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Etiology and antimicrobial resistance of

community-acquired pneumonia in adult
patients in China
ARTICLE in CHINESE MEDICAL JOURNAL SEPTEMBER 2012
Impact Factor: 1.05 DOI: 10.3760/cma.j.issn.0366-6999.2012.17.002 Source: PubMed

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Chinese Medical Journal 2012;125(17):2967-2972

2967

Original article
Etiology and antimicrobial resistance of community-acquired
pneumonia in adult patients in China
TAO Li-li, HU Bi-jie, HE Li-xian, WEI Li, XIE Hong-mei, WANG Bao-qing, LI Hua-ying, CHEN Xue-hua,
ZHOU Chun-mei and DENG Wei-wu
Keywords: community-acquired infection; pneumonia; etiology; antimicrobial drug resistance; epidemiology
Background Appropriate antimicrobial therapy of community-acquired pneumonia (CAP) is mainly based on the
distribution of etiology and antimicrobial resistance of major pathogens. We performed a prospective observational study
of adult with CAP in 36 hospitals in China.
Methods Etiological pathogens were isolated in each of the centers, and all of the isolated pathogens were sent to
Zhongshan Hospital for antimicrobial susceptibility tests using agar dilution.
Results A total of 593 patients were enrolled in this study, and 242 strains of bacteria were isolated from 225 patients.
Streptococcus pneumoniae (79/242, 32.6%) was the most frequently isolated pathogen, followed by Haemophilus
influenzae (55/242, 22.7%) and Klebsiella pneumoniae (25/242, 10.3%). Totally 527 patients underwent serological tests
for atypical pathogens; Mycoplasma pneumoniae and Chlamydia pneumoniae infections were identified in 205 (38.9%)
and 60 (11.4%) patients respectively. Legionella pneumophila infections were identified in 4.0% (13/324) of patients. The
non-susceptibility rate of isolated Streptococcus pneumoniae to erythromycin and penicillin was 63.2% and 19.1%
respectively. Six patients died from the disease, the 30-day mortality rate was 1.1% (6/533).
Conclusions The top three bacteria responsible for CAP in Chinese adults were Streptococcus pneumonia,
Haemophilus influenza and Klebsiella pneumonia. There was also a high prevalence of atypical pathogens and mixed
pathogens. The resistance rates of the major isolated pathogens were relatively low except for the high prevalence of
macrolide resistance in Streptococcus pneumoniae.
Chin Med J 2012;125(17):2967-2972

ommunity-acquired pneumonia (CAP) remains a

common disease associated with significant
morbidity and mortality. In adults, the incidence varies
among countries from 1.6 to 11 per 1000 adults, and
40%60% of the patients need hospitalization.1 CAP has
been described as a leading cause of death from
infectious diseases.2 Mortality varied from <1% to 48%
and is associated with advanced age, co-morbid
conditions, and CAP severity.3 CAP entails a heavy
economic burden, with an annual cost of $8.4 billion, and
the mean per-case cost for successful and failed treatment
of CAP in outpatients was $493 and $3019,
respectively.4,5 Early and effective antimicrobial
treatment is the major focus in clinical practice, and it is
important to choose proper antimicrobial agents based on
the local pathogen distribution and antimicrobial
resistance. Major identifiable pathogens of CAP include
Streptococcus pneumoniae, Haemophilus influenzae and
atypical pathogens such as Mycoplasma pneumoniae,
Chlamydia pneumoniae and Legionella pneumophila.6
However, the distribution of major pathogens and
antimicrobial resistance may vary from country to
country. Up to now, most of the data reported were from
Western countries, while only few data have been
published from China.7,8
We performed a prospective observational study of the
etiology of CAP in adult patients at 36 centers in 22

