- David Ost, MD, MPH
David Ost, MD, MPH
- Associate Professor
- Department of Pulmonary Medicine
- The University of Texas MD Anderson Cancer Center
- Alan Fein, MD
Alan Fein, MD
- Director, Center for Pulmonary and Critical Care Medicine
- North Shore University Hospital
- Steven H Feinsilver, MD
Steven H Feinsilver, MD
- Professor of Medicine
- Hofstra Northwell School of Medicine
Slow or incomplete resolution of pneumonia despite treatment is a common clinical problem, estimated to be responsible for approximately 15 percent of inpatient pulmonary consultations and 8 percent of bronchoscopies . There are a variety of reasons that a case of pneumonia might resolve slowly or incompletely, including those relating to the etiology of the pneumonia (misdiagnosis of the pathogen or the presence of a resistant pathogen); those relating to the host, including mechanical processes; and the development of complications from the initial infection. In addition, noninfectious etiologies of pulmonary infiltrates can mimic infectious pneumonia, thus making it appear that resolution is not following the expected course. Approximately 20 percent of presumed nonresponding community-acquired pneumonia is due to noninfectious causes . Despite the frequency of this problem, there has been a paucity of studies specifically addressing this issue.
In this review, we will use the term "nonresolving pneumonia" to include those cases of presumed pneumonia that progress, resolve slowly, or fail to achieve complete resolution despite what is thought to be appropriate therapy. We will first discuss those factors that normally affect the resolution of pneumonia, and we will then focus on specific causes of nonresolving pneumonia. Aspiration pneumonia, community-acquired pneumonia, hospital-acquired pneumonia, ventilator-associated pneumonia, and the approach to fever and pulmonary infiltrates in the immunocompromised patient are discussed separately. (See "Aspiration pneumonia in adults" and "Epidemiology, pathogenesis, and microbiology of community-acquired pneumonia in adults" and "Diagnostic approach to community-acquired pneumonia in adults" and "Epidemiology, pathogenesis, microbiology, and diagnosis of hospital-acquired and ventilator-associated pneumonia in adults" and "Clinical presentation and diagnosis of ventilator-associated pneumonia" and "Approach to the immunocompromised patient with fever and pulmonary infiltrates".)
NORMAL VERSUS DELAYED RESOLUTION OF PNEUMONIA
Normal resolution of pneumonia is not easily defined and may vary depending upon the underlying cause. Patients typically note subjective improvement within three to five days of treatment; more specific clinical criteria for resolution include improvement in tachycardia and hypotension, which are expected to improve in two days; fever, tachypnea, and arterial oxygenation (PaO2), which are expected to improve within three days; and cough and fatigue, which may take 14 days or longer to improve [3,4] (table 1). The 2009 British Thoracic Society guidelines for the management of community-acquired pneumonia suggest that chest x-ray and hospitalization be considered for outpatients with pneumonia who fail to improve after 48 hours of treatment .
Most studies on the natural history of pneumonia have focused upon the resolution of chest radiographic abnormalities, with "slow resolution" often being defined as the persistence of radiographic abnormalities for greater than one month in a clinically improved host .
Determining whether a patient has nonresolving or progressive pneumonia must also take into account several factors that affect the expected rate of resolution. These include:
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- NORMAL VERSUS DELAYED RESOLUTION OF PNEUMONIA
- INFLUENCE OF SPECIFIC BACTERIAL PATHOGENS
- Streptococcus pneumoniae
- Legionella infection
- Mycoplasma pneumoniae
- Chlamydia pneumoniae
- Haemophilus influenzae
- MISDIAGNOSIS OF PATHOGENS
- Nocardia and Actinomyces
- RESISTANT BACTERIAL PATHOGENS
- HOST FACTORS
- Primary humoral immune deficiencies
- DEVELOPMENT OF COMPLICATIONS FROM THE INITIAL PNEUMONIA
- Lung abscess
- NONINFECTIOUS ETIOLOGIES
- Neoplastic disorders
- Inflammatory disorders
- Drug-induced lung disease
- Pulmonary embolism
- Hydrostatic pulmonary edema
- FURTHER EVALUATION OF NONRESOLVING PNEUMONIA
- Imaging studies
- Thoracoscopic or open lung biopsy
- Approach to diagnosis
- SUMMARY AND RECOMMENDATIONS