RESPIRATORY INFECTIONS

Risk Factors for Community-acquired

Pneumonia in Adults: A Review
Jordi Almirall, MD, PhD,*wz Mateu Serra-Prat, MD, PhD,y
and Ignasi Bolibar, MD, PhDw8z

participants (below 60 y), COPD was reported to be a non-

Abstract: The knowledge of risk factors for community-acquired significant factor for CAP.6 These results suggest a possible
pneumonia (CAP) is essential to the design of preventive measures to interaction between chronic bronchitis/COPD and age. Several
reduce its incidence. We present a review of the main risk factors for studies report that chronic lung diseases not only increases the
CAP in adults, paying particular attention to chronic comorbidities,
risk of outpatient pneumonia but also the risk of CAP requiring
medication, and lifestyle factors. The most frequently observed
comorbidities associated with CAP are chronic obstructive pulmonary hospitalization.2,4,7As for the mortality associated with CAP,
disease, asthma, and heart failure. Certain lifestyle factors such as studies are contradictory, with some reporting no increased
smoking, dental hygiene, nutritional and dietary habits, and certain risk8,9 and others indicating an increased risk.7
working and environmental conditions (such as contact with dust and Asthma has also been identified as a risk factor for CAP,
sudden changes of temperature) have been shown to be modifiable risk with 5 studies independently documenting a link between
factors for CAP. Moreover, in the elderly, oropharyngeal dysphagia is asthma and CAP risk and reporting adjusted risk estimates of
a major risk factor for CAP, as an impaired swallow response and 1.67 (1.28 to 2.19) to 4.2 (3.3 to 5.4).2–4,7,10 Nonetheless,
delayed airway protection favor tracheobronchial aspirations. Finally, asthma was not an independent risk factor in another 3 pop-
vaccination against pneumococcal disease with the pneumococcal
conjugate vaccine (PCV-13) has been shown to be effective and is
ulation-based studies.3,10,11 In most studies on older people,
recommended for high-risk patients and elderly individuals, as Strep- asthma is a clear risk factor for CAP, whereas in the only study
tococcus pneumoniae is the most frequently isolated pathogen from conducted on individuals of all ages above 14 years,3 asthma
patients with CAP. was a nonsignificant factor, suggesting again a possible inter-
action with age. In general, inflammatory disorders, bronchial
obstruction, and the hyperresponsiveness typical of asthma
Key Words: community-acquired pneumonia, bundles, prevention,
may favor microorganism colonization of the epithelial surface
risk factors
of the lower respiratory airways.
(Clin Pulm Med 2016;23:99–104) Evidence regarding the effect of other respiratory dis-
eases such as bronchiectasis, pulmonary fibrosis, and nonactive
pulmonary tuberculosis is scarce.
CAP RISK FACTORS ASSOCIATED WITH The inhaled medication used by many patients with res-
DISEASES AND THEIR TREATMENT piratory diseases may also represent a risk factor that is
independent of the underlying respiratory disease and its
The Respiratory System severity.12,13 However, the role of these drugs is not clear
Chronic diseases of the respiratory system such as because the studies are heterogenous with regard to the specific
chronic obstructive pulmonary disease (COPD) play a key role drug considered and the baseline diagnosis (eg, asthma,
in the development of community-acquired pneumonia (CAP), chronic bronchitis, COPD) requiring inhaled drug treat-
especially when they present simultaneously in a patient. This ment.5,12 In addition, collinearity may exist between the
is confirmed by the medical literature both regarding the eld- inhaled treatment and the baseline diagnosis. Some random-
erly population and the general population. The observed ized clinical trials indicate that the use of corticosteroids may
effects, which vary according to the population and the trigger a lung infection as a serious adverse event,7,14 espe-
adjustment variables used, range from 1.95 to 3.0.1–5 Risk cially in patients with COPD.7,9 Other authors have studied the
estimates for older populations (above 65 y) are higher than for association between b2 agonists/anticholinergics and CAP
the general population. In the only study including younger risk, although without arriving at any clear conclusions.13 For
the subcohort of patients with asthma, anticholinergics were
From the *Intensive Care Unit, Hospital of Mataró; yResearch Unit, Con- signficant, but steroids and b2 agonists were nonsignificant.12
sorci Sanitari del Maresme, Mataró; wUniversitat Autònoma de Bar- For the subcohort of patients with COPD, steroids were sig-
celona; 8Department of Clinical Epidemiology and Public Health, nificant, but b2 agonists and anticholinergics were non-
Institut de Recerca Biomédica (IIB Sant Pau), Barcelona; zCiber de
Enfermedades Respiratorias (CIBERES); and zCiber de Epidemiologı́a significant, and for the subcohort with chronic bronchitis, all
y Salud Pública (CIBERESP), Madrid, Spain. types of steroids were nonsignificant.12
Supported in part by a grant from Fondo de Investigaciones Sanitarias (FIS) The role of oxygen therapy in CAP is not clear, as studies
and CIBERes 06/06/0028. have reported conflicting results. A number of population-
Disclosure: The authors declare that they have no conflicts of interest.
Address correspondence to: Jordi Almirall, MD, PhD, Unitat de Cures based studies point toward an association, reporting risk esti-
Intensives, Hospital de Mataró, CIBER de Enfermedades Respiratorias mates of 1.40 (1.16 to 1.69) and 1.96 (1.08 to 3.57).4,10 In a
(CIBERes), Universitat Autónoma de Barcelona, Carretera de Cirera general population study (above 14 y), after adjusting for
s/n 08304 Mataró, Barcelona, Spain. E-mail: [email protected]. asthma and chronic bronchitis, oxygen therapy was identified
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 1068-0640/16/2303-0099 as a risk factor.12 However, oxygen therapy became non-
DOI: 10.1097/CPM.0000000000000120 significant in a restricted analysis of the subcohorts with