Chinese cities. Antimicrobial susceptibility of isolates

from clinical specimens was tested to evaluate the
prevalence of drug resistance of common CAP-causing
bacteria.
METHODS
Participating centers
This prospective surveillance study was conducted from
June 2004 to August 2005 at 36 centers in 22 cities of 16
provinces: Beijing, Shanghai, Tianjin, Guangdong
DOI: 10.3760/cma.j.issn.0366-6999.2012.17.002
Department of Respiratory Medicine, Zhongshan Hospital, Fudan
University, Shanghai 200032, China (Tao LL, Hu BJ, He LX, Xie
HM, Wang BQ, Li HY, Chen XH and Zhou CM)
Department of Respiratory Medicine, Taishan Medical University
Affiliated Hospital, Taian, Shandong 271000, China (Wei L)
Department of Respiratory Medicine, Ruijin Hospital, Shanghai
Jiao Tong University School of Medicine, Shanghai 200025, China
(Deng WW)
Correspondence to: Dr. HU Bi-jie, Department of Respiratory
Medicine, Zhongshan Hospital, Fudan University, Shanghai
200032, China (Tel: 86-13601621604. Fax: 86-21-64038770.
Email: hubijie@vip.sina.com)
This study was financially supported by Bristol-Myers Squibb
(Shanghai, China), Bayer Healthcare (Beijing, China), Pfizer
(Dalian, China), MERCK (Hangzhou, China), Eli Lilly (Soochow,
China), Roche (Shanghai, China), Xian-Janssen (Xian, China),
Abbott (Chicago, America), Daiichi (Beijing, China). No other
potential conflict of interest was relevant to this article.

2968

(Guangzhou, Shenzhen), Liaoning (Shenyang), Shandong

(Jinan, Qingdao), Jiangsu (Nanjing, Suzhou, Wuxi),
Zhejiang (Hangzhou, Ningbo, Jiaxing), Anhui (Hefei),
Jiangxi (Nanchang), Shanxi (Xian), Henan (Zhengzhou),
Hubei (Wuhan), Hunan (Changsha), Sichuan (Chengdu),
and Yunnan (Kunming). Zhongshan Hospital, Fudan
University was responsible for this study. The study was
approved by ethics committee of each center, and
informed consent was acquired from all the patients.
Study population
According to guidelines of the American Thoracic
Society and Society of Respiratory Disease, Chinese
Medical Association, CAP was defined as a new or
progressive pulmonary infiltration with/without pleural
effusion on a chest radiograph and at least one of the
following signs or symptoms: (1) new or increased
cough, (2) purulent sputum or a change in sputum
characteristics, (3) fever or a history of fever (defined as
an oral temperature >38C), (4) auscultatory findings on
pulmonary examination of rales and/or evidence of
pulmonary consolidation, (5) peripheral white blood cell
(WBC) count 10109/L or immature neutrophils >15%
or leukopenia with a total WBC count <4109/L.
Patients were excluded from this study if: (1) they were
younger than 18 years of age, (2) they reported use of
antimicrobial agents one week prior to presentation at the
study centers, (3) there was no radiological evidence, and
(4) there was evidence of any of the following:
pulmonary tuberculosis, neoplasm or non-infectious
pulmonary diseases, or severe acute respiratory syndrome
(SARS).
Clinical evaluation of the population
All enrolled patients were evaluated with regard to
clinical, radiological and microbiological findings. Risk
class was determined according to the criteria from the
Pneumonia Patient Outcomes Research Team (PORT)
study.8 The treatment settings, radiological and
microbiological responses to antimicrobial therapy were
all recorded. The clinical outcome was measured by the
30-day mortality rate.
Microbiological evaluation
At the time of enrollment, sputum cultures and
serological tests for atypical pathogens had to have been
performed before initiation of antimicrobial treatment.
All lower respiratory tract secretions were Gram stained
and examined microscopically for the presence of WBCs,
epithelial cells and bacteria. The specimens were
considered to be acceptable if there were >25 WBCs and
<10 squamous epithelial cells under the microscope. All
the specimens were inoculated on both blood agar and
chocolate agar using four lines of division. Bacterial
isolates from initial cultures were subjected to in vitro
testing in each local microbiology laboratories as per
routine. All isolates were sent to Zhongshan Hospital for
antimicrobial susceptibility tests using the agar dilution

