Nonresolving Pneumonia
Section snippets
Pneumonia resolution
Normal resolution of pneumonia is variable and depends on the causative agent and the host response to the invading pathogen. In as many as half of cases, the pathogen remains unidentified. In one large series of CAP, Marston et al [15] reported no etiologic diagnosis in 60% of patients despite extensive diagnostic testing. Similarly, Luna and colleagues [16] evaluated 132 patients by bronchoscopy within the first 24 hours of diagnosis. An etiology was found in 65 patients (49%). Most of the
Community-acquired pneumonia
Data from patients with CAP reveal that the most carefully documented clinical response is the time to defervescence. Occurring most rapidly with infection owing to Streptococcus pneumoniae, the average duration of fever after the initiation of appropriate therapy is 2.5 days. The time to defervescence for cases owing to Haemophilus is 2.7 days, whereas Legionella commonly requires up to 6 days of therapy for a patient to become afebrile [17], [18]. Bacteremic pneumonias may also require more
Pneumococcus
S pneumoniae is the most common cause of CAP and accounts for most cases of slowly resolving pneumonia. In an early review of slowly resolving infiltrates, Israel and colleagues [2] reported isolation of pneumococcus in 78 of 139 pneumonias attributable to specific organisms. Factors associated with delayed resolution included multilobar disease and bacteremia. Jay [27] monitored 72 patients who were hospitalized for bacteremic pneumococcal pneumonia. Radiographic resolution of the
Host abnormalities
A variety of abnormalities in host defense may result in delayed resolution of pneumonia. The most common conditions associated with a delayed resolution are advanced age, COPD, and alcoholism [27]. When these factors are present, the infection may be expected to take longer than usual to clear.
Advanced age
Several studies have demonstrated that prolonged radiographic abnormalities are more common in the elderly. Mittl and colleagues [45] prospectively examined 81 individuals with CAP at The Hospital of the
General antimicrobial resistance
Although numerous factors affect the outcome in pneumonia, the rapid institution of effective antibiotics is known to reduce mortality [22], [56]. In a retrospective review of 111 patients, Dupont and coworkers [57] found that 50% of empiric therapy for VAP was inappropriate. Among these cases, 55% were due to infection by resistant organisms. The past decade has witnessed a dramatic increase in this prevalence. Resistance is a common concern when a patient with presumed pneumonia does not
Unusual infections
Pathogens other than the most common bacterial ones must be considered in cases of pneumonia that fail to resolve. Additional testing, often invasive, is frequently performed. Serial bronchoscopy has been used to identify unusual or resistant organisms in such situations. In one prospective series of patients with nosocomial pneumonia, the lack of response to initial therapy was usually the result of infection with P aeruginosa [12]. Similarly, Arancibia et al [4] evaluated 49 patients with CAP
Noninfectious etiologies of nonresolving pneumonia
The reported incidence of noninfectious conditions mimicking pneumonia is variable, depending on the study and the type of patient evaluated. Timsit and colleagues [81] reviewed a large number of studies and concluded that two-thirds of suspected pneumonias in intubated patients were caused by unrelated conditions, including atelectasis and pulmonary edema. In another retrospective series of 130 intensive care unit patients [82], BAL fluid was used to exclude pneumonia in the absence of a
Diagnostic evaluation of nonresolving pneumonia
The initial consideration in a patient with nonresolving pneumonia should be re-evaluation of possible host-related factors (Fig. 1). If there are no factors associated with delayed resolution, such as advanced age or alcohol abuse, a thorough investigation for an alternative diagnosis should be entertained, particularly in younger patients who are nonsmokers and who have multilobar disease [86].
The most common causes for lack of resolution include inadequate antimicrobial selection,
Summary
Although common, a pneumonia that appears to be slowly resolving or nonresolving can be problematic. The sheer number of alternative diagnoses, both infectious and noninfectious, can overwhelm the clinician and lead to unnecessary testing. Knowledge of typical resolution patterns and risk factors for delayed resolution can aid the clinician and prevent an exhaustive search for alternative etiologies. In most cases, the illness is slow to resolve because of host-related factors, such as older
References (104)
- et al.
Delayed resolution of pneumonia
Med Clin North Am
(1956) - et al.
Diagnostic fiberoptic bronchoscopy and protected brush culture in patients with community-acquired pneumonia
Chest
(1990) - et al.
Slowly-resolving, chronic, and recurrent pneumonia
Clin Chest Med
(1991) - et al.
The diagnosis of pneumonia in the critically ill
Chest
(1995) - et al.
Impact of bronchoalveolar lavage data on the therapy and outcome of ventilator associated pneumonia
Chest
(1997) - et al.