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Almirall et al Clinical Pulmonary Medicine  Volume 23, Number 3, May 2016

chronic bronchitis and with COPD.12 In a single study on The Neurological System
elderly people, home oxygen therapy was nonsignificant after Convulsive conditions are associated with CAP as an
adjusting for COPD, asthma, and other factors.4 Oxygen independent risk factor.10 Results for various neurological
therapy is strongly correlated with other risk factors such as conditions (Parkinson disease, debilitating neuromuscular
advanced chronic disorders, aging, polymedication, and insti- diseases, and cranial nerve palsies) are not conclusive, given
tutionalization, among others. It has also been associated with the variations in the effects and the low prevalence of exposure
the drying of the nasal and the oropharyngeal mucosa, which, in the studied populations. Population-based studies of CAP
in turn, leads to superinfected lesions, difficulty in swallowing, have reported an increased risk of CAP in patients with stroke
and a greater risk of aspiration. and dementia,1,4,10,11,21 possibly attributable to a greater like-
A previous upper airway infection (especially in the last lihood of oropharyngeal aspiration due, in turn, to dysphagia or
month or year) and frequent colds have proved to be key risk depressed swallowing and cough reflexes. Dysphagia itself
factors for CAP for all age groups.3,5,9,10,12,15 might be a risk factor for CAP in the elderly.11,26 Studies
A lifelong history of pneumonia—also from childhood— where dysphagia was nonsignificant were based on populations
and prior hospitalizations for CAP (in the last 1 to 2 y) are with a low exposure prevalence27 in contrast to other studies
other well-known risk factors for CAP for all age that had higher dysphagia prevalence rates.
groups3,4,10,16 and are, furthermore, also associated with a
poorer prognosis (CAP-related readmission within 30 d, The Digestive and Liver System
delayed recovery, and death). Gastroesophageal reflux, hiatal hernia, and gastro-
Upper respiratory tract diagnostic and therapeutic techniques duodenal ulcers have not been linked to the risk of CAP.10
may produce contamination or affect natural aspiration barriers Dysphagia in older people diagnosed by videofluoroscopy has
(the glottis or the gastroesophageal sphincter) or may lead to an independent effect on CAP.26
epithelial destruction of the airways and so facilitate infection.17–20 Some published articles relate the use of antiulcer drugs or
The most studied techniques have been bronchoscopy, nasogastric gastric secretion inhibitors—especially when recently initiated—
probes (implying the risks of reflux, microaspiration, aspiration with an increased risk of CAP. Laheij et al28 were the first to
pneumonia, and colonization by biofilm-forming bacteria), nose observe the association between gastric acid suppressants and the
and throat examinations, gastroscopy, general anesthesia, tonsil- risk of CAP in a large-scale population study of patients who had
lectomy, and adenoidectomy. recently started (in the previous 30 d) treatment with proton
pump inhibitors (omeprazole) and H2-receptor antagonists
The Cardiovascular System (ranitidine). These authors suggested that the reduced secretion
A risk factor for CAP in all age groups is heart disease: a of gastric acid (wall acid) facilitates pathogen colonization of the
broad category of conditions that includes heart failure, con- upper gastrointestinal tract.28 Almirall et al10 and Gau et al13
gestive heart failure, ischemic heart disease, and coronary artery found no association on comparing the current use with no use/
disease. The impact of heart failure on CAP has been widely past use of gastric acid suppressants.
described in both population and hospital stud- Chronic liver disease may be associated with CAP risk. A
ies.1,2,4,6,10,11,13,16,21,22 Whereas the reasons for this enhanced study conducted in the elderly reported liver disease to be a risk
risk are not well understood, it has been postulated that the factor for CAP16 and a study by Fernández-Solà et al6 also
alveolar fluid in the lungs of some patients (pulmonary edema suggested that liver disease was independently associated with
secondary to left ventricular failure) promotes the multiplication CAP. In contrast, other studies conducted in more general pop-
of aspirated germs.1,23 Moreover, heart failure treatments, often ulations (below 14 y and 18 to 60 y) found no association5,10
used in combination, have also been demonstrated to pose a Oral pathologies are a clear risk factor for CAP, both in
possible CAP risk. Diuretics, digoxin and amiodarone have been elderly people and in the general population. Severe perio-
shown to be toxic even at low doses (causing pneumonitis, dontitis is a risk factor, whereas a dental visit in the previous
interstitial pneumonia and pulmonary fibrosis).10 More studies 30 days was an independent protective factor for CAP,10 a
are needed, however, to confirm the links between these treat- finding that may be related to better oral hygiene.
ments and etiopathogenic mechanisms. No clear association with
CAP has been demonstrated for other cardiovascular conditions.
Acquired Immune Deficiency
Results of studies reporting a possible link between coronary
artery disease and CAP are inconsistent.1,4,10 The hypothesis Cancer and Cancer Treatments
regarding a possible link between coronary artery disease and Cancer as a risk factor for CAP has been studied in
pneumonia was based on the demonstration, in the early 1990s, numerous published population studies.1–5,16,21 The observed
of the presence of Chlamydophila pneumoniae in atherosclerotic effect of cancer on CAP reflects the nature of the lesion (organ
lesions of the coronary arteries.24 This pathogen is reported to be involved, local, regional, or disseminated), the general con-
responsible for 10% of the CAP cases. dition of the patient, and the severity of immunosuppression,
whether attributable to the cancer or to the cancer treatment
The Endocrine System (radiotherapy, palliative care, chemotherapy, and surgery).
Some studies have established that diabetes increases the In general, low cancer prevalence in population-based
risk of infection due to hyperglycemia and ketosis. By altering studies has meant that a statistically significant risk for CAP has
the immune response, these conditions predispose the host to not been found after adjusting for various confounders.1–3,10,11
infection. Some population-based studies of CAP report a However, interesting results have been obtained in some studies.
significant association between diabetes and the risk of Thus, according to LaCroix et al,21 CAP mortality is associated
CAP,4,21,25 whereas other studies have found no associa- with a history of cancer in women and with hospitalization for
tion.1–3,5,10 Given that the results overall are inconsistent, cancer in men and women, and according to Koivula2 immu-
diabetes cannot be considered definitively as a risk factor, even nosuppressive cancer treatments are associated with a high risk
though the biological plausibility of the relationship is well of severe CAP, hospitalization, and death. Vila-Corcoles et al16
established. observed an independent risk for CAP in patients with

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Clinical Pulmonary Medicine  Volume 23, Number 3, May 2016 Review of Risk Factors for CAP