Chin Med J 2012;125(17):2967-2972

method according to standards of the Clinical Laboratory

Standard Institution.
In order to detect atypical pathogens causing CAP, three
serological kits were chosen based on their practical
performance, sensitivity and specificity. Serodia Myco II
Particle Agglutination Test Kits (Fujirebio, Japan) were
used to detect M. pneumoniae, and C. pneumoniae
IgG/IgM Micro-IF Test kits (Ani Labsystems, Finland)
used to detect C. pneumoniae. Both of the kits use the
particle agglutination method to detect IgG and IgM. An
infection was identified by the presence of IgM in acute
serum or elevated IgG in convalescent serum (2 fold
than acute serum). The Mardx Legionella IFA test system
(Trinity Biotech, America) was selected to detect L.
pneumoniae in sera; both acute sera and convalescent sera
were needed to confirm an acute infection.
RESULTS
General information
A total of 593 cases were enrolled in the study (339 males
and 254 females), the mean age of the patients was
(51.919.2) years old (range 1897 years); 185 (31.3%)
patients were older than 65 years. When classified into
the five classes based on PORT criteria at the time of
enrollment, most of the patients belonged to the low risk
class I 46.7%, class II 29.0%, and class III 15.6%, while
8.0% of patients were in the moderate-risk class IV and
only 0.8% of the patients were in class V. The clinical
symptoms, signs, risk factors, and radiological findings
are summarized in Table 1. One hundred and eleven
patients were found to have bilateral pneumonia, and 41
patients had pleural effusion.
Etiology of CAP
Sputum cultures were obtained from 534 patients and
blood cultures were obtained from 167 of them, 242
bacterial strains were isolated from 225 patients.
Serological tests were performed on 507 patients to detect
atypical pathogens; both acute and convalescent sera
were obtained from 320 patients, and single acute
infection sera were obtained from 207 patients. The
causative pathogens of CAP were confirmed in 399 of the
593 patients (Table 2). M. pneumoniae was the most
frequently identified pathogen, 205 patients were
confirmed to have M. pneumoniae infection using
serological tests. The most prevalent bacteria in CAP
were S. penumoniae (79/534, 14.8%), H. influenzae
(55/534, 10.3%), K. pneumoniae (25/534, 4.7%) and S.
aureus (17/534, 3.2%).
Among 399 patients with identified pathogens, 107 had
mixed infections. The prevalence of mixed infections is
illustrated in Table 2. Two different pathogens were
isolated in 92 patients, while three pathogens were
isolated in 15. Out of 205 patients infected with M.
pneumoniae, 81 of them were co-infected with other
pathogens, mostly with S. pneumoniae (15 in 81), C.
pneumoniae (13 in 81) and H. influenzae (13 in 81).

Chinese Medical Journal 2012;125(17):2967-2972

2969

Table 1. Summary of characteristics of enrolled patients

Characteristics
Patient number (n (%))*
Symptoms and signs
Fever
312/523 (59.7)
Cough
513/593 (86.5)
Purulent sputum
255/532 (42.3)
Leukocytosis >10109/L
203/532 (38.2)
Mental alteration
10/529 (1.9)
Radiological findings
Bilateral infiltration
111/593 (18.7)
Cavity
5/593 (0.8)
Pleural effusion
41/593 (6.9)
Risk factors
Immune compromised
5/531 (0.9)
Long-term smoking
163/533 (30.6)
Alcoholism
28/530 (5.3)
Residence in nursing home
1/531 (0.2)
Recent hospitalization
38/528 (7.2)
Antibiotic therapy within past 3 months
81/531 (15.3)
Underlying disease
COPD
88/528 (16.7)
Bronchiectasis
18/532 (3.4)
Heart failure
12/532 (2.3)
Chronic kidney disease
1/533 (0.2)
Diabetes
14/533 (2.6)
*
Parts of the patients do not have an integrated medical history.

