Klinik und Diagnose bronchopulmonaler Infektionen im Alter

G. Hoheisel; J. Winkler; C. Gessner; S. Hammerschmidt; H.-J. Seyfarth; A. C. Rodloff; U.-G. Liebert; H. Wirtz; A. Gillissen

doi:10.1055/s-2008-1038146

Pneumologie 2008; 62(5): 297-304
DOI: 10.1055/s-2008-1038146

Übersicht

Klinik und Diagnose bronchopulmonaler Infektionen im Alter

Clinical Features and Diagnosis of Bronchopulmonary Infections in the ElderlyG. Hoheisel¹ , J. Winkler² , C. Gessner³ , S. Hammerschmidt⁴ , H.-J. Seyfarth⁴ , A. C. Rodloff⁵ , U.-G. Liebert⁶ , H. Wirtz⁴ , A. Gillissen⁷

¹Internistisch-Pneumologische Praxen, Leipzig
²Internistisch-Pneumologische Praxen, Leipzig
³Internistisch-Pneumologische Praxen, Leipzig
⁴Department Innere Medizin, Abteilung Pneumologie, Universitätsklinikum Leipzig
⁵Institut für Medizinische Mikrobiologie und Infektionsepidemiologie, Universitätsklinikum Leipzig
⁶Institut für Virologie, Universitätsklinikum Leipzig
⁷Thorax-Zentrum, Klinikum St. Georg eGmbH, Robert Koch-Klinik, Leipzig

Abstract

Zusammenfassung

Erkrankungen der Lunge sind bei älteren Menschen eine der Hauptursachen von Morbidität und Letalität. Das Risiko von Atemwegsinfektionen ist durch strukturelle Lungenveränderungen, Mangelernährung, Begleiterkrankungen und eine Vielzahl weiterer Faktoren im Alter erhöht. Bakterielle und virale Erreger verursachen akute Bronchitiden und Exazerbationen chronisch obstruktiver Atemwegserkrankungen (AECB). Ambulant erworbene Pneumonien (community acquired pneumonias, CAP) unterscheiden sich von nosokomialen Pneumonien (hospital acquired pneumonia, HAP) durch ihr Erregerspektrum und den Verlauf. Institutionalisierte Patienten sind gefährdet eine health care associated pneumonia (HCAP) zu erleiden, deren Erregerspektrum sich oft von CAP und HAP unterscheidet. Ältere mit zerebrovaskulären Erkrankungen und Beeinträchtigung der Schluck- und Hustenreflexe erleiden häufig eine Aspirationspneumonie. Die Letalität ist bei älteren komorbiden und immunsupprimierten Patienten mit nosokomialen Pneumonien am höchsten. Wichtige Präventivmaßnahmen sind die Influenza- und Pneumokokken-Schutzimpfung, Vermeidung von Immobilität, Mundpflege und ausreichende Ernährung.

Abstract

Diseases of the lung are one of the main causes of morbidity and mortality in the elderly. The risk of respiratory infections is increased due to structural changes, malnutrition, co-morbidity, and a variety of other factors. Bacterial and viral pathogens cause acute bronchitis and exacerbations of chronic bronchitis (AECB). Community acquired pneumonias (CAP) show a different spectrum of pathogens and clinical course in comparison to nosocomial pneumonias (hospital acquired pneumonia, HAP). Institutionalised patients are at risk of a health care associated pneumonia (HCAP), with often a different spectrum of pathogens in comparison to CAP and HAP. Elderly patients with cerebrovascular disease and impairment of swallowing or cough reflexes often suffer from aspiration pneumonias. The mortality is highest in the elderly, comorbid, and immunocompromised patient with nosocomial pneumonia. Important preventive measures include influenza and pneumococcal vaccination, avoidance of immobility, oral hygiene, and sufficient nutrition.