hematological or solid organ cancers, whereas Jackson et al4 bronchitis, COPD, and heart failure, with which it is also
were the only authors who found a relationship between CAP closely associated. Furthermore, evidence regarding the effect
and lung cancer and other serious tumors. of smoking reveals that the risk of pneumonia grows in line
with more years and a greater intensity of smoking as meas-
Human Immunodeficiency Virus Seropositivity ured in the number of cigarettes/day or pack-years. No dif-
Recurrent bacterial pneumonia was added to the defi- ference has been reported for blond against dark tobacco or for
nition of AIDS in 1992, on the basis of the fact that bacterial filtered against unfiltered cigarettes. It would seem, therefore,
pneumonia rates were increased in HIV-infected individuals that the risk of pneumonia depends not so much on these
and were indicative of immunosuppression in this features as on smoking itself and its duration and intensity.
population.29 The risk of CAP is as high in ex-smokers as in smokers in
the 2 years after giving up; thereafter, the risk tends to decrease
Other Non–Organ-specific/Non–System-specific with the years of abstinence.5,32 These findings are consistent
Clinical Risk Factors with those of other studies that demonstrate that the risk of
Numerous studies have established that previous hospi- death from pneumonia is reduced to the level of nonsmokers
talization is a risk factor for CAP.10 Fedson et al30 hypothe- 10 years after giving up smoking The impact of passive
sized that previous hospitalization could be a good marker for smoking is still not well understood; although most studies
identifying persons with an increased risk of acquiring pneu- have observed no significant effect in the overall population,
monia and also that immunization on discharge (pneumococcal an effect has been described for people aged 65 years and
vaccination) could be a highly cost-effective prevention older.34 It would seem that the effect of passive smoking is
measure. Lipsky et al1 suggest that the association between enhanced by age; thus, whereas the defense mechanisms of
previous hospitlization and CAP may be due to increased younger people would be sufficient to counter the effects of
exposure to multiple adverse circumstances such as nasogastric others’ smoking, the more diminished lung defense mecha-
intubation, sedation, etc. nisms of the elderly would be overwhelmed.
As for drugs, the immunosuppressive effect of oral corti-
costeroids, which increase the vulnerability to and the severity of Alcohol Consumption
infections, has been widely described in the literature.31 How- The effect of alcohol on CAP is not clear, as studies have
ever, because results from different studies are to some degree reported differing findings, probably due to different ways of
inconsistent, studies with a greater statistical power are neces- measuring alcohol consumption. Nonetheless, several studies
sary.1,3–5,10,16 In relation to antibiotic use, several reviews have agree that a high level of alcohol consumption (> 40 to 80 g/d) is
pointed toward inappropriate antibiotic use increasing bacterial a risk factor for CAP. A study by Koivula et al2 demonstrated a
resistance to common antibiotics and also altering the normal very important independent effect of alcoholism; although this
bacterial flora of the host.10,27 Nonetheless, no population-based study did not clearly define the level of exposure (data were
studies of risk factors for CAP have found any association collected from medical histories), consumption was implied to be
between taking antibiotics and CAP.10,27 abusive and associated with sociopathy. Another study found an
Disability may be a risk factor for CAP, including at low independent effect of alcohol only for men with high levels of
and intermediate levels of dependence, defined in different alcohol consumption (> 40 g/d of pure alcohol)5; from this cutoff
ways (Barthel Index <100, incontinence, being bedridden).10,11 point, a dose-response relationship was observed, with no effect
Other studies found no association between CAP risk and observed for moderate drinkers (< 40 g/d pure alcohol), even if
being bedridden27 or the score for activities of daily living. the intake was daily. In this study, multivariate analysis revealed
Age is widely reported to be a significant risk factor for an effect of consumption of >80 g/d of pure alcohol, independent
CAP, with the risk growing especially for older people as they of smoking, chronic bronchitis, heart failure, or chronic liver
age. In studies conducted on individuals of all ages, only disease. Other authors have also concluded that heavy alcohol
results for the oldest age brackets were significant,3 and in the consumption (>100 g/d for men and 80 g/d for women) is an
only study conducted in young people, age was not a sig- important risk factor for CAP in middle-aged people.6 A US
nificant factor. This would suggest a possible nonlinear effect, cohort study of >100,000 health care professionals found no
with older age being a risk factor for CAP. association between low or moderate alcohol consumption and
The role of sex as a risk factor for CAP is not clear, as the CAP, while stating a lack of sufficient statistical power to
study results are inconsistent. In 4 studies conducted in older determine a statistically significant association between CAP and
people, being male was a risk factor in 2 studies, but was heavy alcohol consumption (>100 g/d for men and 80 g/d for
nonsignificant in the other 2 studies. In the only study women), given the very low exposure prevalence.32 Other
including individuals of all ages (10 to 80 y), being male was a authors have come to a similar conclusion,1,5,21 probably due to
protective factor for CAP. the insufficient statistical power and the choice of relatively low
cutoff points. The effect of alcohol seems to be determined by
CAP RISK FACTORS ASSOCIATED WITH the amount ingested per day—consumption intensity—and not
LIFESTYLE AND THE ENVIRONMENT by the alcohol type or the consumption pattern.