Table 2. Etiological distribution of community-acquired

pneumonia among 593 adult patients
Pathogens
Mono-infection
Mycoplasma pneumoniae
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydophila pneumoniae
Klebsiella pneumoniae
Staphylococcus aureus
Pseudomonas aeruginosa
Legionella pneumophila
Moraxella catarrhalis
Other bacteria
Mixed infection
Two pathogens
S. pneumoniae + M. pneumoniae
M. pneumoniae+C. pneumoniae
M. pneumoniae+H. influenzae
Other combination
Three pathogens
Total

Patient number (n (%))

124 (31.1)
48 (12.0)
31 (7.8)
25 (6.3)
13 (3.2)
10 (2.5)
9 (2.3)
5 (1.2)
4 (1.0)
23 (5.8)

15 (3.8)
13 (3.2)
13 (3.2)
51 (12.8)
15 (3.8)
399

Infections with some pathogens were found to relate with

the age of the patient. M. pneumoniae infections were
much more frequent in young patients than in the elderly
(defined as 65 years), whereas K. pneumoniae and C.
pneumoniae infections were more prevalent in the elderly.
In our study, we failed to discover any relationship
between S. pneumoniae infections and the age of the
patients (Table 3).
Antimicrobial susceptibility
The results of antimicrobial susceptibility testing for the
major pathogens are summarized in Table 4. Of the 79 S.
pneumoniae isolates, 55 (80.9%) were susceptible to
penicillin, 7 (10.3%) were intermediate and 6 (8.8%)
were resistant to penicillin. Resistance rate to
erythromycin was as high as 63.2% (43/79). In our study,
no S. pneumoniae isolate was found to be resistant to
amoxicillin or moxifloxacin.

Table 3. The relationship between age and pathogen infections

(n (%))
Pathogens
Old patients
Young patients
Mycoplasma pneumoniae
42/172 (24.4)
163/357 (45.7)
Streptococcus pneumoniae
31/186 (16.7)
48/407 (11.8)
Haemophilus influenzae
21/186 (11.3)
34/407 (8.4)
33/357 (9.2)
Chlamydophila pneumoniae
27/172 (15.7)
Klebsiella pneumoniae
13/186 (7.0) *
12/407 (2.9)
Staphylococcus aureus
7/186 (3.8)
10/407 (2.5)
Pseudomonas aeruginosa
5/186 (2.7)
9/407 (2.2)
Legionella pneumophila
7/118 (5.9)
6/206(2.9)
Moraxella catarrhalis
6/186 (3.2)*
3/407 (0.7)
The incidence of infection was significantly higher than that in the other age
group, *P <0.05, P <0.01.

Table 4. Antimicrobial susceptibility of major bacteria

Major pathogens
Streptococcus
pneumonia (n=79)*
Penicillin
Erythromycin
Azithromycin
Amoxicillin
Clarithromycin
Cefaclor
Ceftriaxone
Moxifloxacin
Gatifloxacin
Haemophilus
influenzae (n=55)*
Amoxicillin
Azithromycin
Clarithromycin
Cefaclor
Ceftriaxone
Moxifloxacin
Ertapenem
Klebsiella
pneumoniae (n=26)*
Cefaclor
Ceftriaxone
Ceftazidime
Cefepime
Ciprofloxacin
Ertapenem

Isolates (n (%))
I

MIC
MIC50 MIC90

55 (80.9)
24 (35.3)
24 (35.3)
65 (95.6)
23 (34.3)
58 (85.3)
65 (95.6)
66 (97.1)
61 (95.3)

7 (10.3)
1 (1.5)
0 (0)
3 (4.4)
0 (0)
1 (1.5)
1 (1.5)
2 (2.9)
0 (0)

6 (8.8)
43 (63.2)
44 (65.7)
0 (0)
44 (65.7)
9 (13.2)
2 (2.9)
0 (0)
3 (4.7)

0.03
0.5
0.5
0.25
4.0
1.0
16
0.5
0.125

4
64
1
2
256
256
64
4
2

31 (91.2)
34 (100.0)
26 (76.5)
26 (100.0)
34 (100.0)
26 (100.0)
34 (100.0)

0 (0)
0 (0)
4 (11.8)
0 (0)
0 (0)
0 (0)
0 (0)

3 (8.8)
0 (0)
4 (11.8)
0 (0)
0 (0)
0 (0)
0 (0)

