Progressive Pneumonia

Nonresolving or Progressive Pneumonia

OVERVIEW

Treatment failure in pneumonia is, despite antimicrobial therapy:

  • failure to normalize the clinical features (eg, fever, cough, sputum production), or
  • nonresolving image in chest radiograph

Nonresolving CAP occurs 6 – 15% of the time and increases mortality 5-fold

EXPECTED COURSE

With appropriate treatment of CAP expect:

  • Defervescence, diminished symptoms, and resolution of leukocytosis <72 hours strongly support a response to antibiotic therapy
  • Persistence or even progression of infiltrates on chest radiographs in the first few days is not unusual
  • Stable infiltrates 4 weeks after starting  antibiotic therapy does not need intervention if there is clinical improvement

FACTORS AFFECTING RATE OF RESOLUTION

Host

  • Age
  • Comorbidities — DM, COPD, alcoholism, malignancy, neuromuscular disease
  • Immunocompromise — AIDS, splenectomy, immunosuppressants
  • Smoker (impaired mucociliary clearance)

Pathogen

  • In general, resolution is more rapid with Mycoplasma pneumoniae, non-bacteremic Streptococcus pneumoniae, Chlamydophila (formerly Chlamydia) spp, and Moraxella catarrhalis than with other organisms
  • Unusual pathogens may not be covered by antibiotics or may be more resistant to treatment
    — e.g. Mycobacterium tuberculosis, Nocardia spp, Actinomyces israelii, Aspergillus spp, Coxiella burnetii (Q fever), Chlamydia psittaci (psittacosis), Leptospira interrogans (leptospirosis), Burkholderia pseudomallei (melioidosis)
  • antibiotic resistance

Complications

  • empyema, lung abscess
  • secondary infection
  • activation of underlying disease

Therapy

  • correct dose, route, timing, duration, interactions/ antagonism, 
  • Antibiotic Resistance

Cause (underlying disease or wrong diagnosis)

  • Respiratory Malignancy, lymphoma, Granulomatosis with polyangiitis (Wegener’s), Diffuse alveolar hemorrhage, Bronchiolitis obliterans-organizing pneumonia (BOOP), Acute or Chronic eosinophilic pneumonia, Acute interstitial pneumonia, Pulmonary alveolar proteinosis, Sarcoidosis, Systemic lupus erythematosus, Heart failure, Pulmonary embolism

See general reasons for unresolved sepsis

INVESTIGATIONS

Bedside

  • ABG, glucose, ECG

Laboratory

  • FBC (WBCs, eosinophilia)
  • UEC
  • LFTs
  • CK (consider legionella, influenza)
  • serum biomarkers, procalcitonin and C-reactive protein

Microbiology

  • Sputum MCS / BAL – gram stain, AFBs, PCR, cytology, culture
  • Blood culture
  • Urinary pneumococcal and legionella antigens

Imaging

  • Chest CT to look for sequestered areas of infection or for findings that suggest an alternative diagnosis
  • repeat CXR
  • lung ultrasound
  • echocardiography

Special test

  • Fiberoptic bronchoscopy – lesions, mechanical respiratory lesion, unusual pathogen
  • Thoracoscopic or open lung biopsy

MANAGEMENT

  • broaden antibiotic coverage
    — check if recent antibiotic use
    — check if previous infection with resistant organisms
    — check compliance and correct dose, route and duration and consider drug interactions
    — check history (e.g. travel, exposures)
  • seek and treat complications
    — e.g. abscess, empyema, metastatic spread, septic shock
  • treat underlying cause
  • change treatment if other diagnosis confirmed or suspected
  • consult respiratory /cardiothoracics if needed

References and Links

Journal articles

  • Kuru T, Lynch JP 3rd. Nonresolving or slowly resolving pneumonia. Clin Chest Med. 1999 Sep;20(3):623-51. Review. PubMed PMID: 10516909.
  • Sialer S, Liapikou A, Torres A. What is the best approach to the nonresponding patient with community-acquired pneumonia? Infect Dis Clin North Am. 2013 Mar;27(1):189-203. doi: 10.1016/j.idc.2012.11.009. Review. PubMed PMID: 23398874.
  • Weyers CM, Leeper KV. Nonresolving pneumonia. Clin Chest Med. 2005 Mar;26(1):143-58. Review. PubMed PMID: 15802176.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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