Smoking Habit Occupations and Working Conditions

Abundant evidence attests that tobacco is the main There is abundant evidence of the effect of occupational
modifiable risk factor for CAP, both for the magnitude of the exposure on the respiratory system; especially, there is evi-
effect and for the prevalence of exposure. It has been estimated dence of the involvement of certain substances associated with
that the risk of pneumonia increases between 50% and 400% in environmental pollution in the pathogenesis of major chronic
smokers32 and that between 15% and 30% of the CAP cases lung diseases such as bronchitis, bronchiolitis, asthma, COPD,
could be avoided if smoking was eliminated.33 Multivariate and lung cancer. Nonetheless, very few studies have studied
analyses have shown that smoking has a direct effect on the effect of environmental substances on CAP. Soot, crystal
pneumonia onset that is independent of the effect of chronic silicon, cadmium, and cotton dust, among others, can cause

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Almirall et al Clinical Pulmonary Medicine  Volume 23, Number 3, May 2016

COPD35—itself a major risk factor for CAP—but it is not they then transmit to their caregivers. Regarding pets, it has
known whether the dust of these and other substances may been observed that living with cats, dogs, or birds increases the
directly lead to the development of CAP. No association has risk of CAP; furthermore, the risk of CAP increases in line
been described between CAP and occupational contact with with the number of pets in the home. This effect may be due to
fumes, gases, vapors, gasoline, oil, hydrocarbons, organic and animal hygiene, as dust and germs accumulating in the fur or
inorganic fibers, or ionizing and nonionizing radiation. What the feathers may be transmitted to people. Indeed, contact with
has been described is an independent effect resulting from birds has been associated with psittacosis (parrot fever) and
recent (previous month) exposure to dust.36 No in-depth contact with pet hair has been linked to asthma. The effect of
studies have been conducted as to what type of dust (stone, contact with domestic animals is independent of other housing
cement, mineral, metal, etc.) is responsible for this increased conditions and comorbidity. A stratified analysis showed a
risk. The airways are in contact with about 14,000 L of air in significant interaction between chronic bronchitis and having
the workplace over a 40-hour working week; furthermore, birds in the home (a doubled effect).10
physical movement at work can increase ventilation and Regarding the body mass index, low weight has been
therefore exposure to possible pollutants in the air. Pollutant observed to be a major risk factor for CAP, possibly due to the
particles are deposited in various sections of the airways fact that low weight is an indicator of malnutrition or of an
depending on the concentration and the particle size. A case- underlying disease that may alter the immune system and so
control study by Palmer et al37 concluded that metal fumes, favor CAP development. Indeed, malnutrition has been asso-
especially iron, reversibly predisposes one to CAP. ciated with an increased risk of CAP27 and with an increased
Construction and industrial work (carpentry, painting, risk of death from pneumonia. Other studies have also noted
etc.) has been demonstrated to be a risk factor for CAP, the association between low weight and CAP. Being over-
whereas administrative work is a protective factor.36 The weight or obese, in contrast, has not been reported to imply a
relationship between exposure to dust and the aforementioned risk for CAP. An increased risk of CAP in individuals who had
occupations seems obvious. Referring specifically to the experienced significant weight gain during adulthood was
working conditions, an association has been reported between observed, however, in a prospective study by Baik et al.32
CAP and sudden changes in the workplace temperature; this Studies have also shown that obesity can impair immune
effect is, moreover, independent of chronic bronchitis and function. Nonetheless, further evidence regarding a possible