0.5
1.0
16
0.5
0.03
0.12
0.03

1.6
256
64
64
4
2
0.25

20 (83.3)
22 (91.7)
23 (95.8)
24 (100.0)
22 (91.7)
24 (100)

0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)

4 (16.7)
2 (8.3)
1 (4.2)
0 (0)
2 (8.3)
0 (0)

0.5
0.03
0.25
0.125
0.125
0.03

64
4
8
2
8
0.25
*
Few of the isolated bacteria do not perform the given antimicrobial
susceptibility test. S: sensitive; I: intermediate; R: resistant.

H. influenzae had a high susceptibility to antimicrobials;

all isolates were susceptible to amoxicillin/clavulanic
acid, ciprofloxacin and ertapenem. Only three isolates
were resistant to amoxicillin and four isolates were
resistant to clindamycin.
K. pneumoniae also showed a high susceptibility to
antimicrobial agents. Resistance rates to cefaclor and
ceftriaxone were 15.4% and 7.7%, respectively. All
isolates were susceptible to ertapenem.
Mortality from CAP
The clinical outcomes were evaluated in 533 patients. Six
patients died during the study; the overall 30-day
mortality rate was 1.1%. In these six patients, three of
them had underlying diseases and CAP led to the
exacerbation of their underlying diseases, which finally

Chin Med J 2012;125(17):2967-2972

2970

resulted in their death. The other three patients were

previously healthy, and they died of respiratory failure
due to the severe infection.
DISCUSSION
This study is the largest, multicenter, prospective
epidemiological study in China. The results of the study
highlight several characteristics of CAP in China.
High prevalence of S. pneumoniae as an etiology of
CAP in China
In our study, etiological pathogens were identified in
70.9% of cases based on cultures and serological tests.
Among identified bacteria, S. pneumoniae was the major
pathogen, as previously reported from other regions.9-11
Prior use of antimicrobial agents can influence the
isolation of pathogens and antimicrobial susceptibility.
Lim et al12 have reported that usage of antimicrobial
drugs before sampling would reduce the isolation of S.
pneumoniae significantly. Our study enrolled patients
who had not received any antimicrobial agents for one
week prior to presentation in order to increase the
isolation of bacteria, especially for fastidious
microorganisms.
The relatively high incidence of K. pneumoniae
pneumonia was observed in our study compared to the
findings of US and European countries, but the result was
coincident with the former studies conducted in Shanghai
and Taiwan.8,13 The selective pressure of antibiotics may
be partly responsible for such a phenomenon.
High prevalence of atypical pathogens and mixed
infections
Many previous studies have reported the high prevalence
of atypical pathogens in CAP, sometimes even higher
than bacterial infections. In our study, serological tests for
atypical pathogens had been done for 527 patients.
Approximately 38.9% of them were confirmed with M.
pneumonia infection, 11.4% with C. pneumonia infection,
and 4.0% with L. pneumophila infection. These results
were comparable with those from other regions.11,14-16
Another meaningful finding from our study was the
relatively high incidence of mixed infection by bacteria
and atypical pathogens. Overall, 107 cases of mixed
infections were detected, and 35.6% of cases of M.
pneumoniae infection were combined with bacterial
infection. The importance of mixed pathogens in CAP has
been demonstrated by many studies, although the
incidence differs from 10% to 38%.12,17,18 Previous
studies have shown that C. pneumoniae induced
ciliostasis can influence the normal function of the
bronchial mucosa, and M. pneumoniae can deliver toxins
to ciliated epithelial cells.19 These mechanisms promote
mixed infection with bacteria. This epidemiological
finding is important in clinical practice because this type
of mixed infection requires combined therapy with

