Risk factors for community-acquired pneumonia in adults in Europe: a literature review
Identifieur interne : 000472 ( Pmc/Corpus ); précédent : 000471; suivant : 000473Risk factors for community-acquired pneumonia in adults in Europe: a literature review
Auteurs : Antoni Torres ; Willy E. Peetermans ; Giovanni Viegi ; Francesco BlasiSource :
- Thorax [ 0040-6376 ] ; 2013.
Abstract
Community-acquired pneumonia (CAP) causes considerable morbidity and mortality in adults, particularly in the elderly.
Structured searches of PubMed were conducted to identify up-to-date information on the incidence of CAP in adults in Europe, as well as data on lifestyle and medical risk factors for CAP.
The overall annual incidence of CAP in adults ranged between 1.07 to 1.2 per 1000 person-years and 1.54 to 1.7 per 1000 population and increased with age (14 per 1000 person-years in adults aged ≥65 years). Incidence was also higher in men than in women and in patients with chronic respiratory disease or HIV infection. Lifestyle factors associated with an increased risk of CAP included smoking, alcohol abuse, being underweight, having regular contact with children and poor dental hygiene. The presence of comorbid conditions, including chronic respiratory and cardiovascular diseases, cerebrovascular disease, Parkinson's disease, epilepsy, dementia, dysphagia, HIV or chronic renal or liver disease all increased the risk of CAP by twofold to fourfold.
A range of lifestyle factors and underlying medical conditions are associated with an increased risk of CAP in European adults. Understanding of the types of individual at greatest risk of CAP can help to ensure that interventions to reduce the risk of infection and burden of disease are targeted appropriately.
Url:
DOI: 10.1136/thoraxjnl-2013-204282
PubMed: 24130229
PubMed Central: 3812874
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PMC:3812874Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Risk factors for community-acquired pneumonia in adults in Europe: a literature review</title><author><name sortKey="Torres, Antoni" sort="Torres, Antoni" uniqKey="Torres A" first="Antoni" last="Torres">Antoni Torres</name><affiliation><nlm:aff id="af1"><addr-line>Servei de Pneumologia, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBER de Enfermedades Respiratorias (CIBERes), University of Barcelona, Barcelona, Spain</addr-line></nlm:aff></affiliation></author><author><name sortKey="Peetermans, Willy E" sort="Peetermans, Willy E" uniqKey="Peetermans W" first="Willy E" last="Peetermans">Willy E. Peetermans</name><affiliation><nlm:aff id="af2"><addr-line>Department of Internal Medicine</addr-line>,<institution>University Hospital, KU Leuven</institution>,<addr-line>Leuven</addr-line>,<country>Belgium</country></nlm:aff></affiliation></author><author><name sortKey="Viegi, Giovanni" sort="Viegi, Giovanni" uniqKey="Viegi G" first="Giovanni" last="Viegi">Giovanni Viegi</name><affiliation><nlm:aff id="af3"><institution>CNR Institute of Clinical Physiology</institution>,<addr-line>Pisa</addr-line>,<country>Italy</country></nlm:aff></affiliation><affiliation><nlm:aff id="af4"><institution>CNR Institute of Biomedicine and Molecular Immunology</institution>,<addr-line>Palermo</addr-line>,<country>Italy</country></nlm:aff></affiliation></author><author><name sortKey="Blasi, Francesco" sort="Blasi, Francesco" uniqKey="Blasi F" first="Francesco" last="Blasi">Francesco Blasi</name><affiliation><nlm:aff id="af5"><addr-line>Department of Pathophysiology and</addr-line> Transplantation,<institution>University of Milan, IRCCS Fondazione Ca` Granda Ospedale Maggiore</institution>,<addr-line>Milan</addr-line>,<country>Italy</country></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">24130229</idno><idno type="pmc">3812874</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3812874</idno><idno type="RBID">PMC:3812874</idno><idno type="doi">10.1136/thoraxjnl-2013-204282</idno><date when="2013">2013</date><idno type="wicri:Area/Pmc/Corpus">000472</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Risk factors for community-acquired pneumonia in adults in Europe: a literature review</title><author><name sortKey="Torres, Antoni" sort="Torres, Antoni" uniqKey="Torres A" first="Antoni" last="Torres">Antoni Torres</name><affiliation><nlm:aff id="af1"><addr-line>Servei de Pneumologia, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBER de Enfermedades Respiratorias (CIBERes), University of Barcelona, Barcelona, Spain</addr-line></nlm:aff></affiliation></author><author><name sortKey="Peetermans, Willy E" sort="Peetermans, Willy E" uniqKey="Peetermans W" first="Willy E" last="Peetermans">Willy E. Peetermans</name><affiliation><nlm:aff id="af2"><addr-line>Department of Internal Medicine</addr-line>,<institution>University Hospital, KU Leuven</institution>,<addr-line>Leuven</addr-line>,<country>Belgium</country></nlm:aff></affiliation></author><author><name sortKey="Viegi, Giovanni" sort="Viegi, Giovanni" uniqKey="Viegi G" first="Giovanni" last="Viegi">Giovanni Viegi</name><affiliation><nlm:aff id="af3"><institution>CNR Institute of Clinical Physiology</institution>,<addr-line>Pisa</addr-line>,<country>Italy</country></nlm:aff></affiliation><affiliation><nlm:aff id="af4"><institution>CNR Institute of Biomedicine and Molecular Immunology</institution>,<addr-line>Palermo</addr-line>,<country>Italy</country></nlm:aff></affiliation></author><author><name sortKey="Blasi, Francesco" sort="Blasi, Francesco" uniqKey="Blasi F" first="Francesco" last="Blasi">Francesco Blasi</name><affiliation><nlm:aff id="af5"><addr-line>Department of Pathophysiology and</addr-line> Transplantation,<institution>University of Milan, IRCCS Fondazione Ca` Granda Ospedale Maggiore</institution>,<addr-line>Milan</addr-line>,<country>Italy</country></nlm:aff></affiliation></author></analytic><series><title level="j">Thorax</title><idno type="ISSN">0040-6376</idno><idno type="eISSN">1468-3296</idno><imprint><date when="2013">2013</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>Community-acquired pneumonia (CAP) causes considerable morbidity and mortality in adults, particularly in the elderly.</p></sec><sec><title>Methods</title><p>Structured searches of PubMed were conducted to identify up-to-date information on the incidence of CAP in adults in Europe, as well as data on lifestyle and medical risk factors for CAP.</p></sec><sec><title>Results</title><p>The overall annual incidence of CAP in adults ranged between 1.07 to 1.2 per 1000 person-years and 1.54 to 1.7 per 1000 population and increased with age (14 per 1000 person-years in adults aged ≥65 years). Incidence was also higher in men than in women and in patients with chronic respiratory disease or HIV infection. Lifestyle factors associated with an increased risk of CAP included smoking, alcohol abuse, being underweight, having regular contact with children and poor dental hygiene. The presence of comorbid conditions, including chronic respiratory and cardiovascular diseases, cerebrovascular disease, Parkinson's disease, epilepsy, dementia, dysphagia, HIV or chronic renal or liver disease all increased the risk of CAP by twofold to fourfold.</p></sec><sec><title>Conclusion</title><p>A range of lifestyle factors and underlying medical conditions are associated with an increased risk of CAP in European adults. Understanding of the types of individual at greatest risk of CAP can help to ensure that interventions to reduce the risk of infection and burden of disease are targeted appropriately.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Welte, T" uniqKey="Welte T">T Welte</name></author><author><name sortKey="Torres, A" uniqKey="Torres A">A Torres</name></author><author><name sortKey="Nathwani, D" uniqKey="Nathwani D">D Nathwani</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Blasi, F" uniqKey="Blasi F">F Blasi</name></author><author><name sortKey="Mantero, M" uniqKey="Mantero M">M Mantero</name></author><author><name sortKey="Santus, P" uniqKey="Santus P">P Santus</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lozano, R" uniqKey="Lozano R">R Lozano</name></author><author><name sortKey="Naghavi, M" uniqKey="Naghavi M">M Naghavi</name></author><author><name sortKey="Foreman, K" uniqKey="Foreman K">K Foreman</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Baik, I" uniqKey="Baik I">I Baik</name></author><author><name sortKey="Curhan, Gc" uniqKey="Curhan G">GC Curhan</name></author><author><name sortKey="Rimm, Eb" uniqKey="Rimm E">EB Rimm</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Koivalu, I" uniqKey="Koivalu I">I Koivalu</name></author><author><name sortKey="Sten, M" uniqKey="Sten M">M Sten</name></author><author><name sortKey="Makela, Ph" uniqKey="Makela P">PH Makela</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mannino, Dm" uniqKey="Mannino D">DM Mannino</name></author><author><name sortKey="Davis, Kj" uniqKey="Davis K">KJ Davis</name></author><author><name sortKey="Kiri, Va" uniqKey="Kiri V">VA Kiri</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Polverino, E" uniqKey="Polverino E">E Polverino</name></author><author><name sortKey="Torres Marti, A" uniqKey="Torres Marti A">A Torres Marti</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="De Roux, A" uniqKey="De Roux A">A de Roux</name></author><author><name sortKey="Cavalcanti, M" uniqKey="Cavalcanti M">M Cavalcanti</name></author><author><name sortKey="Marcos, Ma" uniqKey="Marcos M">MA Marcos</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Jover, F" uniqKey="Jover F">F Jover</name></author><author><name sortKey="Cuadrado, Jm" uniqKey="Cuadrado J">JM Cuadrado</name></author><author><name sortKey="Andreu, L" uniqKey="Andreu L">L Andreu</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Almirall, J" uniqKey="Almirall J">J Almirall</name></author><author><name sortKey="Rofes, L" uniqKey="Rofes L">L Rofes</name></author><author><name sortKey="Serra Prat, M" uniqKey="Serra Prat M">M Serra-Prat</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Cabre, M" uniqKey="Cabre M">M Cabre</name></author><author><name sortKey="Serra Prat, M" uniqKey="Serra Prat M">M Serra-Prat</name></author><author><name sortKey="Palomera, E" uniqKey="Palomera E">E Palomera</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hennessy, S" uniqKey="Hennessy S">S Hennessy</name></author><author><name sortKey="Bilker, Wb" uniqKey="Bilker W">WB Bilker</name></author><author><name sortKey="Leonard, Ce" uniqKey="Leonard C">CE Leonard</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Trifiro, G" uniqKey="Trifiro G">G Trifiro</name></author><author><name sortKey="Gambassi, G" uniqKey="Gambassi G">G Gambassi</name></author><author><name sortKey="Sen, Ef" uniqKey="Sen E">EF Sen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Vila Corcoles, A" uniqKey="Vila Corcoles A">A Vila-Corcoles</name></author><author><name sortKey="Ochoa Gondar, O" uniqKey="Ochoa Gondar O">O Ochoa-Gondar</name></author><author><name sortKey="Rodriguez Blanco, T" uniqKey="Rodriguez Blanco T">T Rodriguez-Blanco</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kornum, Jb" uniqKey="Kornum J">JB Kornum</name></author><author><name sortKey="Norgaard, M" uniqKey="Norgaard M">M Norgaard</name></author><author><name sortKey="Dethlefsen, C" uniqKey="Dethlefsen C">C Dethlefsen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kornum, Jb" uniqKey="Kornum J">JB Kornum</name></author><author><name sortKey="Due, Km" uniqKey="Due K">KM Due</name></author><author><name sortKey="Norgaard, M" uniqKey="Norgaard M">M Norgaard</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mullerova, H" uniqKey="Mullerova H">H Mullerova</name></author><author><name sortKey="Chigbo, C" uniqKey="Chigbo C">C Chigbo</name></author><author><name sortKey="Hagan, Gw" uniqKey="Hagan G">GW Hagan</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Vinogradova, Y" uniqKey="Vinogradova Y">Y Vinogradova</name></author><author><name sortKey="Coupland, C" uniqKey="Coupland C">C Coupland</name></author><author><name sortKey="Hippisley Cox, J" uniqKey="Hippisley Cox J">J Hippisley-Cox</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Schlienger, Rg" uniqKey="Schlienger R">RG Schlienger</name></author><author><name sortKey="Fedson, Ds" uniqKey="Fedson D">DS Fedson</name></author><author><name sortKey="Jick, Ss" uniqKey="Jick S">SS Jick</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Myles, Pr" uniqKey="Myles P">PR Myles</name></author><author><name sortKey="Hubbard, Rb" uniqKey="Hubbard R">RB Hubbard</name></author><author><name sortKey="Mckeever, Tm" uniqKey="Mckeever T">TM McKeever</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Teepe, J" uniqKey="Teepe J">J Teepe</name></author><author><name sortKey="Grigoryan, L" uniqKey="Grigoryan L">L Grigoryan</name></author><author><name sortKey="Verheij, Tj" uniqKey="Verheij T">TJ Verheij</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Benard, A" uniqKey="Benard A">A Benard</name></author><author><name sortKey="Mercie, P" uniqKey="Mercie P">P Mercie</name></author><author><name sortKey="Alioum, A" uniqKey="Alioum A">A Alioum</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Curran, A" uniqKey="Curran A">A Curran</name></author><author><name sortKey="Falco, V" uniqKey="Falco V">V Falco</name></author><author><name sortKey="Crespo, M" uniqKey="Crespo M">M Crespo</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Le Moing, V" uniqKey="Le Moing V">V Le Moing</name></author><author><name sortKey="Rabaud, C" uniqKey="Rabaud C">C Rabaud</name></author><author><name sortKey="Journot, V" uniqKey="Journot V">V Journot</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Madeddu, G" uniqKey="Madeddu G">G Madeddu</name></author><author><name sortKey="Porqueddu, Em" uniqKey="Porqueddu E">EM Porqueddu</name></author><author><name sortKey="Cambosu, F" uniqKey="Cambosu F">F Cambosu</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Manno, D" uniqKey="Manno D">D Manno</name></author><author><name sortKey="Puoti, M" uniqKey="Puoti M">M Puoti</name></author><author><name sortKey="Signorini, L" uniqKey="Signorini L">L Signorini</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Saindou, M" uniqKey="Saindou M">M Saindou</name></author><author><name sortKey="Chidiac, C" uniqKey="Chidiac C">C Chidiac</name></author><author><name sortKey="Miailhes, P" uniqKey="Miailhes P">P Miailhes</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Che, D" uniqKey="Che D">D Che</name></author><author><name sortKey="Campese, C" uniqKey="Campese C">C Campese</name></author><author><name sortKey="Santa Olalla, P" uniqKey="Santa Olalla P">P Santa-Olalla</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chidiac, C" uniqKey="Chidiac C">C Chidiac</name></author><author><name sortKey="Che, D" uniqKey="Che D">D Che</name></author><author><name sortKey="Pires Cronenberger, S" uniqKey="Pires Cronenberger S">S Pires-Cronenberger</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sopena, N" uniqKey="Sopena N">N Sopena</name></author><author><name sortKey="Force, L" uniqKey="Force L">L Force</name></author><author><name sortKey="Pedro Botet, Ml" uniqKey="Pedro Botet M">ML Pedro-Botet</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sopena, N" uniqKey="Sopena N">N Sopena</name></author><author><name sortKey="Pedro Botet, L" uniqKey="Pedro Botet L">L Pedro-Botet</name></author><author><name sortKey="Mateu, L" uniqKey="Mateu L">L Mateu</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kofteridis, D" uniqKey="Kofteridis D">D Kofteridis</name></author><author><name sortKey="Samonis, G" uniqKey="Samonis G">G Samonis</name></author><author><name sortKey="Mantadakis, E" uniqKey="Mantadakis E">E Mantadakis</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ruiz, La" uniqKey="Ruiz L">LA Ruiz</name></author><author><name sortKey="Gomez, A" uniqKey="Gomez A">A Gomez</name></author><author><name sortKey="Jaca, C" uniqKey="Jaca C">C Jaca</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ewig, S" uniqKey="Ewig S">S Ewig</name></author><author><name sortKey="Birkner, N" uniqKey="Birkner N">N Birkner</name></author><author><name sortKey="Strauss, R" uniqKey="Strauss R">R Strauss</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Viegi, G" uniqKey="Viegi G">G Viegi</name></author><author><name sortKey="Pistelli, R" uniqKey="Pistelli R">R Pistelli</name></author><author><name sortKey="Cazzola, M" uniqKey="Cazzola M">M Cazzola</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Almirall, J" uniqKey="Almirall J">J Almirall</name></author><author><name sortKey="Bolibar, I" uniqKey="Bolibar I">I Bolibar</name></author><author><name sortKey="Serra Prat, M" uniqKey="Serra Prat M">M Serra-Prat</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gutierrez, F" uniqKey="Gutierrez F">F Gutierrez</name></author><author><name sortKey="Masia, M" uniqKey="Masia M">M Masia</name></author><author><name sortKey="Mirete, C" uniqKey="Mirete C">C Mirete</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Perez Sola, Mj" uniqKey="Perez Sola M">MJ Perez-Sola</name></author><author><name sortKey="Torre Cisneros, J" uniqKey="Torre Cisneros J">J Torre-Cisneros</name></author><author><name sortKey="Perez Zafrilla, B" uniqKey="Perez Zafrilla B">B Perez-Zafrilla</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bewick, T" uniqKey="Bewick T">T Bewick</name></author><author><name sortKey="Sheppard, C" uniqKey="Sheppard C">C Sheppard</name></author><author><name sortKey="Greenwood, S" uniqKey="Greenwood S">S Greenwood</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Rodriguez, La" uniqKey="Rodriguez L">LA Rodriguez</name></author><author><name sortKey="Ruigomez, A" uniqKey="Ruigomez A">A Ruigomez</name></author><author><name sortKey="Wallander, Ma" uniqKey="Wallander M">MA Wallander</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gutierrez, F" uniqKey="Gutierrez F">F Gutierrez</name></author><author><name sortKey="Masia, M" uniqKey="Masia M">M Masia</name></author><author><name sortKey="Rodriguez, Jc" uniqKey="Rodriguez J">JC Rodriguez</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Schnoor, M" uniqKey="Schnoor M">M Schnoor</name></author><author><name sortKey="Klante, T" uniqKey="Klante T">T Klante</name></author><author><name sortKey="Beckmann, M" uniqKey="Beckmann M">M Beckmann</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Van De Garde, Em" uniqKey="Van De Garde E">EM van de