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Neuchatel,
Switzerland
4 years* 161 17 (11) 3 (2) 28 (17.4) ND 47%
15
Amherst,
Nova Scotia
July 1989
to June 1990
75 22 (29) 1 (5.3) 55%
Total 439 23 (5) 10 (2.3) 104 (24) 211 (48%)
95% CI 3.7 to 14 5 to 12 11 to 38 38.6 to 56
*Start and stop dates not available;
8.7%required hospitalization in Erard et als study (14), 35%in Langille et als study (15). CpneumChlamydia
pneumoniae; H influen Haemophilus influenzae; M pneum Mycoplasma pneumoniae; ND No data; S pneum Streptococcus pneumoniae
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the results of blood, sputum or pleural fluid culture, and the
results of serological tests to make an etiological diagnosis.
Blood cultures are positive in only 6% to 10% of patients
with pneumonia, and pleural fluid is usually obtained only
from patients with a complicated pleural effusion. Sputum is
obtained for culture in about one-third of the patients who
present with pneumonia, but because sputum passes through a
heavily colonized oral cavity, any pathogen isolated fromthis
specimen can at best only be presumed to be the cause of the
pneumonia (10). Because of this, investigators have categorized
the etiology of pneumonia as definite, probable or possible (11).
Definite infection is defined as the isolation of a pathogen
from blood or pleural fluid with a fourfold or greater rise in
antibody titre to Legionella pneumophila, Mycoplasma pneu-
moniae, Chlamydia pneumoniae, respiratory syncytial virus or
influenza antigens. Isolation of Legionella species fromrespi-
ratory secretions is always considered definite evidence that
this pathogen is responsible for the pneumonia. A positive
Legionella species urinary antigen test is also considered
definite evidence that this pathogen is causing the infec-
tion.
Probable infection is defined as the isolation of Staphylo-
coccus aureus, Streptococcus pneumoniae, Haemophilus
influenzae, Moraxella catarrhalis, Enterobacteriaceae or
Pseudomonas aeruginosa from purulent sputum (sputum
with moderate or large numbers of neutrophils seen on Gram
stain) in which a compatible organism was seen in moderate
or large amounts on sputum Gram stain.
Possible infection is defined as the isolation of pneumo-
nia pathogens other than Legionella species from a culture
of purulent sputum seen on a Gram stain: predominance of
Gram-positive diplococci (possible diagnosis of infection
with S pneumoniae assigned) or Gram-positive cocci in
clusters (possible diagnosis of infection with S aureus as-
signed), indicative of possible infection due to either of
these agents; an antibody titre of 1:1024 or greater to
L pneumophila in either the acute or convalescent phase
serum; an antibody titre of 1:64 or greater to M pneumo-
niae; or an immunoglobulin (Ig) G antibody titre of 1:512
or greater, or an IgM antibody titre of 1:16 or greater to
C pneumoniae.
CAP is not a homogeneous entity, and it is useful to con-
sider its etiology according to the following:
site of acquisition of pneumonia community at large,
nursing home;
site of care outpatients, inpatients, intensive care unit,
nursing home;
immune status exogenous immunosuppression or hu-
man immunodeficiency virus (HIV) infection; and
specific comorbid illness such as COPD.
Can Respir J Vol 7 No 5 September/October 2000 373
Revised Canadian guidelines for CAP management
TABLE 2
Selected studies showing the etiology of community-acquired pneumonia requiring hospitalization
Etiology (% of total)
Reference Location Date N
S
pneum
H
influen
S
aureus
L
pneum
M
pneum
C
pneum AGNR
10 Halifax,
Nova Scotia
November 1981
to March 1987
588 52 (8.8) 26 (4.4) 22 (3.7) 14 (2.3) 39 (6.6) 19 (3.2)
16 Pittsburgh,
USA
July 1986
to June 1987
359 55 (15.3) 39 (10.9) 12 (3.3) 22 (6) 7 (2) 22 (6.1) 21 (5.9)
17 Columbes,
France
February 1983
to January 1984
116 30 (26) 13 (12) 3 (2.5) 5 (4) 4 (3.5) 8 (7)
18* Oulu,
Finland
May 1986
to May 1987
125 69 (55) 14 (11) 6 (5) 54 (43) 1 (1)
19* Umea,
Sweden
December 1982
to November 1984
196 63 (32) 8 (4) 3 (1.5) 3 (1.5) 13 (6.6) 1 (0.5)
20 Baltimore,
USA
November 1991
to November 1991
385 69 (17.9) 28 (7.3) 14 (3.6) 13 (3.4) 3 (0.8) 14 (3.6) 26 (6.8)
21* Southern
Israel
November 1991
to November 1992
346 148 (42.8) 19 (5.5) 101 (29.2) 62 (17.9)
11 Ohio, USA 1991 2776 351 (12.6) 184 (6.6) 94 (3.4) 404/1244
(32.5)
172/1923
(8.9)
124 (4.5)
22
23
Leiden,
Netherlands
Arkansas,
USA
1985
1985
334
154
90 (27)
8 (5)
26 (8)
2 (1)
4 (1)
7 (5)
8 (2)
6 (4)
19 (6)
3 (2)
8 (5)
11 (3.2)
7 (5)
Total 5379 935 (17.3) 359 (6.6) 159 (2.9) 70 (1.3) 598/4361
(13.7)
332/3292
(10.1)
218 (4.05)
95% CI 12.9 to
35.4
4.5 to
9.5
1.1 to
3.6
0.8 to
3.7
1.2 to
17.6
1.2 to
17.6
1.8 to
5.5
*Serological tests for Streptococcus pneumoniae (usually antibodies to pneumolysin or pneumolysin complexes) used to diagnose pneumo-
coccal pneumonia in addition to blood and, in some cases, sputum culture. AGNR Aerobic Gram-negative rods (such as Escherichia coli, etc);
C pneum Chlamydia pneumoniae; H influen Haemophilus influenzae; L pneum Legionella pneumophila; M pneum Mycoplasma pneumoniae;
S aureus Staphylococcus aureus
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Pneumonia treated on an ambulatory basis: M pneumo-
niae accounts for 17% to 37% of patients with pneumonia
treated on an ambulatory basis. Table 1 gives a summary of
the studies that have examined the etiology of pneumonia in
outpatients (12-15). It is likely that S pneumoniae is under-
diagnosed in this setting.
