Bronchopneumonia: Difference between revisions
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== Historical Perspective[edit | edit source] == | == Historical Perspective[edit | edit source] == | ||
* Pneumonia was first recognized by Hippocrates. It was first identified and described by Laennec in 1819. | * Pneumonia was first recognized by Hippocrates. It was first identified and described by Laennec in 1819.<ref name="Mackenzie2016">{{cite journal|last1=Mackenzie|first1=Grant|title=The definition and classification of pneumonia|journal=Pneumonia|volume=8|issue=1|year=2016|issn=2200-6133|doi=10.1186/s41479-016-0012-z}}</ref> | ||
* In 1842, Rokitansky differentiated Pneumonia into Bronchopneumonia and Lobar Pneumonia. | * In 1842, Rokitansky differentiated Pneumonia into Bronchopneumonia and Lobar Pneumonia.<ref name="Mackenzie20162">{{cite journal|last1=Mackenzie|first1=Grant|title=The definition and classification of pneumonia|journal=Pneumonia|volume=8|issue=1|year=2016|issn=2200-6133|doi=10.1186/s41479-016-0012-z}}</ref> | ||
== Classification[edit | edit source] == | == Classification[edit | edit source] == | ||
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** Lobular (Bronchopneumonia) | ** Lobular (Bronchopneumonia) | ||
== Pathophysiology[edit | edit source] == | == Pathophysiology[edit | edit source] == | ||
* The pathogenesis of Bronchopneumonia is characterized by inflammation of lung parenchyma. | * The pathogenesis of Bronchopneumonia is characterized by inflammation of lung parenchyma.<ref name="Mackenzie20163">{{cite journal|last1=Mackenzie|first1=Grant|title=The definition and classification of pneumonia|journal=Pneumonia|volume=8|issue=1|year=2016|issn=2200-6133|doi=10.1186/s41479-016-0012-z}}</ref> | ||
* On gross pathology, multiple foci of consolidation is a characteristic feature of Bronchopneumonia. They are present bilaterally, most commonly in the basal lobes. These lesions are 2-4 cm in diameter, grey-yellow, dry, often centered by a [[bronchia]], are poorly delimited and have the tendency to confluence, especially in children. | * On gross pathology, multiple foci of consolidation is a characteristic feature of Bronchopneumonia. They are present bilaterally, most commonly in the basal lobes. These lesions are 2-4 cm in diameter, grey-yellow, dry, often centered by a [[bronchia]], are poorly delimited and have the tendency to confluence, especially in children. | ||
* On microscopic histopathological analysis, a focus of inflammatory condensation, centered by a bronchiola with acute bronchiolitis is a characteristic finding in Bronchopneumonia. In addition, alveolar lumens surrounding the bronchia are filled with neutrophils and suppurative exudate("leukocytic alveolitis"), massive congestion is present and inflammatory foci are separated by normal, aerated parenchyma.. | * On microscopic histopathological analysis, a focus of inflammatory condensation, centered by a bronchiola with acute bronchiolitis is a characteristic finding in Bronchopneumonia. In addition, alveolar lumens surrounding the bronchia are filled with neutrophils and suppurative exudate("leukocytic alveolitis"), massive congestion is present and inflammatory foci are separated by normal, aerated parenchyma.. | ||
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== Clinical Features[edit | edit source] == | == Clinical Features[edit | edit source] == | ||
* Common clinical findings in Bronchopneumonia include cough, fever, chills, dyspnea, pleuritic chest pain and sputum production. However, many of these features may be absent in older patients. | * Common clinical findings in Bronchopneumonia include cough, fever, chills, dyspnea, pleuritic chest pain and sputum production. However, many of these features may be absent in older patients.<ref name="Mackenzie20164">{{cite journal|last1=Mackenzie|first1=Grant|title=The definition and classification of pneumonia|journal=Pneumonia|volume=8|issue=1|year=2016|issn=2200-6133|doi=10.1186/s41479-016-0012-z}}</ref> | ||
* Bronchopneumonia can also case Gastrointestinal symptoms such as nausea, vomiting and diarrhea. | * Bronchopneumonia can also case Gastrointestinal symptoms such as nausea, vomiting and diarrhea. | ||
* Older patients may also present with altered mental status. | * Older patients may also present with altered mental status. | ||
