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'''Editor-In-Chief:''' [[User:C Michael Gibson|C. Michael Gibson, M.S., M.D.]] [Mailto:charlesmichaelgibson@gmail.com| <nowiki>[1]</nowiki>]; '''Associate Editor(s)-in-Chief:''' Arooj Naz<br />
'''Editor-In-Chief:''' [[User:C Michael Gibson|C. Michael Gibson, M.S., M.D.]] [Mailto:charlesmichaelgibson@gmail.com| <nowiki>[1]</nowiki>]; '''Associate Editor(s)-in-Chief:''' [[User:AroojNaz|Arooj Naz, M.B.B.S]]<br />


==Overview==
==Overview==
Bacterial pneumonia can affect individuals any age, gender, or race and has minimal significance in relation to family history although those with underlying immunoglobulin defects have a higher likelihood of infection. It tends to affect men more often than women, and is more common in African Americans compared to Caucasians. Socioeconomic status is an important contributing factors and may explain the increased prevalence rate in low to middle income nations.<ref name="pmid27633638">{{cite journal| author=Roomaney RA, Pillay-van Wyk V, Awotiwon OF, Dhansay A, Groenewald P, Joubert JD | display-authors=etal| title=Epidemiology of lower respiratory infection and pneumonia in South Africa (1997-2015): a systematic review protocol. | journal=BMJ Open | year= 2016 | volume= 6 | issue= 9 | pages= e012154 | pmid=27633638 | doi=10.1136/bmjopen-2016-012154 | pmc=5030548 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27633638  }} </ref>
[[Bacterial pneumonia]] can affect individuals of any age, gender, or race and has minimal significance in relation to family history. Individuals with underlying [[Immunoglobulin|immunoglobulin defects]] have a significantly higher likelihood of infection. [[Bacterial pneumonia]] tends to affect men more often than women, and is more common in African Americans compared to Caucasians. Socioeconomic status is an important contributing factors and may explain the increased prevalence rate in low to middle-income nations. [[Pneumonia]] may also be affected by the use of medications such as [[proton pump inhibitors]] and [[ACE inhibitor|ACE inhibitors]]. [[Immunocompromised]] patients requiring in-hospital treatment may develop [[nosocomial pneumonia]] but this can also present in seemingly healthy patients with prolonged durations of stay. A majority of [[nosocomial pneumonia]] will developed within 48 hours but some may present later on. The most common pathogens causing [[nosocomial pneumonia]] include [[Gram-positive cocci]] (e.g, ''[[Staphylococcus aureus]]'', which includes ''[[methicillin-resistant S. aureus]]'', and ''[[Streptococcus]]'' species) and [[Aerobic organism|Aerobic]] [[gram-negative bacilli]] (e.g. ''[[Pseudomonas aeruginosa|Pseudomonas Aeruginosa]], [[Escherichia Coli]], [[Klebsiella|Klebsiella Pneumoniae]], [[Enterobacter]] species, [[Acinetobacter spp|Acinetobacter]] species'').  