Full Text

References

Literatur

1 National Center for Health Statistics .Health, United States, 2004 with chartbook on trends in the health of Americans. Hyattsville MD 2004; http://www.cdc.gov/nchs
2 Esposito A L. The effect of common pharmacologic agents on pulmonary antibacterial defenses: implications for the geriatric patient. Clin Chest Med. 1987; 8 373-380
3 Gomez C R, Boehmer E D, Kovacs E J. The aging innate immune system. Curr Opin Immunol. 2005; 5 457-462
4 Meyer K C. Aging. Proc Am Thorac Soc. 2005; 2 433-439
5 Beckham J D, Cadena A, Lin J. et al . Respiratory viral infections in patients with chronic, obstructive pulmonary disease. J Infect. 2005; 50 322-330
6 Falsey A R. Community-acquired viral pneumonia. Clin Geriatr Med. 2007; 23 535-552, vi
7 Murata Y, Walsh E E, Falsey A R. Pulmonary complications of interpandemic influenza A in hospitalized adults. J Infect Dis. 2007; 195 1029-1037
8 Loeb M. Epidemiology of community- and nursing home-acquired pneumonia in older adults. Expert Rev Anti Infect Ther. 2005; 3 263-270
9 Janssens J P, Herrmann F, MacGee W. et al . Cause of death in older patients with anatomo-pathological evidence of chronic bronchitis or emphysema: a case-control study based on autopsy findings. J Am Geriatr Soc. 2001; 49 571-576
10 Chodosh S, McCarty J, Farkas S. et al . Randomized, double-blind study of Ciprofloxacin and cefuroxime axetil for treatment of acute bacterial exacerbations of chronic bronchitis. The Bronchitis Study Group. Clin Infect Dis. 1998; 27 722-729
11 Flamaing J, Engelmann I, Joosten E. et al . Viral lower respiratory tract infection in the elderly: a prospective in-hospital study. Eur J Clin Microbiol Infect Dis. 2003; 22 720-725
12 Creer D D, Dilworth J P, Gillespie S H. et al . Aetiological role of viral and bacterial infections in acute adult lower respiratory tract infection (LRTI) in primary care. Thorax. 2006; 61 75-79
13 Gillissen A, Gessner C, Hammerschmidt S. et al . Akute Bronchitis: wann sind Antibiotika und wann ist eine symptomatische Therapie indiziert?. MMW Fortschr Med. 2006; 148 26-28
14 Worth G, Buhl R, Cegla U. et al . Leitlinie der Deutschen Atemwegsliga und der Deutschen Gesellschaft für Pneumologie zur Diagnostik und Therapie von Patienten mit chronisch obstruktiver Bronchitis und Lungenemphysem (COPD). Pneumologie. 2003; 56 704-738
15 Vogelmeier C, Buhl R, Criée C P. et al . Leitlinie der Deutschen Atemwegsliga und der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin zur Diagnostik und Therapie von Patienten mit chronisch obstruktiver Bronchitis und Lungenemphysem (COPD). Pneumologie. 2007; 61 e1-e40
16 Höffken G, Kolditz M, Halank M. Schwere ambulant erworbene Pneumonie. Chemotherapie J. 2005; 4 97-155
17 Seemungal T, Harper-Owen R, Bhowmik A. et al . Respiratory Viruses, Symptoms, and Inflammatory Markers in Acute Exacerbation and Stable Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2001; 164 1618-1623
18 Rohde G, Wiethege A, Borg I. et al . Respiratory viruses in exacerbations of chronic obstructive pulmonary disease requiring hospitalization - a case control study. Thorax. 2003; 58 37-42
19 Groenewegen K H, Schols A MWJ, Wouters E FM. Mortality and Mortality-Related Factors After Hospitalization for Acute Exacerbation of COPD. Chest. 2003; 124 459-467
20 Patil S P, Krishnan J A, Lechtzin N. et al . In-hospital mortality following acute exacerbations of chronic obstructive pulmonary disease. Arch Intern Med. 2003; 163 1180-1186
21 Höffken G, Lorenz L, Kern W. et al . S3-Leitlinie zu ambulant erworbener Pneumonien und tiefen Atemwegsinfektionen. Leitlinie der Paul-Ehrlich-Gesellschaft für Chemotherapie, der Deutschen Gesellschaft für Pneumologie, der Deutschen Gesellschaft für Infektiologie und vom Kompetenznetzwerk CAPNETZ. Pneumologie. 2005; 59 612-664
