After 14 days in ICU with a diagnosis of community-acquired pneumonia, a patient's signs and symptoms have not improved despite antimicrobial therapy.
a) List the factors that might be responsible for the slow resolution. (60% marks)
b) Outline your assessment to identify the cause of the slow resolution. (40% marks)
Factors contributing to non-resolution or delayed resolution of pneumonia
Agent or Organism factors
Extent of disease
As a result of Complications of pneumonia.
Diseases mimicking pneumonia
Assessment will involve history, examination and investigations to delineate which of the causes from the above list may be contributing.
Will depend upon the findings of the history and examination. Specific respiratory investigations may include:
Other investigations may include:
Wrong antimicrobial agents
Predictors of poor response to antibiotics:
A brilliant article on this topic is offered from Clinics in Chest Medicine (Kuru and Lynch, 1999), but unfortunately it is behind a paywall. The next best source is probably the UpToDate page on nonresolving pneumonia. Again, access to the latter requires the exchange of money. This LITFL article, however, is free.
Li, Meiling, et al. "Risk factors for slowly resolving pneumonia in the intensive care unit." Journal of Microbiology, Immunology and Infection (2014).
Sialer, Salvador, Adamantia Liapikou, and Antoni Torres. "What is the best approach to the nonresponding patient with community-acquired pneumonia?." Infectious disease clinics of North America 27.1 (2013): 189-203.
COJOCARU, Manole, et al. "Pulmonary manifestations of systemic autoimmune diseases." Maedica 6.3 (2011): 224.
Kuru, Tünay, and Joseph P. Lynch. "Nonresolving or slowly resolving pneumonia." Clinics in chest medicine 20.3 (1999): 623-651.
Kyprianou, Andreas, et al. "The challenge of non resolving pneumonia." Postgrad Med 113.1 (2003): 79-92.
Rome, Lauren, Ganesan Murali, and Michael Lippmann. "Nonresolving pneumonia and mimics of pneumonia." Medical clinics of North America 85.6 (2001): 1511-1530.
Menéndez, Rosario, and A. Torres. "Evaluation of non-resolving and progressive pneumonia." Intensive Care Medicine. Springer New York, 2003. 175-187.
Oster, Gerry, et al. "Initial treatment failure in non-ICU community-acquired pneumonia: risk factors and association with length of stay, total hospital charges, and mortality." Journal of medical economics 16.6 (2013): 809-819.
Pareja, Jaime G., Robert Garland, and Henry Koziel. "Use of adjunctive corticosteroids in severe adult non-HIV Pneumocystis carinii pneumonia." CHEST Journal 113.5 (1998): 1215-1224.
Rodrigo, Chamira, et al. "Effect of corticosteroid therapy on influenza-related mortality: a systematic review and meta-analysis." Journal of Infectious Diseases 212.2 (2015): 183-194.
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Bradley, B., et al. "Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society (vol 63, Suppl V, pg v1, 2008)." Thorax 63.11 (2008): 1029-1029.
Davis, William B., Henry E. Wilson, and Robert L. Wall. "Eosinophilic alveolitis in acute respiratory failure. A clinical marker for a non-infectious etiology." CHEST Journal 90.1 (1986): 7-10.
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