antibiotic resistance

Influenza is known to exacerbate underlying pulmonary and cardiac conditions and to lead to secondary bacterial pneumonia or primary viral pneumonia; in addition, infection with influenza virus may occur concurrently with other pathogens. The use of influenza vaccination in target groups is supported by the Centers for Disease Control and Prevention in the United States and the National Advisory Committee on Immunization (NACI) in Canada. The target groups for whom NACI recommended influenza vaccination for the 2004/05 influenza season are listed in Table 4. In addition to these target groups, vaccination is also encouraged for healthy individuals 2 to 64 years of age. The benefit of vaccination has been reported by Nichol and others, who studied elderly residents living in the community. Influenza vaccination reduced the risk of hospital admission due to pneumonia, cardiac disease, and cerebrovascular disease by 32%, 19%, and 16%, respectively, and the risk of death by 48%. The importance of vaccinating health care workers was demonstrated by Carman and others, who found that the mortality rate due to influenza was lower in hospitals with a high vaccination rate for health care workers than in hospitals with a lower vaccination rate. In a study of influenza vaccination rates in Alberta, under-utilization of vaccination for elderly people was associated with increased utilization of health services for CAP.

Given the prevalence of S. pneumoniae, pneumococcal vaccination of at-risk groups is also recommended. Vaccination with the pneumococcal 23-valent polysaccharide vaccine is recommended for elderly patients and patients with risk factors (Table 5). For patients less than 2 years of age, the 7-valent pneumococcal conjugate vaccine may be used. Pneumococcal antibody levels may decline over 5 to 10 years, although the exact duration of immunity is unknown. Antibody levels may decline more rapidly in certain patient groups. The benefits of pneumococcal vaccination have been widely discussed and supported.
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Table 4. Target Groups for Influenza Vaccination (National Advisory Committee on Immunization)
Adults and children with chronic cardiac or pulmonary disease
(including bronchopulmonary dysplasia, cystic fibrosis, and asthma)
severe enough to require medical follow-up or hospital care
People of any age who are residents of nursing homes or other
chronic care facilities
People  65 years of age
Adults and children with chronic conditions, such as diabetes
mellitus and other metabolic diseases, cancer, immunodeficiency,
immunosuppression (due to underlying disease and/or therapy),
renal disease, anemia, or hemoglobinopathy
Children and adolescents (6 months to 18 years of age) with
conditions treated for long periods with acetylsalicylic acid
People at high risk of influenza complications who are embarking
on travel to destinations where influenza is likely to be circulating
People capable of transmitting influenza to those at high risk of
influenza-related complications (e.g., health care and other service
providers, household members, child care workers)
People who provide essential community services
People in direct contact with poultry infected with avian influenza
during culling operations

Spanish investigators found a direct correlation between amount of tobacco smoking and incidence of CAP. In a case-control study of patients with CAP, tobacco smoking was identified as an avoidable risk factor for the disease. Because tobacco smoking impairs the normal pulmonary defences, smoking cessation programs should be encouraged.
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Table 5. Patients at Risk of Pneumococcal Disease

Highest risk
People 2 years of age,* not previously immunized , in the following
risk categories, especially those with a recent diagnosis and/or newly
entering programs
Sickle cell disease, congenital or acquired asplenia, or splenic
Dialysis: upon commencement of dialysis, nephrotic syndrome
Multiple myeloma
Residence in a long-term care facility
Congenital immune deficiencies, specifically IgG, IgG subclass,
and IgM deficiencies, and severe combined immunodeficiency†
Chronic cerebrospinal fluid leaks
Induced immunosuppression for organ transplant or posttransplantation
(bone marrow or stem cell and solid organ transplants)
Cochlear implants
Moderate to high risk
Age  75 years
Age 65–74 years of age with any of the following chronic underlying
Chronic renal disease, chronic renal insufficiency
Chronic cardiac disease (particularly cyanotic congenital heart
disease or cardiac failure)
Chronic pulmonary disease (excluding asthma, except those
treated with high-dose oral corticosteroid therapy)
Chronic liver disease with or without ascites (e.g., cirrhosis,
Diseases associated with immunosuppressive therapy or radiation
therapy, including autoimmune diseases being treated with
high-dose steroids and chemotherapy agent(s)
Malignancy (e.g., leukemia, Hodgkin’s or non-Hodgkin’s lymphoma)
Poorly controlled diabetes mellitus