In hospital

Discuss with a senior colleague any patient who does not improve as expected.[1][65]

  • 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.[1][65]

  • Consider referral to a respiratory physician.[1][65]

Practical tip

The main reasons why patients do not improve as expected include:[1][65]

  • 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

  • Overwhelming infection

  • 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.[1][65]

  • Consider initial and follow-up viral and atypical pathogen serology.[1][65]

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.[63]

  • About 10% of patients managed in the community do not respond to antibiotic therapy and require hospitalisation.[140]

Admit urgently to hospital any patient on antibiotic treatment with features of moderate- or high-severity infection.[1][65]

Discharge and follow-up

Do not request a repeat chest radiograph before discharge from hospital in patients who have recovered satisfactorily from CAP.[1][65]

Arrange a follow-up visit at around 6 weeks either with the patient’s general practitioner or in a hospital clinic.[1][65]

  • Request a repeat chest radiograph during recovery after about 6 weeks for patients (regardless of whether they have been admitted to hospital):[1][65]

    • 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.[1][65]

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