22 Anon J M, Garcia d L, Zarazaga A. et al . Mechanical Ventilation of patients on long-term oxygen therapy with acute exacerbations of chronic obstructive pulmonary disease: prognosis and cost-utility analysis. Intensive Care Med. 1999; 25 452-457
23 Woolhouse I S, Hill S L, Stockley R A. Symptom resolution assessed using a patient directed diary card during treatment of acute exacerbations of chronic bronchitis. Thorax. 2001; 56 947-953
24 Donaldson G C, Seemungal T A, Bhowmik A. et al . Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease. Thorax. 2002; 57 847-852
25 Papi A, Bellettato C M, Braccioni F. et al . Infections and airway inflammation in chronic obstructive pulmonary disease severe exacerbations. Am J Respir Crit Care Med. 2006; 173 1114-1121
26 Wilkinson T M, Hurst J R, Perera W R. et al . Effect of interactions between lower airway bacterial and rhinoviral infection in exacerbations of COPD. Chest. 2006; 129 317-324
27 Schmidt-Ioanas M, Lode H. Treatment of pneumonia in elderly patients. Expert Opin Pharmacother.. 2006; 7 499-507
28 Metlay J P, Fine M J, Schulz R. et al . Measuring symptomatic and functional recovery in patients with community-acquired pneumonia. J Gen Intern Med. 1997; 12 423-430
29 Metlay J P, Schulz R, Li Y H. et al . Influence of age on Symptoms at presentation in patients with community-acquired pneumonia. Arch Intern Med. 1997; 157 1453-1459
30 Ewig S. Community-acquired pneumonia: epidemiology, risk, and prognosis. In: Torres A, Woodhead M (Hrsg). Pneumonia. Sheffield: European Respiratory Society Journals Ltd 1997: 13-35
31 Macfarlane J T. An overview of community-acquired pneumonia with lessons learned from the British Thoracic Society study. Semin Respir Infect. 1994; 9 153-165
32 Finkelstein M S, Petkun W M, Freedman M L. et al . Pneumococcal bacteremia in adults: age-dependent differences in presentation and in out come. J Am Geriatr Soc. 1983; 31 19-27
33 Fine M J, Smith D N, Singer D E. Hospitalization decision in patients with community-acquired pneumonia: a prospective cohort study. Am J Med. 1990; 89 713-721
34 Bates J H, Campbell G D, Barron A L. et al . Microbial etiology of acute pneumonia in hospitalized patients. Chest. 1992; 101 1005-1012
35 Niederman M S, Bass J B, Campbell G D. et al . Guidelines of the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. Official statement of the American Thoracic Society. Am Rev Respir Dis. 1993; 148 1418-1426
36 Höffken G, Steinhoff D, Lode H. et al . Ätiologie von ambulant erworbenen Pneumonien bei älteren Menschen. Chemotherapie J. 1995; 4 13-19
37 García-Ordóñez M A, García-Jiménez J M, Páez F. et al . Clinical aspects and prognostic factors in elderly patients hospitalised for community-acquired pneumonia. Eur J Clin Microbiol Infect Dis. 2001; 20 14-19
38 Woodhead M, Ortqvist A. Pulmonary infections: what to do when it's a bug that you do not know. Eur Respir J. 2003; 21 201
39 Riquelme R, Torres A, el-Ebiary M. et al . Community-acquired pneumonia in the elderly. clinical and nutritional aspects. Am J Respir Crit Care Med. 1997; 156 1908-1914
40 Arancibia F, Bauer T T, Ewig S. et al . Community-acquired pneumonia due to gram-negative bacteria and pseudomonas aeruginosa: incidence, risk, and prognosis. Arch Intern Med. 2002; 162 1849-58
41 Falsey A R. Respiratory syncytial virus infection in adults. Semin Respir Crit Care Med. 2007; 28 171-181
42 Falsey A R, Hennessey P A, Formica M A. et al . Respiratory syncytial virus infection in elderly and high-risk adults. N Engl J Med. 2005; 352 1749-1759
43 Deffrasnes C, Hamelin M E, Boivin G. Human metapneumovirus. Semin Respir Crit Care Med. 2007; 28 213-221
