • If you add fever, body aches and headache that come on quickly, it could be you have the flu. Pneumonia is usually a complication of cold or flu, when the illness lodges in the lungs.[fox17online.com]
Seizure
  • A depressed gag reflex, such as from alcohol intoxication, overdose, head injury, stroke or seizure increases the risk of aspiration pneumonia [3] .[ems1.com]
  • Reduced consciousness: Whether you're sedated, prone to generalized seizures, or have had anesthesia, these episodes of reduced consciousness can contribute to aspiration pneumonia.[verywell.com]
  • People with recent viral infections, lung disease, heart disease , and swallowing problems , as well as alcoholics, drug users, and those who have suffered a stroke or seizure are at higher risk for developing pneumonia than the general population.[emedicinehealth.com]
  • This can happen when you have had a medical condition that affects your ability to swallow, such as a seizure or a stroke. A healthy person's nose and throat often contain bacteria or viruses that cause pneumonia.[uwhealth.org]
Grunting
  • The following may also occur: dyspnoea sharp chest pain worsening cough fever/chills Tachycardia pleuritic chest pain headaches malaise muscle pains cyanosis due to poorly oxygenated blood loss of appetite rapid breathing wheezing or grunting during breathing[physio-pedia.com]
  • In children, symptoms may depend on age: In infants younger than 1 month of age, symptoms may include having little or no energy (lethargy), feeding poorly, grunting, or having a fever.[uwhealth.org]

Workup

Physical examinations and imaging studies are the chief methods of diagnosis [7].

Diagnosis for pneumonia is often based on a combination of physical signs and a chest X-ray. The underlying cause however can be difficult to confirm as there is often no definitive test for distinguishing between pneumonia of bacterial origin and pneumonia of other origins. In children, the WHO guideline defines pneumonia clinically as decreased level of consciousness, chest indrawing, rapid respiratory rate, difficulty in breathing and/or cough.

Pulmonary Infiltrate
  • Twenty-four days after the initiation of daptomycin and sulbactam/ampicillin, he developed a fever and pulmonary infiltration.[ncbi.nlm.nih.gov]
Pleural Rub
  • Signs: tachypnoea, bronchial breathing, crepitations, pleural rub, dullness with percussion.[patient.info]
  • Pleural rub Chest X-ray usually done to confirm the diagnosis Sputum samples and blood tests done to diagnose the type of pneumonia that is present sputum test is done to determine whether it is a fungal or bacterial infection blood test is done to examine[physio-pedia.com]

Treatment

Pneumonia is often treated with antibiotics. Most of the cases require the intake of oral antibiotics and these are often prescribed at any health care centre [8]. The average case of pneumonia can be treated with inexpensive oral antibiotics at the community level by trained community health workers. Hospitalisation is only recommended for severe cases of pneumonia and for cases of pneumonia in infants younger than 2 months of age.

Prognosis

The prognosis is generally positive as most kinds of bacterial pneumonia stabilises with a week. Most symptoms get resolved within a week. Findings in X-ray clear within four weeks and mortality is generally low [5]. People with other lung conditions and the elderly may recover after a longer period of time (as long as 3 months).

Etiology

Pneumonia arises due to infections caused primarily by bacteria or viruses. In less common cases, fungi and parasites can bring about pneumonia. Even though over 100 types of infectious agents have been recorded, only a few of these cause the majority of pneumonia cases [2]. In 45% of infections in children, both viruses and bacteria may be responsible for the condition. In adult pneumonia infections, the figure is placed at 15%. Despite careful testing, it is possible to not isolate any causative agent in 50% of pneumonia cases.

Epidemiology

Pneumonia is a very common condition that affects around 450 million people around the world. It is equally a major cause of death amongst people of all age groups as it results in over 4 million deaths. This accounts for more than 7% of the total deaths recorded around the world each year. The rates are at their peak in children who are less than five years old and in adults who are older than the age of 75. Every year, more than 1.1 million children with the condition die every year [3]. The occurrence is 5 times lower in the developed world when compared to the developing world. In the United States for example, pneumonia is the 8th leading cause of deaths.