== Differentiating [disease name] from other Diseases[edit | edit source] == | == Differentiating [disease name] from other Diseases[edit | edit source] == | ||
* Lobular pneumonia must be differentiated from other diseases that cause similar clinical symptoms and interstitial infiltrates on chest x-ray such as: | * Lobular pneumonia must be differentiated from other diseases that cause similar clinical symptoms and interstitial infiltrates on chest x-ray such as:<ref name="WuytsCavazza2014">{{cite journal|last1=Wuyts|first1=W. A.|last2=Cavazza|first2=A.|last3=Rossi|first3=G.|last4=Bonella|first4=F.|last5=Sverzellati|first5=N.|last6=Spagnolo|first6=P.|title=Differential diagnosis of usual interstitial pneumonia: when is it truly idiopathic?|journal=European Respiratory Review|volume=23|issue=133|year=2014|pages=308–319|issn=0905-9180|doi=10.1183/09059180.00004914}}</ref> | ||
:* Lobar pneumonia | :* Lobar pneumonia | ||
:* Non-infectious lung conditions such as: Hypersensitivity pneumonitis, Collagen vascular disease, Asbestosis, Drug toxicities, Pulmonary fibrosis, Pulmonary edema, Pulmonary embolism and neoplastic lesions. | :* Non-infectious lung conditions such as: Hypersensitivity pneumonitis, Collagen vascular disease, Asbestosis, Drug toxicities, Pulmonary fibrosis, Pulmonary edema, Pulmonary embolism and neoplastic lesions. | ||
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== Epidemiology and Demographics[edit | edit source] == | == Epidemiology and Demographics[edit | edit source] == | ||
* The rate of Community acquired pneumonia is approximately 5.16-7.06 cases per 1000 individuals per year. | * The rate of Community acquired pneumonia is approximately 5.16-7.06 cases per 1000 individuals per year. <ref name="CillonizMartin-Loeches20162">{{cite journal|last1=Cilloniz|first1=Catia|last2=Martin-Loeches|first2=Ignacio|last3=Garcia-Vidal|first3=Carolina|last4=San Jose|first4=Alicia|last5=Torres|first5=Antoni|title=Microbial Etiology of Pneumonia: Epidemiology, Diagnosis and Resistance Patterns|journal=International Journal of Molecular Sciences|volume=17|issue=12|year=2016|pages=2120|issn=1422-0067|doi=10.3390/ijms17122120}}</ref> | ||
=== Age[edit | edit source] === | === Age[edit | edit source] === | ||
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== Risk Factors[edit | edit source] == | == Risk Factors[edit | edit source] == | ||
* Common risk factors in the development of Bronchopneumonia are Influenza infection, Alcohol abuse, Hyposplenism/splenectomy, smoking, COPD/Asthma and Immunocompromise. Additional risk factors include, homelessness, incarceration, pregnancy, crack cocaine use, opioid use and occupational welding. | * Common risk factors in the development of Bronchopneumonia are Influenza infection, Alcohol abuse, Hyposplenism/splenectomy, smoking, COPD/Asthma and Immunocompromise. Additional risk factors include, homelessness, incarceration, pregnancy, crack cocaine use, opioid use and occupational welding.<ref name="pmid107068972">{{cite journal |vauthors=Nuorti JP, Butler JC, Farley MM, Harrison LH, McGeer A, Kolczak MS, Breiman RF |title=Cigarette smoking and invasive pneumococcal disease. Active Bacterial Core Surveillance Team |journal=N. Engl. J. Med. |volume=342 |issue=10 |pages=681–9 |date=March 2000 |pmid=10706897 |doi=10.1056/NEJM200003093421002 |url=}}</ref> | ||
* Risk factors for a complicated course include, older age, preexisting lung condition, immunodeficiency/AIDS, and acquisition of a nosocomial infection. | * Risk factors for a complicated course include, older age, preexisting lung condition, immunodeficiency/AIDS, and acquisition of a nosocomial infection. | ||
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* The diagnosis is made when clinical and radiological evidence suggests the presence of Bronchopneumonia. | * The diagnosis is made when clinical and radiological evidence suggests the presence of Bronchopneumonia. | ||
=== Symptoms[edit | edit source] === | === Symptoms[edit | edit source] === | ||
*Symptoms of Bronchopneumonia may include the following: | *Symptoms of Bronchopneumonia may include the following:<ref name="Mackenzie20165">{{cite journal|last1=Mackenzie|first1=Grant|title=The definition and classification of pneumonia|journal=Pneumonia|volume=8|issue=1|year=2016|issn=2200-6133|doi=10.1186/s41479-016-0012-z}}</ref> | ||