-lactam agents and macrolides, or monotherapy of

fluoroquinolones.
Low resistance of antimicrobial agents to major
pathogens of CAP
The spread of penicillin resistant S. pneumoniae (PRSP)
is a big concern worldwide. In America, as much as
30%40% cases of S. pneumonia infection were caused
by penicillin non-susceptible S. pneumonia (PNSSP), and
10%20% were highly resistant to penicillin.20
Asian-Pacific countries have resistance rates as high as
60%. In our study, the prevalence of PNSSP was 19.1%,
much lower than many international reports, and
comparable to other results reported from China.21
However the prevalence of PRSP (8.8%) was higher than
reported by Sun et al,22 who found an extremely low rate
of penicillin resistance (0.5%). The relative low resistant
rate in our study might be the result of the exclusion
criteria. We had excluded patients younger than 18 years,
and patients who used antimicrobial agents one week
prior to presentation. The criteria helped us to improve
the sensitivity of the sputum culture, but might also have
influenced the results of drug resistance. Despite low
resistant rate to penicillin, the strains were highly
resistant to macrolides, more than 60% were resistant to
erythromycin,
clarothromycin
and
azithromycin.
According to the Infectious Diseases Society of America
(IDSA)/American Thoracic Society (ATS) guidelines,
macrolides are recommended as a monotherapy option
for treating outpatients with CAP without risk factors.23
However, this may not be an appropriate option in China.
Multi-drug resistance was common in PNSSP isolates,
most PNSSP were resistant to macrolides (11/13), and
69.2% were resistant to cefaclor. It was a big challenge to
choose antimicrobial agents for isolates which were
multi-drug resistant. The relationship between clinical
outcome and drug resistance is controversial; the increase
of the drug resistance did not significantly affect the
reported mortality in S. pneumoniae infection.24 Several
studies reported a complex relationship between
penicillin susceptibility and virulence in mice but do not
entirely separate these characteristics from the role of the
capsular type. It is probably because penicillin resistance
is related to a loss of virulence.25
All isolated strains of H. influenzae were highly
susceptible to most of antimicrobial agents; few of them
were resistant to amoxicillin and clarithromycin (8.8%
and 11.8%). K. penumoniae still had a high susceptibility
to -lactams, the susceptible rates to ceftriaxone and
ceftazidime being 91.7% and 95.8% respectively, and all
of the isolates were susceptible to ertapenem.
The resistance patterns of atypical pathogens were not
carried out in our study due to the diagnostic methods.
Recent studies of atypical pathogens suggested that these
pathogens are highly resistant to macrolides, especially
M. pneumoniae.26,27 The molecular mechanisms of such

Chinese Medical Journal 2012;125(17):2967-2972

resistance mainly involved the modification of the target

sites on the 23S rRNA by methylation or mutation, as
well as on the efflux pump.28,29
Relatively low overall mortality of CAP
The overall mortality rate in our study was 1.1%, while
studies from other countries showed a mortality rate of
about 4% in outpatients,3 4%10% in hospitalized
patients,12 and ANSORP reported an overall mortality
rate of 7.3%,9 much higher than our study. The low
mortality rate may involve the exclusion criteria. We
excluded patients who received antimicrobial agents in
the previous week, so the enrolled patients were in
relatively good condition, concomitant with less
underlying disease and had lower PORT classifications.
The prognosis of CAP was influenced by many factors.
The British Thoracic Society has proposed the CURB-65
criteria to evaluate the prognosis of pneumonia.30 Jinks et
al31 considers liver function as a predictive factor of the
prognosis. He found that patients with hypoalbuminemia
and elevated ALT correlated with a higher mortality rate.
Trend of etiology in CAP
The etiology of CAP is different between countries and
changes over time. The application of nucleic acid
amplification technology for epidemiological studies has
led to a new understanding of etiology in CAP.32,33
Viruses should be considered as the pathogen causing
CAP due to its high prevalence. Our study focused on the
bacteria pathogens of CAP, so it was the limitation that
viruses were not tested. Increasingly reported numbers of
infections by S. aureus, especially methicillin resistant S.
aureus (MRSA), is also a major concern.34 The high
virulence of the bacteria and lack of effective
antimicrobial agents result in a high mortality rate of
MRSA pneumonia, yet in our study, the prevalence of S.
aureus was low, and did not lead to any death.

