eMedicine Specialties > Pulmonology > Infectious Lung Diseases

Pneumonia, Bacterial: Follow-up

Author: Nader Kamangar, MD, FACP, FCCP, FAASM, Associate Professor of Clinical Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Multi-campus Pulmonary and Critical Care Fellowship Program, University of California, Los Angeles, David Geffen School of Medicine; Medical Director, Hospitalist/Intensivist Program, Olive View-UCLA Medical Center; Associate Program Director, Combined Pulmonary and Critical Care Fellowship Program, Cedars-Sinai/Olive View-UCLA Medical Center/West Los Angeles Veterans Affairs Medical Center
Coauthor(s): Christina Rager, MD, Resident Physician, Internal and Emergency Medicine, Olive View-University of California at Los Angeles Medical Center; Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital
Contributor Information and Disclosures

Updated: Aug 21, 2009

Follow-up

Further Inpatient Care

Additional supportive care measures include the following:

  • Analgesia and antipyretics
  • Chest physiotherapy
  • Intravenous fluids (and, conversely, diuretics) if indicated
  • Monitoring: pulse oximetry with or without cardiac monitoring as indicated
  • Oxygen supplementation
  • Positioning of the patient to minimize aspiration risk
  • Respiratory therapy, including treatment with bronchodilators and N-acetylcysteine
  • Suctioning and bronchial hygiene
  • Ventilation with low tidal volumes (6 mL/kg of ideal body weight) in patients requiring mechanical ventilation secondary to bilateral pneumonia or acute respiratory distress syndrome (ARDS).10
Clinical response to antibiotic therapy should be evaluated within 48-72 hours of initiation.
  • With appropriate antibiotic therapy, improvement in the clinical manifestations of pneumonia should be observed in 48-72 hours.
  • Because of the time required for antibiotics to act, antibiotics should not be changed within the first 72 hours unless marked clinical deterioration occurs.
  • With pneumococcal pneumonia, the cough usually resolves within 8 days and crackles heard on auscultation clear within 3 weeks.
  • The timing of radiologic resolution of pneumococcal pneumonia varies with patient age and the presence or absence of an underlying lung disease. The chest radiograph usually clears within 4 weeks in patients younger than 50 years without underlying pulmonary disease. In contrast, resolution may be delayed for 12 weeks or longer in older individuals and those with underlying lung disease.
Pneumonia that does not respond to treatment poses a clinical dilemma and is a common concern.
  • If patients do not improve within 72 hours, an organism that is not susceptible or is resistant to the initial empiric antibiotic regimen should be considered.
  • Lack of response may also be secondary to a complication such as empyema or abscess formation.
  • Also consider broadening the differential diagnosis to include noninfectious etiologies such as malignancies, inflammatory conditions, or congestive heart failure
  • Carefully review the patient's medical history, especially in regard to potential exposure.
  • Diagnostic testing may require more complex studies when the cause of disease is less apparent.  
    • Bronchoscopy helps evaluate for obstruction due to a foreign body or malignancy; transbronchial biopsy may be helpful in some cases.
    • CT scanning may be helpful in delineating more complex pulmonary processes.
    • Lung biopsy may need to be performed if all other procedures do not aid in diagnosis and the illness continues; biopsy may be performed under CT guidance, with the aid of thoracoscopy, or with open thoracotomy.

Further Outpatient Care

  • When treated in an outpatient setting, arranging adequate follow-up evaluations for the patient is mandatory. Patients also should be instructed to return if their condition deteriorates.
  • Patients should have a follow-up chest radiograph in approximately 6 weeks to ensure resolution of consolidation.
  • Chest radiograph findings indicating nonresolution of symptoms should raise the consideration of an endobronchial obstruction as a cause of postobstructive pneumonia. A CT scan may be of benefit in these cases.

Deterrence/Prevention

Prevention of community-acquired pneumonia

  • Influenza vaccination for elderly individuals results in a reduction of the rate of hospitalization for pneumonia and influenza by 48-57%.
  • S pneumoniae is the most common cause of fatal pneumonia and pneumonia overall. The incidence of pneumococcal disease is the highest in children younger than 2 years and in adults older than 65 years. Other important risk factors are chronic heart disease, chronic lung disease, cigarette smoking, and asplenia. A 23-valent capsular polysaccharide vaccine and a heptavalent protein-polysaccharide conjugate vaccine are currently available. Both vaccines are efficacious in prevention of invasive pneumococcal disease. The role of the pneumococcal vaccine has not been defined as clearly as that of the influenza vaccine in adults. However, the advisory committee on immunization practice recommends pneumococcal vaccination for persons older than 65 years and for younger patients with chronic illnesses.
  • Emphasize smoking cessation to patients.