__NOTOC__
__NOTOC__
{{Bacterial pneumonia}}
{{Bacterial pneumonia}}
==Risk Factors==
==Risk Factors==
Common risk factors in the development of bacterial pneumonia include:<br />
Common risk factors in the development of bacterial pneumonia include:<br />
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**[[Selective IgA deficiency]]
**[[Selective IgA deficiency]]
**[[Common variable immunodeficiency]]
**[[Common variable immunodeficiency]]
**[[Immotile cilia syndrome]]
**[[Kartagener's syndrome]]
*[[Smoking]]<ref name="pmid31318967">{{cite journal| author=Baskaran V, Murray RL, Hunter A, Lim WS, McKeever TM| title=Effect of tobacco smoking on the risk of developing community acquired pneumonia: A systematic review and meta-analysis. | journal=PLoS One | year= 2019 | volume= 14 | issue= 7 | pages= e0220204 | pmid=31318967 | doi=10.1371/journal.pone.0220204 | pmc=6638981 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318967  }} </ref>
*[[Smoking]]<ref name="pmid31318967">{{cite journal| author=Baskaran V, Murray RL, Hunter A, Lim WS, McKeever TM| title=Effect of tobacco smoking on the risk of developing community acquired pneumonia: A systematic review and meta-analysis. | journal=PLoS One | year= 2019 | volume= 14 | issue= 7 | pages= e0220204 | pmid=31318967 | doi=10.1371/journal.pone.0220204 | pmc=6638981 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31318967  }} </ref>
*Excessive alcohol intake<ref name="pmid28613500">{{cite journal| author=| title=StatPearls | journal= | year= 2021 | volume=  | issue=  | pages=  | pmid=28613500 | doi= | pmc= | url= }} </ref>
*Excessive [[Alcoholic|alcohol intake]]<ref name="pmid28613500">{{cite journal| author=| title=StatPearls | journal= | year= 2021 | volume=  | issue=  | pages=  | pmid=28613500 | doi= | pmc= | url= }} </ref>
*Post viral complication<ref name="pmid28159155">{{cite journal| author=Prasso JE, Deng JC| title=Postviral Complications: Bacterial Pneumonia. | journal=Clin Chest Med | year= 2017 | volume= 38 | issue= 1 | pages= 127-138 | pmid=28159155 | doi=10.1016/j.ccm.2016.11.006 | pmc=5324726 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28159155  }} </ref> (often after an [[Influenza (flu)|Influenza]] infection)
*Post viral complication<ref name="pmid28159155">{{cite journal| author=Prasso JE, Deng JC| title=Postviral Complications: Bacterial Pneumonia. | journal=Clin Chest Med | year= 2017 | volume= 38 | issue= 1 | pages= 127-138 | pmid=28159155 | doi=10.1016/j.ccm.2016.11.006 | pmc=5324726 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28159155  }} </ref> (often after an [[Influenza (flu)|Influenza]] infection)
*Immunosuppresion (eg, [[Human Immunodeficiency Virus (HIV)|HIV]], use of [[corticosteroids]] that may be iatrogenic)<ref name="pmid28613500">{{cite journal| author=| title=StatPearls | journal= | year= 2021 | volume=  | issue=  | pages=  | pmid=28613500 | doi= | pmc= | url= }} </ref>
*Immunosuppresion (eg, [[Human Immunodeficiency Virus (HIV)|HIV]], use of [[corticosteroids]] that may be iatrogenic)<ref name="pmid28613500">{{cite journal| author=| title=StatPearls | journal= | year= 2021 | volume=  | issue=  | pages=  | pmid=28613500 | doi= | pmc= | url= }} </ref>
*Low socioeconomic status <ref name="pmid27633638" />
*Low socioeconomic status <ref name="pmid27633638">{{cite journal| author=Roomaney RA, Pillay-van Wyk V, Awotiwon OF, Dhansay A, Groenewald P, Joubert JD | display-authors=etal| title=Epidemiology of lower respiratory infection and pneumonia in South Africa (1997-2015): a systematic review protocol. | journal=BMJ Open | year= 2016 | volume= 6 | issue= 9 | pages= e012154 | pmid=27633638 | doi=10.1136/bmjopen-2016-012154 | pmc=5030548 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27633638  }} </ref>
*Males<ref name="pmid30020693">{{cite journal| author=| title=StatPearls | journal= | year= 2021 | volume=  | issue=  | pages=  | pmid=30020693 | doi= | pmc= | url= }} </ref>
*Males<ref name="pmid30020693">{{cite journal| author=| title=StatPearls | journal= | year= 2021 | volume=  | issue=  | pages=  | pmid=30020693 | doi= | pmc= | url= }} </ref>
*African Americans<ref name="pmid30020693">{{cite journal| author=| title=StatPearls | journal= | year= 2021 | volume=  | issue=  | pages=  | pmid=30020693 | doi= | pmc= | url= }} </ref>
*African Americans<ref name="pmid30020693">{{cite journal| author=| title=StatPearls | journal= | year= 2021 | volume=  | issue=  | pages=  | pmid=30020693 | doi= | pmc= | url= }} </ref>


====Pneumonia in relation to other Drugs/ Other medications used:====
===Pneumonia in relation to other Drugs/ Other medications used:===