Garde</name></author><author><name sortKey="Souverein, Pc" uniqKey="Souverein P">PC Souverein</name></author><author><name sortKey="Van Den Bosch, Jm" uniqKey="Van Den Bosch J">JM van den Bosch</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Vinogradova, Y" uniqKey="Vinogradova Y">Y Vinogradova</name></author><author><name sortKey="Hippisley Cox, J" uniqKey="Hippisley Cox J">J Hippisley-Cox</name></author><author><name sortKey="Coupland, C" uniqKey="Coupland C">C Coupland</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Van De Garde, Em" uniqKey="Van De Garde E">EM van de Garde</name></author><author><name sortKey="Hak, E" uniqKey="Hak E">E Hak</name></author><author><name sortKey="Souverein, Pc" uniqKey="Souverein P">PC Souverein</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kornum, Jb" uniqKey="Kornum J">JB Kornum</name></author><author><name sortKey="Thomsen, Rw" uniqKey="Thomsen R">RW Thomsen</name></author><author><name sortKey="Riis, A" uniqKey="Riis A">A Riis</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Van De Garde, Em" uniqKey="Van De Garde E">EM van de Garde</name></author><author><name sortKey="Souverein, Pc" uniqKey="Souverein P">PC Souverein</name></author><author><name sortKey="Hak, E" uniqKey="Hak E">E Hak</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Almirall, J" uniqKey="Almirall J">J Almirall</name></author><author><name sortKey="Bolibar, I" uniqKey="Bolibar I">I Bolibar</name></author><author><name sortKey="Serra Prat, M" uniqKey="Serra Prat M">M Serra-Prat</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gulmez, Se" uniqKey="Gulmez S">SE Gulmez</name></author><author><name sortKey="Holm, A" uniqKey="Holm A">A Holm</name></author><author><name sortKey="Frederiksen, H" uniqKey="Frederiksen H">H Frederiksen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nielsen, Ag" uniqKey="Nielsen A">AG Nielsen</name></author><author><name sortKey="Nielsen, Rb" uniqKey="Nielsen R">RB Nielsen</name></author><author><name sortKey="Riis, Ah" uniqKey="Riis A">AH Riis</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sarkar, M" uniqKey="Sarkar M">M Sarkar</name></author><author><name sortKey="Hennessy, S" uniqKey="Hennessy S">S Hennessy</name></author><author><name sortKey="Yang, Yx" uniqKey="Yang Y">YX Yang</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Carratala, J" uniqKey="Carratala J">J Carratala</name></author><author><name sortKey="Mykietiuk, A" uniqKey="Mykietiuk A">A Mykietiuk</name></author><author><name sortKey="Fernandez Sabe, N" uniqKey="Fernandez Sabe N">N Fernandez-Sabe</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Cilloniz, C" uniqKey="Cilloniz C">C Cilloniz</name></author><author><name sortKey="Ewig, S" uniqKey="Ewig S">S Ewig</name></author><author><name sortKey="Ferrer, M" uniqKey="Ferrer M">M Ferrer</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Cilloniz, C" uniqKey="Cilloniz C">C Cilloniz</name></author><author><name sortKey="Ewig, S" uniqKey="Ewig S">S Ewig</name></author><author><name sortKey="Polverino, E" uniqKey="Polverino E">E Polverino</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Falguera, M" uniqKey="Falguera M">M Falguera</name></author><author><name sortKey="Carratala, J" uniqKey="Carratala J">J Carratala</name></author><author><name sortKey="Ruiz Gonzalez, A" uniqKey="Ruiz Gonzalez A">A Ruiz-Gonzalez</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Garcia Vidal, C" uniqKey="Garcia Vidal C">C Garcia-Vidal</name></author><author><name sortKey="Carratala, J" uniqKey="Carratala J">J Carratala</name></author><author><name sortKey="Fernandez Sabe, N" uniqKey="Fernandez Sabe N">N Fernandez-Sabe</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Giannella, M" uniqKey="Giannella M">M Giannella</name></author><author><name sortKey="Pinilla, B" uniqKey="Pinilla B">B Pinilla</name></author><author><name sortKey="Capdevila, Ja" uniqKey="Capdevila J">JA Capdevila</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Holm, A" uniqKey="Holm A">A Holm</name></author><author><name sortKey="Nexoe, J" uniqKey="Nexoe J">J Nexoe</name></author><author><name sortKey="Bistrup, La" uniqKey="Bistrup L">LA Bistrup</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Klapdor, B" uniqKey="Klapdor B">B Klapdor</name></author><author><name sortKey="Ewig, S" uniqKey="Ewig S">S Ewig</name></author><author><name sortKey="Pletz, Mw" uniqKey="Pletz M">MW Pletz</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kothe, H" uniqKey="Kothe H">H Kothe</name></author><author><name sortKey="Bauer, T" uniqKey="Bauer T">T Bauer</name></author><author><name sortKey="Marre, R" uniqKey="Marre R">R Marre</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Liapikou, A" uniqKey="Liapikou A">A Liapikou</name></author><author><name sortKey="Polverino, E" uniqKey="Polverino E">E Polverino</name></author><author><name sortKey="Ewig, S" uniqKey="Ewig S">S Ewig</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Migliorati, Pl" uniqKey="Migliorati P">PL Migliorati</name></author><author><name sortKey="Boccoli, E" uniqKey="Boccoli E">E Boccoli</name></author><author><name sortKey="Bracci, Ls" uniqKey="Bracci L">LS Bracci</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Molinos, L" uniqKey="Molinos L">L Molinos</name></author><author><name sortKey="Clemente, Mg" uniqKey="Clemente M">MG Clemente</name></author><author><name sortKey="Miranda, B" uniqKey="Miranda B">B Miranda</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Myint, Pk" uniqKey="Myint P">PK Myint</name></author><author><name sortKey="Lowe, D" uniqKey="Lowe D">D Lowe</name></author><author><name sortKey="Stone, Ra" uniqKey="Stone R">RA Stone</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Thomsen, Rw" uniqKey="Thomsen R">RW Thomsen</name></author><author><name sortKey="Riis, A" uniqKey="Riis A">A Riis</name></author><author><name sortKey="Kornum, Jb" uniqKey="Kornum J">JB Kornum</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Viasus, D" uniqKey="Viasus D">D Viasus</name></author><author><name sortKey="Garcia Vidal, C" uniqKey="Garcia Vidal C">C Garcia-Vidal</name></author><author><name sortKey="Cruzado, Jm" uniqKey="Cruzado J">JM Cruzado</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Viasus, D" uniqKey="Viasus D">D Viasus</name></author><author><name sortKey="Garcia Vidal, C" uniqKey="Garcia Vidal C">C Garcia-Vidal</name></author><author><name sortKey="Castellote, J" uniqKey="Castellote J">J Castellote</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Von Baum, H" uniqKey="Von Baum H">H von Baum</name></author><author><name sortKey="Welte, T" uniqKey="Welte T">T Welte</name></author><author><name sortKey="Marre, R" uniqKey="Marre R">R Marre</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sogaard, Os" uniqKey="Sogaard O">OS Sogaard</name></author><author><name sortKey="Lohse, N" uniqKey="Lohse N">N Lohse</name></author><author><name sortKey="Gerstoft, J" uniqKey="Gerstoft J">J Gerstoft</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Almirall, J" uniqKey="Almirall J">J Almirall</name></author><author><name sortKey="Gonzalez, Ca" uniqKey="Gonzalez C">CA Gonzalez</name></author><author><name sortKey="Balanz, X" uniqKey="Balanz X">X Balanzó</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Dye, Ja" uniqKey="Dye J">JA Dye</name></author><author><name sortKey="Adler, Kb" uniqKey="Adler K">KB Adler</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nelson, S" uniqKey="Nelson S">S Nelson</name></author><author><name sortKey="Kolls, Jk" uniqKey="Kolls J">JK Kolls</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Hedlund, J" uniqKey="Hedlund J">J Hedlund</name></author><author><name sortKey="Hansson, Lo" uniqKey="Hansson L">LO Hansson</name></author><author><name sortKey="Ortqvist, A" uniqKey="Ortqvist A">A Ortqvist</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hendley, Jo" uniqKey="Hendley J">JO Hendley</name></author><author><name sortKey="Sande, Ma" uniqKey="Sande M">MA Sande</name></author><author><name sortKey="Stewart, Pm" uniqKey="Stewart P">PM Stewart</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Arranz, S" uniqKey="Arranz S">S Arranz</name></author><author><name sortKey="Chiva Blanch, G" uniqKey="Chiva Blanch G">G Chiva-Blanch</name></author><author><name sortKey="Valderas Martinez, P" uniqKey="Valderas Martinez P">P Valderas-Martínez</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ronksley, Pe" uniqKey="Ronksley P">PE Ronksley</name></author><author><name sortKey="Brien, Se" uniqKey="Brien S">SE Brien</name></author><author><name sortKey="Turner, Bj" uniqKey="Turner B">BJ Turner</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Quagliarello, V" uniqKey="Quagliarello V">V Quagliarello</name></author><author><name sortKey="Ginter, S" uniqKey="Ginter S">S Ginter</name></author><author><name sortKey="Han, L" uniqKey="Han L">L Han</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nuorti, Jp" uniqKey="Nuorti J">JP Nuorti</name></author><author><name sortKey="Butler, Jc" uniqKey="Butler J">JC Butler</name></author><author><name sortKey="Farley, Mm" uniqKey="Farley M">MM Farley</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Winkleby, Ma" uniqKey="Winkleby M">MA Winkleby</name></author><author><name sortKey="Jatulis, De" uniqKey="Jatulis D">DE Jatulis</name></author><author><name sortKey="Frank, E" uniqKey="Frank E">E Frank</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gaillat, J" uniqKey="Gaillat J">J Gaillat</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Loeb, M" uniqKey="Loeb M">M Loeb</name></author><author><name sortKey="Mcgeer, A" uniqKey="Mcgeer A">A McGeer</name></author><author><name sortKey="Mcarthur, M" uniqKey="Mcarthur M">M McArthur</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mandell, La" uniqKey="Mandell L">LA Mandell</name></author><author><name sortKey="Wunderink, Rg" uniqKey="Wunderink R">RG Wunderink</name></author><author><name sortKey="Anzueto, A" uniqKey="Anzueto A">A Anzueto</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Woodhead, M" uniqKey="Woodhead M">M Woodhead</name></author><author><name sortKey="Blasi, F" uniqKey="Blasi F">F Blasi</name></author><author><name sortKey="Ewig, S" uniqKey="Ewig S">S Ewig</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Huss, A" uniqKey="Huss A">A Huss</name></author><author><name sortKey="Scott, P" uniqKey="Scott P">P Scott</name></author><author><name sortKey="Stuck, Ae" uniqKey="Stuck A">AE Stuck</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Moberley, S" uniqKey="Moberley S">S Moberley</name></author><author><name sortKey="Holden, J" uniqKey="Holden J">J Holden</name></author><author><name sortKey="Tatham, Dp" uniqKey="Tatham D">DP Tatham</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Hak, E" uniqKey="Hak E">E Hak</name></author><author><name sortKey="Grobbee, De" uniqKey="Grobbee D">DE Grobbee</name></author><author><name sortKey="Sanders, Ea" uniqKey="Sanders E">EA Sanders</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="review-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Thorax</journal-id><journal-id journal-id-type="iso-abbrev">Thorax</journal-id><journal-id journal-id-type="hwp">thoraxjnl</journal-id><journal-id journal-id-type="publisher-id">thorax</journal-id><journal-title-group><journal-title>Thorax</journal-title></journal-title-group><issn pub-type="ppub">0040-6376</issn><issn pub-type="epub">1468-3296</issn><publisher><publisher-name>BMJ Publishing Group</publisher-name><publisher-loc>BMA House, Tavistock Square, London, WC1H 9JR</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">24130229</article-id><article-id pub-id-type="pmc">3812874</article-id><article-id pub-id-type="publisher-id">thoraxjnl-2013-204282</article-id><article-id pub-id-type="doi">10.1136/thoraxjnl-2013-204282</article-id><article-categories><subj-group subj-group-type="hwp-journal-coll"><subject>1506</subject></subj-group><subj-group subj-group-type="heading"><subject>Review</subject></subj-group></article-categories><title-group><article-title>Risk factors for community-acquired pneumonia in adults in Europe: a literature review</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Torres</surname><given-names>Antoni</given-names></name><xref ref-type="aff" rid="af1">1</xref></contrib><contrib contrib-type="author"><name><surname>Peetermans</surname><given-names>Willy E</given-names></name><xref ref-type="aff" rid="af2">2</xref></contrib><contrib contrib-type="author"><name><surname>Viegi</surname><given-names>Giovanni</given-names></name><xref ref-type="aff" rid="af3">3</xref><xref ref-type="aff" rid="af4">4</xref></contrib><contrib contrib-type="author"><name><surname>Blasi</surname><given-names>Francesco</given-names></name><xref ref-type="aff" rid="af5">5</xref></contrib></contrib-group><aff id="af1"><label>1</label><addr-line>Servei de Pneumologia, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBER de Enfermedades Respiratorias (CIBERes), University of Barcelona, Barcelona, Spain</addr-line></aff><aff id="af2"><label>2</label><addr-line>Department of Internal Medicine</addr-line>,<institution>University Hospital, KU Leuven</institution>,<addr-line>Leuven</addr-line>,<country>Belgium</country></aff><aff id="af3"><label>3</label><institution>CNR Institute of Clinical Physiology</institution>,<addr-line>Pisa</addr-line>,<country>Italy</country></aff><aff id="af4"><label>4</label><institution>CNR Institute of Biomedicine and Molecular Immunology</institution>,<addr-line>Palermo</addr-line>,<country>Italy</country></aff><aff id="af5"><label>5</label><addr-line>Department of Pathophysiology and</addr-line> Transplantation,<institution>University of Milan, IRCCS Fondazione Ca` Granda Ospedale Maggiore</institution>,<addr-line>Milan</addr-line>,<country>Italy</country></aff><author-notes><corresp><label>Correspondence to</label> Professor Antoni Torres, Servei de Pneumologia, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBER de Enfermedades Respiratorias (CIBERes), University of Barcelona, 08036 Barcelona, Spain; <email>ATORRES@clinic.ub.es</email></corresp></author-notes><pub-date pub-type="ppub"><month>11</month><year>2013</year></pub-date><volume>68</volume><issue>11</issue><fpage>1057</fpage><lpage>1065</lpage><history><date date-type="received"><day>1</day><month>8</month><year>2013</year></date><date date-type="accepted"><day>11</day><month>8</month><year>2013</year></date></history><permissions><copyright-statement>Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions</copyright-statement><copyright-year>2013</copyright-year><license license-type="open-access"><license-p>This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/3.0/">http://creativecommons.org/licenses/by-nc/3.0/</ext-link></license-p></license></permissions><self-uri xlink:title="pdf" xlink:type="simple" xlink:href="thoraxjnl-2013-204282.pdf"></self-uri><abstract><sec><title>Background</title><p>Community-acquired pneumonia (CAP) causes considerable morbidity and mortality in adults, particularly in the elderly.</p></sec><sec><title>Methods</title><p>Structured searches of PubMed were conducted to identify up-to-date information on the incidence of CAP in adults in Europe, as well as data on lifestyle and medical risk factors for CAP.</p></sec><sec><title>Results</title><p>The overall annual incidence of CAP in adults ranged between 1.07 to 1.2 per 1000 person-years and 1.54 to 1.7 per 1000 population and increased with age (14 per 1000 person-years in adults aged ≥65 years). Incidence was also higher in men than in women and in patients with chronic respiratory disease or HIV infection. Lifestyle factors associated with an increased risk of CAP included smoking, alcohol abuse, being underweight, having regular contact with children and poor dental hygiene. The presence of comorbid conditions, including chronic respiratory and cardiovascular diseases, cerebrovascular disease, Parkinson's disease, epilepsy, dementia, dysphagia, HIV or chronic renal or liver disease all increased the risk of CAP by twofold to fourfold.</p></sec><sec><title>Conclusion</title><p>A range of lifestyle factors and underlying medical conditions are associated with an increased risk of CAP in European adults. Understanding of the types of individual at greatest risk of CAP can help to ensure that interventions to reduce the risk of infection and burden of disease are targeted appropriately.</p></sec></abstract><kwd-group><kwd>Pneumonia</kwd><kwd>Respiratory Infection</kwd><kwd>Clinical Epidemiology</kwd></kwd-group><custom-meta-group><custom-meta><meta-name>special-feature</meta-name><meta-value>unlocked</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="s1"><title>Introduction</title><p>Community-acquired pneumonia (CAP) is a cause of considerable morbidity and mortality in adults in developed countries, leading to high rates of hospitalisations, especially in the elderly.<xref ref-type="bibr" rid="R1">1</xref><xref ref-type="bibr" rid="R2">2</xref> The 2010 Global Burden of Disease Study reported that lower respiratory tract infections, including pneumonia, are the fourth most common cause of death globally, exceeded only by ischaemic heart disease, strokes and chronic obstructive pulmonary disease (COPD), and they are the second most frequent reason for years of life lost.<xref ref-type="bibr" rid="R3">3</xref> Within Europe, CAP is the leading cause of death due to infection,<xref ref-type="bibr" rid="R2">2</xref> with approximately 90% of deaths due to pneumonia occurring in people aged >65 years.<xref ref-type="bibr" rid="R4">4</xref> Pneumonia places a considerable burden on healthcare resources and society, with associated annual costs in Europe estimated at approximately €10 billion, mainly due to hospitalisation and lost working days.<xref ref-type="bibr" rid="R5">5</xref></p><p>Several risk factors for CAP are recognised, including age >65 years,<xref ref-type="bibr" rid="R1">1</xref><xref ref-type="bibr" rid="R6">6</xref><xref ref-type="bibr" rid="R7">7</xref> smoking,<xref ref-type="bibr" rid="R6">6</xref> alcoholism,<xref ref-type="bibr" rid="R7">7</xref> immunosuppressive conditions,<xref ref-type="bibr" rid="R7">7</xref> and conditions such as COPD,<xref ref-type="bibr" rid="R8">8</xref> cardiovascular disease, cerebrovascular disease, chronic liver or renal disease, diabetes mellitus and dementia.<xref ref-type="bibr" rid="R9">9</xref> Although many European studies have reported on the incidence of CAP and associated risk factors, no comprehensive overviews of these data are currently available. This literature review was conducted to generate up-to-date information on the incidence of CAP in adults in Europe, and of the risk factors for contracting CAP. A secondary objective was to collect data on the rates of comorbidities in patients with CAP.</p></sec><sec sec-type="methods" id="s2"><title>Methods</title><p>The PubMed database was searched using the following search string: pneumonia AND English AND 2005/01/01–2012/07/31 AND risk NOT clinical trial, phase i OR clinical trial, phase ii OR clinical trial, phase iii OR controlled clinical trial OR randomised controlled trial OR case reports OR practice guideline OR editorial OR review OR cost OR cost effectiveness OR efficacy OR immunogenicity OR economic OR nosocomial. Additional searches used the same search string, but replaced ‘risk’ with either ‘comorbidity’ or ‘co-morbidity’.</p><p>Papers were included if they reported observational studies performed in Western European countries (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, The Netherlands, Norway, Portugal, Spain, Sweden, Switzerland, UK) and presented data from individuals aged >15 years on any of the following: incidence of CAP in at-risk individuals, defined as those with underlying risk factors for contracting CAP (<xref ref-type="table" rid="THORAXJNL2013204282TB1">table 1</xref>); risk factors for CAP; comorbidities in patients with CAP; pharmacotherapeutic agents associated with an increase or decrease in the risk of CAP; pathogens identified in patients with CAP. Studies that focused on nosocomial or healthcare acquired pneumonia were excluded.</p><table-wrap id="THORAXJNL2013204282TB1" position="float"><label>Table 1</label><caption><p>Risk categories for community-acquired pneumonia included in the review</p></caption><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="left" span="1"></col></colgroup><thead valign="bottom"><tr><th align="left" rowspan="1" colspan="1">Immunocompetent at risk</th><th align="left" rowspan="1" colspan="1">Immunocompromised at risk</th></tr></thead><tbody><tr><td rowspan="1" colspan="1"><list list-type="simple"><list-item><label>▸</label><p>Age</p></list-item><list-item><label>▸</label><p>Lifestyle