44 Kikuta H. Human metapneumovirus. Uirusu. 2006; 56 173-181
45 Falsey A R, Walsh E E. Viral pneumonia in older adults. Clin Infect Dis. 2006; 42 518-524
46 de Roux A, Ewig S, Garcia E. et al . Mixed community-acquired pneumonia in hospitalised patients. Eur Respir J. 2006; 27 795-800
47 de Roux A, Marcos M A, Garcia E. et al . Viral community-acquired pneumonia in non-immunocompromised adults. Chest. 2004; 125 1343-1351
48 Hak E, Verheij T J, Essen G A van. et al . Prognostic factors for influenza-associated hospitalization and death during an epidemic. Epidemiol Infect. 2001; 126 261-268
49 Schaberg T. Diagnosis, therapy, and prevention of influenza. Pneumologie. 2003; 57 27-33
50 Lee N, Hui D, Wu A. et al . A major outbreak of severe acute respiratory syndrome in Hong Kong. N Engl J Med. 2003; 348 1986-1994
51 Tsang K W, Ho P L, Ooi G C. et al . A cluster of cases of severe acute respiratory syndrome in Hong Kong. N Engl J Med. 2003; 348 1977-1985
52 Hoheisel G, Wu A, Lee N. et al . Schweres akutes respiratorische Syndrom (SARS). Pneumologie. 2003; 57 315-321
53 Hoheisel G, Luk W K, Winkler J. et al . Schweres Akutes Respiratorisches Syndrom (SARS). Med Klin (Munich). 2006; 101 957-963
54 Hui D S. An overview on severe acute respiratory syndrome (SARS). Monaldi Arch Chest Dis. 2005; 63 149-157
55 Yuen K Y, Chan P K, Peiris M. et al . Clinical features and rapid viral diagnosis of human disease associated with avian influenza A H5N1 virus. Lancet. 1998; 351 467-471
56 Beigel J H, Farrar J, Han A M. et al . Writing Committee of the World Health Organization (WHO) Consultation on Human Influenza A/H5: Avian influenza A (H5N1) infection in humans. N Engl J Med. 2005; 353 1374-1385
57 Ewig S, de Roux A, Bauer T. et al . Validation of predictive rules and indices of severity for community acquired pneumonia. Thorax. 2004; 59 421-427
58 Clavo-Sánchez A J, Girón-González J A, López-Prieto D. et al . Multivariate analysis of risk factors for infection due to penicillin-resistant and multidrug-resistant Streptococcus pneumoniae: A multicenter study. Clin Infect Dis. 1997; 24 1052-1059
59 Ewig S, Torres A, Angeles Marcos M. et al . Factors associated with unknown aetiology in patients with community-acquired pneumonia. Eur Respir J. 2002; 20 1254-1262
60 Marrie T. Normal resolution of community-acquired pneumonia. Semin Respir Infect. 1992; 7 289-293
61 Mittl R L, Schwab R J, Duchin J S. et al . Radiographic resolution of community-acquired pneumonia. Am J Respir Crit Care Med. 1994; 149 630-635
62 El Solh A A, Aquilina A T, Gunen H. et al . Radiographic resolution of community-acquired bacterial pneumonia in the elderly. J Am Geriatr Soc. 2004; 52 224-229
63 Metlay J P, Kapoor W N, Fine M J. Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA. 1997; 278 1440-1445
64 The British Thoracic Society Research Committee and The Public Health Laboratory Service . The aetiology, management and outcome of severe community-acquired pneumonia on the intensive care unit. Respir Med. 1992; 86 7-13
65 Feinsilver S H, Fein A M, Niederman M S. et al . Utility of fiberoptic bronchoscopy in non-resolving pneumonia. Chest. 1990; 98 1322-1326
66 Ruiz M, Ewig S, Marcos M A. et al . Etiology of community-acquired pneumonia in hospitalized patients: Impact of age, comorbidity and severity. Am J Respir Crit Care Med. 1999; 159 A559
67 Ruiz M, Ewig S, Torres A. et al . Severe community-acquired pneumonia. Risk factors and follow-up epidemiology. Am Respir Crit Care Med. 1999; 160 923-929
68 Ewig S, Ruiz M, Mensa J. et al . Severe community-acquired pneumonia: Assessment of severity criteria. Am J Respir Crit Care Med. 1998; 158 1102-1108