*Atypical antipsychotics have been shown to ''increase'' the risk of pneumonia, especially in elderly individuals. <ref name="pmid18266664">{{cite journal| author=Knol W, van Marum RJ, Jansen PA, Souverein PC, Schobben AF, Egberts AC| title=Antipsychotic drug use and risk of pneumonia in elderly people. | journal=J Am Geriatr Soc | year= 2008 | volume= 56 | issue= 4 | pages= 661-6 | pmid=18266664 | doi=10.1111/j.1532-5415.2007.01625.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18266664  }} </ref>
*[[Atypical antipsychotics]] have been shown to ''increase'' the risk of [[pneumonia]], especially in [[elderly]] individuals.<ref name="pmid18266664">{{cite journal| author=Knol W, van Marum RJ, Jansen PA, Souverein PC, Schobben AF, Egberts AC| title=Antipsychotic drug use and risk of pneumonia in elderly people. | journal=J Am Geriatr Soc | year= 2008 | volume= 56 | issue= 4 | pages= 661-6 | pmid=18266664 | doi=10.1111/j.1532-5415.2007.01625.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18266664  }} </ref>
*Use of Acid Suppressing drugs ([[H2 blocker|H2 blockers]], [[Proton pump inhibitor|proton pump inhibitors]], and other [[Antacid|antacids]]) may ''increase'' the risk of pneumonia.<ref name="pmid15507580">{{cite journal| author=Laheij RJ, Sturkenboom MC, Hassing RJ, Dieleman J, Stricker BH, Jansen JB| title=Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs. | journal=JAMA | year= 2004 | volume= 292 | issue= 16 | pages= 1955-60 | pmid=15507580 | doi=10.1001/jama.292.16.1955 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15507580  }} </ref>
*Use of Acid Suppressing drugs ([[H2 blocker|H2 blockers]], [[Proton pump inhibitor|proton pump inhibitors]], and other [[Antacid|antacids]]) may ''increase'' the risk of [[pneumonia]].<ref name="pmid15507580">{{cite journal| author=Laheij RJ, Sturkenboom MC, Hassing RJ, Dieleman J, Stricker BH, Jansen JB| title=Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs. | journal=JAMA | year= 2004 | volume= 292 | issue= 16 | pages= 1955-60 | pmid=15507580 | doi=10.1001/jama.292.16.1955 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15507580  }} </ref>
*ACE inhibitors may be helpful in ''reducing'' the risk of pneumonia.<ref name="pmid22786934">{{cite journal| author=Caldeira D, Alarcão J, Vaz-Carneiro A, Costa J| title=Risk of pneumonia associated with use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers: systematic review and meta-analysis. | journal=BMJ | year= 2012 | volume= 345 | issue=  | pages= e4260 | pmid=22786934 | doi=10.1136/bmj.e4260 | pmc=3394697 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22786934  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=23165678 Review in: Ann Intern Med. 2012 Nov 20;157(10):JC5-2] </ref>
*[[ACE inhibitor|ACE inhibitors]] may be helpful in ''reducing'' the risk of pneumonia.<ref name="pmid22786934">{{cite journal| author=Caldeira D, Alarcão J, Vaz-Carneiro A, Costa J| title=Risk of pneumonia associated with use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers: systematic review and meta-analysis. | journal=BMJ | year= 2012 | volume= 345 | issue=  | pages= e4260 | pmid=22786934 | doi=10.1136/bmj.e4260 | pmc=3394697 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22786934  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=23165678 Review in: Ann Intern Med. 2012 Nov 20;157(10):JC5-2] </ref>
 
===Risk Factors and specific bacterial microorganisms leading to Pneumonia:===
{| class="wikitable"
|+
!Underlying Condition<ref name="ClinicalInfectiousDiseases"><nowiki>{{</nowiki>https://academic.oup.com/cid/article/44/Supplement_2/S27/372079<nowiki>}} </nowiki></ref><ref name="WikidocPneumonia"><nowiki>{{</nowiki>https://www.wikidoc.org/index.php/Pneumonia_risk_factors<nowiki>}} </nowiki></ref>
!Most Common Bacterial Microorganisms
|-
|'''Alcohol Abuse'''
|''[[Streptococcus pneumoniae|Streptococcus Pneumoniae]], oral [[anaerobes]], [[Klebsiella pneumoniae|Klebsiella Pneumoniae]], [[Acinetobacter spp|Acinetobacter]]''
|-
|'''[[Aspiration]]'''
|''Oral [[anaerobes]], [[Gram-negative]] enteric bacteria''
|-
|'''[[COPD]]'''
|''[[Haemophilus influenzae|Haemophilus Influenzae]], [[Pseudomonas aeruginosa|Pseudomonas Aeruginosa]], [[Legionella spp|Legionella]], [[S. pneumoniae|Streptococcus Pneumoniae]], [[Moraxella catarrhalis|Moraxella Catarrhalis]]''
|-
|'''Endotracheal Obstruction'''
|''[[S. pneumoniae|Streptococcus Pneumoniae]], oral flora [[anaerobes]], [[Haemophilus influenzae|Haemophilus Influenzae]], [[S. aureus|Staphylococcus Aureus]]''
|-
|'''[[Abscess|Lung Abscess]]'''
|''Community-acquired [[MRSA]], oral [[anaerobes]], [[Atypical mycobacteria|Atypical Mycobacteria]]''
|-
|'''[[HIV]]'''
|''[[S. pneumoniae|Streptococcus Pneumoniae]], [[H. influenzae|Haemophilus Influenzae]]''
|-
|'''[[Intravenous drug use|IV Drug Abuse]]'''
|''[[S. aureus|Staphylococcus Aureus]], oral [[anaerobes]], [[S. pneumoniae|Streptococcus Pneumoniae]]''
|-
|'''[[Smoking]]'''
|''[[Haemophilus influenzae|Haemophilus Influenzae]], [[Pseudomonas aeruginosa|Pseudomonas Aeruginosa]], [[Legionella spp|Legionella]], [[S. pneumoniae|Streptococcus Pneumoniae]], [[Moraxella catarrhalis|Moraxella Catarrhalis]]''
|-
|'''Structural Lung Diseases'''
|''[[P. aeruginosa|Pseudomonas Aeruginosa]], [[Burkholderia cepacia|Burkholderia Cepacia]], [[S. aureus|Staphylococcus Aureus]]''
|-
|'''Avian Related'''
|''[[Chlamydophila psittaci|Chlamydia psittaci]]''
|}
 