<list list-type="simple"><list-item><label>▸</label><p>Alcoholism</p></list-item><list-item><label>▸</label><p>Smoking</p></list-item></list></p></list-item><list-item><label>▸</label><p>Underlying diseases
<list list-type="simple"><list-item><label>▸</label><p>Chronic heart disease</p></list-item><list-item><label>▸</label><p>Chronic renal disease</p></list-item><list-item><label>▸</label><p>Chronic liver disease</p></list-item><list-item><label>▸</label><p>Chronic respiratory disease</p></list-item><list-item><label>▸</label><p>Metabolic disease</p></list-item><list-item><label>▸</label><p>CNS disease</p></list-item></list></p></list-item><list-item><label>▸</label><p>Prior IPD</p></list-item><list-item><label>▸</label><p>Previous pneumonia</p></list-item><list-item><label>▸</label><p>Other
<list list-type="simple"><list-item><label>▸</label><p>Aspiration</p></list-item><list-item><label>▸</label><p>Concomitant treatment</p></list-item></list></p></list-item></list></td><td rowspan="1" colspan="1"><list list-type="simple"><list-item><label>▸</label><p>Immunosuppression
<list list-type="simple"><list-item><label>–</label><p>Autoimmune diseases receiving steroid or immunosuppressive therapy or biological therapy</p></list-item><list-item><label>▸</label><p>Cancer with immunosuppressive treatment</p></list-item><list-item><label>▸</label><p>Waiting list for solid-organ transplantation (with or without immunosuppressive treatment)</p></list-item><list-item><label>▸</label><p>Other immunosuppression</p></list-item></list></p></list-item><list-item><label>▸</label><p>Immunocompromised
<list list-type="simple"><list-item><label>▸</label><p>Asplenia/splenic dysfunction</p></list-item><list-item><label>▸</label><p>Primary immunodeficiencies</p></list-item></list></p></list-item><list-item><label>▸</label><p>HIV</p></list-item></list></td></tr></tbody></table><table-wrap-foot><fn><p>CNS, central nervous system; IPD invasive pneumococcal disease.</p></fn></table-wrap-foot></table-wrap><p>Included papers were reviewed in full and data on the study setting and methodology, characteristics of the study population, incidence of CAP, risk factors for CAP (ORs or relative risks (RRs), and 95% CIs) reported in case-control studies, and observational data on rates of comorbidities, associated pharmacotherapies and pathogens were collected. If more than one paper reported different aspects of the same study, all relevant papers were included. Where the same data were reported in more than one paper, the earliest published paper was selected.</p><p>Analysis of the included papers was descriptive and no meta-analyses of data were performed. Unless otherwise stated, all data are reported as OR (95% CI) or RR (95% CI).</p></sec><sec sec-type="results" id="s3"><title>Results</title><sec id="s3a"><title>Included studies</title><p>Of the 3330 references identified, 3240 were excluded on the basis of the title or abstract. The authors identified one additional reference<xref ref-type="bibr" rid="R10">10</xref> that did not include the terms ‘risk’ or ‘co-morbidity’/'comorbidity’ in the title or abstract and was therefore not identified in the PubMed searches. However, it satisfied the other inclusion criteria. Final screening of the full papers identified 61 references meeting the inclusion and exclusion criteria, of which one paper<xref ref-type="bibr" rid="R11">11</xref> was later excluded due to data discrepancies that we were unable to resolve by correspondence with the author (<xref ref-type="fig" rid="THORAXJNL2013204282F1">figure 1</xref>).</p><fig id="THORAXJNL2013204282F1" position="float"><label>Figure 1</label><caption><p>Summary of the study selection procedure. CAP, community acquired pneumonia. *One study did not include the terms ‘risk’ or ‘co-morbidity’/'comorbidity’ in either the title or abstract and so was not identified in the PubMed searches; however, ‘risk factors’ was included in the list of MeSH terms for the article.</p></caption><graphic xlink:href="thoraxjnl-2013-204282f01"></graphic></fig><p>Of the 60 publications, a majority (34) focused on hospitalised patients. Included studies were from Denmark (n=7), France (n=5), Germany (n=5), Greece (n=1), Italy (n=4), The Netherlands (n=3), Spain (n=23) and the UK (n=12). Study designs and populations are summarised in online supplementary table S1. Most studies included adults of all ages. However, five studies considered only patients aged ≥65 years,<xref ref-type="bibr" rid="R12 R13 R14 R15 R16">12–16</xref> two included patients aged 50–65 years,<xref ref-type="bibr" rid="R17">17</xref><xref ref-type="bibr" rid="R18">18</xref> two included patients aged ≥45 years<xref ref-type="bibr" rid="R19">19</xref><xref ref-type="bibr" rid="R20">20</xref> and single studies included patients aged ≥30 years,<xref ref-type="bibr" rid="R21">21</xref> ≥40 years<xref ref-type="bibr" rid="R22">22</xref> or 16–40 years.<xref ref-type="bibr" rid="R23">23</xref> Six studies included only patients infected with HIV.<xref ref-type="bibr" rid="R24 R25 R26 R27 R28 R29">24–29</xref></p><p>Most studies included patients with pneumonia of any aetiology, but six were performed in patients with pneumonia due to a specified bacterial agent: four studies in patients with <italic>Legionella pneumophila</italic> infection,<xref ref-type="bibr" rid="R30 R31 R32 R33">30–33</xref> and one each in patients with <italic>Haemophilus influenzae</italic><xref ref-type="bibr" rid="R34">34</xref> or Gram-negative bacteria<xref ref-type="bibr" rid="R35">35</xref> infections.</p></sec><sec id="s3b"><title>Incidence of CAP</title><p>The incidence of CAP was reported in 16 studies, from Denmark (n=2),<xref ref-type="bibr" rid="R17">17</xref><xref ref-type="bibr" rid="R18">18</xref> France (n=3),<xref ref-type="bibr" rid="R24">24</xref><xref ref-type="bibr" rid="R26">26</xref><xref ref-type="bibr" rid="R29">29</xref> Germany (n=1),<xref ref-type="bibr" rid="R36">36</xref> Italy (n=2),<xref ref-type="bibr" rid="R27">27</xref><xref ref-type="bibr" rid="R37">37</xref> Spain (n=5)<xref ref-type="bibr" rid="R16">16</xref><xref ref-type="bibr" rid="R25">25</xref><xref ref-type="bibr" rid="R38 R39 R40">38–40</xref> and the UK (n=3).<xref ref-type="bibr" rid="R19">19</xref><xref ref-type="bibr" rid="R41">41</xref><xref ref-type="bibr" rid="R42">42</xref> Data are summarised in <xref ref-type="table" rid="THORAXJNL2013204282TB2">table 2</xref>, with more details available in online supplementary table S2.</p><table-wrap id="THORAXJNL2013204282TB2" position="float"><label>Table 2</label><caption><p>Incidence of community-acquired pneumonia (CAP) in adults in Europe</p></caption><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="left" span="1"></col><col align="left" span="1"></col><col align="left" span="1"></col></colgroup><thead valign="bottom"><tr><th align="left" rowspan="1" colspan="1">Study</th><th align="left" rowspan="1" colspan="1">Country; region</th><th align="left" rowspan="1" colspan="1">Study period</th><th align="left" rowspan="1" colspan="1">CAP incidence (95% CI)</th></tr></thead><tbody><tr><td colspan="4" rowspan="1">Overall population</td></tr><tr><td rowspan="1" colspan="1"> Almirall <italic>et al</italic><xref ref-type="bibr" rid="R38">38</xref></td><td rowspan="1" colspan="1">Spain; east coast</td><td rowspan="1" colspan="1">1 November 1999–30 November 2000</td><td rowspan="1" colspan="1">Per 1000 population >14 years: <break></break>1.54</td></tr><tr><td rowspan="3" colspan="1"> Gutierrez <italic>et al</italic><xref ref-type="bibr" rid="R39">39</xref></td><td rowspan="3" colspan="1">Spain; Alicante</td><td rowspan="3" colspan="1">15 October 1999–14 October 2001</td><td rowspan="1" colspan="1">Per 1000 person-years: <break></break>Overall, 1.230</td></tr><tr><td rowspan="1" colspan="1">Men, 1.556</td></tr><tr><td rowspan="1" colspan="1">Women, 0.911</td></tr><tr><td rowspan="3" colspan="1"> Rodriguez <italic>et al</italic><xref ref-type="bibr" rid="R42">42</xref></td><td rowspan="3" colspan="1">UK; national</td><td rowspan="3" colspan="1">1 January 2000–31 December 2005</td><td rowspan="1" colspan="1">Primary care patients, per 1000 person-years: <break></break>Overall, 1.07 (1.04 to 1.09)</td></tr><tr><td rowspan="1" colspan="1">Women, 0.93 (0.89 to 0.96)</td></tr><tr><td rowspan="1" colspan="1">Men, 1.22 (1.18 to 1.26)</td></tr><tr><td rowspan="3" colspan="1"> Viegi <italic>et al</italic><xref ref-type="bibr" rid="R37">37</xref>*</td><td rowspan="3" colspan="1">Italy; national</td><td rowspan="3" colspan="1">15 February 1999–14 February 2000</td><td rowspan="1" colspan="1">Annual incidence per 1000 population: <break></break>Overall, 1.703</td></tr><tr><td rowspan="1" colspan="1">Males, 1.692</td></tr><tr><td rowspan="1" colspan="1">Females, 1.713</td></tr><tr><td rowspan="3" colspan="1"> Vila-Corcoles <italic>et al</italic><xref ref-type="bibr" rid="R16">16</xref></td><td rowspan="3" colspan="1">Spain; Tarragona</td><td rowspan="3" colspan="1">1 January 2002–30 April 2005</td><td rowspan="1" colspan="1">Age ≥65 years, per 1000 person-years: <break></break>Overall, 14.0 (12.7 to 15.3)</td></tr><tr><td rowspan="1" colspan="1">Men, 19.2 (17.1 to 21.6)</td></tr><tr><td rowspan="1" colspan="1">Women, 10.0 (8.6 to 11.5)</td></tr><tr><td colspan="4" rowspan="1">Hospitalisation for CAP</td></tr><tr><td rowspan="1" colspan="1"> Bewick <italic>et al</italic><xref ref-type="bibr" rid="R41">41</xref></td><td rowspan="1" colspan="1">UK; Nottingham</td><td rowspan="1" colspan="1">September 2008–September 2010</td><td rowspan="1" colspan="1">Per 1000 population ≥16 years: Overall, 1.097</td></tr><tr><td rowspan="2" colspan="1"> Ewig <italic>et al</italic><xref ref-type="bibr" rid="R36">36</xref></td><td rowspan="2" colspan="1">Germany; national</td><td rowspan="2" colspan="1">2005 and 2006</td><td rowspan="1" colspan="1">Per 1000 population/year ≥18 years: <break></break>2005, 2.75 <break></break>2006, 2.96</td></tr><tr><td rowspan="1" colspan="1">Mean incidence: <break></break>Men, 3.21 <break></break>Women, 2.52</td></tr><tr><td rowspan="1" colspan="1"> Kornum <italic>et al</italic><xref ref-type="bibr" rid="R17">17</xref></td><td rowspan="1" colspan="1">Denmark; Copenhagen and Aarhus</td><td rowspan="1" colspan="1">December 1993–April 2008</td><td rowspan="1" colspan="1">Per 1000 person-years, >50 years: <break></break>Men, 4.2 <break></break>Women, 3.4</td></tr><tr><td rowspan="1" colspan="1"> Kornum <italic>et al</italic><xref ref-type="bibr" rid="R18">18</xref></td><td rowspan="1" colspan="1">Denmark; Copenhagen and Aarhus</td><td rowspan="1" colspan="1">December 1993–April 2008</td><td rowspan="1" colspan="1">Per 1000 person-years, >50 years: <break></break>Men, 4.25 <break></break>Women, 3.28</td></tr><tr><td colspan="4" rowspan="1">Patients with COPD</td></tr><tr><td rowspan="3" colspan="1"> Müllerova <italic>et al</italic><xref ref-type="bibr" rid="R19">19</xref></td><td rowspan="3" colspan="1">UK; England and Wales</td><td rowspan="3" colspan="1">1 January 1996–31 December 2005</td><td rowspan="1" colspan="1">Per 1000 patient-years: <break></break>Overall, 22.4 (21.7 to 23.2)</td></tr><tr><td rowspan="1" colspan="1">Women, 21.4 (20.4 to 22.5)</td></tr><tr><td rowspan="1" colspan="1">Men, 23.1 (22.1 to 24.2)</td></tr><tr><td colspan="4" rowspan="1">Immunocompromised individuals</td></tr><tr><td rowspan="1" colspan="1"> Perez-Sola <italic>et al</italic><xref ref-type="bibr" rid="R40">40</xref>†</td><td rowspan="1" colspan="1">Spain; national</td><td rowspan="1" colspan="1">February 2000–January 2006</td><td rowspan="1" colspan="1">Patients with rheumatic diseases treated with TNF antagonists, per 1000 patient-years: <break></break>5.97 (4.87 to 7.25)</td></tr><tr><td colspan="4" rowspan="1">HIV-infected individuals</td></tr><tr><td rowspan="1" colspan="1"> Bénard <italic>et al</italic><xref ref-type="bibr" rid="R24">24</xref></td><td rowspan="1" colspan="1">France; Aquitaine</td><td rowspan="1" colspan="1">2000–2007</td><td rowspan="1" colspan="1">Per 1000 patient-years: <break></break>Overall: 12.0 (9.9 to 14.0)</td></tr><tr><td rowspan="7" colspan="1"> Curran <italic>et al</italic><xref ref-type="bibr" rid="R25">25</xref></td><td rowspan="7" colspan="1">Spain; Barcelona</td><td rowspan="7" colspan="1">January 2000–December 2005</td><td rowspan="1" colspan="1">Cases/1000 patients/year:</td></tr><tr><td rowspan="1" colspan="1">2000, 30.90</td></tr><tr><td rowspan="1" colspan="1">2001, 31.80</td></tr><tr><td rowspan="1" colspan="1">2002, 25.70</td></tr><tr><td rowspan="1" colspan="1">2003, 21.90</td></tr><tr><td rowspan="1" colspan="1">2004, 20.50</td></tr><tr><td rowspan="1" colspan="1">2005, 24.00</td></tr><tr><td rowspan="1" colspan="1"> Le Moing <italic>et al</italic><xref ref-type="bibr" rid="R26">26</xref></td><td rowspan="1" colspan="1">France; national</td><td rowspan="1" colspan="1">May 1997–December 2001</td><td rowspan="1" colspan="1">Hospitalisation for first episode of bacterial pneumonia in protease inhibitor-treated patients: <break></break>8/1000 patient-years (3–13)</td></tr><tr><td rowspan="2" colspan="1"> Madeddu <italic>et al</italic><xref ref-type="bibr" rid="R27">27</xref>‡</td><td rowspan="2" colspan="1">Italy; northern Sardinia</td><td rowspan="2" colspan="1">January 1999–December 2004</td><td rowspan="1" colspan="1">Per 1000 inpatients/year: <break></break>1999, 177</td></tr><tr><td rowspan="1" colspan="1">2004, 280</td></tr><tr><td rowspan="3" colspan="1"> Saindou <italic>et al</italic><xref ref-type="bibr" rid="R29">29</xref></td><td rowspan="3" colspan="1">France; Lyon</td><td rowspan="3" colspan="1">1993–2004</td><td rowspan="1" colspan="1">Pneumococcal pneumonia, per 1000 patient-years: <break></break>Cohort followed 1993–1 July 1996 (pre-HAART), 10.6 (5.4 to 15.7)</td></tr><tr><td rowspan="1" colspan="1">Cohort followed before 1 July 1996–2004 (pre-HAART and HAART era), 1.5 (0.9 to 2.1)</td></tr><tr><td rowspan="1" colspan="1">Cohort followed 1 July 1996–2004 (HAART era), 2.5 (1.4 to 3.6)</td></tr></tbody></table><table-wrap-foot><fn><p>Incidence rates standardised per 1000 population or per 1000 person-years; original study data are available in online <ext-link ext-link-type="uri" xlink:href="http://thorax.bmj.com/lookup/suppl/doi:10.1136/thoraxjnl-2013-204282/-/DC1">supplementary table</ext-link> S2.</p></fn><fn><p>*This study included data for 10 children aged <14 years.</p></fn><fn><p>†In this study, ‘pneumonia’ included fungal and viral aetiologies.</p></fn><fn><p>‡A majority of patients (84%) in this study were also intravenous drug users.</p></fn><fn><p>COPD, chronic obstructive pulmonary disease; HAART, highly active antiretroviral therapy; TNF, tumour necrosis factor.</p></fn></table-wrap-foot></table-wrap><p>Differences in study populations and measures used for incidence rates make it difficult to make direct comparisons across studies. Nevertheless, several trends were apparent. The overall annual incidence of CAP in adults ranged between 1.07 to 1.2 per 1000 person-years and 1.54 to 1.7 per 1000 population<xref ref-type="bibr" rid="R37">37</xref><xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R42">42</xref><xref ref-type="bibr" rid="R43">43</xref> (<xref ref-type="table" rid="THORAXJNL2013204282TB2">table 2</xref>). Rates of hospitalisation for CAP were typically higher than overall incidence rates; for example, a German study<xref ref-type="bibr" rid="R36">36</xref> reported rates of 2.75 and 2.96 per 1000 population/year aged ≥18 years in 2005 and 2006, respectively (<xref ref-type="table" rid="THORAXJNL2013204282TB2">table 2</xref>). Overall CAP incidence and hospitalisation for CAP were higher in men than in women. The overall incidence per 1000 person-years in a UK study was 1.22 (1.18 to 1.26) in men compared with 0.93 (0.89 to 0.96) in women,<xref ref-type="bibr" rid="R42">42</xref> whereas a study in Denmark in men and women aged >50 years reported rates of hospitalisation for pneumonia per 1000 person-years of 4.2 in men and 3.4 in women.