69 Kuru T, Lyons J P3. Nonresolving or slowly resolving pneumonia. Clin Chest Med. 1999; 20 623-651
70 Mody L, Sun R, Bradley S F. Assessment of pneumonia in older adults: effect of functional status. J Am Geriatr Soc. 2006; 54 1062-1067
71 Fine M J, Auble T E, Yealy D M. et al . A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997; 336 243-250
72 The British Thoracic Society . BTS Guidelines for the Management of Community Acquired Pneumonia in Adults. Thorax. 2001; 56 liv-64
73 Neill A M, Martin I R, Weir R. et al . Community-acquired pneumonia: aetiology and usefulness of severity criteria on admission. Thorax. 1996; 51 1010-1016
74 Halm E A, Fine M J, Marrie T J. et al . Time to clinical stability in patients hospitalized with community-acquired pneumonia: implications for practice guidelines. JAMA. 1998; 279 1452-1457
75 Welte T. Community-acquired and nosocomial pneumonia. Internist. 2003; 44 44-58
76 Janssens J P. Pneumonia in the elderly (geriatric) population. Curr Opin Pulm Med. 2005; 11 226-230
77 Saldias Penafiel F, O'Brien Solar A, Gederlini Gollerino A. et al . Community-acquired pneumonia requiring hospitalization in immunocompetent elderly patients: clinical features, prognostic factors and treatment. Arch Bronco pneumol. 2003; 39 333-340
78 Pascual F E, Matthay M A, Bacchetti P. et al . Assessment of prognosis in patients with community-acquired pneumonia who require mechanical ventilation. Chest. 2000; 117 503-512
79 Hauer T, Lacour M, Gastmeier P. et al . Nosokomiale Infektionen in Deutschland (NIDEP). Med Klinik. 1996; 91 681-686
80 Rüden H, Gastmeier P, Wischnewski N. et al . Prävalenz der wichtigsten nosokomialen Infektionen in Deutschland, Ergebnisse der NIDEP-Studie. Bundesgesundheitsblatt. 1997; 6 198-203
81 Steinbrecher E, Sohr D, Nassauer A. et al . Die häufigsten Erreger bei Intensivpatienten mit nosokomialen Infektionen, Ergebnisse des Krankenhaus-Infektions-Surveillance-Systems (KISS). Chemotherapie Journal. 2000; 5 179-184
82 Lorenz J, Bodmann K F, Bauer T T. et al . Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI).Nosokomiale Pneumonie, Prävention, Diagnose, Therapie. Pneumologie. 2003; 57 532-545
83 The Canadian Critical Care Trials Group . A Randomized Trial of Diagnostic Techniques for Ventilator-Associated Pneumonia. N Engl J Med. 2006; 355 2619-2630
84 Abdallah A, Rowland K E, Schepetiuk S K. et al . An outbreak of respiratory syncytial virus infection in a bone marrow transplant unit: effect on engraftment and outcome of pneumonia without specific antiviral treatment. Bone Marrow Transplant. 2003; 32 195-203
85 Oliveira E C, Lee B, Colice G L. Influenza in the intensive care unit. J Intensive Care Med. 2003; 18 80-91
86 Daubin C, Vincent S, Vabret A. et al . Nosocomial viral ventilator-associated pneumonia in the intensive care unit: a prospective cohort study. Intensive Care Med. 2005; 31 1116-1122
87 Dalhoff K, Ewig S, Höffken G. et al . Recommendations for the diagnosis, therapy and prevention of pneumonia in the immunocompromised host German Pathology Society. Pneumologie. 2002; 56 807-831
88 Hoheisel G, Lange S, Winkler J. et al . Nosokomiale Pneumonien bei hämatologischen Malignomen in der internistischen Intensivmedizin. Pneumologie. 2003; 57 73-77
89 Winkler J, Müller U, Nenoff P. et al . Treatment of invasive pulmonary aspergillosis in neutropenic patients by additional bronchoscopic amphotericin B instillation. Respiration. 2007; 74 663-673
90 Ewig S, Dalhoff K, Lorenz J. et al . Nosokomiale Pneumonie: Empfehlungen zur Therapie und Prophylaxe. Pneumologie. 2000; 54 525-538
91 Celis R, Torres A, Gatell J M. et al . Nosocomial pneumonia. A multivariate analysis of risk and prognosis. Chest. 1988; 93 318-324