respiratory infection experienced in the previous month.36 link between obesity and CAP risk is required.
There is evidence that cold reduces ciliary activity and effec- Enhanced education and socioeconomic levels have an
tiveness, thus favoring respiratory infection. This may explain important impact on health, but as social policy issues, they do
the higher incidence of CAP in the coldest months of the year not belong in the health sphere. However, from a clinical and
and in colder countries. It is likely that although the body individual perspective, a knowledge of CAP risk factors
adapts to prolonged cold, sudden changes in temperature that related to living, housing, and nutritional conditions and status
do not enable gradual adaptation may represent true risk fac- should serve to establish CAP prevention recommendations,
tors for CAP. An analysis stratified by age showed that sudden especially for more vulnerable population segments.
temperature changes have a more important effect on people
aged over 65 years.10
Certain work situations are associated with the develop-
ment of CAP, and although they cannot be avoided as being VACCINATIONS
inherent to the occupation, proper preventive measures such as A 23-valent pneumococcal polysaccharide vaccine has
the use of masks and appropriate clothing mitigate the effects. been recommended for the routine vaccination of adults aged
The study of mechanisms, transmission, control, and pre- above 65 years old and for patients at an increased risk of CAP.
vention of pneumonia acquired in certain workplaces remains a However, there is little evidence that it is effective in elderly
challenge for occupational health officers and specifically people or adults with chronic diseases.38 Pneumococcal vac-
designed studies are needed to assess the effectiveness of CAP cination was a protective factor for CAP in a cohort of patients
prevention interventions. of all ages, both in the analysis of the whole cohort (adjusting
for asthma and chronic bronchitis) and in the analysis of
Sociocultural and Housing Conditions asthma patients. In elderly patients, results for pneumococcal
Overcrowding, defined as >10 people living in a house- vaccination were inconclusive, with 2 publications regarding
hold, has been reported as a risk factor for CAP. This may be a the same cohort16 reporting vaccination as a protective factor
risk factor in itself, as a consequence of the closer contact and as a nonsignificant factor (in both cases adjusted for
between different individuals in the household, or it may be an influenza vaccination). A third study with patients above 65
indicator of poor hygiene and health conditions and of a low years old (also adjusted for influenza vaccination) deemed
socioeconomic status. A low education level (incomplete pri- pneumococcal vaccination to be nonsignificant. However, our
mary) has also been reported to represent a higher risk for CAP review of observational studies can only partially shed light on
compared with higher education levels (upper secondary and the role of vaccines, which can only be fully explored through
higher).10 A low education level is also associated with specific randomized clinical trials.
dietary and hygiene habits and conditions that favor the However, a 13-valent pneumococcal conjugate vaccine
development of CAP. In fact, education loses its effect once (PCV-13) is now available for the prevention of pneumonia
adjustments are made for comorbidity (chronic bronchitis, and invasive pneumococcal disease caused by PCV-13 sero-
heart failure, and severe respiratory infection in the previous types in adults aged above 18 years. A recently published
month) and for the occupational status.10 Being married or in a parallel-group, randomized, double-blind, placebo-controlled
partnership is a protective factor in comparison with being trial involving 84,496 adults aged 65 years and older reported
single, widowed, or separated. Living or working with children significant efficacy for the prevention of vaccine-type pneu-
aged under 15 years is also an independent risk factor for CAP, mococcal, bacterial, and nonbacterial CAP and vaccine-type
as children more easily acquire respiratory infections which invasive pneumococcal disease.39

