What to Do When a Patient with Community

Acquired Pneumonia Fails to improve?

Gamal Rabie Agmy, MD,FCCP Professor of Chest Diseases, Assiut university

Introduction

Treatment failure is a matter of

particular concern in the

management of CAP.

Treatment failure is associated with

high morbidity and mortality rates.

Its detection and management

require careful clinical assessment.

Definition

Lack of response or worsening of

clinical status (i.e., hemodynamic

instability, incidence of respiratory

failure, need for mechanical

ventilation, radiographic progression

, or appearance of new metastatic

infectious foci)

Definition

Failure to respond to

antimicrobial treatment was

classified as nonresponding or

progressive pneumonia.

Definition

◙Nonresponding pneumonia was defined as

persistent fever > 38°C and/or clinical

symptoms (malaise, cough, expectoration,

dyspnea) after at least 72 hours of

antimicrobial treatment.

◙Progressive pneumonia was defined as

clinical deterioration in terms of the

development of either or both septic shock

and acute respiratory failure requiring

ventilator support after at least 72 hours of

treatment.

Types

1-Early Failure: within 72 hours

2-Late failure: after 72 hours

Incidence

2.4 to 31% for early failure and

from 3.9 to 11% for late failure.

Factors associated with treatment failure

◙ High-risk pneumonia

◙ Liver disease ,neurological, neoplasia and

aspiration

◙ Multilobar infiltrates

◙ Legionella pneumonia

◙ Gram-negative pneumonia

◙ Pleural effusion

◙ Cavitation

◙ Leucopenia, and

◙ Discordant antimicrobial therapy.

Lower risk of failure

◙ Influenza vaccination

◙Initial treatment with

fluoroquinolones, and

◙ Chronic obstructive pulmonary

disease

Microbiology of Treatment Failure

◙ Gram negative bacteria

◙ MRSA

◙ Streptococcus pneumoniae

◙ L. pneumophila

Treatment of community-acquired pneumonia in adults who require

hospitalization. File et al, Jan 2016, Up to Date

Laboratory markers for treatment failure

1-Procalcitonin

2-CRP

3- IL6, IL8

4- IL1

5-Pleural effusion

6-Multilobar affection

7-CURB 65>3

Predicting treatment failure in patients with community acquired pneumonia: a

case-control study. Loeches et al, Respiratory Research2014 ,15:75

Evaluating a patient who is not responding to therapy

◙Repeating the history (including travel and pet

exposures to look for unusual pathogens), chest

radiograph, and sputum cultures, blood cultures, and urine antigen testing for Streptococcal

pneumoniae and Legionella if not previously done .

◙If this is unrevealing, then further diagnostic

procedures,, such as chest computed

tomography [CT], bronchoscopy, and lung biopsy

can be performed.

Chest sonography

Chest sonography

Post-stenotic pneumonia Posterior intercostal scan shows a

hypoechoic consolidated area that contains

anechoic, branched tubular structures in the

bronchial tree (fluid bronchogram).

Chest sonography

Chest sonography

Chest CT

Chest CT can detect pleural effusion, lung

abscess, or central airway obstruction, all of

which can cause treatment failure.

It may also detect noninfectious causes such as

bronchiolitis obliterans organizing pneumonia .

Since empyema and parapneumonic effusion can

contribute to nonresponse, thoracentesis should

be performed in all nonresponding patients with

significant pleural fluid accumulation.

Chest CT

http://radiographics.rsnajnls.org/cgi/content/full/23/6/1521/F5B

Bronchoscopy

Bronchoscopy can evaluate the airway for

obstruction due to a foreign body or

malignancy, which can cause a

postobstructive pneumonia.

Protected brushings and bronchoalveolar

lavage (BAL) may be obtained for

microbiologic and cytologic studies; in

some cases, transbronchial biopsy may be

helpful.

Bronchoscopy

In addition, BAL may reveal evidence of

noninfectious disorders or, if there is a

lymphocytic rather than neutrophilic

alveolitis, viral or Chlamydia infection

Thoracoscopic lung biopsy

Thoracoscopic or open lung biopsy may be

performed if all of these procedures are

nondiagnostic and the patient continues to

be ill. The advent of thoracoscopic

procedures has significantly reduced the

need for open lung biopsy and its

associated morbidity.

Considerations*

Scenario

Resistant microorganism or uncovered

pathogen

Parapneumonic effusion or empyema

Nosocomial superinfection

Noninfectious condition, such as pulmonary embolism, drug fever, bronchiolitis obliterans,

organizing pneumonia, congestive heart

failure, vasculitis

Delayed response to

therapy with no

improvement after 72

hours

Severity of illness at presentation

Metastatic infection, such as empyema,

endocarditis, meningitis, arthritis

Inaccurate diagnosis, such as acute respiratory

distress syndrome, aspiration Exacerbation of comorbid illness or coexisting

noninfectious disease, such as renal failure,

acute myocardial infarction, pulmonary

embolism

Clinical deterioration

or continued

progression of illness

Nov. 2011

Nov. 2011