===Nosocomial Pneumonia:===
While in the hospital, especially after surgical procedures when immunity may be affected, patients are at risk of acquiring [[infections]], especially with certain strains of [[bacteria]]. Furthermore, patients with pre-existing  comorbidities or risk factors and have a prolonged duration of stay at the hospital predisposing them to increased susceptibility. A majority of cases of [[nosocomial pneumonia]] occur after 48 hours or more. The most common pathogens causing pneumonia include:<ref name="pmid30571062">{{cite journal| author=| title=StatPearls | journal= | year= 2021 | volume=  | issue=  | pages=  | pmid=30571062 | doi= | pmc= | url= }} </ref>
 
*[[Gram-positive cocci]] (e.g, ''[[Staphylococcus aureus]]'', which includes [[methicillin-resistant S. aureus]], and ''[[Streptococcus]]'' species)
*[[Aerobic]] [[gram-negative bacilli]] (e.g. ''[[Pseudomonas aeruginosa|Pseudomonas Aeruginosa]]'', ''[[Escherichia Coli]]'', ''[[Klebsiella]] Pneumoniae'', ''[[Enterobacter]]'' species, '' [[Acinetobacter spp|Acinetobacter]]'' species)


==References==
==References==
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[[Category:Pneumonia|Pneumonia]]
[[Category:Pneumonia|Pneumonia]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
 
[[Category:Up to date]]
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{{WH}}
{{WS}}
{{WS}}

Latest revision as of 16:29, 1 December 2022

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Arooj Naz, M.B.B.S

Overview

Bacterial pneumonia can affect individuals of any age, gender, or race and has minimal significance in relation to family history. Individuals with underlying immunoglobulin defects have a significantly higher likelihood of infection. Bacterial pneumonia tends to affect men more often than women, and is more common in African Americans compared to Caucasians. Socioeconomic status is an important contributing factors and may explain the increased prevalence rate in low to middle-income nations. Pneumonia may also be affected by the use of medications such as proton pump inhibitors and ACE inhibitors. Immunocompromised patients requiring in-hospital treatment may develop nosocomial pneumonia but this can also present in seemingly healthy patients with prolonged durations of stay. A majority of nosocomial pneumonia will developed within 48 hours but some may present later on. The most common pathogens causing nosocomial pneumonia include Gram-positive cocci (e.g, Staphylococcus aureus, which includes methicillin-resistant S. aureus, and Streptococcus species) and Aerobic gram-negative bacilli (e.g. Pseudomonas Aeruginosa, Escherichia Coli, Klebsiella Pneumoniae, Enterobacter species, Acinetobacter species).