2971
Municipal Peoples Hospital (ZENG Jun, YE Hui-fen, ZHONG
Wei-nong), Shenzhen Peoples Hospital (CHEN Sheng-wen, FU
Ying-yun, WU Wei-yuan), First Hospital of China Medical
University (LI Yan-ling, LI Zhen-hua, LI Meng), Second Hospital
of China Medical University (LI Sheng-qi, LIU Yong, ZHANG
Zhe-jie), Qilu Hospital of Shandong University (WU Da-wei, YU
Xiu-jian), Affiliated Hospital of Qingdao University (CHENG
Zhao-zhong, LIU Peng-peng), Nanjing General Hospital of
Nanjing Military Command (SI Yi, SHAO Hai-feng, XIAO
Yong-ying), Jiangsu Province Hospital (YIN Kai-sheng, HUANG
Mao, ZHAO Wang-sheng), First Affiliated Hospital of Soochow
University (HUANG Jian-an, ZHANG Xian-feng, JIANG
Jun-hong), Wuxi No. 2 Peoples Hospital (LI Xian-cun, YAN
Zi-he), First Affiliated Hospital of Zhejiang University School of
Medicine (WANG Xue-feng, KONG Hai-shen), Second Affiliated
Hospital of Zhejiang University School of Medicine (WANG
Xuan-ding, YUAN Shuang-jin), Zhejiang Provincial Peoples
Hospital (YAN Jian-ping, L Huo-yang), Ningbo No. 2 Hospital
(ZHAO Wei-he, MA Jian-bo, CHEN Lin, XU Xiao-min), First
Hospital of Jiaxing (ZHUANG Yan-bing, SONG Xiu-lan), First
Affiliated Hospital of Anhui Medical University (SUN Geng-yun,
XU Yuan-hong, HE Jie-gui), First Affiliated Hospital of Nanchang
University (WEN Gui-lan, MIU Wan-zheng, LIU Qin), Xijing
Hospital (LI Zhi-kui XU Xiu-li, YANG Pei-hong), First Affiliated
Hospital of Zhengzhou University (WANG Jing, FENG Xian-ju),
Union Hospital, Huazhong University of Science and Technology
(XIN Jian-bo, ZHOU Xian-qin, DAI Li-ren, LIU Ying, XIONG
Yan), Tongji Hospital, Huazhong University of Science and
Technology (XIONG Sheng-dao, SUN Zi-yong), Xiangya Hospital
of Central South University (HU Cheng-ping, LI Xian, PAN
Pin-hua), Second Xiangya Hospital of Central South University
(CHEN Ping, CAO Wei, CHEN Yan, LI Wen-pu), West China
Center of Medical Sciences (L Xiao-ju, LIANG Zong-an, FAN
Hong, CHEN Zhi-xing), First Affiliated Hospital of Kunming
Medical College (HAO Qing-lin, SHEN Bing, LIU Ling).
REFERENCES
1.

In conclusion, our study provides a better understanding

of etiology, clinical and laboratory characteristics,
antimicrobial susceptibility, along with outcome of CAP
in China. These results may benefit clinicians to choose
antimicrobial agents and determine the prognosis of CAP.
Acknowledgements: We are grateful to the following people and
hospitals for their participation in the study: Beijing Union Hospital
(CAI Bai-qiang, CAO Bing, XU Ying-chun, XIE Xiu-li), Beijing
Hospital (SUN Tie-ying, ZHANG Xiu-zheng, PU Chun, HU
Yun-jian), Peking University Third Hospital (YAO Wan-zhen,
WANG Xiao-hong, HAO Zhen-ting), Shanghai Ruijin Hospital
(DENG Wei-wu, LI Min, SUN Jing-yong), Shanghai Renji
Hospital (LI Yan-qin, XIONG Li-fan), Shanghai Changhai Hospital
(HUANG Yi, WANG Jin), Sixth Hospital of Shanghai (SHEN Ce,
JIANG Yan-qun), Tianjin Medical University General Hospital
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Jin-ping, LI De-rong), Third Affiliated Hospital of Sun Yat-sen
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(Received December 21, 2011)

Edited by WANG Mou-yue and LIU Huan