** Fever | ** Fever | ||
** Chills | ** Chills | ||
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** Shortness of breath | ** Shortness of breath | ||
=== Physical Examination[edit | edit source] === | === Physical Examination[edit | edit source] === | ||
* Physical examination may be remarkable for: | * Physical examination may be remarkable for: <ref name="EvertsenBaumgardner2010">{{cite journal|last1=Evertsen|first1=Jennifer|last2=Baumgardner|first2=Dennis J|last3=Regnery|first3=Ann|last4=Banerjee|first4=Indrani|title=Diagnosis and management of pneumonia and bronchitis in outpatient primary care practices|journal=Primary Care Respiratory Journal|volume=19|issue=3|year=2010|pages=237–241|issn=1471-4418|doi=10.4104/pcrj.2010.00024}}</ref> | ||
** Fever | ** Fever | ||
** Respiratory rate >24 breaths/min (Tachypnea) | ** Respiratory rate >24 breaths/min (Tachypnea) | ||
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=== Other Diagnostic Studies[edit | edit source] === | === Other Diagnostic Studies[edit | edit source] === | ||
* Microbial analysis in Bronchopneumonia can be performed using techniques such as Blood culture, Sputum analysis, PCR and Urine antigen detection, however, pathogens are not commonly identified and empiric treatment should be started once the diagnosis is made. | * Microbial analysis in Bronchopneumonia can be performed using techniques such as Blood culture, Sputum analysis, PCR and Urine antigen detection, however, pathogens are not commonly identified and empiric treatment should be started once the diagnosis is made.<ref name="CillonizMartin-Loeches2016">{{cite journal|last1=Cilloniz|first1=Catia|last2=Martin-Loeches|first2=Ignacio|last3=Garcia-Vidal|first3=Carolina|last4=San Jose|first4=Alicia|last5=Torres|first5=Antoni|title=Microbial Etiology of Pneumonia: Epidemiology, Diagnosis and Resistance Patterns|journal=International Journal of Molecular Sciences|volume=17|issue=12|year=2016|pages=2120|issn=1422-0067|doi=10.3390/ijms17122120}}</ref> | ||
== Treatment[edit | edit source] == | == Treatment[edit | edit source] == | ||
=== Medical Therapy[edit | edit source] === | === Medical Therapy[edit | edit source] === | ||
* The mainstay of therapy for Bronchopneumonia is antibiotics and supportive care. | * The mainstay of therapy for Bronchopneumonia is antibiotics and supportive care.<ref name="pmid17278083">{{cite journal |vauthors=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=Clin. Infect. Dis. |volume=44 Suppl 2 |issue= |pages=S27–72 |date=March 2007 |pmid=17278083 |doi=10.1086/511159 |url=}}</ref> | ||
* Choice of antibiotics is dependent on epidemiology of microbes, resistance and patients' co-morbidities and severity of illness. | * Choice of antibiotics is dependent on epidemiology of microbes, resistance and patients' co-morbidities and severity of illness.<ref name="pmid172780832">{{cite journal |vauthors=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=Clin. Infect. Dis. |volume=44 Suppl 2 |issue= |pages=S27–72 |date=March 2007 |pmid=17278083 |doi=10.1086/511159 |url=}}</ref> | ||
* In patients without co-morbidities Macrolides such as Azithromycin and Clarithromycin can be used. In the case of Macrolide resistant pneumonias and patients with multiple co-morbidities, Doxycycline, Amoxicillin-Clavulanate, and Cephalosporins such as Cefpodoxime and Cefuroxime may be used. | * In patients without co-morbidities Macrolides such as Azithromycin and Clarithromycin can be used. In the case of Macrolide resistant pneumonias and patients with multiple co-morbidities, Doxycycline, Amoxicillin-Clavulanate, and Cephalosporins such as Cefpodoxime and Cefuroxime may be used.<ref name="pmid172780833">{{cite journal |vauthors=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=Clin. Infect. Dis. |volume=44 Suppl 2 |issue= |pages=S27–72 |date=March 2007 |pmid=17278083 |doi=10.1086/511159 |url=}}</ref> | ||