<xref ref-type="bibr" rid="R17">17</xref></p><p>The incidence of CAP increased with age and with the presence of comorbidities (see online supplementary table S2). Among individuals aged ≥65 years in Spain, the incidence per 1000 person-years was 14.0 (12.7 to 15.3).<xref ref-type="bibr" rid="R16">16</xref> A study of patients with COPD reported the highest overall incidence of 22.4 (21.7 to 23.2) per 1000 person-years, with rates of 23.1 (22.1 to 24.2) and 21.4 (20.4 to 22.5) in men and women, respectively.<xref ref-type="bibr" rid="R19">19</xref></p><p>High incidence rates were also reported in immunocompromised patients (<xref ref-type="table" rid="THORAXJNL2013204282TB2">table 2</xref>). Among patients with rheumatic diseases in Spain treated with tumour necrosis factor antagonists, the incidence per 1000 patient-years was 5.97 (4.87 to 7.25).<xref ref-type="bibr" rid="R40">40</xref> The incidence in patients with HIV in France, was 12.0 (9.9 to 14.0) per 1000 patient-years.<xref ref-type="bibr" rid="R24">24</xref> However, highly active antiretroviral therapy (HAART) appears to reduce the risk of CAP, with another French study reporting a reduction from 10.6 (5.4 to 15.7) per 1000 patient-years in the pre-HAART era to 2.5 (1.4 to 3.6) in the post-HAART era.<xref ref-type="bibr" rid="R29">29</xref></p></sec><sec id="s3c"><title>Lifestyle factors and risk of CAP</title><p>The potential association between lifestyle factors and the risk of CAP was investigated in 12 case-control studies, performed in France (n=1),<xref ref-type="bibr" rid="R30">30</xref> Germany (n=1),<xref ref-type="bibr" rid="R44">44</xref> The Netherlands (n=1),<xref ref-type="bibr" rid="R23">23</xref><xref ref-type="bibr" rid="R45">45</xref> Spain (n=2)<xref ref-type="bibr" rid="R12">12</xref><xref ref-type="bibr" rid="R38">38</xref> and the UK (n=7).<xref ref-type="bibr" rid="R19 R20 R21 R22">19–22</xref><xref ref-type="bibr" rid="R42">42</xref><xref ref-type="bibr" rid="R46">46</xref><xref ref-type="bibr" rid="R47">47</xref> Study details are summarised in online supplementary table S3.</p><p>There was consistent evidence that smoking was associated with an increased risk of CAP.<xref ref-type="bibr" rid="R19 R20 R21 R22 R23">19–23</xref><xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R42">42</xref><xref ref-type="bibr" rid="R46">46</xref><xref ref-type="bibr" rid="R47">47</xref> Compared with non-smokers (OR 1.00), the risk of CAP was increased in current smokers (crude ORs: 1.37 (1.14 to 1.64) to 1.81 (1.53 to 2.15); adjusted ORs: 0.99 (0.86 to 1.14) to 2.00 (1.20 to 3.36)) and former smokers (crude ORs: 1.34 (1.11 to 1.62) to 1.40 (1.17 to 1.68); adjusted OR: 1.04 (0.90 to 1.2)).</p><p>Compared with individuals who consumed no alcohol (OR 1.00), consumption of ≤40 g alcohol daily appeared to protect against CAP (21–40 g/day, crude ORs: 0.53 (0.22 to 1.25) and 0.88 (0.63 to 1.22)).<xref ref-type="bibr" rid="R23">23</xref><xref ref-type="bibr" rid="R38">38</xref> However, the risk increased in individuals with higher consumption (>41 g/day, crude OR: 1.59 (0.59 to 4.25)<xref ref-type="bibr" rid="R23">23</xref>; >80 g/day, crude OR: 2.34 (1.13 to 4.85)<xref ref-type="bibr" rid="R38">38</xref>) or with a history of alcohol abuse/alcoholism (crude ORs: 1.85 (1.19 to 2.88)<xref ref-type="bibr" rid="R21">21</xref> and 1.62 (0.91 to 2.91)<xref ref-type="bibr" rid="R47">47</xref>).</p><p>Being underweight was generally associated with an increased risk of CAP (crude ORs: 1.04 (0.57 to 1.89) to 2.20 (1.57 to 3.09)<xref ref-type="bibr" rid="R23">23</xref><xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R44">44</xref><xref ref-type="bibr" rid="R47">47</xref>) compared with normal bodyweight (OR 1.00). A reduced risk was seen in individuals classified as overweight (crude ORs: 0.6 (0.5 to 0.7) to 0.89 (0.72 to 1.09)<xref ref-type="bibr" rid="R21">21</xref><xref ref-type="bibr" rid="R23">23</xref><xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R44">44</xref><xref ref-type="bibr" rid="R47">47</xref>; adjusted ORs: 0.6 (0.5 to 0.7)<xref ref-type="bibr" rid="R44">44</xref> and 0.78 (0.67 to 0.90)<xref ref-type="bibr" rid="R19">19</xref>), whereas those classified as obese had either a lower risk (crude ORs: 0.66 (0.58 to 0.75) to 0.81 (0.66 to 0.99)<xref ref-type="bibr" rid="R21">21</xref><xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R44">44</xref><xref ref-type="bibr" rid="R47">47</xref>; adjusted ORs: 0.7 (0.5 to 0.9)<xref ref-type="bibr" rid="R44">44</xref> and 0.71 (0.60 to 0.85)<xref ref-type="bibr" rid="R19">19</xref>) or the same risk (crude OR 1.04 (0.57 to 1.89)<xref ref-type="bibr" rid="R23">23</xref>) as those of normal weight.</p><p>Household arrangements were also associated with the risk of CAP. Living in a household of over 10 people was associated with a crude OR of 2.20 (1.21 to 4.00).<xref ref-type="bibr" rid="R38">38</xref> Regular contacts with children also increased the risk of CAP (crude OR: 1.48 (1.26 to 1.75)<xref ref-type="bibr" rid="R38">38</xref>). Two studies found that having children in the household increased the adjusted OR from 1.00 for ‘no children’ to 3.2 (1.5 to 7.0)<xref ref-type="bibr" rid="R44">44</xref> or 3.41 (1.57 to 7.41)<xref ref-type="bibr" rid="R23">23</xref> for three or more children. There was no clear evidence regarding the influence of contact with pets; one study demonstrated an increased risk of CAP (crude OR 1.37 (1.18 to 1.60)<xref ref-type="bibr" rid="R38">38</xref>), whereas a study in young adults (aged 16–40 years) found a decreased risk (crude OR 0.85 (0.58 to 1.24)<xref ref-type="bibr" rid="R23">23</xref>).</p><p>Higher levels of education were associated with a lower risk of CAP.<xref ref-type="bibr" rid="R23">23</xref><xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R44">44</xref> Compared with individuals with a low level of education (OR 1.00), risk declined in those with an intermediate (secondary; crude ORs: 0.69 (0.41 to 1.19) to 0.86 (0.72 to 1.01)) or high level (university; crude ORs: 0.67 (0.41 to 1.10) to 0.78 (0.64 to 0.96)).<xref ref-type="bibr" rid="R23">23</xref><xref ref-type="bibr" rid="R38">38</xref> In another study, individuals with ≥12 years of education had a lower risk of CAP (adjusted OR 0.8 (0.6 to 1.1)) compared with those who had ≤9 years of education (OR 1.00).<xref ref-type="bibr" rid="R44">44</xref></p><p>Two studies found that visiting the dentist was associated with a decreased risk of CAP (in the past month, crude OR 0.71 (0.55 to 0.92)<xref ref-type="bibr" rid="R38">38</xref>; in the past year, OR 0.59 (0.34 to 1.04)<xref ref-type="bibr" rid="R23">23</xref>). In contrast, one study found that frequent visits to the general practitioner in the previous year were associated with a substantial increase in the risk of CAP (1–4 visits, OR 1.00; ≥30 visits, crude OR 3.73 (3.14 to 4.42)).<xref ref-type="bibr" rid="R21">21</xref></p></sec><sec id="s3d"><title>Comorbid conditions and risk of CAP</title><p>The association between comorbidities and the risk of CAP was investigated in 14 case-control studies (Denmark (n=1),<xref ref-type="bibr" rid="R48">48</xref> Germany (n=1),<xref ref-type="bibr" rid="R44">44</xref> The Netherlands (n=1),<xref ref-type="bibr" rid="R23">23</xref> Spain (n=2)<xref ref-type="bibr" rid="R12">12</xref><xref ref-type="bibr" rid="R38">38</xref> and the UK (n=9)<xref ref-type="bibr" rid="R14">14</xref><xref ref-type="bibr" rid="R19 R20 R21 R22">19–22</xref><xref ref-type="bibr" rid="R42">42</xref><xref ref-type="bibr" rid="R46">46</xref><xref ref-type="bibr" rid="R47">47</xref><xref ref-type="bibr" rid="R49">49</xref> (see online supplementary table S4).</p><p>A history of respiratory disease was associated with an increased risk of CAP. A history of pneumonia increased the risk of a subsequent episode (crude ORs: 2.39 to 6.25 (1.83 to 21.40)<xref ref-type="bibr" rid="R22">22</xref><xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R44">44</xref>). Patients with chronic respiratory diseases, including COPD, bronchitis or asthma, had a twofold to fourfold increase in the risk of CAP (crude ORs: 2.17 (1.99 to 2.37) to 3.92 (3.67 to 4.18)<xref ref-type="bibr" rid="R12">12</xref><xref ref-type="bibr" rid="R14">14</xref><xref ref-type="bibr" rid="R21 R22 R23">21–23</xref><xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R44">44</xref><xref ref-type="bibr" rid="R46">46</xref><xref ref-type="bibr" rid="R47">47</xref>). Additional data also support this association. One study reported an adjusted OR of 2.47 (2.37 to 2.58) for chronic respiratory disease,<xref ref-type="bibr" rid="R20">20</xref> and another study reported adjusted RRs of 2.82 (2.45 to 3.24) for COPD and 1.58 (1.44 to 1.74) for asthma.<xref ref-type="bibr" rid="R42">42</xref> Patients with at least one respiratory tract infection in the past year were also at increased risk of CAP (crude ORs: 1.57 (1.35 to 1.84)<xref ref-type="bibr" rid="R38">38</xref> to 4.5 (3.7 to 5.4)<xref ref-type="bibr" rid="R44">44</xref>). In young adults, the risk of CAP increased in line with the number of infections over the previous 6 years (1–2 infections, adjusted OR 1.49 (0.87 to 2.56); >3 infections, adjusted OR 4.84 (1.24 to 18.9)).<xref ref-type="bibr" rid="R23">23</xref></p><p>Chronic cardiovascular disease increased the risk of CAP up to threefold (crude ORs from 1.4 (1.2 to 1.5) to 3.2 (2.6 to 4.1)<xref ref-type="bibr" rid="R12">12</xref><xref ref-type="bibr" rid="R21">21</xref><xref ref-type="bibr" rid="R22">22</xref><xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R44">44</xref><xref ref-type="bibr" rid="R46">46</xref><xref ref-type="bibr" rid="R47">47</xref><xref ref-type="bibr" rid="R49">49</xref>). Additional studies supported an association between chronic heart disease (adjusted ORs: 1.63 (1.54 to 1.72)<xref ref-type="bibr" rid="R46">46</xref> and 1.66 (1.59 to 1.73)<xref ref-type="bibr" rid="R20">20</xref>) or heart failure (adjusted ORs: 2.19 (0.69 to 6.95)<xref ref-type="bibr" rid="R12">12</xref> and 1.37 (1.20 to 1.57)<xref ref-type="bibr" rid="R19">19</xref>; adjusted RR: 2.63 (2.21 to 3.14)<xref ref-type="bibr" rid="R42">42</xref>) and the risk of CAP.</p><p>Cerebrovascular disease/stroke and dementia approximately doubled the risk of CAP (for cerebrovascular disease/stroke, crude ORs: 1.86 (1.74 to 1.99) to 2.37 (2.19 to 2.57),<xref ref-type="bibr" rid="R14">14</xref><xref ref-type="bibr" rid="R21">21</xref><xref ref-type="bibr" rid="R46">46</xref><xref ref-type="bibr" rid="R49">49</xref> adjusted ORs: 1.08 (0.93 to 1.26)<xref ref-type="bibr" rid="R19">19</xref> and 1.68 (1.58 to 1.77),<xref ref-type="bibr" rid="R20">20</xref> adjusted RR: 1.42 (1.25 to 1.61)<xref ref-type="bibr" rid="R42">42</xref> for dementia, crude ORs: 2.12 (0.91 to 4.94) to 2.41 (2.11 to 2.75),<xref ref-type="bibr" rid="R14">14</xref><xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R46">46</xref> adjusted ORs: 2.64 (1.86 to 3.75)<xref ref-type="bibr" rid="R19">19</xref> and 2.68 (2.42 to 2.97)<xref ref-type="bibr" rid="R20">20</xref>). Other neurological or psychiatric conditions were also associated with an increased risk of CAP in some studies (epilepsy, crude ORs: 2.81 (1.83 to 4.30) and 2.83 (1.11 to 7.21)<xref ref-type="bibr" rid="R21">21</xref><xref ref-type="bibr" rid="R38">38</xref>; Parkinson's disease, crude ORs: 1.82 (1.52 to 2.19) and 1.87 (1.60 to 2.19)<xref ref-type="bibr" rid="R14">14</xref><xref ref-type="bibr" rid="R46">46</xref>; multiple sclerosis, crude OR 3.20 (2.40 to 4.26)<xref ref-type="bibr" rid="R46">46</xref>). Crude ORs for CAP in patients with depression or bipolar disorder ranged from 1.75 (1.65 to 1.86) to 2.54 (1.03 to 6.26).<xref ref-type="bibr" rid="R14">14</xref><xref ref-type="bibr" rid="R21">21</xref><xref ref-type="bibr" rid="R23">23</xref> However, the association with depression may have been confounded by other factors, as other studies reported an adjusted OR of 1.13 (0.99 to 1.28)<xref ref-type="bibr" rid="R19">19</xref> or an adjusted RR of 1.30 (1.19 to 1.40).<xref ref-type="bibr" rid="R42">42</xref></p><p>Two studies in elderly patients found a strong association between dysphagia and risk of CAP. A large database study in patients aged ≥65 years reported a crude OR of 2.10 (1.85 to 2.38),<xref ref-type="bibr" rid="R14">14</xref> whereas a small study in patients aged ≥70 years reported a crude OR of 16.3 (4.57 to 58.2) and an adjusted OR of 11.9 (3.03 to 46.9).<xref ref-type="bibr" rid="R12">12</xref></p><p>Data from several studies suggested that diabetes mellitus was associated with a moderate increase in the risk of CAP (crude ORs: 1.43 (1.11 to 1.92) to 1.54 (1.44 to 1.65),<xref ref-type="bibr" rid="R21">21</xref><xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R46">46</xref> adjusted ORs: 1.07 (0.89 to 1.28)<xref ref-type="bibr" rid="R19">19</xref> and 1.33 (1.26 to 1.41),<xref ref-type="bibr" rid="R20">20</xref> adjusted RRs: 1.26 (1.21 to 1.31)<xref ref-type="bibr" rid="R48">48</xref> and 1.28 (1.13 to 1.44)<xref ref-type="bibr" rid="R42">42</xref>).</p><p>Cancer was also associated with a moderate increase in the risk of CAP (crude ORs: 1.42 (1.04 to 1.92)<xref ref-type="bibr" rid="R38">38</xref> and 1.70 (1.58 to 1.82),<xref ref-type="bibr" rid="R46">46</xref> adjusted ORs: 1.42 (1.3 to 1.56)<xref ref-type="bibr" rid="R46">46</xref> and 1.36 (1.24 to 1.49),<xref ref-type="bibr" rid="R20">20</xref> adjusted RR: 1.37 (1.22 to 1.54)<xref ref-type="bibr" rid="R42">42</xref>). One study reported a fivefold higher risk in patients with lung cancer (crude OR: 4.73 (3.58 to 6.25)).<xref ref-type="bibr" rid="R46">46</xref></p><p>Chronic liver or renal disease increased the risk of CAP approximately twofold (chronic liver disease, crude ORs: 1.67 (0.99 to 2.82) to 2.24 (1.74 to 2.89),<xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R44">44</xref><xref ref-type="bibr" rid="R46">46</xref> adjusted ORs: 1.87 (1.43 to 2.44)<xref ref-type="bibr" rid="R46">46</xref> and 1.85 (1.48 to 2.31)<xref ref-type="bibr" rid="R20">20</xref>; chronic renal disease, crude ORs: 1.7 (1.1 to 2.8)<xref ref-type="bibr" rid="R44">44</xref> and 2.15 (1.81 to 2.56),<xref ref-type="bibr" rid="R46">46</xref> adjusted ORs: 1.72 (1.43 to 2.07)<xref ref-type="bibr" rid="R46">46</xref> and 1.78 (1.53 to 2.07)<xref ref-type="bibr" rid="R20">20</xref>).</p><p>Associations between conditions affecting immune function and the risk of CAP were reported. There was a moderate increase in risk in patients with rheumatoid arthritis (crude ORs: 1.46 (1.14 to 1.88)<xref ref-type="bibr" rid="R21">21</xref> and 2.02 (1.79 to 2.29),<xref ref-type="bibr" rid="R46">46</xref> adjusted ORs: 1.84 (1.62 to 2.10)<xref ref-type="bibr" rid="R46">46</xref> and 1.83 (1.64 to 2.03),<xref ref-type="bibr" rid="R20">20</xref> adjusted RR: 1.37 (1.12 to 1.69)<xref ref-type="bibr" rid="R42">42</xref>). Additionally, there was over a twofold increase in risk in patients with asplenia (adjusted OR: 2.58 (1.80 to 3.71)<xref ref-type="bibr" rid="R46">46</xref>) or with HIV or AIDS (adjusted ORs: 2.48 (1.34 to 4.58)<xref ref-type="bibr" rid="R46">46</xref> and 5.90 (2.55 to 13.64)<xref ref-type="bibr" rid="R20">20</xref>).</p><p>In addition to the above medical conditions, a moderate increase in risk of CAP was reported in patients with anaemia (adjusted RR: 1.43 (1.25 to 1.62)).<xref ref-type="bibr" rid="R42">42</xref></p><p>Hospitalisation in the previous 5 years was associated with an increased risk of CAP (crude ORs: 1.6 (1.4 to 1.9)<xref ref-type="bibr" rid="R44">44</xref> and 1.68 (1.44 to 1.96)<xref ref-type="bibr" rid="R38">38</xref>). An adjusted RR of 1.77 (1.59 to 1.97) was calculated in patients with more than one hospitalisation in the previous year.<xref ref-type="bibr" rid="R42">42</xref> The risk of CAP was increased in patients who had undergone either bronchoscopy (crude OR: 2.09 (1.07 to 4.06)) or passage of a nasogastric tube (crude OR: 3.21 (1.17 to 8.77)) during the previous year.<xref ref-type="bibr" rid="R38">38</xref></p></sec><sec id="s3e"><title>Comorbid conditions in patients with CAP</title><p>The frequency of comorbidities in patients diagnosed with CAP was presented in 39 studies (7 case-control studies of observational data,<xref ref-type="bibr" rid="R15">15</xref><xref ref-type="bibr" rid="R19">19</xref><xref ref-type="bibr" rid="R45">45</xref><xref ref-type="bibr" rid="R50 R51 R52 R53">50–53</xref> and 31 observational, cohort studies<xref ref-type="bibr" rid="R10">10</xref><xref ref-type="bibr" rid="R13">13</xref><xref ref-type="bibr" rid="R16">16</xref><xref ref-type="bibr" rid="R27">27</xref><xref ref-type="bibr" rid="R28">28</xref><xref ref-type="bibr" rid="R31 R32 R33 R34 R35 R36 R37">31–37</xref><xref ref-type="bibr" rid="R41">41</xref><xref ref-type="bibr" rid="R43">43</xref><xref ref-type="bibr" rid="R54 R55 R56 R57 R58 R59 R60 R61 R62 R63 R64 R65 R66 R67 R68 R69 R70">54–70</xref>). Study details are summarised in online supplementary table S5.</p><p>The most common comorbidities were chronic respiratory diseases (up to 68% of patients), chronic heart disease (up to 47%) or heart failure (up to 46%), diabetes mellitus, cerebrovascular diseases and dementia (all up to 33%; <xref ref-type="table" rid="THORAXJNL2013204282TB3">table 3</xref>). Chronic liver and chronic renal diseases were observed in up to 20% and 27% of patients, respectively. The frequency of comorbidities was generally higher in patients aged ≥65 years compared with those aged <65 years, and in patients with COPD, chronic renal failure or cirrhosis compared with those without such conditions (see online supplementary table S5).