Incorrect diagnosis or complicating condition (e.g., pulmonary embolism, bronchial carcinoma, bronchiectasis)
Unexpected pathogen or pathogens not covered by antibiotic choice (e.g., ‘atypical’ pathogens, pathogens resistant to commonly used antibiotics such as ampicillin-resistant Haemophilus influenzae)
Antibiotic ineffective or causing allergic reaction (e.g., poor absorption of oral antibiotic, inadequate dose, antibiotic hypersensitivity)
Impaired local (e.g., bronchiectasis, endobronchial obstruction, aspiration) or systemic (e.g., HIV infection, myeloma) defenses
Local (e.g., parapneumonic effusion, empyema, lung abscess) or distant (e.g., metastatic infection, septicaemia, phlebitis at intravenous cannula site) complications of CAP
Improvement expected too soon (e.g., in older patients).
In patients with high-severity CAP who are not responding to beta-lactam antibiotics or for whom an atypical or viral pathogen is suspected, order polymerase chain reaction (or other antigen detection test) of sputum or other respiratory tract sample.
In the community
Advise patients (and their carers) to seek medical advice if their symptoms worsen rapidly or significantly; symptoms do not start to improve within 3 days; or they become systemically very unwell.
About 10% of patients managed in the community do not respond to antibiotic therapy and require hospitalisation.
Discharge and follow-up
With persisting symptoms or physical signs
Who are at higher risk of underlying malignancy (especially smokers and those aged >50 years).
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