* Response to antibiotics can be monitored with clinical improvement, serum inflammatory markers and chest x-ray findings. However, most non-complicated pneumonias are treated out-patient and only require two follow up treatments to clinically determine improvement and resolution of the pneumonia, respectively. Follow-up chest x-rays are only required in male patients over the age of 50 years and smokers. | * Response to antibiotics can be monitored with clinical improvement, serum inflammatory markers and chest x-ray findings. However, most non-complicated pneumonias are treated out-patient and only require two follow up treatments to clinically determine improvement and resolution of the pneumonia, respectively. Follow-up chest x-rays are only required in male patients over the age of 50 years and smokers.<ref name="pmid172780834">{{cite journal |vauthors=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG |title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults |journal=Clin. Infect. Dis. |volume=44 Suppl 2 |issue= |pages=S27–72 |date=March 2007 |pmid=17278083 |doi=10.1086/511159 |url=}}</ref> | ||
=== Prevention[edit | edit source] === | === Prevention[edit | edit source] === | ||
* Effective measures for the primary prevention of Bronchopneumonia include vaccination against influenza and pneumococcal antigens, and smoking cessation. Pneumococcal vaccination is indicated in patients over the age of 65 years. | * Effective measures for the primary prevention of Bronchopneumonia include vaccination against influenza and pneumococcal antigens, and smoking cessation. Pneumococcal vaccination is indicated in patients over the age of 65 years. <ref name="pmid10706897">{{cite journal |vauthors=Nuorti JP, Butler JC, Farley MM, Harrison LH, McGeer A, Kolczak MS, Breiman RF |title=Cigarette smoking and invasive pneumococcal disease. Active Bacterial Core Surveillance Team |journal=N. Engl. J. Med. |volume=342 |issue=10 |pages=681–9 |date=March 2000 |pmid=10706897 |doi=10.1056/NEJM200003093421002 |url=}}</ref> | ||
== References[edit | edit source] == | == References[edit | edit source] == | ||
Revision as of 16:57, 2 January 2019
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Historical Perspective[edit | edit source]
- Pneumonia was first recognized by Hippocrates. It was first identified and described by Laennec in 1819.[1]
- In 1842, Rokitansky differentiated Pneumonia into Bronchopneumonia and Lobar Pneumonia.[2]
Classification[edit | edit source]
- Pneumonia may be classified according to anatomic distribution of consolidation into two subtypes/groups:
- Lobar
- Lobular (Bronchopneumonia)
Pathophysiology[edit | edit source]
- The pathogenesis of Bronchopneumonia is characterized by inflammation of lung parenchyma.[3]
- On gross pathology, multiple foci of consolidation is a characteristic feature of Bronchopneumonia. They are present bilaterally, most commonly in the basal lobes. These lesions are 2-4 cm in diameter, grey-yellow, dry, often centered by a bronchia, are poorly delimited and have the tendency to confluence, especially in children.
- On microscopic histopathological analysis, a focus of inflammatory condensation, centered by a bronchiola with acute bronchiolitis is a characteristic finding in Bronchopneumonia. In addition, alveolar lumens surrounding the bronchia are filled with neutrophils and suppurative exudate("leukocytic alveolitis"), massive congestion is present and inflammatory foci are separated by normal, aerated parenchyma..
- Bronchopneumonia is most commonly caused by pneumococcal serotypes 3, 7,8,10,18 and 20.
- Common mechanisms in development of pneumonia include, micro-aspiration, hematogenous spread, spread from a contiguous focus and macro-aspiration.
Clinical Features[edit | edit source]
- Common clinical findings in Bronchopneumonia include cough, fever, chills, dyspnea, pleuritic chest pain and sputum production. However, many of these features may be absent in older patients.[4]
- Bronchopneumonia can also case Gastrointestinal symptoms such as nausea, vomiting and diarrhea.
- Older patients may also present with altered mental status.
Differentiating [disease name] from other Diseases[edit | edit source]
- Lobular pneumonia must be differentiated from other diseases that cause similar clinical symptoms and interstitial infiltrates on chest x-ray such as:[5]
- Lobar pneumonia
- Non-infectious lung conditions such as: Hypersensitivity pneumonitis, Collagen vascular disease, Asbestosis, Drug toxicities, Pulmonary fibrosis, Pulmonary edema, Pulmonary embolism and neoplastic lesions.