</p><table-wrap id="THORAXJNL2013204282TB3" position="float"><label>Table 3</label><caption><p>Frequency of comorbid conditions in adults with community-acquired pneumonia</p></caption><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="char" char="." span="1"></col><col align="char" char="ndash" span="1"></col></colgroup><thead valign="bottom"><tr><th align="left" rowspan="1" colspan="1">Comorbid condition</th><th align="left" rowspan="1" colspan="1">Number of cohorts with data*</th><th align="left" rowspan="1" colspan="1">Patients with condition (%)</th></tr></thead><tbody><tr><td rowspan="1" colspan="1">Previous pneumonia</td><td rowspan="1" colspan="1">10</td><td rowspan="1" colspan="1">3.2–33.8</td></tr><tr><td rowspan="1" colspan="1">Chronic respiratory disease</td><td rowspan="1" colspan="1">25</td><td rowspan="1" colspan="1">9.7–68</td></tr><tr><td rowspan="1" colspan="1"> COPD</td><td rowspan="1" colspan="1">21</td><td rowspan="1" colspan="1">9.4–62</td></tr><tr><td rowspan="1" colspan="1"> Asthma</td><td rowspan="1" colspan="1">9</td><td rowspan="1" colspan="1">3–50.0</td></tr><tr><td rowspan="1" colspan="1">Chronic heart disease</td><td rowspan="1" colspan="1">23</td><td rowspan="1" colspan="1">10–47.2</td></tr><tr><td rowspan="1" colspan="1"> Heart failure</td><td rowspan="1" colspan="1">27</td><td rowspan="1" colspan="1">1.0–46</td></tr><tr><td rowspan="1" colspan="1">Diabetes mellitus</td><td rowspan="1" colspan="1">48</td><td rowspan="1" colspan="1">4.9–33.0</td></tr><tr><td rowspan="1" colspan="1">Cerebrovascular disease/stroke</td><td rowspan="1" colspan="1">26</td><td rowspan="1" colspan="1">3.2–33</td></tr><tr><td rowspan="1" colspan="1">Dementia</td><td rowspan="1" colspan="1">12</td><td rowspan="1" colspan="1">1.1–33.6</td></tr><tr><td rowspan="1" colspan="1">Cancer</td><td rowspan="1" colspan="1">33</td><td rowspan="1" colspan="1">4.3–18.0</td></tr><tr><td rowspan="1" colspan="1">Chronic liver disease</td><td rowspan="1" colspan="1">36</td><td rowspan="1" colspan="1">0.3–20</td></tr><tr><td rowspan="1" colspan="1">Chronic renal disease</td><td rowspan="1" colspan="1">39</td><td rowspan="1" colspan="1">0.5–26.7</td></tr></tbody></table><table-wrap-foot><fn><p>*For studies that only reported data separately for each cohort, all cohorts were included; for studies that reported data for the overall study population, the summary data were used.</p></fn><fn><p>COPD, chronic obstructive pulmonary disease.</p></fn></table-wrap-foot></table-wrap></sec></sec><sec sec-type="discussion" id="s4"><title>Discussion</title><p>This review represents a comprehensive compilation of data about the incidence of and risk factors for CAP in adults in Western Europe.</p><p>Notwithstanding the heterogeneity of the populations studied and measures of incidence rates used, overall the annual incidence was 1.07–1.7 per 1000 population. Studies consistently showed that the incidence was higher in men than in women, and that it increased with age; in patients aged ≥65 years, an incidence rate of 14 cases per 1000 person-years was reported.<xref ref-type="bibr" rid="R16">16</xref> These findings are consistent with those of a recent review of European incidence rates published between 1990 and 2007.<xref ref-type="bibr" rid="R1">1</xref> Also in line with previous studies of CAP epidemiology, incidence rates were higher in patients with comorbidities such as COPD,<xref ref-type="bibr" rid="R8">8</xref> and in patients with HIV compared with those without HIV.<xref ref-type="bibr" rid="R71">71</xref> Possible explanations for the higher rates of hospitalisation for CAP compared with overall incidence rates include the inclusion of data from different countries (Italy,<xref ref-type="bibr" rid="R37">37</xref> Spain<xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R43">43</xref> and the UK<xref ref-type="bibr" rid="R42">42</xref> for overall incidence rates; Denmark,<xref ref-type="bibr" rid="R17">17</xref><xref ref-type="bibr" rid="R18">18</xref> Germany<xref ref-type="bibr" rid="R36">36</xref> and the UK<xref ref-type="bibr" rid="R41">41</xref> for hospitalisation) reflecting national differences in medical practice, and that Danish studies were performed in patients aged >50 years,<xref ref-type="bibr" rid="R17">17</xref><xref ref-type="bibr" rid="R18">18</xref> and so represent a population at increased risk of CAP.<xref ref-type="bibr" rid="R1">1</xref><xref ref-type="bibr" rid="R2">2</xref></p><p>Importantly, this review included data obtained from observational and case-control studies. While observational studies provide valuable data on the rates of comorbidities observed in patients with CAP, they do not permit their identification as risk factors for infection. However, case-control studies of patients allow us to establish which comorbidities are indeed risk factors for CAP.</p><p>Pooled data from observational studies demonstrated the overall burden of CAP in patients with other medical conditions.<xref ref-type="bibr" rid="R10">10</xref><xref ref-type="bibr" rid="R13">13</xref><xref ref-type="bibr" rid="R16">16</xref><xref ref-type="bibr" rid="R27">27</xref><xref ref-type="bibr" rid="R28">28</xref><xref ref-type="bibr" rid="R31 R32 R33 R34 R35 R36 R37">31–37</xref><xref ref-type="bibr" rid="R41">41</xref><xref ref-type="bibr" rid="R43">43</xref><xref ref-type="bibr" rid="R54 R55 R56 R57 R58 R59 R60 R61 R62 R63 R64 R65 R66 R67 R68 R69 R70">54–70</xref> Chronic respiratory diseases, cardiovascular diseases, cerebrovascular diseases, dementia and diabetes mellitus were the most frequently observed comorbidities. Up to two-thirds of patients had a chronic respiratory disease and almost half had a chronic cardiovascular disease, highlighting the need for appropriate management of these patients to reduce their risk of CAP.</p><p>Lifestyle factors such as smoking, high alcohol intake, being underweight, living in a large household or having regular contact with children were associated with an increased risk of CAP.<xref ref-type="bibr" rid="R12">12</xref><xref ref-type="bibr" rid="R19 R20 R21 R22 R23">19–23</xref><xref ref-type="bibr" rid="R30">30</xref><xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R42">42</xref><xref ref-type="bibr" rid="R44">44</xref><xref ref-type="bibr" rid="R46">46</xref><xref ref-type="bibr" rid="R47">47</xref> Smoking is an established risk factor for CAP,<xref ref-type="bibr" rid="R6">6</xref><xref ref-type="bibr" rid="R72">72</xref> probably due to its adverse effects on the respiratory epithelium and the clearance of bacteria from the respiratory tract.<xref ref-type="bibr" rid="R73">73</xref> Alcoholism has been associated with defects in innate and adaptive immunity,<xref ref-type="bibr" rid="R74">74</xref> and is a recognised CAP risk factor.<xref ref-type="bibr" rid="R7">7</xref> Smoking and excessive alcohol consumption are major health risks globally and are targets for interventions to reduce the global burden of disease.<xref ref-type="bibr" rid="R75">75</xref> Ensuring that patients make appropriate lifestyle changes would help to reduce the overall burden of CAP. Being underweight may predispose patients to CAP due to the consequences of undernutrition or underlying conditions on immune function.<xref ref-type="bibr" rid="R6">6</xref><xref ref-type="bibr" rid="R44">44</xref><xref ref-type="bibr" rid="R72">72</xref><xref ref-type="bibr" rid="R76">76</xref> Assessment of the nutritional status of vulnerable patients might help to identify those at increased risk of CAP. Regular contact with children has also been identified previously as a risk factor for CAP, possibly due to the high carriage of <italic>Streptococcus pneumoniae</italic> by children.<xref ref-type="bibr" rid="R44">44</xref><xref ref-type="bibr" rid="R77">77</xref> Appropriate measures for infection control may be advisable in vulnerable patients who are in regular contact with children.</p><p>Some lifestyle factors may provide protection against CAP. Young adults who consumed <40 g of alcohol per day had a lower risk of CAP than those who drank no alcohol,<xref ref-type="bibr" rid="R23">23</xref> potentially because individuals who consumed no alcohol had other comorbidities that increased the risk of CAP. However, light-to-moderate alcohol intake has been reported to reduce the risk of atherosclerosis and cardiovascular disease,<xref ref-type="bibr" rid="R78">78</xref><xref ref-type="bibr" rid="R79">79</xref> due to the antioxidant activities of alcohol,<xref ref-type="bibr" rid="R78">78</xref> and this may also protect against CAP. Adherence to good dental hygiene was also associated with a reduced risk of CAP. Poor oral care has previously been identified as a risk factor for nursing-home acquired pneumonia, possibly due to the colonisation of the oral cavity by respiratory pathogens,<xref ref-type="bibr" rid="R80">80</xref> and this risk may also be relevant for CAP. Finally, a higher level of education appeared to reduce the risk of CAP compared with a low level of education, as reported previously for invasive pneumococcal disease.<xref ref-type="bibr" rid="R81">81</xref> A similar protective association of higher educational levels has also been described in relation to cardiovascular risk factors.<xref ref-type="bibr" rid="R82">82</xref> Measures to reduce social and health inequalities could have the benefit of reducing costs associated with diseases like CAP.</p><p>The review also provides robust evidence that several comorbidities are associated with an increased risk of CAP, including a history of respiratory disease (including pneumonia) and cardiovascular disease. Patients with COPD are recognised as having a high risk of CAP<xref ref-type="bibr" rid="R8">8</xref> and are targets for vaccination against influenza and pneumococcal disease,<xref ref-type="bibr" rid="R83">83</xref><xref ref-type="bibr" rid="R84">84</xref> as are patients with chronic cardiovascular diseases.<xref ref-type="bibr" rid="R84 R85 R86">84–86</xref></p><p>Patients with cerebrovascular disease or stroke, and neurological disorders (dementia, epilepsy, Parkinson's disease and multiple sclerosis) had approximately twice the risk of CAP compared with individuals without these conditions; dysphagia was also associated with a substantial increase in risk. The use of sedative medications and problems with swallowing might contribute to the risk of CAP in patients with dementia,<xref ref-type="bibr" rid="R19">19</xref><xref ref-type="bibr" rid="R43">43</xref> probably due to aspiration and its associated risk of pneumonia.<xref ref-type="bibr" rid="R87">87</xref> This could apply to patients with other neurological disorders.</p><p>Other comorbid conditions associated with an increased risk of CAP in the present study, including diabetes mellitus, cancer, chronic liver or renal disease, and impaired immune function, have previously been identified as risk factors for CAP.<xref ref-type="bibr" rid="R9">9</xref></p><p>The main strength of this review is that many of the included publications were of case-control studies performed in large numbers of patients from registries or primary care databases, rather than small, single-centre studies, providing reassurance that the included studies provide a good representation of CAP in European populations.</p><p>This review also has some limitations. Patient registries and primary care databases are dependent on the quality of the information included in the records, and rely on the accuracy of the individuals responsible for entering diagnostic codes and demographic data. However, the inclusion of several thousand patients in such studies should help to minimise any potential introduced bias. Most of the included studies were based on patient populations in either Spain (23 studies<xref ref-type="bibr" rid="R10">10</xref><xref ref-type="bibr" rid="R12">12</xref><xref ref-type="bibr" rid="R13">13</xref><xref ref-type="bibr" rid="R16">16</xref><xref ref-type="bibr" rid="R25">25</xref><xref ref-type="bibr" rid="R32">32</xref><xref ref-type="bibr" rid="R33">33</xref><xref ref-type="bibr" rid="R35">35</xref><xref ref-type="bibr" rid="R38 R39 R40">38–40</xref><xref ref-type="bibr" rid="R43">43</xref><xref ref-type="bibr" rid="R50">50</xref><xref ref-type="bibr" rid="R54 R55 R56 R57 R58 R59">54–59</xref><xref ref-type="bibr" rid="R63">63</xref><xref ref-type="bibr" rid="R65">65</xref><xref ref-type="bibr" rid="R68">68</xref><xref ref-type="bibr" rid="R69">69</xref>) or the UK (12 studies<xref ref-type="bibr" rid="R14">14</xref><xref ref-type="bibr" rid="R19 R20 R21 R22">19–22</xref><xref ref-type="bibr" rid="R41">41</xref><xref ref-type="bibr" rid="R42">42</xref><xref ref-type="bibr" rid="R46">46</xref><xref ref-type="bibr" rid="R47">47</xref><xref ref-type="bibr" rid="R49">49</xref><xref ref-type="bibr" rid="R53">53</xref><xref ref-type="bibr" rid="R66">66</xref>), and this could limit the validity of the review for extrapolating the data to other European populations. Only those studies that were indexed in the PubMed database were included, and data from, for example, national surveillance databases were not included. Nevertheless, we believe it provides a good representation of the incidence and risk factors for CAP in European countries.</p><p>Lifestyle interventions, such as stopping smoking, reducing alcohol consumption, having regular dental checks and maintaining good nutritional status could help to reduce the burden of CAP. Patients with conditions such as chronic respiratory, cardiovascular and neurological diseases should be managed in accordance with current clinical guidelines to optimise their overall health status, and elderly patients should try to minimise contact with children who have acute viral respiratory infections. Finally, adults at risk of CAP should be vaccinated against influenza and pneumococcal pneumonia to reduce the risk of lower respiratory tract infections, in accordance with current guidelines (<xref ref-type="table" rid="THORAXJNL2013204282TB4">table 4</xref>).<xref ref-type="bibr" rid="R88">88</xref><xref ref-type="bibr" rid="R89">89</xref></p><table-wrap id="THORAXJNL2013204282TB4" position="float"><label>Table 4</label><caption><p>Bundles for lifestyle interventions to reduce the risk of CAP in adults</p></caption><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="left" span="1"></col><col align="left" span="1"></col></colgroup><thead valign="bottom"><tr><th align="left" rowspan="1" colspan="1">Risk factor</th><th align="left" rowspan="1" colspan="1">Evidence</th><th align="left" rowspan="1" colspan="1">Recommendation</th></tr></thead><tbody><tr><td rowspan="1" colspan="1">Smoking</td><td rowspan="1" colspan="1">Risk of CAP increased in current and former smokers (9 studies)<xref ref-type="bibr" rid="R19 R20 R21 R22 R23">19–23</xref><xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R42">42</xref><xref ref-type="bibr" rid="R46">46</xref><xref ref-type="bibr" rid="R47">47</xref></td><td rowspan="1" colspan="1">Smoking cessation</td></tr><tr><td rowspan="1" colspan="1">Alcohol consumption</td><td rowspan="1" colspan="1">Risk of CAP increased with high consumption or history of alcohol abuse (4 studies)<xref ref-type="bibr" rid="R21">21</xref><xref ref-type="bibr" rid="R23">23</xref><xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R47">47</xref></td><td rowspan="1" colspan="1">Reduce alcohol consumption</td></tr><tr><td rowspan="1" colspan="1">Nutritional status</td><td rowspan="1" colspan="1">Being underweight was generally associated with an increased risk of CAP (4 studies)<xref ref-type="bibr" rid="R23">23</xref><xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R44">44</xref><xref ref-type="bibr" rid="R47">47</xref></td><td rowspan="1" colspan="1">Dietary advice to ensure good nutritional status</td></tr><tr><td rowspan="1" colspan="1">Contact with children</td><td rowspan="1" colspan="1">Regular contact with children increased the risk of CAP (3 studies)<xref ref-type="bibr" rid="R23">23</xref><xref ref-type="bibr" rid="R38">38</xref><xref ref-type="bibr" rid="R44">44</xref></td><td rowspan="1" colspan="1">Avoid contacts with children with lower respiratory tract infections</td></tr><tr><td rowspan="1" colspan="1">Dental hygiene</td><td rowspan="1" colspan="1">Risk of CAP decreased in individuals with a recent (within past year) dental visit (2 studies)<xref ref-type="bibr" rid="R23">23</xref><xref ref-type="bibr" rid="R38">38</xref></td><td rowspan="1" colspan="1">Ensure regular dental visits</td></tr><tr><td rowspan="1" colspan="1">Vaccination against influenza and <italic>Streptococcus pneumoniae</italic></td><td rowspan="1" colspan="1">Current guidelines<xref ref-type="bibr" rid="R88">88</xref><xref ref-type="bibr" rid="R89">89</xref></td><td rowspan="1" colspan="1">Ensure compliance with guidelines</td></tr></tbody></table><table-wrap-foot><fn><p>CAP, community-acquired pneumonia.</p></fn></table-wrap-foot></table-wrap><p>All but six of the studies included patients with pneumonia of any aetiology. <italic>S pneumoniae</italic> is the most frequently isolated pathogen from patients with CAP in Europe,<xref ref-type="bibr" rid="R1">1</xref> and has been estimated to be the cause of 30–50% cases of CAP requiring hospitalisation in adults in developed countries.<xref ref-type="bibr" rid="R90">90</xref> A 23-valent pneumococcal polysaccharide vaccine is recommended in some countries for the routine vaccination of adults aged ≥65 years, and for patients at increased risk of CAP.<xref ref-type="bibr" rid="R85">85</xref><xref ref-type="bibr" rid="R86">86</xref> However, there is little evidence that it is effective in elderly people or adults with chronic diseases.<xref ref-type="bibr" rid="R91">91</xref><xref ref-type="bibr" rid="R92">92</xref> A 13-valent pneumococcal conjugate vaccine (PCV-13) is available for the prevention of pneumonia and invasive pneumococcal disease caused by PCV-13 serotypes in adults aged ≥18 years.<xref ref-type="bibr" rid="R93">93</xref> Efficacy of PCV-13 for the prevention of a first episode of vaccine serotype-specific pneumococcal CAP in community-dwelling adults aged ≥65 years is being investigated in the ongoing Community Acquired Pneumonia Immunisation Trial in Adults.<xref ref-type="bibr" rid="R94">94</xref></p><p>In conclusion, this review of risk factors for CAP in European adults has highlighted the range of lifestyle factors and underlying medical conditions that are associated with an increased risk of infection. Lifestyle factors included smoking, alcohol abuse, being underweight and regular contact with children, whereas patients with chronic respiratory or cardiovascular diseases, cerebrovascular disease, epilepsy, dementia, dysphagia, HIV, or chronic renal or liver disease were all at increased risk of CAP. Greater understanding of the types of individuals at risk of CAP can help to ensure that interventions to reduce the risk of infection and burden of disease are targeted appropriately.</p></sec><sec sec-type="supplementary-material"><title>Supplementary Material</title><supplementary-material content-type="loca-data" id="SD1"><caption><title>Web tables</title></caption><media mimetype="application" mime-subtype="pdf" xlink:href="thoraxjnl-2013-204282-s1.pdf" xlink:type="simple" id="d35e2106" position="anchor"></media></supplementary-material></sec></body><back><ack><p>The authors take full responsibility for the content of this article and thank Neostar Communications Limited, Oxford, UK (supported by Pfizer, France), for their assistance in preparing the manuscript, including preparing the first draft in close collaboration with the authors and the collation of author comments.