Prevention of nosocomial pneumonia

  • A number of preventative strategies have been applied. Some of these probably are effective or promising, and some are currently being evaluated.
  • The efficacious regimens are hand washing and isolation of patients with multiple resistant respiratory tract pathogens. Hand washing between patient contacts is a basic and often neglected behavior by medical personnel.
  • Interventions that should be considered or undertaken include nutritional support, attention to the size and nature of the GI reservoir of microorganisms, careful handling of ventilator tubing and associated equipment, subglottic secretion drainage, and lateral-rotation bed therapy.

Complications

Potential complications include the following:

  • Destruction and fibrosis/organization of lung parenchyma
  • Bronchiectasis
  • Necrotizing pneumonia
  • Empyema
  • Pulmonary abscess
  • Respiratory failure
  • Acute respiratory distress syndrome
  • Ventilator dependence
  • Death

Prognosis

  • Generally, the prognosis is good in otherwise healthy patients with uncomplicated pneumonia.
  • Advanced age, aggressive organisms (eg, Klebsiella, Legionella, resistant Streptococcus pneumoniae), comorbidity, respiratory failure, neutropenia, and features of sepsis, alone or in combination, increase morbidity and mortality.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Empiric therapy for hospitalized patients initially should be broad and cover the likely causative organisms.
  • The possibility of Legionella infection should always be considered when evaluating community-acquired pneumonia because delayed treatment significantly increases mortality.
  • The most prevalent causative organism is S pneumoniae, regardless of the host or the setting; empiric therapy must be selected with this consideration in mind.
 


More on Pneumonia, Bacterial

Overview: Pneumonia, Bacterial
Differential Diagnoses & Workup: Pneumonia, Bacterial
Treatment & Medication: Pneumonia, Bacterial
Follow-up: Pneumonia, Bacterial
References
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Further Reading

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Keywords

bacterial pneumonia, pneumonia, pneumococcus, Streptococcus pneumoniae, S pneumoniae, Haemophilus influenzae, H influenzae, Staphylococcus aureus, S aureus, Legionella, Legionella pneumophila, Mycoplasma, Mycoplasma pneumoniae,  Chlamydophila psittaci, Coxiella burnetii, C burnetii, Pseudomonas, Klebsiella, Klebsiella pneumoniae, K pneumoniae, Moraxella catarrhalis, M catarrhalis, Nocardia, Escherichia coli, Enterobacter, Serratia species, Bacteroides, Peptostreptococcus, Fusobacterium species, hospital-acquired pneumonia, community-acquired pneumonia, CAP, nosocomial pneumonia, viral pneumonia, typical pneumonia, atypical pneumonia, lobular pneumonia, lobar pneumonia, bronchial pneumonia

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Contributor Information and Disclosures

Author

Nader Kamangar, MD, FACP, FCCP, FAASM, Associate Professor of Clinical Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Multi-campus Pulmonary and Critical Care Fellowship Program, University of California, Los Angeles, David Geffen School of Medicine; Medical Director, Hospitalist/Intensivist Program, Olive View-UCLA Medical Center; Associate Program Director, Combined Pulmonary and Critical Care Fellowship Program, Cedars-Sinai/Olive View-UCLA Medical Center/West Los Angeles Veterans Affairs Medical Center
Nader Kamangar, MD, FACP, FCCP, FAASM is a member of the following medical societies: American Academy of Sleep Medicine, American Association of Bronchology, American College of Chest Physicians, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, California Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Christina Rager, MD, Resident Physician, Internal and Emergency Medicine, Olive View-University of California at Los Angeles Medical Center
Christina Rager, MD is a member of the following medical societies: American College of Physicians, American Medical Student Association/Foundation, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital
Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Ryland P Byrd Jr, MD, Professor, Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, Program Director of Pulmonary Diseases and Critical Care Medicine Fellowship, James H Quillen College of Medicine, East Tennessee State University; Medical Director of Respiratory Therapy, James H Quillen Veterans Affairs Medical Center
Ryland P Byrd Jr, MD is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
Disclosure: Nothing to disclose.

 
 
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