CAP requiring admission to hospital: Table 2 gives de-
tailed information on 10 studies of CAP requiring hospitali-
zation (10,11,16-23). S pneumoniae is the most commonly
implicated agent and accounts for about one-half of all cases
of CAP requiring admission to hospital. The second most
commonly implicated agent is C pneumoniae and the third is
Hinfluenzae. L pneumophila accounts for 2%to 6%of cases of
CAP requiring hospitalization. Aerobic Gram-negative bacilli,
such as Escherichia coli and Klebsiella species, are uncommon
causes of CAP but are important considerations in patients
who require admission to an intensive care unit (ICU). Myco-
bacteriumtuberculosis must always be considered as a poten-
tial cause of CAP.
Nursing home-acquired pneumonia: Data from six studies
of nursing home-acquired pneumonia are presented in Table 3.
S pneumoniae is the most commonly isolated organism; how-
ever, aerobic Gram-negative bacilli such as Klebsiella species
are commonly isolated from sputum of these patients. The
problem is distinguishing colonization from infection.
Pneumonia in patients with chronic obstructive pulmo-
nary disease: S pneumoniae, H influenzae, Legionella spe-
cies and viridans streptococci were most commonly
implicated in one study (29).
Severe CAP: Anumber of pathogens may be responsible for
374 Can Respir J Vol 7 No 5 September/October 2000
Mandell et al
TABLE 3
Etiology of nursing home-acquired pneumonia
Etiology (%)
Reference N
S
pneum
C
pneum
H
influen
S
aureus
M
catarr
K
pneum
Other
AGNRs Aspiration Unknown
24 35 9 (26) 2 (6) 9 (26) 14 (40) 0
10 131 9 (6.8) 1 (0.8) 7 (5.3) 7 (5.3) 19 (14.5) 77 (59)
25 104 31 (29.8) 20 (19) 11 (10.5) 4 (3.8) 24 (23) 14 (13)
26 56 5 (8.9) 4 (7.1) 1 (1.8) 3 (5.5) 43 (77)
27 115 7 (6) 3 (2.5) 2 (1.7) 7 (16) 20 (17) 83 (72.8)
28* 30 2 (6.6) 23 (76.7)
Total 471 61 (12.9) 30 (6.4) 30 (6.4) 7 (1.5) 21 (4.4) 51 (10.8) 240 (51)
95% CI 1.2 to 29.7 1.9 to 15 3.5 to 21 13.6 to 85
*Serological study Chlamydia pneumoniae and respiratory syncytial virus-1 and parainfluenza virus 3-1, and influenza virus type A-1, and one
each of parainfluenza virus type 3 and influenza virus type A. AGNRs Aerobic Gram-negative rods; H influen Haemophilus influenzae; K pneum
Klebsiella pneumoniae; M catarr Moraxella catarrhalis; S aureus Staphylococcus aureus; S pneum Streptococcus pneumoniae
TABLE 4
Etiology of community-acquired pneumonia requiring admission to an intensive care unit (ICU)
Etiology (%)
Reference Location Date N
S
pneum
L
pneum AGNRs
S
aureus Unknown Ventilated Mortality
30 Spain 1988 to
1990
58 13 (37) 8 (22.8) 4 (11.4) 39.6% 72% 22.4%
31 United Kingdom
(25 hospitals)
1987 60 11 (18) 7 (12) 2 (3) 30% 88% 48%
32* France 1987 to
1989
132 43 (32) 4 (3) 14 (11) 5 (4) 28% 37% 24%
33 Spain (26 ICUs) 1991 to
1992
262 30 (11) 21 (8) 8 (3) 10 (4) 41.2% NS NS
34 Sweden 1977 to
1981
53 15 (28) 2 (4) 25% 58% 25%
35 Seville, Spain 1985 to
1987
67 12 (37.5) 7 (21.8) 8 (25) 52.3% 20.8%
36* Barcelona, Spain 1984 to
1987
92 13 (14) 13 (14) 5
Doxycycline
COPD (recent antibiotics or oral steroids
within past 3 months) Haemophilus
influenzae and enteric Gram-negative
rods
Respiratory fluoroquinolone
Amoxicillin-clavulanate + macrolide
or second-generation
cephalosporin + macrolide
Suspected macroaspiration oral
anaerobes
Amoxicillin-clavulanate + macrolide,
or fourth-generation fluoroquinolone
(eg, moxifloxacin)
Third-generation fluoroquinolones
alone
or amoxicillin-clavulanate +
macrolide
Second-generation cephalosporin +
macrolide
Nursing home residents
in hospital
Identical to treatment for other
hospitalized patients (see below)
Hospitalized patient on
medical ward
S pneumoniae,
Legionella pneumophila,
Chlamydia pneumoniae
Respiratory fluoroquinolone