</p></ack><fn-group><fn><p><bold>Contributors:</bold> AT, WEP, GV and FB approved the literature search, commented on drafts of the manuscript and approved the final draft. AT is guarantor. Nathalie Dartois (Pfizer Ltd, Paris, France) discussed the manuscript concept with AT and reviewed drafts of the manuscript. Neostar Communications collaborated closely with the authors throughout the development of the manuscript and were responsible for performing the literature search, preparing the first draft of the article and providing author comments.</p></fn><fn><p><bold>Funding:</bold> Pfizer supported Neostar Communications for preparation of the manuscript in close collaboration with the authors.</p></fn><fn><p><bold>Competing interests:</bold> AT has received consulting fees/honorarium from Astra-Zeneca, Bayer, Curetis, GlaxoSmithKline, Pfizer and Polyphor. WEP has received consulting fees/honorarium from Pfizer; fees for board membership from Astellas, AstraZeneca, Bayer, GlaxoSmithKline Biologicals, Merck-Shering and Pfizer; and his institution has received research grants for investigator-initiated research from AstraZeneca, Bayer, Pfizer and Sanofi-Aventis. GV's institution has received consulting fees/honorarium from Pfizer. FB has received financial support for travel to meetings from Pfizer; consultancy fees from AstraZeneca, Pfizer and Zambon; fees for board membership from AstraZeneca, Chiesi, GlaxoSmithKline, Novartis and Pfizer; lecture fees/speaker bureaus fees from AstraZeneca, Chiesi, Novartis, Pfizer and Zambon; and his institution has received grants from Chiesi, Novartis, Pfizer and Zambon.</p></fn><fn><p><bold>Provenance and peer review:</bold> Not commissioned; internally peer reviewed.</p></fn></fn-group><ref-list><title>References</title><ref id="R1"><label>1</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Welte</surname><given-names>T</given-names></name><name><surname>Torres</surname><given-names>A</given-names></name><name><surname>Nathwani</surname><given-names>D</given-names></name></person-group><article-title>Clinical and economic burden of community-acquired pneumonia among adults in Europe</article-title>. <source>Thorax</source><year>2012</year>;<volume>67</volume>:<fpage>71</fpage>–<lpage>9</lpage><pub-id pub-id-type="pmid">20729232</pub-id></mixed-citation></ref><ref id="R2"><label>2</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Blasi</surname><given-names>F</given-names></name><name><surname>Mantero</surname><given-names>M</given-names></name><name><surname>Santus</surname><given-names>P</given-names></name><etal></etal></person-group><article-title>Understanding the burden of pneumococcal disease in adults</article-title>. <source>Clin Microbiol Infect</source><year>2012</year>;<volume>18</volume>:<fpage>1</fpage>–<lpage>8</lpage></mixed-citation></ref><ref id="R3"><label>3</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Lozano</surname><given-names>R</given-names></name><name><surname>Naghavi</surname><given-names>M</given-names></name><name><surname>Foreman</surname><given-names>K</given-names></name><etal></etal></person-group><article-title>Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010</article-title>. <source>Lancet</source><year>2012</year>;<volume>380</volume>:<fpage>2095</fpage>–<lpage>128</lpage><pub-id pub-id-type="pmid">23245604</pub-id></mixed-citation></ref><ref id="R4"><label>4</label><mixed-citation publication-type="book"><collab>European Commission</collab><source>Health statistics. Atlas on mortality in the European Union</source>. <publisher-loc>Luxembourg</publisher-loc>: <publisher-name>Office for Official Publications of the European Communities</publisher-name>, <year>2008</year></mixed-citation></ref><ref id="R5"><label>5</label><mixed-citation publication-type="book"><source>Pneumonia</source>. <comment>In: <italic>European lung white book</italic></comment><edition>2nd edn.</edition><publisher-loc>Sheffield, UK</publisher-loc>: <publisher-name>European Respiratory Society/European Lung Foundation</publisher-name>, <year>2003</year>:<fpage>55</fpage>–<lpage>65</lpage></mixed-citation></ref><ref id="R6"><label>6</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Baik</surname><given-names>I</given-names></name><name><surname>Curhan</surname><given-names>GC</given-names></name><name><surname>Rimm</surname><given-names>EB</given-names></name><etal></etal></person-group><article-title>A prospective study of age and lifestyle factors in relation to community-acquired pneumonia in US men and women</article-title>. <source>Arch Intern Med</source><year>2000</year>;<volume>160</volume>:<fpage>3082</fpage>–<lpage>8</lpage><pub-id pub-id-type="pmid">11074737</pub-id></mixed-citation></ref><ref id="R7"><label>7</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Koivalu</surname><given-names>I</given-names></name><name><surname>Sten</surname><given-names>M</given-names></name><name><surname>Makela</surname><given-names>PH</given-names></name></person-group><article-title>Risk factors for pneumonia in the elderly</article-title>. <source>Am J Med</source><year>1994</year>;<volume>96</volume>:<fpage>313</fpage>–<lpage>20</lpage><pub-id pub-id-type="pmid">8166149</pub-id></mixed-citation></ref><ref id="R8"><label>8</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Mannino</surname><given-names>DM</given-names></name><name><surname>Davis</surname><given-names>KJ</given-names></name><name><surname>Kiri</surname><given-names>VA</given-names></name></person-group><article-title>Chronic obstructive pulmonary disease and hospitalizations for pneumonia in a US cohort</article-title>. <source>Respir Med</source><year>2009</year>;<volume>103</volume>:<fpage>224</fpage>–<lpage>9</lpage><pub-id pub-id-type="pmid">18945605</pub-id></mixed-citation></ref><ref id="R9"><label>9</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Polverino</surname><given-names>E</given-names></name><name><surname>Torres Marti</surname><given-names>A</given-names></name></person-group><article-title>Community-acquired pneumonia</article-title>. <source>Minerva Anestesiol</source><year>2011</year>;<volume>77</volume>:<fpage>196</fpage>–<lpage>211</lpage><pub-id pub-id-type="pmid">21242952</pub-id></mixed-citation></ref><ref id="R10"><label>10</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>de Roux</surname><given-names>A</given-names></name><name><surname>Cavalcanti</surname><given-names>M</given-names></name><name><surname>Marcos</surname><given-names>MA</given-names></name><etal></etal></person-group><article-title>Impact of alcohol abuse in the etiology and severity of community-acquired pneumonia</article-title>. <source>Chest</source><year>2006</year>;<volume>129</volume>:<fpage>1219</fpage>–<lpage>25</lpage><pub-id pub-id-type="pmid">16685012</pub-id></mixed-citation></ref><ref id="R11"><label>11</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Jover</surname><given-names>F</given-names></name><name><surname>Cuadrado</surname><given-names>JM</given-names></name><name><surname>Andreu</surname><given-names>L</given-names></name><etal></etal></person-group><article-title>A comparative study of bacteremic and non-bacteremic pneumococcal pneumonia</article-title>. <source>Eur J Intern Med</source><year>2008</year>;<volume>19</volume>:<fpage>15</fpage>–<lpage>21</lpage><pub-id pub-id-type="pmid">18206596</pub-id></mixed-citation></ref><ref id="R12"><label>12</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Almirall</surname><given-names>J</given-names></name><name><surname>Rofes</surname><given-names>L</given-names></name><name><surname>Serra-Prat</surname><given-names>M</given-names></name><etal></etal></person-group><article-title>Oropharyngeal dysphagia is a risk factor for community-acquired pneumonia in the elderly</article-title>. <source>Eur Respir J</source><year>2013</year>;<volume>41</volume>:<fpage>923</fpage>–<lpage>8</lpage><pub-id pub-id-type="pmid">22835620</pub-id></mixed-citation></ref><ref id="R13"><label>13</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Cabre</surname><given-names>M</given-names></name><name><surname>Serra-Prat</surname><given-names>M</given-names></name><name><surname>Palomera</surname><given-names>E</given-names></name><etal></etal></person-group><article-title>Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia</article-title>. <source>Age Ageing</source><year>2010</year>;<volume>39</volume>:<fpage>39</fpage>–<lpage>45</lpage><pub-id pub-id-type="pmid">19561160</pub-id></mixed-citation></ref><ref id="R14"><label>14</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Hennessy</surname><given-names>S</given-names></name><name><surname>Bilker</surname><given-names>WB</given-names></name><name><surname>Leonard</surname><given-names>CE</given-names></name><etal></etal></person-group><article-title>Observed association between antidepressant use and pneumonia risk was confounded by comorbidity measures</article-title>. <source>J Clin Epidemiol</source><year>2007</year>;<volume>60</volume>:<fpage>911</fpage>–<lpage>18</lpage><pub-id pub-id-type="pmid">17689807</pub-id></mixed-citation></ref><ref id="R15"><label>15</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Trifiro</surname><given-names>G</given-names></name><name><surname>Gambassi</surname><given-names>G</given-names></name><name><surname>Sen</surname><given-names>EF</given-names></name><etal></etal></person-group><article-title>Association of community-acquired pneumonia with antipsychotic drug use in elderly patients: a nested case-control study</article-title>. <source>Ann Intern Med</source><year>2010</year>;<volume>152</volume>:<fpage>418</fpage>–<lpage>40</lpage><pub-id pub-id-type="pmid">20368647</pub-id></mixed-citation></ref><ref id="R16"><label>16</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Vila-Corcoles</surname><given-names>A</given-names></name><name><surname>Ochoa-Gondar</surname><given-names>O</given-names></name><name><surname>Rodriguez-Blanco</surname><given-names>T</given-names></name><etal></etal></person-group><article-title>Epidemiology of community-acquired pneumonia in older adults: a population-based study</article-title>. <source>Respir Med</source><year>2009</year>;<volume>103</volume>:<fpage>309</fpage>–<lpage>16</lpage><pub-id pub-id-type="pmid">18804355</pub-id></mixed-citation></ref><ref id="R17"><label>17</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kornum</surname><given-names>JB</given-names></name><name><surname>Norgaard</surname><given-names>M</given-names></name><name><surname>Dethlefsen</surname><given-names>C</given-names></name><etal></etal></person-group><article-title>Obesity and risk of subsequent hospitalisation with pneumonia</article-title>. <source>Eur Respir J</source><year>2010</year>;<volume>36</volume>:<fpage>1330</fpage>–<lpage>6</lpage><pub-id pub-id-type="pmid">20351023</pub-id></mixed-citation></ref><ref id="R18"><label>18</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kornum</surname><given-names>JB</given-names></name><name><surname>Due</surname><given-names>KM</given-names></name><name><surname>Norgaard</surname><given-names>M</given-names></name><etal></etal></person-group><article-title>Alcohol drinking and risk of subsequent hospitalisation with pneumonia</article-title>. <source>Eur Respir J</source><year>2012</year>;<volume>39</volume>:<fpage>149</fpage>–<lpage>55</lpage><pub-id pub-id-type="pmid">21659417</pub-id></mixed-citation></ref><ref id="R19"><label>19</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Mullerova</surname><given-names>H</given-names></name><name><surname>Chigbo</surname><given-names>C</given-names></name><name><surname>Hagan</surname><given-names>GW</given-names></name><etal></etal></person-group><article-title>The natural history of community-acquired pneumonia in COPD patients: A population database analysis</article-title>. <source>Respir Med</source><year>2012</year>;<volume>106</volume>:<fpage>1124</fpage>–<lpage>33</lpage><pub-id pub-id-type="pmid">22621820</pub-id></mixed-citation></ref><ref id="R20"><label>20</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Vinogradova</surname><given-names>Y</given-names></name><name><surname>Coupland</surname><given-names>C</given-names></name><name><surname>Hippisley-Cox</surname><given-names>J</given-names></name></person-group><article-title>Risk of pneumonia in patients taking statins: population-based nested case-control study</article-title>. <source>Br J Gen Pract</source><year>2011</year>;<volume>61</volume>:<fpage>e742</fpage>–<lpage>8</lpage><pub-id pub-id-type="pmid">22054338</pub-id></mixed-citation></ref><ref id="R21"><label>21</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Schlienger</surname><given-names>RG</given-names></name><name><surname>Fedson</surname><given-names>DS</given-names></name><name><surname>Jick</surname><given-names>SS</given-names></name><etal></etal></person-group><article-title>Statins and the risk of pneumonia: a population-based, nested case-control study</article-title>. <source>Pharmacotherapy</source><year>2007</year>;<volume>27</volume>:<fpage>325</fpage>–<lpage>32</lpage><pub-id pub-id-type="pmid">17316144</pub-id></mixed-citation></ref><ref id="R22"><label>22</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Myles</surname><given-names>PR</given-names></name><name><surname>Hubbard</surname><given-names>RB</given-names></name><name><surname>McKeever</surname><given-names>TM</given-names></name><etal></etal></person-group><article-title>Risk of community-acquired pneumonia and the use of statins, ace inhibitors and gastric acid suppressants: a population-based case-control study</article-title>. <source>Pharmacoepidemiol Drug Saf</source><year>2009</year>;<volume>18</volume>:<fpage>269</fpage>–<lpage>75</lpage><pub-id pub-id-type="pmid">19235776</pub-id></mixed-citation></ref><ref id="R23"><label>23</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Teepe</surname><given-names>J</given-names></name><name><surname>Grigoryan</surname><given-names>L</given-names></name><name><surname>Verheij</surname><given-names>TJ</given-names></name></person-group><article-title>Determinants of community-acquired pneumonia in children and young adults in primary care</article-title>. <source>Eur Respir J</source><year>2010</year>;<volume>35</volume>:<fpage>1113</fpage>–<lpage>17</lpage><pub-id pub-id-type="pmid">20436174</pub-id></mixed-citation></ref><ref id="R24"><label>24</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Benard</surname><given-names>A</given-names></name><name><surname>Mercie</surname><given-names>P</given-names></name><name><surname>Alioum</surname><given-names>A</given-names></name><etal></etal></person-group><article-title>Bacterial pneumonia among HIV-infected patients: decreased risk after tobacco smoking cessation. ANRS CO3 Aquitaine Cohort, 2000–2007</article-title>. <source>PLoS ONE</source><year>2010</year>;<volume>5</volume>:<fpage>e8896</fpage><pub-id pub-id-type="pmid">20126646</pub-id></mixed-citation></ref><ref id="R25"><label>25</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Curran</surname><given-names>A</given-names></name><name><surname>Falco</surname><given-names>V</given-names></name><name><surname>Crespo</surname><given-names>M</given-names></name><etal></etal></person-group><article-title>Bacterial pneumonia in HIV-infected patients: use of the pneumonia severity index and impact of current management on incidence, aetiology and outcome</article-title>. <source>HIV Med</source><year>2008</year>;<volume>9</volume>:<fpage>609</fpage>–<lpage>15</lpage><pub-id pub-id-type="pmid">18557951</pub-id></mixed-citation></ref><ref id="R26"><label>26</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Le Moing</surname><given-names>V</given-names></name><name><surname>Rabaud</surname><given-names>C</given-names></name><name><surname>Journot</surname><given-names>V</given-names></name><etal></etal></person-group><article-title>Incidence and risk factors of bacterial pneumonia requiring hospitalization in HIV-infected patients started on a protease inhibitor-containing regimen</article-title>. <source>HIV Med</source><year>2006</year>;<volume>7</volume>:<fpage>261</fpage>–<lpage>7</lpage><pub-id pub-id-type="pmid">16630039</pub-id></mixed-citation></ref><ref id="R27"><label>27</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Madeddu</surname><given-names>G</given-names></name><name><surname>Porqueddu</surname><given-names>EM</given-names></name><name><surname>Cambosu</surname><given-names>F</given-names></name><etal></etal></person-group><article-title>Bacterial community acquired pneumonia in HIV-infected inpatients in the highly active antiretroviral therapy era</article-title>. <source>Infection</source><year>2008</year>;<volume>36</volume>:<fpage>231</fpage>–<lpage>6</lpage><pub-id pub-id-type="pmid">18463787</pub-id></mixed-citation></ref><ref id="R28"><label>28</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Manno</surname><given-names>D</given-names></name><name><surname>Puoti</surname><given-names>M</given-names></name><name><surname>Signorini</surname><given-names>L</given-names></name><etal></etal></person-group><article-title>Risk factors and clinical characteristics associated with hospitalization for community-acquired bacterial pneumonia in HIV-positive patients according to the presence of liver cirrhosis</article-title>. <source>Infection</source><year>2009</year>;<volume>37</volume>:<fpage>334</fpage>–<lpage>9</lpage><pub-id pub-id-type="pmid">19629382</pub-id></mixed-citation></ref><ref id="R29"><label>29</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Saindou</surname><given-names>M</given-names></name><name><surname>Chidiac</surname><given-names>C</given-names></name><name><surname>Miailhes</surname><given-names>P</given-names></name><etal></etal></person-group><article-title>Pneumococcal pneumonia in HIV-infected patients by antiretroviral therapy periods</article-title>. <source>HIV Med</source><year>2008</year>;<volume>9</volume>:<fpage>203</fpage>–<lpage>7</lpage><pub-id pub-id-type="pmid">18298578</pub-id></mixed-citation></ref><ref id="R30"><label>30</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Che</surname><given-names>D</given-names></name><name><surname>Campese</surname><given-names>C</given-names></name><name><surname>Santa-Olalla</surname><given-names>P</given-names></name><etal></etal></person-group><article-title>Sporadic community-acquired Legionnaires’ disease in France: a 2-year national matched case-control study</article-title>. <source>Epidemiol Infect</source><year>2008</year>;<volume>136</volume>:<fpage>1684</fpage>–<lpage>90</lpage><pub-id pub-id-type="pmid">18211725</pub-id></mixed-citation></ref><ref id="R31"><label>31</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Chidiac</surname><given-names>C</given-names></name><name><surname>Che</surname><given-names>D</given-names></name><name><surname>Pires-Cronenberger</surname><given-names>S</given-names></name><etal></etal></person-group><article-title>Factors associated with hospital mortality in community-acquired legionellosis in France</article-title>. <source>Eur Respir J</source><year>2012</year>;<volume>39</volume>:<fpage>963</fpage>–<lpage>70</lpage><pub-id pub-id-type="pmid">22005914</pub-id></mixed-citation></ref><ref id="R32"><label>32</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sopena</surname><given-names>N</given-names></name><name><surname>Force</surname><given-names>L</given-names></name><name><surname>Pedro-Botet</surname><given-names>ML</given-names></name><etal></etal></person-group><article-title>Sporadic and epidemic community legionellosis: two faces of the same illness</article-title>. <source>Eur Respir J</source><year>2007</year>;<volume>29</volume>:<fpage>138</fpage>–<lpage>42</lpage><pub-id pub-id-type="pmid">17005576</pub-id></mixed-citation></ref><ref id="R33"><label>33</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sopena</surname><given-names>N</given-names></name><name><surname>Pedro-Botet</surname><given-names>L</given-names></name><name><surname>Mateu</surname><given-names>L</given-names></name><etal></etal></person-group><article-title>Community-acquired legionella pneumonia in elderly patients: characteristics and outcome</article-title>. <source>J Am Geriatr Soc</source><year>2007</year>;<volume>55</volume>:
<fpage>114</fpage>–<lpage>19</lpage><pub-id pub-id-type="pmid">17233694</pub-id></mixed-citation></ref><ref id="R34"><label>34</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kofteridis</surname><given-names>D</given-names></name><name><surname>Samonis</surname><given-names>G</given-names></name><name><surname>Mantadakis</surname><given-names>E</given-names></name><etal></etal></person-group><article-title>Lower respiratory tract infections caused by Haemophilus influenzae: clinical features and predictors of outcome</article-title>. <source>Med Sci Monit</source><year>2009</year>;<volume>15</volume>:<fpage>CR135</fpage>–<lpage>39</lpage><pub-id pub-id-type="pmid">19333196</pub-id></mixed-citation></ref><ref id="R35"><label>35</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ruiz</surname><given-names>LA</given-names></name><name><surname>Gomez</surname><given-names>A</given-names></name><name><surname>Jaca</surname><given-names>C</given-names></name><etal></etal></person-group><article-title>Bacteraemic community-acquired pneumonia due to Gram-negative bacteria: incidence, clinical presentation and factors associated with severity during hospital stay</article-title>. <source>Infection</source><year>2010</year>;<volume>38</volume>:<fpage>453</fpage>–<lpage>8</lpage><pub-id pub-id-type="pmid">20878457</pub-id></mixed-citation></ref><ref id="R36"><label>36</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ewig</surname><given-names>S</given-names></name><name><surname>Birkner</surname><given-names>N</given-names></name><name><surname>Strauss</surname><given-names>R</given-names></name><etal></etal></person-group><article-title>New perspectives on community-acquired pneumonia in 388 406 patients. Results from a nationwide mandatory performance measurement programme in healthcare quality</article-title>. <source>Thorax</source><year>2009</year>;<volume>64</volume>:<fpage>1062</fpage>–<lpage>9</lpage><pub-id pub-id-type="pmid">19454409</pub-id></mixed-citation></ref><ref id="R37"><label>37</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Viegi</surname><given-names>G</given-names></name><name><surname>Pistelli</surname><given-names>R</given-names></name><name><surname>Cazzola</surname><given-names>M</given-names></name><etal></etal></person-group><article-title>Epidemiological survey on incidence and treatment of community acquired pneumonia in Italy</article-title>. <source>Respir Med</source><year>2006</year>;<volume>100</volume>:<fpage>46</fpage>–<lpage>55</lpage><pub-id pub-id-type="pmid">16046113</pub-id></mixed-citation></ref><ref id="R38"><label>38</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Almirall</surname><given-names>J</given-names></name><name><surname>Bolibar</surname><given-names>I</given-names></name><name><surname>Serra-Prat</surname><given-names>M</given-names></name><etal></etal></person-group><article-title>New evidence of risk factors for community-acquired pneumonia: a population-based study</article-title>. <source>Eur Respir J</source><year>2008</year>;<volume>31</volume>:<fpage>1274</fpage>–<lpage>84</lpage><pub-id pub-id-type="pmid">18216057</pub-id></mixed-citation></ref><ref id="R39"><label>39</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Gutierrez</surname><given-names>F</given-names></name><name><surname>Masia</surname><given-names>M</given-names></name><name><surname>Mirete</surname><given-names>C</given-names></name><etal></etal></person-group><article-title>The influence of age and gender on the population-based incidence of community-acquired pneumonia caused by different microbial pathogens</article-title>. <source>J Infect</source><year>2006</year>;<volume>53</volume>:<fpage>166</fpage>–<lpage>74</lpage><pub-id pub-id-type="pmid">16375972</pub-id></mixed-citation></ref><ref id="R40"><label>40</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Perez-Sola</surname><given-names>MJ</given-names></name><name><surname>Torre-Cisneros</surname><given-names>J</given-names></name><name><surname>Perez-Zafrilla</surname><given-names>B</given-names></name><etal></etal></person-group><article-title>Infections in patients treated with tumor necrosis factor antagonists: incidence, etiology and mortality in the BIOBADASER registry</article-title>. <source>Med Clin (Barc)</source><year>2011</year>;<volume>137</volume>:<fpage>533</fpage>–<lpage>40</lpage><pub-id pub-id-type="pmid">21514606</pub-id></mixed-citation></ref><ref id="R41"><label>41</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Bewick</surname><given-names>T</given-names></name><name><surname>Sheppard</surname><given-names>C</given-names></name><name><surname>Greenwood</surname><given-names>S</given-names></name><etal></etal></person-group><article-title>Serotype prevalence in adults hospitalised with pneumococcal non-invasive community-acquired pneumonia</article-title>. <source>Thorax</source><year>2012</year>;<volume>67</volume>:<fpage>540</fpage>–<lpage>5</lpage><pub-id pub-id-type="pmid">22374921</pub-id></mixed-citation></ref><ref id="R42"><label>42</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Rodriguez</surname><given-names>LA</given-names></name><name><surname>Ruigomez</surname><given-names>A</given-names></name><name><surname>Wallander</surname><given-names>MA</given-names></name><etal></etal></person-group><article-title>Acid-suppressive drugs and community-acquired pneumonia</article-title>. <source>Epidemiology</source><year>2009</year>;<volume>20</volume>:<fpage>800</fpage>–<lpage>6</lpage><pub-id pub-id-type="pmid">19797970</pub-id></mixed-citation></ref><ref id="R43"><label>43</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Gutierrez</surname><given-names>F</given-names></name><name><surname>Masia</surname><given-names>M</given-names></name><name><surname>Rodriguez</surname><given-names>JC</given-names></name><etal></etal></person-group><article-title>Epidemiology of community-acquired pneumonia in adult patients at the dawn of the 21st century: a prospective study on the Mediterranean coast of Spain</article-title>. <source>Clin Microbiol Infect</source><year>2005</year>;<volume>11</volume>:<fpage>788</fpage>–<lpage>800</lpage><pub-id pub-id-type="pmid">16153252</pub-id></mixed-citation></ref><ref id="R44"><label>44</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Schnoor</surname><given-names>M</given-names></name><name><surname>Klante</surname><given-names>T</given-names></name><name><surname>Beckmann</surname><given-names>M</given-names></name><etal></etal></person-group><article-title>Risk factors for community-acquired pneumonia in German adults: the impact of children in the household</article-title>. <source>Epidemiol Infect</source><year>2007</year>;<volume>135</volume>:<fpage>1389</fpage>–<lpage>97</lpage><pub-id pub-id-type="pmid">17291378</pub-id></mixed-citation></ref><ref id="R45"><label>45</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>van de Garde</surname><given-names>EM</given-names></name><name><surname>Souverein</surname><given-names>PC</given-names></name><name><surname>van den Bosch</surname><given-names>JM</given-names></name><etal></etal></person-group><article-title>Angiotensin-converting enzyme inhibitor use and pneumonia risk in a general population</article-title>. <source>Eur Respir J</source><year>2006</year>;<volume>27</volume>:<fpage>1217</fpage>–<lpage>22</lpage><pub-id pub-id-type="pmid">16455828</pub-id></mixed-citation></ref><ref id="R46"><label>46</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Vinogradova</surname><given-names>Y</given-names></name><name><surname>Hippisley-Cox</surname><given-names>J</given-names></name><name><surname>Coupland</surname><given-names>C</given-names></name></person-group><article-title>Identification of new risk factors for pneumonia: population-based case-control study</article-title>. <source>Br J Gen Pract</source><year>2009</year>;<volume>59</volume>:<fpage>e329</fpage>–<lpage>38</lpage><pub-id pub-id-type="pmid">19843413</pub-id></mixed-citation></ref><ref id="R47"><label>47</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>van de Garde</surname><given-names>EM</given-names></name><name><surname>Hak</surname><given-names>E</given-names></name><name><surname>Souverein</surname><given-names>PC</given-names></name><etal></etal></person-group><article-title>Statin treatment and reduced risk of pneumonia in patients with diabetes</article-title>. <source>Thorax</source><year>2006</year>;<volume>61</volume>:<fpage>957</fpage>–<lpage>61</lpage><pub-id pub-id-type="pmid">16809409</pub-id></mixed-citation></ref><ref id="R48"><label>48</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kornum</surname><given-names>JB</given-names></name><name><surname>Thomsen</surname><given-names>RW</given-names></name><name><surname>Riis</surname><given-names>A</given-names></name><etal></etal></person-group><article-title>Diabetes, glycemic control, and risk of hospitalization with pneumonia: a population-based case-control study</article-title>. <source>Diabetes Care</source><year>2008</year>;<volume>31</volume>:<fpage>1541</fpage>–<lpage>5</lpage><pub-id pub-id-type="pmid">18487479</pub-id></mixed-citation></ref><ref id="R49"><label>49</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>van de Garde</surname><given-names>EM</given-names></name><name><surname>Souverein</surname><given-names>PC</given-names></name><name><surname>Hak</surname><given-names>E</given-names></name><etal></etal></person-group><article-title>Angiotensin-converting enzyme inhibitor use and protection against pneumonia in patients with diabetes</article-title>. <source>J Hypertens</source><year>2007</year>;<volume>25</volume>:<fpage>235</fpage>–<lpage>9</lpage><pub-id pub-id-type="pmid">17143196</pub-id></mixed-citation></ref><ref id="R50"><label>50</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Almirall</surname><given-names>J</given-names></name><name><surname>Bolibar</surname><given-names>I</given-names></name><name><surname>Serra-Prat</surname><given-names>M</given-names></name><etal></etal></person-group><article-title>Inhaled drugs as risk factors for community-acquired pneumonia</article-title>. <source>Eur Respir J</source><year>2010</year>;<volume>36</volume>:<fpage>1080</fpage>–<lpage>7</lpage><pub-id pub-id-type="pmid">20525710</pub-id></mixed-citation></ref><ref id="R51"><label>51</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Gulmez</surname><given-names>SE</given-names></name><name><surname>Holm</surname><given-names>A</given-names></name><name><surname>Frederiksen</surname><given-names>H</given-names></name><etal></etal></person-group><article-title>Use of proton pump inhibitors and the risk of community-acquired pneumonia: a population-based case-control study</article-title>. <source>Arch Intern Med</source><year>2007</year>;<volume>167</volume>:<fpage>950</fpage>–<lpage>5</lpage><pub-id pub-id-type="pmid">17502537</pub-id></mixed-citation></ref><ref id="R52"><label>52</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Nielsen</surname><given-names>AG</given-names></name><name><surname>Nielsen</surname><given-names>RB</given-names></name><name><surname>Riis</surname><given-names>AH</given-names></name><etal></etal></person-group><article-title>The impact of statin use on pneumonia risk and outcome: a combined population-based case-control and cohort study</article-title>. <source>Crit Care</source><year>2012</year>;<volume>16</volume>:<fpage>R122</fpage><pub-id pub-id-type="pmid">22789037</pub-id></mixed-citation></ref><ref id="R53"><label>53</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sarkar</surname><given-names>M</given-names></name><name><surname>Hennessy</surname><given-names>S</given-names></name><name><surname>Yang</surname><given-names>YX</given-names></name></person-group><article-title>Proton-pump inhibitor use and the risk for community-acquired pneumonia</article-title>. <source>Ann Intern Med</source><year>2008</year>;<volume>149</volume>:<fpage>391</fpage>–<lpage>8</lpage><pub-id pub-id-type="pmid">18794558</pub-id></mixed-citation></ref><ref id="R54"><label>54</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Carratala</surname><given-names>J</given-names></name><name><surname>Mykietiuk</surname><given-names>A</given-names></name><name><surname>Fernandez-Sabe</surname><given-names>N</given-names></name><etal></etal></person-group><article-title>Health care-associated pneumonia requiring hospital admission: epidemiology, antibiotic therapy, and clinical outcomes</article-title>. <source>Arch Intern Med</source><year>2007</year>;<volume>167</volume>:<fpage>1393</fpage>–<lpage>9</lpage><pub-id pub-id-type="pmid">17620533</pub-id></mixed-citation></ref><ref id="R55"><label>55</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Cilloniz</surname><given-names>C</given-names></name><name><surname>Ewig</surname><given-names>S</given-names></name><name><surname>Ferrer</surname><given-names>M</given-names></name><etal></etal></person-group><article-title>Community-acquired polymicrobial pneumonia in the intensive care unit: aetiology and prognosis</article-title>. <source>Crit Care</source><year>2011</year>;<volume>15</volume>:<fpage>R209</fpage><pub-id pub-id-type="pmid">21914220</pub-id></mixed-citation></ref><ref id="R56"><label>56</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Cilloniz</surname><given-names>C</given-names></name><name><surname>Ewig</surname><given-names>S</given-names></name><name><surname>Polverino</surname><given-names>E</given-names></name><etal></etal></person-group><article-title>Pulmonary complications of pneumococcal community-acquired pneumonia: incidence, predictors, and outcomes</article-title>. <source>Clin Microbiol Infect</source><year>2012</year>;<volume>18</volume>:<fpage>1134</fpage>–<lpage>42</lpage><pub-id pub-id-type="pmid">22044658</pub-id></mixed-citation></ref><ref id="R57"><label>57</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Falguera</surname><given-names>M</given-names></name><name><surname>Carratala</surname><given-names>J</given-names></name><name><surname>Ruiz-Gonzalez</surname><given-names>A</given-names></name><etal></etal></person-group><article-title>Risk factors and outcome of community-acquired pneumonia due to Gram-negative bacilli</article-title>. <source>Respirology</source><year>2009</year>;<volume>14</volume>:<fpage>105</fpage>–<lpage>11</lpage><pub-id pub-id-type="pmid">18699803</pub-id></mixed-citation></ref><ref id="R58"><label>58</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Garcia-Vidal</surname><given-names>C</given-names></name><name><surname>Carratala</surname><given-names>J</given-names></name><name><surname>Fernandez-Sabe</surname><given-names>N</given-names></name><etal></etal></person-group><article-title>Aetiology of, and risk factors for, recurrent community-acquired pneumonia</article-title>. <source>Clin Microbiol Infect</source><year>2009</year>;<volume>15</volume>:<fpage>1033</fpage>–<lpage>8</lpage><pub-id pub-id-type="pmid">19673961</pub-id></mixed-citation></ref><ref id="R59"><label>59</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Giannella</surname><given-names>M</given-names></name><name><surname>Pinilla</surname><given-names>B</given-names></name><name><surname>Capdevila</surname><given-names>JA</given-names></name><etal></etal></person-group><article-title>Pneumonia treated in the internal medicine department: focus on healthcare-associated pneumonia</article-title>. <source>Clin Microbiol Infect</source><year>2012</year>;<volume>18</volume>:<fpage>786</fpage>–<lpage>94</lpage><pub-id pub-id-type="pmid">22284436</pub-id></mixed-citation></ref><ref id="R60"><label>60</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Holm</surname><given-names>A</given-names></name><name><surname>Nexoe</surname><given-names>J</given-names></name><name><surname>Bistrup</surname><given-names>LA</given-names></name><etal></etal></person-group><article-title>Aetiology and prediction of pneumonia in lower respiratory tract infection in primary care</article-title>. <source>Br J Gen Pract</source><year>2007</year>;<volume>57</volume>:<fpage>547</fpage>–<lpage>54</lpage><pub-id