92 Torres A, Aznar R, Gatell J M. et al . Incidence, risk, and prognostic factors of nosocomial pneumonia in mechaniccally ventilated patients. Am Rev Respir Dis. 1990; 142 523-528
93 Bodmann K F, Lorenz J, Bauer T T. et al . Nosokomiale Pneumonie: Prävention, Diagnostik und Therapie. Ein Konsensuspapier der Paul-Ehrlich-Gesellschaft für Chemotherapie (PEG) und der Deutschen Gesellschaft für Pneumologie (DGP) unter Mitarbeit von Experten der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI). Chemotherapie J. 2003; 12 33-44
94 Rello J, Quintana E, Ausina V. et al . Incidence, etiology, and outcome of nosocomial pneumonia in mechanically ventilated patients. Chest Vol. 1991; 100 439-444
95 Fagon J Y, Chastre J, Vuagnat A. et al . Nosocomial pneumonia and mortality among patients in intensive care units. JAMA. 1996; 275 866-869
96 Kollef M H. Ventilator-associated pneumonia. A multivariate analysis. JAMA. 1993; 270 1965-1970
97 Papazian L, Bregeon F, Thirion X. et al . Effect of ventilator-associated pneumonia on mortality and morbidity. Am J Respir Crit Care Med. 1997; 154 91-97
98 Carratalà J, Mykietiuk A, Fernández-Sabé N. et al . Health care-associated pneumonia requiring hospital admission: epidemiology, antibiotic therapy, and clinical outcomes. Arch Intern Med. 2007; 167 1393-1399
99 Kollef M H, Shorr A, Tabak Y P. et al . Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest. 2005; 128 3854-3862
100 Micek S T, Kollef K E, Reichley R M. et al . Health care-associated pneumonia and community-acquired pneumonia: a single-center experience. Antimicrob Agents Chemother.. 2007; 51 3568-3573
101 Ohrui T. Preventive strategies for aspiration pneumonia in elderly disabled persons. Tohoku J Exp Med. 2005; 207 3-12
102 Paju S, Scannapieco F A. Oral biofilms, periodontitis, and pulmonary infections. Oral Diseases. 2007; 13 508-512
103 Didilescu A C, Skaug N, Marica C. et al . Respiratory pathogens in dental plaque of hospitalized patients with chronic lung diseases. Clin Oral Invest. 2005; 9 141-147
104 Hennessy S, Bilker W B, Leonard C E. et al . Observed association between antidepressant use and pneumonia risk was confounded by comorbidity measures. J Clin Epidemiol. 2007; 60 911-918
105 Smithard D G, O'Neill P A, Park C. et al . North West Dysphagia Group. Can bedside assessment reliably exclude aspiration following acute stroke?. Age Ageing. 1998; 27 99-106
106 Quagliarello V, Ginter S, Han L. et al . Modifiable risk factors for nursing home-acquired pneumonia. Clin Infect Dis. 2005; 40 7-8
107 El-Solh A A, Pietrantoni C, Bhat A. et al . Colonization of dental plaques: a reservoir of respiratory pathogens for hospital-acquired pneumonia in institutionalized elders. Chest. 2004; 126 1575-1582
108 Watando A, Ebihara S, Ebihara T. et al . Daily oral care and cough reflex sensitivity in elderly nursing home patients. Chest. 2004; 126 1066-1070
109 El Solh A A, Pietrantoni C, Bhat A. et al . Microbiology of severe aspiration pneumonia in institutionalized elderly. Am J Respir Crit Care Med. 2003; 167 1650-1654
110 Brandt H E, Ooms M E, Deliens L. et al . The last two days of life of nursing home patients - a nationwide study on causes of death and burdensome symptoms in The Netherlands. Palliat Med. 2006; 20 533-540
111 Abdel-Karim I A, Sammel R B, Prange M A. Causes of death at autopsy in an inpatient hospice program. J Palliat Med 2007. Aug ; 10 (4) 894-898
112 Skull S A, Andrews R M, Byrnes G B. et al . Prevention of community-acquired pneumonia among a cohort of hospitalized elderly: benefit due to influenza and pneumococcal vaccination not demonstrated. Vaccine. 2007; 25 4631-4640

Priv.-Doz. Dr. med. Gerhard Hoheisel

August-Bebel-Str. 69

04275 Leipzig

Email: gerhard.hoheisel@t-online.de