Discuss with a senior colleague any patient who does not improve as expected.
Consider repeat chest radiograph, C-reactive protein, white cell count, and further specimens for microbiology in patients not progressing satisfactorily after 3 days of treatment.
Consider referral to a respiratory physician.
The main reasons why patients do not improve as expected include:
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.
Consider initial and follow-up viral and atypical pathogen serology.
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.
Admit urgently to hospital any patient on antibiotic treatment with features of moderate- or high-severity infection.
Discharge and follow-up
Do not request a repeat chest radiograph before discharge from hospital in patients who have recovered satisfactorily from CAP.
Arrange a follow-up visit at around 6 weeks either with the patient’s general practitioner or in a hospital clinic.
Request a repeat chest radiograph during recovery after about 6 weeks for patients (regardless of whether they have been admitted to hospital):
With persisting symptoms or physical signs
Who are at higher risk of underlying malignancy (especially smokers and those aged >50 years).
Consider bronchoscopy in patients with persisting signs, symptoms, and radiological abnormalities at around 6 weeks after completing treatment.
Consider a chest and upper abdomen CT scan in patients with persistent signs or symptoms or with chest radiograph changes prior to bronchoscopy (e.g., if lung cancer is suspected).
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