- Other types of pneumonias such as: cryptogenic pneumonia.
Epidemiology and Demographics[edit | edit source]
- The rate of Community acquired pneumonia is approximately 5.16-7.06 cases per 1000 individuals per year. [6]
Age[edit | edit source]
- Patients of all age groups may develop Bronchopneumonia.
- Bronchopneumonia is more commonly observed among elderly patients.
Gender[edit | edit source]
- Brochopneumonia is more commonly observed in men than women.
Race[edit | edit source]
- Bronchopneumonia is more commonly observed in Black persons than caucasians.
Risk Factors[edit | edit source]
- Common risk factors in the development of Bronchopneumonia are Influenza infection, Alcohol abuse, Hyposplenism/splenectomy, smoking, COPD/Asthma and Immunocompromise. Additional risk factors include, homelessness, incarceration, pregnancy, crack cocaine use, opioid use and occupational welding.[7]
- Risk factors for a complicated course include, older age, preexisting lung condition, immunodeficiency/AIDS, and acquisition of a nosocomial infection.
Natural History, Complications and Prognosis[edit | edit source]
- Early clinical features include sudden fever, chills, cough and chest pain.
- If left untreated, patients with Bronchopneumonia may progress to develop tachypnea and increasing systemic toxicity. They may also progress to develop Lobar pneumonia.
- Common complications of Bronchopneumonia include parapneumonic effusion, empyema, necrotizing pneumonia, lung abscess and metastatic infections such as endocarditis, septic arthritis, peritonitis, pericarditis and meningitis, and other cardiac complications.
Diagnosis[edit | edit source]
Diagnostic Criteria[edit | edit source]
- The diagnosis is made when clinical and radiological evidence suggests the presence of Bronchopneumonia.
Symptoms[edit | edit source]
- Symptoms of Bronchopneumonia may include the following:[8]
- Fever
- Chills
- Cough
- Chest Pain
- Shortness of breath
Physical Examination[edit | edit source]
- Physical examination may be remarkable for: [9]
- Fever
- Respiratory rate >24 breaths/min (Tachypnea)
- Tachycardia
- Chest Examination:
- Audible crackles
- Decreased or bronchial breath sounds
- Dullness to percussion in areas of consolidation
- Tactile fremitus
- Egophony
Laboratory Findings[edit | edit source]
- There are no specific laboratory findings associated with Bronchopneumonia.
- A Leukocytosis (15000-30000 per mm3) with a left ward shift on a blood test can aid in diagnosis of Bronchopneumonia.
- An elevated concentration of ESR or CRP is a non-specific indication of inflammation in the body.
Imaging Findings[edit | edit source]
- Chest x-ray is the imaging modality of choice for Bronchopneumonia.
- On chest x-ray, Bronchopneumonia is characterized by multiple foci of isolated, acute consolidation, affecting one or more pulmonary lobes.
- In the case of a negative chest x-ray and a high clinical suspicion, HRCT scan may be used to confirm the diagnosis as it has a higher sensitivity and accuracy in detecting lesions and anatomical changes.
- In case of emergency where chest x-ray and HRCT cannot be performed, lung ultrasound performed by an experienced physician can yield findings.
Other Diagnostic Studies[edit | edit source]
- Microbial analysis in Bronchopneumonia can be performed using techniques such as Blood culture, Sputum analysis, PCR and Urine antigen detection, however, pathogens are not commonly identified and empiric treatment should be started once the diagnosis is made.[10]
Treatment[edit | edit source]
Medical Therapy[edit | edit source]
- The mainstay of therapy for Bronchopneumonia is antibiotics and supportive care.[11]
- Choice of antibiotics is dependent on epidemiology of microbes, resistance and patients' co-morbidities and severity of illness.[12]
- In patients without co-morbidities Macrolides such as Azithromycin and Clarithromycin can be used. In the case of Macrolide resistant pneumonias and patients with multiple co-morbidities, Doxycycline, Amoxicillin-Clavulanate, and Cephalosporins such as Cefpodoxime and Cefuroxime may be used.[13]
- Response to antibiotics can be monitored with clinical improvement, serum inflammatory markers and chest x-ray findings. However, most non-complicated pneumonias are treated out-patient and only require two follow up treatments to clinically determine improvement and resolution of the pneumonia, respectively. Follow-up chest x-rays are only required in male patients over the age of 50 years and smokers.[14]
Prevention[edit | edit source]
- Effective measures for the primary prevention of Bronchopneumonia include vaccination against influenza and pneumococcal antigens, and smoking cessation. Pneumococcal vaccination is indicated in patients over the age of 65 years. [15]
References[edit | edit source]
- Abbas, Abul K, Kumar, Vinay and Fausto, Nelson. Robbins and Coltran Pathologic Basis of Disease, 7th ed. Philadelphia: Elsevier Saunders, 2005.