Legionella species community acquired pneumonia: a review of 56 hospitalized patients
Chest
(1996) - et al.
Nosocomial pneumonia: a multivariate analysis of risk and prognosis
Chest
(1988) - et al.
Incidence, etiology, and outcome of nosocomial pneumonia in mechanically-ventilated patients
Chest
(1991) Community acquired pneumonia: etiology, epidemiology, and treatment
Chest
(1995)- et al.
Hospital study of adult community-acquired pneumonia
Lancet
(1982)
Atypical pathogens in community acquired pneumonia
Clin Chest Med
Aetiology and outcome of severe community acquired pneumonia
J Infect
Infective exacerbations of chronic bronchitis: relation between bacteriologic etiology and lung function
Chest
Nonresolving pneumonia in steroid-treated patients with obstructive lung disease
Am J Med
Detection of noninfectious conditions mimicking pneumonia in the intensive care setting: usefulness of BAL fluid cytology
Respir Med
Causes of fever and pulmonary densities in patients with clinical manifestations of VAP
Chest
The radiologic diagnosis of autopsy-proven VAP
Chest
Utility of fiberoptic bronchoscopy in nonresolving pneumonia
Chest
VAP: failure to respond to antibiotic therapy
Clin Chest Med
A clinical profile of chronic bacterial pneumonia: report of 115 cases
Chest
Amiodarone pulmonary toxicity: recognition and pathogenesis (Part I)
Chest
Bilateral symmetrical upper-lobe opacities: an unusual presentation of BOOP
Chest
Quantitative culture of endotracheal aspirates in the diagnosis of VAP in patients with treatment failure
Chest
Impact of BAL in the management of pneumonia with treatment failure: positivity of BAL culture under antibiotic therapy
Chest
Major etiologic factors producing delayed resolution in pneumonia
Am J Med Sci
Antimicrobial treatment failures in patients with community-acquired pneumonia: causes and prognostic implications
Am J Respir Crit Care Med
Etiology of community-acquired pneumonia: impact of age, comorbidity, and severity
Am J Respir Crit Care Med
Modifications of empiric antibiotic treatment in patients with pneumonia acquired in the ICU: ICU-Acquired Pneumonia Study Group
Intensive Care Med
Evaluation of nonresolving and progressive pneumonia
Semin Respir Infect
Significance of unresolved organized or protracted pneumonia
J Mich State Med Soc
Clinical diagnosis of pneumococcal, adenoviral, mycoplasmal, and mixed pneumonias in young men
Eur Respir J
Diagnosis of ventilator associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic “blind” bronchoalveolar lavage fluid
Am Rev Respir Dis
Resolution of ventilator associated pneumonia: prospective evaluation of the CPIS as an early clinical predictor of outcome
Crit Care Med
Incidence of community acquired pneumonia requiring hospitalization: results of a population-based active surveillance study in Ohio. The Community-Based Pneumonia Incidence Study Group
Arch Intern Med
An outbreak of Legionnaires' disease in Sweden: a report of 68 cases
Scand J Infect Dis
Atypical manifestations of pneumonia in the elderly
Clin Chest Med
Time to clinical stability in patients hospitalized with community acquired pneumonia: implications for practice guidelines
JAMA
Predictors of symptom resolution in patients with CAP
Clin Infect Dis
Nosocomial pneumonia: a continuing major problem
Am Rev Respir Dis
Follow-up PSB to assess treatment in nosocomial pneumonia
Am Rev Respir Dis
Resolution of infectious parameters after antimicrobial therapy in patients with ventilator associated pneumonia
Am J Respir Crit Care Med
The radiographic resolution of Streptococcus pneumoniae pneumonia
N Engl J Med
Comparative radiographic features of community-acquired Legionnaires' disease, pneumococcal pneumonia, mycoplasmal pneumonia, and psittacosis
Thorax
Prospective study of prognostic factors in community-acquired bacteremic pneumococcal disease in 5 countries
J Infect Dis
New and emerging etiologies for community acquired pneumonia with implications for therapy: a prospective multicenter study of 159 cases
Medicine
Bacteriologic flora of the lower respiratory tract
N Engl J Med
Aetiology, outcome and prognostic factors in CAP requiring hospitalization
Eur Respir J
The Philadelphia epidemic of Legionnaires' disease: clinical, pulmonary, and serologic findings twenty years later
Ann Intern Med
Clinical picture of community-acquired Chlamydia pneumoniae pneumonia requiring hospital treatment: a comparison between chlamydial and pneumococcal pneumonia
Thorax
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