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Risk Factors

Common risk factors in the development of bacterial pneumonia include:

Pneumonia in relation to other Drugs/ Other medications used:

Risk Factors and specific bacterial microorganisms leading to Pneumonia:

Underlying Condition[11][12] Most Common Bacterial Microorganisms
Alcohol Abuse Streptococcus Pneumoniae, oral anaerobes, Klebsiella Pneumoniae, Acinetobacter
Aspiration Oral anaerobes, Gram-negative enteric bacteria
COPD Haemophilus Influenzae, Pseudomonas Aeruginosa, Legionella, Streptococcus Pneumoniae, Moraxella Catarrhalis
Endotracheal Obstruction Streptococcus Pneumoniae, oral flora anaerobes, Haemophilus Influenzae, Staphylococcus Aureus
Lung Abscess Community-acquired MRSA, oral anaerobes, Atypical Mycobacteria
HIV Streptococcus Pneumoniae, Haemophilus Influenzae
IV Drug Abuse Staphylococcus Aureus, oral anaerobes, Streptococcus Pneumoniae
Smoking Haemophilus Influenzae, Pseudomonas Aeruginosa, Legionella, Streptococcus Pneumoniae, Moraxella Catarrhalis
Structural Lung Diseases Pseudomonas Aeruginosa, Burkholderia Cepacia, Staphylococcus Aureus
Avian Related Chlamydia psittaci

Nosocomial Pneumonia:

While in the hospital, especially after surgical procedures when immunity may be affected, patients are at risk of acquiring infections, especially with certain strains of bacteria. Furthermore, patients with pre-existing comorbidities or risk factors and have a prolonged duration of stay at the hospital predisposing them to increased susceptibility. A majority of cases of nosocomial pneumonia occur after 48 hours or more. The most common pathogens causing pneumonia include:[13]

References

  1. ↑ 1.0 1.1 1.2 "StatPearls". 2021. PMID 28613500.
  2. ↑ Alshahwan SI, Alsowailmi G, Alsahli A, Alotaibi A, Alshaikh M, Almajed M; et al. (2019). "The prevalence of complications of pneumonia among adults admitted to a tertiary care center in Riyadh from 2010-2017". Ann Saudi Med. 39 (1): 29–36. doi:10.5144/0256-4947.2019.29. PMC 6464674. PMID 30712048.
  3. ↑ Schussler E, Beasley MB, Maglione PJ (2016). "Lung Disease in Primary Antibody Deficiencies". J Allergy Clin Immunol Pract. 4 (6): 1039–1052. doi:10.1016/j.jaip.2016.08.005. PMC 5129846. PMID 27836055.
  4. ↑ Baskaran V, Murray RL, Hunter A, Lim WS, McKeever TM (2019). "Effect of tobacco smoking on the risk of developing community acquired pneumonia: A systematic review and meta-analysis". PLoS One. 14 (7): e0220204. doi:10.1371/journal.pone.0220204. PMC 6638981 Check |pmc= value (help). PMID 31318967.
  5. ↑ Prasso JE, Deng JC (2017). "Postviral Complications: Bacterial Pneumonia". Clin Chest Med. 38 (1): 127–138. doi:10.1016/j.ccm.2016.11.006. PMC 5324726. PMID 28159155.
  6. ↑ Roomaney RA, Pillay-van Wyk V, Awotiwon OF, Dhansay A, Groenewald P, Joubert JD; et al. (2016). "Epidemiology of lower respiratory infection and pneumonia in South Africa (1997-2015): a systematic review protocol". BMJ Open. 6 (9): e012154. doi:10.1136/bmjopen-2016-012154. PMC 5030548. PMID 27633638.
  7. ↑ 7.0 7.1 "StatPearls". 2021. PMID 30020693.
  8. ↑ Knol W, van Marum RJ, Jansen PA, Souverein PC, Schobben AF, Egberts AC (2008). "Antipsychotic drug use and risk of pneumonia in elderly people". J Am Geriatr Soc. 56 (4): 661–6. doi:10.1111/j.1532-5415.2007.01625.x. PMID 18266664.
  9. ↑ Laheij RJ, Sturkenboom MC, Hassing RJ, Dieleman J, Stricker BH, Jansen JB (2004). "Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs". JAMA. 292 (16): 1955–60. doi:10.1001/jama.292.16.1955. PMID 15507580.
  10. ↑ Caldeira D, Alarcão J, Vaz-Carneiro A, Costa J (2012). "Risk of pneumonia associated with use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers: systematic review and meta-analysis". BMJ. 345: e4260. doi:10.1136/bmj.e4260. PMC 3394697. PMID 22786934. Review in: Ann Intern Med. 2012 Nov 20;157(10):JC5-2
  11. ↑ {{https://academic.oup.com/cid/article/44/Supplement_2/S27/372079}}
  12. ↑ {{https://www.wikidoc.org/index.php/Pneumonia_risk_factors}}
  13. ↑ "StatPearls". 2021. PMID 30571062.

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