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Monitoring

• Outpatients
  • Follow up by telephone within 48 h.
    • Most patients feel better by this time.
    • ~10% are unchanged.
    • ~5% feel worse and should be reassessed by a physician.
    • Patients should receive written information about warning signs of pneumonia exacerbation, including:
      
      • Shortness of breath while walking on level ground (assuming no underlying lung disease)
      • Temperature of > 38.5°C (101.3°F) after 72 h of antibiotic therapy
      • New onset of confusion or pleuritic chest pain
      • Hemoptysis
• Inpatients
  • Monitor temperature curve and WBC count for resolution.
    • Follow up on culture results and adjust therapy accordingly.
    • Watch for superinfection with S. aureus.
    • Monitor comorbid conditions (e.g., COPD, renal disease)
• Follow up to ensure radiographic clearance of pneumonia.
  • All patients > 40 years old and all tobacco smokers should have a follow-up chest radiograph to document pneumonia resolution, which may lag behind clinical improvement for several weeks.
    • Nonsmokers < 50 years old who lack underlying lung disease: 6 weeks
    • Elderly patients with COPD: 8–12 weeks
  • Up to 2% of patients hospitalized with CAP have cancer in the lung (with pneumonia distal to an obstructed bronchus)
    • 50% of these cancers are evident on the initial chest film.
    • 50% manifest as failure of pneumonia resolution and are diagnosed at bronchoscopic evaluation for unresolving pneumonia.
• Considerations when pneumonia fails to improve despite treatment
  • Reconsider the diagnosis.
    • Is another illness presenting as pneumonia?
      • For example, collagen vascular diseases involving the lung often are initially diagnosed as pneumonia.
    • Are you treating the wrong pathogen?
      • For example, if you are treating conventional bacterial causes of pneumonia, is this case actually due to M. tuberculosis or to Pneumocystis or another fungus?
    • Are you treating the right pathogen with the wrong drug?
      • For example, if you are using nafcillin or cloxacillin to treat S. aureus and your patient is infected with MRSA, you should be using vancomycin or linezolid.
  • Is there a mechanical reason for the patient’s failure to improve (e.g., an obstructed bronchus due to carcinoma or sequestration of a segment of the lung)?
  • Have you overlooked an undrained or metastatic pyogenic focus (e.g., empyema, brain abscess, endocarditis, splenic abscess, osteomyelitis)?
  • Does the patient have drug-associated fever?
• Workup when pneumonia fails to improve
  • Careful physical examination
  • Blood, urine, and sputum cultures
  • Repeat chest film
  • Chest CT
  • Bronchoalveolar lavage to obtain fluid for microbiologic studies and cytology
    

The Harrison's Practice Preview allows you to view 5 FREE complete topics or conduct a search that delivers abstracts for more than 450 medical topics. For full access, please subscribe today!