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Clinical Pulmonary Medicine  Volume 23, Number 3, May 2016 Review of Risk Factors for CAP

TABLE 1. Lifestyle Intervention Bundles to Reduce Community-acquired Pneumonia Risk in Adults

Risk Factors Evidence Preventive Strategies
Smoking CAP risk is increased in smokers Smoking cessation
CAP risk is increased by passive smoking in individuals Avoidance of exposure
aged >65 y
Oral hygiene CAP risk is increased in individuals with oral Good oral health and hygiene habits
dysesthesia and dental prosthesis Regular dental checkups
CAP risk is decreased in individuals who have recently
visited a dentist
Nutritional status CAP risk is increased in individuals with a low body Good nutritional and dietary practices
weight
Working conditions CAP risk is increased by recent exposure to dust and by Avoidance of exposure to dust and of sudden
sudden temperature changes in the workplace temperature changes in the workplace
Oropharyngeal dysphagia CAP is associated with oropharyngeal dysphagia in the Universal screening for oropharyngeal
(elderly) elderly dysphagia in frail elderly and elderly patients
admitted with CAP
Contact with children CAP risk is increased by close and regular contact with Avoidance of contact with children with
children respiratory tract infections and protection
against transmission
Nonvaccination against The effectiveness of the 13-valent pneumococcal Recommended for elderly people and
Streptococcus pneumoniae conjugate vaccine has been demonstrated individuals with risk factors for CAP
CAP indicates community-acquired pneumonia.