Sex distribution
Age distribution

Pathophysiology

Viral cases

The Viruses can enter the lung via different routes. For instance, respiratory syncytial virus is often contacted when individuals touch contaminated objects before touching their eyes or nose while other forms of viral infections occur when contaminated airborne droplets get inhaled through the mouth or nose. As soon as they get into the upper airway, the viruses will move to the lungs where the cells lining the airways, lung parenchyma and the alveoli get invaded [4].

Bacterial cases

The bacteria get into the lungs through small aspirations of organisms that reside in the throat or nose. Most normal people have these aspirations while asleep. Although the throat contains bacteria always, the potentially infectious ones are found there only at certain periods and under specific conditions. Contaminated airborne droplets are responsible for the deposition of Mycobacterium tuberculosis and Legionella pneumophilia. The bacteria can also spread via the blood. As soon as the bacteria is in the lungs, the spaces between cells and alveoli are invaded and the neutrophils and macrophages attempt to get rid of the bacteria. The resultant combination brings about the image seen in X-ray.

Prevention

The prevention of pneumonia is one of the most important strategies to reduce the incidence of child mortality. The most effective way to prevent pneumonia is immunization against measles,pertussis, Pneumococcus and Haemophilus influenzae type B.

Adequate nutrition is also important in improving the natural defences of a child beginning with exclusive breastfeeding for the first six months of life. In addition to being effective in the prevention of pneumonia, the length of periods of illness in a child is reduced greatly [9].

The number of people who fall ill with pneumonia can also be prevented by encouraging good hygiene in crowded homes and addressing of environmental factors such as indoor pollution.

For children who are infected with HIV, daily intake of cotrimoxazole is required so as to decrease the risk of contracting pneumonia.

Summary

Pneumonia is an acute respiratory infection of the lungs [1]. The lungs are filled with small sacs called alveoli. These fill when a healthy individual breathes in. In an individual with any form of pneumonia, the sac get s filled with pus and fluid and this makes breathing painful, thereby limiting the individual’s ability to take in oxygen.

Patient Information

Pneumonia is a condition that affects the air sacs in either one lung or both. Cough producing phlegm or pus, difficulty in breathing, chills and fever are common symptoms of this condition and this happens when the affected air sac gets filled with fluid or pus. 

There are different types of organisms that can cause pneumonia. This includes bacteria, viruses and fungi. 

The level of seriousness of this condition varies greatly but it is the most serious amongst infants, young children and people older than 65 years of age. People with underlying health conditions or weakened immune systems also get more serious cases of pneumonia. 

The chances of recovery from pneumonia is high though as there are several antiviral medications for treating it. 

References

Article

  1. Guidelines for the management of community acquired pneumonia in adults; British Thoracic Society (2009), Thorax Vol 64 Sup III
  2. Durrington HJ, Summers C; Recent changes in the management of community acquired pneumonia in adults. BMJ. 2008 Jun 21;336(7658):1429-33.
  3. Guidelines for the management of adult lower respiratory tract infections, European Respiratory Society and European Society of Clinical Microbiology and Infectious Diseases (September 2011)
  4. Chest infections - adult, Prodigy (August 2007)
  5. Bartlett JG; Is activity against "atypical" pathogens necessary in the treatment protocols for Clin Infect Dis. 2008 Dec 1;47 Suppl 3:S232-6.
  6. Rudan I, Boschi-Pinto C, Biloglav Z, et al. Epidemiology and etiology of childhood pneumonia. Bull World Health Organ 2008; 86:408.
  7. Harris M, Clark J, Coote N, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax 2011; 66 Suppl 2:ii1.
  8. Margolis P, Gadomski A. The rational clinical examination. Does this infant have pneumonia? JAMA 1998; 279:308.
  9. Fiore AE, Shay DK, Broder K, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. MMWR Recomm Rep 2009; 58:1.
  10. Jokinen C, Heiskanen L, Juvonen H, et al. Incidence of community-acquired pneumonia in the population of four municipalities in eastern Finland. Am J Epidemiol 1993; 137:977.

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Last updated: 2017-08-09 17:58