pub-id-type="pmid">17727747</pub-id></mixed-citation></ref><ref id="R61"><label>61</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Klapdor</surname><given-names>B</given-names></name><name><surname>Ewig</surname><given-names>S</given-names></name><name><surname>Pletz</surname><given-names>MW</given-names></name><etal></etal></person-group><article-title>Community-acquired pneumonia in younger patients is an entity on its own</article-title>. <source>Eur Respir J</source><year>2012</year>;<volume>39</volume>:<fpage>1156</fpage>–<lpage>61</lpage><pub-id pub-id-type="pmid">22088967</pub-id></mixed-citation></ref><ref id="R62"><label>62</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kothe</surname><given-names>H</given-names></name><name><surname>Bauer</surname><given-names>T</given-names></name><name><surname>Marre</surname><given-names>R</given-names></name><etal></etal></person-group><article-title>Outcome of community-acquired pneumonia: influence of age, residence status and antimicrobial treatment</article-title>. <source>Eur Respir J</source><year>2008</year>;<volume>32</volume>:<fpage>139</fpage>–<lpage>46</lpage><pub-id pub-id-type="pmid">18287129</pub-id></mixed-citation></ref><ref id="R63"><label>63</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Liapikou</surname><given-names>A</given-names></name><name><surname>Polverino</surname><given-names>E</given-names></name><name><surname>Ewig</surname><given-names>S</given-names></name><etal></etal></person-group><article-title>Severity and outcomes of hospitalised community-acquired pneumonia in COPD patients</article-title>. <source>Eur Respir J</source><year>2012</year>;<volume>39</volume>:<fpage>855</fpage>–<lpage>61</lpage><pub-id pub-id-type="pmid">21920895</pub-id></mixed-citation></ref><ref id="R64"><label>64</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Migliorati</surname><given-names>PL</given-names></name><name><surname>Boccoli</surname><given-names>E</given-names></name><name><surname>Bracci</surname><given-names>LS</given-names></name><etal></etal></person-group><article-title>A survey on hospitalised community-acquired pneumonia in Italy</article-title>. <source>Monaldi Arch Chest Dis</source><year>2006</year>;<volume>65</volume>:<fpage>82</fpage>–<lpage>8</lpage><pub-id pub-id-type="pmid">16913578</pub-id></mixed-citation></ref><ref id="R65"><label>65</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Molinos</surname><given-names>L</given-names></name><name><surname>Clemente</surname><given-names>MG</given-names></name><name><surname>Miranda</surname><given-names>B</given-names></name><etal></etal></person-group><article-title>Community-acquired pneumonia in patients with and without chronic obstructive pulmonary disease</article-title>. <source>J Infect</source><year>2009</year>;<volume>58</volume>:<fpage>417</fpage>–<lpage>24</lpage><pub-id pub-id-type="pmid">19329187</pub-id></mixed-citation></ref><ref id="R66"><label>66</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Myint</surname><given-names>PK</given-names></name><name><surname>Lowe</surname><given-names>D</given-names></name><name><surname>Stone</surname><given-names>RA</given-names></name><etal></etal></person-group><article-title>U.K. National COPD Resources and Outcomes Project 2008: patients with chronic obstructive pulmonary disease exacerbations who present with radiological pneumonia have worse outcome compared to those with non-pneumonic chronic obstructive pulmonary disease exacerbations</article-title>. <source>Respiration</source><year>2011</year>;<volume>82</volume>:<fpage>320</fpage>–<lpage>7</lpage><pub-id pub-id-type="pmid">21597277</pub-id></mixed-citation></ref><ref id="R67"><label>67</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Thomsen</surname><given-names>RW</given-names></name><name><surname>Riis</surname><given-names>A</given-names></name><name><surname>Kornum</surname><given-names>JB</given-names></name><etal></etal></person-group><article-title>Preadmission use of statins and outcomes after hospitalization with pneumonia: population-based cohort study of 29,900 patients</article-title>. <source>Arch Intern Med</source><year>2008</year>;<volume>168</volume>:<fpage>2081</fpage>–<lpage>7</lpage><pub-id pub-id-type="pmid">18955636</pub-id></mixed-citation></ref><ref id="R68"><label>68</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Viasus</surname><given-names>D</given-names></name><name><surname>Garcia-Vidal</surname><given-names>C</given-names></name><name><surname>Cruzado</surname><given-names>JM</given-names></name><etal></etal></person-group><article-title>Epidemiology, clinical features and outcomes of pneumonia in patients with chronic kidney disease</article-title>. <source>Nephrol Dial Transplant</source><year>2011</year>;<volume>26</volume>:<fpage>2899</fpage>–<lpage>906</lpage><pub-id pub-id-type="pmid">21273232</pub-id></mixed-citation></ref><ref id="R69"><label>69</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Viasus</surname><given-names>D</given-names></name><name><surname>Garcia-Vidal</surname><given-names>C</given-names></name><name><surname>Castellote</surname><given-names>J</given-names></name><etal></etal></person-group><article-title>Community-acquired pneumonia in patients with liver cirrhosis: clinical features, outcomes, and usefulness of severity scores</article-title>. <source>Medicine (Baltimore)</source><year>2011</year>;<volume>90</volume>:<fpage>110</fpage>–<lpage>18</lpage><pub-id pub-id-type="pmid">21358441</pub-id></mixed-citation></ref><ref id="R70"><label>70</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>von Baum</surname><given-names>H</given-names></name><name><surname>Welte</surname><given-names>T</given-names></name><name><surname>Marre</surname><given-names>R</given-names></name><etal></etal></person-group><article-title>Community-acquired pneumonia through Enterobacteriaceae and Pseudomonas aeruginosa: diagnosis, incidence and predictors</article-title>. <source>Eur Respir J</source><year>2010</year>;<volume>35</volume>:<fpage>598</fpage>–<lpage>605</lpage><pub-id pub-id-type="pmid">19679601</pub-id></mixed-citation></ref><ref id="R71"><label>71</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sogaard</surname><given-names>OS</given-names></name><name><surname>Lohse</surname><given-names>N</given-names></name><name><surname>Gerstoft</surname><given-names>J</given-names></name><etal></etal></person-group><article-title>Hospitalization for pneumonia among individuals with and without HIV infection, 1995–2007: a Danish population-based, nationwide cohort study</article-title>. <source>Clin Infect Dis</source><year>2008</year>;<volume>47</volume>:<fpage>1345</fpage>–<lpage>53</lpage><pub-id pub-id-type="pmid">18834317</pub-id></mixed-citation></ref><ref id="R72"><label>72</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Almirall</surname><given-names>J</given-names></name><name><surname>Gonzalez</surname><given-names>CA</given-names></name><name><surname>Balanzó</surname><given-names>X</given-names></name><etal></etal></person-group><article-title>Proportion of community-acquired pneumonia cases attributable to tobacco smoking</article-title>. <source>Chest</source><year>1999</year>;<volume>116</volume>:<fpage>375</fpage>–<lpage>9</lpage><pub-id pub-id-type="pmid">10453865</pub-id></mixed-citation></ref><ref id="R73"><label>73</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Dye</surname><given-names>JA</given-names></name><name><surname>Adler</surname><given-names>KB</given-names></name></person-group><article-title>Effects of cigarette smoke on epithelial cells of the respiratory tract</article-title>. <source>Thorax</source><year>1994</year>;<volume>49</volume>:<fpage>825</fpage>–<lpage>34</lpage><pub-id pub-id-type="pmid">8091331</pub-id></mixed-citation></ref><ref id="R74"><label>74</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Nelson</surname><given-names>S</given-names></name><name><surname>Kolls</surname><given-names>JK</given-names></name></person-group><article-title>Alcohol, host defence and society</article-title>. <source>Nat Rev Immunol</source><year>2002</year>;<volume>2</volume>:<fpage>205</fpage>–<lpage>9</lpage><pub-id pub-id-type="pmid">11913071</pub-id></mixed-citation></ref><ref id="R75"><label>75</label><mixed-citation publication-type="book"><comment>World Health Organization</comment><source>The World health Report 2002. Reducing risks, promoting healthy life</source>. <publisher-loc>Geneva, Switzerland</publisher-loc>: <publisher-name>World Health Organization</publisher-name>, <year>2002</year></mixed-citation></ref><ref id="R76"><label>76</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Hedlund</surname><given-names>J</given-names></name><name><surname>Hansson</surname><given-names>LO</given-names></name><name><surname>Ortqvist</surname><given-names>A</given-names></name></person-group><article-title>Short- and long-term prognosis for middle-aged and elderly patients hospitalised with community-acquired pneumonia: impact of nutritional and inflammatory factors</article-title>. <source>Scand J Infect Dis</source><year>1995</year>;<volume>27</volume>:<fpage>32</fpage>–<lpage>7</lpage><pub-id pub-id-type="pmid">7540316</pub-id></mixed-citation></ref><ref id="R77"><label>77</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Hendley</surname><given-names>JO</given-names></name><name><surname>Sande</surname><given-names>MA</given-names></name><name><surname>Stewart</surname><given-names>PM</given-names></name><etal></etal></person-group><article-title>Spread of Streptococcus pneumoniae in families. I. Carriage rates and distribution of types</article-title>. <source>J Infect Dis</source><year>1975</year>;<volume>132</volume>:<fpage>55</fpage>–<lpage>61</lpage><pub-id pub-id-type="pmid">1097544</pub-id></mixed-citation></ref><ref id="R78"><label>78</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Arranz</surname><given-names>S</given-names></name><name><surname>Chiva-Blanch</surname><given-names>G</given-names></name><name><surname>Valderas-Martínez</surname><given-names>P</given-names></name><etal></etal></person-group><article-title>Wine, beer, alcohol and polyphenols on cardiovascular disease and cancer</article-title>. <source>Nutrients</source><year>2012</year>;<volume>4</volume>:<fpage>759</fpage>–<lpage>81</lpage><pub-id pub-id-type="pmid">22852062</pub-id></mixed-citation></ref><ref id="R79"><label>79</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ronksley</surname><given-names>PE</given-names></name><name><surname>Brien</surname><given-names>SE</given-names></name><name><surname>Turner</surname><given-names>BJ</given-names></name><etal></etal></person-group><article-title>Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis</article-title>. <source>BMJ</source><year>2011</year>;<volume>342</volume>:<fpage>d671</fpage><pub-id pub-id-type="pmid">21343207</pub-id></mixed-citation></ref><ref id="R80"><label>80</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Quagliarello</surname><given-names>V</given-names></name><name><surname>Ginter</surname><given-names>S</given-names></name><name><surname>Han</surname><given-names>L</given-names></name><etal></etal></person-group><article-title>Modifiable risk factors for nursing home-acquired pneumonia</article-title>. <source>Clin Infect Dis</source><year>2005</year>;<volume>40</volume>:<fpage>1</fpage>–<lpage>6</lpage><pub-id pub-id-type="pmid">15614684</pub-id></mixed-citation></ref><ref id="R81"><label>81</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Nuorti</surname><given-names>JP</given-names></name><name><surname>Butler</surname><given-names>JC</given-names></name><name><surname>Farley</surname><given-names>MM</given-names></name><etal></etal></person-group><article-title>Cigarette smoking and invasive pneumococcal disease</article-title>. <source>N Engl J Med</source><year>2000</year>;<volume>342</volume>:<fpage>681</fpage>–<lpage>9</lpage><pub-id pub-id-type="pmid">10706897</pub-id></mixed-citation></ref><ref id="R82"><label>82</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Winkleby</surname><given-names>MA</given-names></name><name><surname>Jatulis</surname><given-names>DE</given-names></name><name><surname>Frank</surname><given-names>E</given-names></name><etal></etal></person-group><article-title>Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease</article-title>. <source>Am J Public Health</source><year>1992</year>;<volume>82</volume>:<fpage>816</fpage>–<lpage>20</lpage><pub-id pub-id-type="pmid">1585961</pub-id></mixed-citation></ref><ref id="R83"><label>83</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Gaillat</surname><given-names>J</given-names></name></person-group><article-title>Should patients with chronic obstructive pulmonary disease be vaccinated against pneumococcal diseases?</article-title><source>Expert Rev Respir Med</source><year>2009</year>;<volume>3</volume>:<fpage>585</fpage>–<lpage>96</lpage><pub-id pub-id-type="pmid">20477349</pub-id></mixed-citation></ref><ref id="R84"><label>84</label><mixed-citation publication-type="journal"><collab>World Health Organization</collab><article-title>Vaccines against influenza. WHO position paper—November 2012</article-title>. <source>Wkly Epidemiol Rec</source><year>2012</year>;<volume>87</volume>:<fpage>461</fpage>–<lpage>76</lpage><pub-id pub-id-type="pmid">23210147</pub-id></mixed-citation></ref><ref id="R85"><label>85</label><mixed-citation publication-type="journal"><collab>World Health Organization</collab><article-title>23-valent pneumococcal polysaccharide vaccine. WHO position paper</article-title>. <source>Wkly Epidemiol Rec</source><year>2008</year>;<volume>83</volume>:<fpage>373</fpage>–<lpage>84</lpage><pub-id pub-id-type="pmid">18927997</pub-id></mixed-citation></ref><ref id="R86"><label>86</label><mixed-citation publication-type="journal"><collab>Advisory Committee on Immunization Practices</collab><article-title>Recommended adult immunization schedule: United States, 2009</article-title>. <source>Ann Intern Med</source><year>2009</year>;<volume>150</volume>:<fpage>40</fpage>–<lpage>4</lpage><pub-id pub-id-type="pmid">19124819</pub-id></mixed-citation></ref><ref id="R87"><label>87</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Loeb</surname><given-names>M</given-names></name><name><surname>McGeer</surname><given-names>A</given-names></name><name><surname>McArthur</surname><given-names>M</given-names></name><etal></etal></person-group><article-title>Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities</article-title>. <source>JAMA</source><year>1999</year>;<volume>159</volume>:<fpage>2058</fpage>–<lpage>64</lpage></mixed-citation></ref><ref id="R88"><label>88</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Mandell</surname><given-names>LA</given-names></name><name><surname>Wunderink</surname><given-names>RG</given-names></name><name><surname>Anzueto</surname><given-names>A</given-names></name><etal></etal></person-group><article-title>Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults</article-title>. <source>Clin Infect Dis</source><year>2007</year>;<volume>44</volume>:<fpage>S27</fpage>–<lpage>72</lpage><pub-id pub-id-type="pmid">17278083</pub-id></mixed-citation></ref><ref id="R89"><label>89</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Woodhead</surname><given-names>M</given-names></name><name><surname>Blasi</surname><given-names>F</given-names></name><name><surname>Ewig</surname><given-names>S</given-names></name><etal></etal></person-group><article-title>Guidelines for the management of adult lower respiratory tract infections</article-title>. <source>Eur Respir J</source><year>2005</year>;<volume>26</volume>:<fpage>1138</fpage>–<lpage>80</lpage><pub-id pub-id-type="pmid">16319346</pub-id></mixed-citation></ref><ref id="R90"><label>90</label><mixed-citation publication-type="journal"><collab>World Health Organization</collab><article-title>Pneumococcal vaccines. WHO position paper—2012</article-title>. <source>Wkly Epidemiol Rec</source><year>2012</year>;<volume>87</volume>:<fpage>129</fpage>–<lpage>44</lpage></mixed-citation></ref><ref id="R91"><label>91</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Huss</surname><given-names>A</given-names></name><name><surname>Scott</surname><given-names>P</given-names></name><name><surname>Stuck</surname><given-names>AE</given-names></name><etal></etal></person-group><article-title>Efficacy of pneumococcal vaccination in adults: a meta-analysis</article-title>. <source>CMAJ</source><year>2009</year>;<volume>180</volume>:<fpage>48</fpage>–<lpage>58</lpage><pub-id pub-id-type="pmid">19124790</pub-id></mixed-citation></ref><ref id="R92"><label>92</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Moberley</surname><given-names>S</given-names></name><name><surname>Holden</surname><given-names>J</given-names></name><name><surname>Tatham</surname><given-names>DP</given-names></name><etal></etal></person-group><article-title>Vaccines for preventing pneumococcal infection in adults</article-title>. <source>Cochrane Database Syst Rev</source><year>2008</year>;<fpage>1:CD000422</fpage>.<ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1002/14651858.CD000422.pub2">10.1002/14651858.CD000422.pub2</ext-link></mixed-citation></ref><ref id="R93"><label>93</label><mixed-citation publication-type="other"><collab>European Medicines Agency</collab><comment>Prevenar 13. <ext-link ext-link-type="uri" xlink:href="http://www.medicines.org.uk/emc/medicine/22689/SPC/Prevenar+13+suspension+for+injection/">http://www.medicines.org.uk/emc/medicine/22689/SPC/Prevenar+13+suspension+for+injection/</ext-link> (accessed 29 Jul 2013</comment>).</mixed-citation></ref><ref id="R94"><label>94</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Hak</surname><given-names>E</given-names></name><name><surname>Grobbee</surname><given-names>DE</given-names></name><name><surname>Sanders</surname><given-names>EA</given-names></name><etal></etal></person-group><article-title>Rationale and design of CAPITA: a RCT of 13-valent conjugated pneumococcal vaccine efficacy among older adults</article-title>. <source>Neth J Med</source><year>2008</year>;<volume>66</volume>:<fpage>378</fpage><pub-id pub-id-type="pmid">18990781</pub-id></mixed-citation></ref></ref-list></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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