The role of influenza vaccination as a protective factor for 2. Koivula Y, Sten M, Mäkelä PH. Risk factors for pneumonia in the
CAP is also unclear. A single general population study (above elderly. Am J Med. 1994;96:313–320.
14 y) found it to be a protective factor for the whole cohort 3. Farr BM, Woodhead MA, Macfarlane JT, et al. Risk factors for
(adjusting for asthma and chronic bronchitis), but to be non- community-acquired pneumonia diagnosed by general practi-
tioners in the community. Respir Med. 2000;94:422–427.
significant in the subcohorts of COPD patients and of asthma 4. Jackson ML, Neuzil KM, Thompson WW, et al. The burden of
patients. The only study of elderly patients found vaccination community-acquired pneumonia in seniors: results of a popula-
to be nonsignificant. tion-based study. Clin Infect Dis. 2004;39:1642–1650.
5. Almirall J, Bolibar I, Balanzó X, et al. Risk factors for community-
acquired pneumonia in adults: a population-based case-
control study. Eur Respir J. 1999;13:349–355.
COMMUNITY-ACQUIRED PNEUMONIA 6. Fernández-Solà J, Junque A, Estruch R, et al. High alcohol intake
PREVENTION BUNDLES as a risk and prognostic factor for community-acquired pneumo-
The most frequently observed comorbidities associated nia. Arch Intern Med. 1995;155:1649–1654.
with CAP are COPD, chronic bronchitis, asthma, and heart 7. Fahy JV, Corry DB, Boushey HA. Airway inflammation and
failure. We can only point toward the need for heightened remodeling in asthma. Curr Opin Pulm Med. 2000;6:15–20.
8. Lange P, Vestbo J, Nyboe J. Risk factors for death and
awareness of the risk of CAP in these patients and for appro-
hospitalization from pneumonia. A prospective study of a general
priate management of these diseases. population. Eur Respir J. 1995;8:1694–1698.
Bundles for CAP prevention are summarized in Table 1. 9. Godard P, Chaintreuil J, Damon M, et al. Functional assessment of
Certain lifestyle factors such as smoking, dental hygiene, alveolar macrophages: comparison of cells from asthmatics and
nutritional and dietary habits, and certain working and envi- normal subjects. J Allergy Clin Immunol. 1982;70:88–93.
ronmental conditions (such as contact with dust and sudden 10. Almirall J, Bolı́bar I, Serra-Prat M, et al. The Community-
changes in temperature) have been shown to be modifiable risk Acquired Pneumonia in Catalan Countries (PACAP). New
factors for CAP. evidence of risk factors for community-acquired pneumonia: a
In the elderly, oropharyngeal dysphagia is a major risk population-based study. Eur Respir J. 2008;31:1274–1284.
factor for CAP, as an impaired swallow response and delayed 11. Loeb M, Neupane B, Walter SD, et al. Environmental risk factors
for community-acquired pneumonia hospitalization in older adults.
airway protection favor tracheobronchial aspirations and
J Am Geriatr Soc. 2009;57:1036–1040.
pneumonia. We propose universal screening for oropharyngeal 12. Almirall J, Bolı́bar I, Serra-Prat M, et al. Inhaled drugs as risk
dysphagia in elderly patients admitted with CAP and the factors for community-acquired pneumonia. Eur Respir J. 2010;
adoption of strategies to assess and treat this condition when 36:1080–1087.
aspiration is suspected. 13. Gau JT, Acharya U, Khan S, et al. Pharmacotherapy and the risk
Finally, vaccination against pneumococcal disease with for community-acquired pneumonia. BMC Geriatr. 2010;10:45.
the PCV-13 has been shown to be effective and is also rec- 14. Mason CM, Nelson S. Pulmonary host defenses and factors
ommended for high-risk patients and elderly individuals, as predisposing to lung infection. Clin Chest Med. 2005;26:11–17.
Streptococcus pneumoniae is the most frequently isolated 15. Kim PE, Musher DM, Glezen WP, et al. Association of invasive
pathogen from patients with CAP.40 pneumococcal disease with season, atmospheric conditions, air
pollution, and the isolation of respiratory viruses. Clin Infect Dis.
1996;22:100–106.
REFERENCES 16. Vila-Corcoles A, Ochoa-Gondar O, Rodriguez-Blanco T, et al.
1. Lipsky BA, Boyko EJ, Inui TS, et al. Risk factors for acquiring Epidemiology of community-acquired pneumonia in older adults:
pneumococcal infections. Arch Intern Med. 1986;146:2179–2185. a population-based study. Respir Med. 2009;103:309–316.