External links
Template:Respiratory pathology
- ↑ Mackenzie, Grant (2016). "The definition and classification of pneumonia". Pneumonia. 8 (1). doi:10.1186/s41479-016-0012-z. ISSN 2200-6133.
- ↑ Mackenzie, Grant (2016). "The definition and classification of pneumonia". Pneumonia. 8 (1). doi:10.1186/s41479-016-0012-z. ISSN 2200-6133.
- ↑ Mackenzie, Grant (2016). "The definition and classification of pneumonia". Pneumonia. 8 (1). doi:10.1186/s41479-016-0012-z. ISSN 2200-6133.
- ↑ Mackenzie, Grant (2016). "The definition and classification of pneumonia". Pneumonia. 8 (1). doi:10.1186/s41479-016-0012-z. ISSN 2200-6133.
- ↑ Wuyts, W. A.; Cavazza, A.; Rossi, G.; Bonella, F.; Sverzellati, N.; Spagnolo, P. (2014). "Differential diagnosis of usual interstitial pneumonia: when is it truly idiopathic?". European Respiratory Review. 23 (133): 308–319. doi:10.1183/09059180.00004914. ISSN 0905-9180.
- ↑ Cilloniz, Catia; Martin-Loeches, Ignacio; Garcia-Vidal, Carolina; San Jose, Alicia; Torres, Antoni (2016). "Microbial Etiology of Pneumonia: Epidemiology, Diagnosis and Resistance Patterns". International Journal of Molecular Sciences. 17 (12): 2120. doi:10.3390/ijms17122120. ISSN 1422-0067.
- ↑ Nuorti JP, Butler JC, Farley MM, Harrison LH, McGeer A, Kolczak MS, Breiman RF (March 2000). "Cigarette smoking and invasive pneumococcal disease. Active Bacterial Core Surveillance Team". N. Engl. J. Med. 342 (10): 681–9. doi:10.1056/NEJM200003093421002. PMID 10706897.
- ↑ Mackenzie, Grant (2016). "The definition and classification of pneumonia". Pneumonia. 8 (1). doi:10.1186/s41479-016-0012-z. ISSN 2200-6133.
- ↑ Evertsen, Jennifer; Baumgardner, Dennis J; Regnery, Ann; Banerjee, Indrani (2010). "Diagnosis and management of pneumonia and bronchitis in outpatient primary care practices". Primary Care Respiratory Journal. 19 (3): 237–241. doi:10.4104/pcrj.2010.00024. ISSN 1471-4418.
- ↑ Cilloniz, Catia; Martin-Loeches, Ignacio; Garcia-Vidal, Carolina; San Jose, Alicia; Torres, Antoni (2016). "Microbial Etiology of Pneumonia: Epidemiology, Diagnosis and Resistance Patterns". International Journal of Molecular Sciences. 17 (12): 2120. doi:10.3390/ijms17122120. ISSN 1422-0067.
- ↑ Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG (March 2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clin. Infect. Dis. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083.
- ↑ Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG (March 2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clin. Infect. Dis. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083.
- ↑ Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG (March 2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clin. Infect. Dis. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083.
- ↑ Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM, Musher DM, Niederman MS, Torres A, Whitney CG (March 2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clin. Infect. Dis. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083.
- ↑ Nuorti JP, Butler JC, Farley MM, Harrison LH, McGeer A, Kolczak MS, Breiman RF (March 2000). "Cigarette smoking and invasive pneumococcal disease. Active Bacterial Core Surveillance Team". N. Engl. J. Med. 342 (10): 681–9. doi:10.1056/NEJM200003093421002. PMID 10706897.