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Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Almirall et al Clinical Pulmonary Medicine  Volume 23, Number 3, May 2016

17. Marik PE. Aspiration pneumonitis and aspiration pneumonia. without human immunodeficiency virus infection: incidence,
N Engl J Med. 2001;344:665–671. etiologies, and clinical aspects. Clin Infect Dis. 1996;23:107–113.
18. Leibovitz A, Plotnikov G, Habot B, et al. Pathogenic colonization 30. Fedson DS, Harward MP, Reid RA, et al. Hospital-based
of oral flora in frail elderly patients fed by nasogastric tube or pneumococcal immunization. Epidemiologic rationale from the
percutaneous enterogastric tube. J Gerontol A Biol Sci Med Sci. Shenandoah study. JAMA. 1990;264:1117–1122.
2003;58:52–55. 31. White DA. Drug-induced pulmonary infection. Clin Chest Med.
19. Metheny NA. Preventing respiratory complications of tube feedings: 2004;25:179–187.
evidence-based practice. Am J Crit Care. 2006;15:360–369. 32. Baik I, Curhan GC, Rimm EB, et al. A prospective study of age
20. Segal R, Pogoreliuk I, Dan M, et al. Gastric microbiota in elderly and lifestyle factors in relation to community-acquired pneumonia
patients fed via nasogastric tubes for prolonged periods. J Hosp in US men and women. Arch Intern Med. 2000;160:3082–3088.
Infect. 2006;63:79–83. 33. Almirall J, Gonzalez CA, Balanzó X, et al. Proportion of
21. LaCroix AZ, Lipson S, Miles TP, et al. Prospective study of community-acquired pneumonia cases attributable to tobacco
pneumonia hospitalizations and mortality of US older people: the smoking. Chest. 1999;116:375–379.
role of chronic conditions, health behaviors, and nutritional status. 34. Almirall J, Serra-Prat M, Bolı́bar I, et al. Passive smoking at home
Public Health Rep. 1989;104:350–360. is a risk factor for community-acquired pneumonia in older adults:
22. Klare B, Kubini R, Ewig S. Risk factors for pneumonia in patients a population-based case-control study. BMJ Open. 2014;4:
with cardiovascular diseases. Pneumologie. 2002;56:781–788.
e005133.
23. Ginesu F, Pirina P. Etiology and risk factors of adult pneumonia.
35. Hendrick DJ. Occupation and chronic obstructive pulmonary
J Chemother. 1995;7:277–285.
disease. Thorax. 1996;51:947–955.
24. Mussa FF, Chai H, Wang X, et al. Chlamydia pneumoniae and
vascular disease: an update. J Vasc Surg. 2006;43:1301–1307. 36. Almirall J, Serra-Prat M, Bolibar I, et al. Relación de las
25. Bouter KP, Diepersloot RJ, van Romunde LK, et al. Effect of profesiones y las condiciones laborales con la neumonı́a adquirida
epidemic influenza on ketoacidosis, pneumonia and death in en la comunidad [Professions and working conditions associated
diabetes mellitus: a hospital register survey of 1976-1979 in The with community-acquired pneumonia]. Arch Bronconeumol. 2014.
Netherlands. Diabetes Res Clin Pract. 1991;12:61–68. pii: S0300-2896(14)00431-1. doi: 10.1016/j.arbres.2014.10.003.
26. Almirall J, Rofes L, Serra-Prat M, et al. Oropharyngeal dysphagia [Epub ahead of print].
is a risk factor for community acquired pneumonia in the elderly. 37. Palmer KT, Poole J, Ayres JG, et al. Exposure to metal fume and
Eur Respir J. 2013;41:1–6. infectious pneumonia. Am J Epidemiol. 2003;157:227–233.
27. Riquelme R, Torres A, El-Ebiary M, et al. Community-acquired 38. Huss A, Scott P, Stuck AE, et al. Efficacy of pneumococcal
pneumonia in the elderly: clinical and nutritional aspects. Am J vaccination in adults: a meta-analysis. CMAJ. 2009;180:48–58.
Respir Crit Care Med. 1997;156:1908–1914. 39. Bonten MJM, Huijts SM, Bolkenbaas M, et al. Polysaccharide
28. Laheij RJ, Sturkenboom MC, Hassing RJ, et al. Risk of conjugate vaccine against pneumococcal pneumonia in adults.
community-acquired pneumonia and use of gastric acid- N Engl J Med. 2015;372:1114–1125.
suppressive drugs. JAMA. 2004;292:1955–1960. 40. Sanz F, Blanquer J. Microbiology and risk factors for community-
29. Boschini A, Smacchia C, Di Fine M, et al. Community-acquired acquired pneumonia. Semin Respir Crit Care Med. 2012;33:
pneumonia in a cohort of former injection drug users with and 220–231.

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