eMedicine Specialties > Emergency Medicine > Pulmonary

Pneumonia, Bacterial: Follow-up

Author: James M Stephen, MD, FAAEM, FACEP, Assistant Professor, Tufts University School of Medicine; Attending Physician and Director of Medical Informatics, Department of Emergency Medicine, Associate Director, Kiwanis Pediatric Trauma Service, Tufts Medical Center
Contributor Information and Disclosures

Updated: Oct 15, 2008

Follow-up

Further Inpatient Care

  • Direct the use of antibiotic agents based on laboratory data as well as clinical response.
  • Unresponsive cases of pneumonia may require fiberoptic bronchoscopy or open lung biopsy for definitive diagnosis.
  • Administer adequate respiratory support (eg, as simple as low-flow oxygen or as complex as assisted ventilation), as the patient's clinical situation dictates.
  • Pulmonary toilet may include active suction of secretions, chest physiotherapy, positioning to promote dependent drainage, and incentive spirometry to enhance elimination of purulent sputum and to avoid atelectasis.
  • Systemic support may include proper hydration, nutrition, and mobilization to create a positive host milieu to fight infection and speed recovery. Early mobilization of patients, with encouragement to sit, stand, and walk when tolerated, speeds recovery.

Further Outpatient Care

  • When treated as an outpatient, the patient must undergo adequate follow-up evaluations.
  • A follow-up chest radiograph should be obtained in about 6 weeks to ensure clearing of the infiltrate and to assess persistent abnormality of the lung parenchyma (eg, scarring, bronchiectasis).
  • In patients in whom a precipitating factor was tumoral obstruction of an airway, the infiltrate may fail to clear, or the tumor may be depicted on a chest radiograph. CT scans may be of benefit in unclear cases.

Inpatient & Outpatient Medications

  • Antibiotic therapy is the mainstay of treatment of bacterial pneumonia. However, patients who have bronchospasm with infection benefit from inhaled bronchodilators, administered by means of a nebulizer metered-dose inhalers.

Transfer

  • Transfer, if needed, is safe for a patient in otherwise stable condition who is being admitted for antibiotic therapy and pulmonary toilet.
  • Patients who are severely ill and those with signs of respiratory failure, sepsis, and/or neutropenia must be stabilized prior to transfer.

Deterrence/Prevention

  • Cessation of smoking
  • Immunization
    • Administration of influenza vaccine decreases fall and/or winter risk of viral influenza, which decreases the risk of bacterial superinfection. This vaccine is especially important in patients who are elderly and in those with comorbidity.
    • Pneumococcal vaccines are effective but underused. Administer these to asplenic, transplant, and renal patients; administration in patients who are elderly and in those with comorbidity may not be unreasonable.

Complications

Complications of pneumonia include the following:

  • Local destruction of lung tissue due to infection (may occur, with subsequent scarring)
  • Frank cavitation
  • Bronchiectasis
  • Empyema
  • Pulmonary abscess
  • Respiratory failure
  • Acute respiratory distress syndrome
  • Ventilator dependence
  • Superinfection
  • Death

Prognosis

  • The prognosis generally is good in the otherwise healthy patient with uncomplicated pneumonia.
  • These factors, alone or in combination, increase morbidity and mortality: advanced age, aggressive organisms (eg, Klebsiella species, Legionella species, resistant S pneumoniae), comorbidity, respiratory failure, neutropenia, and features of sepsis.

Patient Education

  • Encourage cessation of smoking and heavy use of alcohol.
  • Encourage keeping teeth in good repair.
  • Instruct patients at risk to receive appropriate influenza immunization.
  • Patients, particularly elderly and debilitated patients, with symptoms such as dyspnea or fever and rigors should seek prompt care.
  • For excellent patient education resources, visit eMedicine's Pneumonia Center. Also, see eMedicine's patient education article Bacterial Pneumonia.

Miscellaneous

Medicolegal Pitfalls

  • Use caution in patients who are elderly or debilitated. If bacteremia is present in persons with pneumococcus who are older than 80 years, the mortality rate remains approximately 40%, even with treatment.
  • Empiric therapy for the hospitalized patient should be initially broad and cover the likely causative organisms.
  • Always consider the possibility of Legionella infection because delayed treatment significantly increases mortality.
  • Remember that the most prevalent causative organism is pneumococcus regardless of the host; empiric therapy must be selected with this in mind.
  • Many regions have guidelines for evaluation and treatment of community-acquired pneumonia. This usually includes a minimum time from door to antibiotic of 4 hours or less. Failure to abide by these time parameters may be associated with poor outcome. When in doubt, administer the first antibiotic dose.
 


More on Pneumonia, Bacterial

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

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Further Reading

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Contributor Information and Disclosures

Author

James M Stephen, MD, FAAEM, FACEP, Assistant Professor, Tufts University School of Medicine; Attending Physician and Director of Medical Informatics, Department of Emergency Medicine, Associate Director, Kiwanis Pediatric Trauma Service, Tufts Medical Center
James M Stephen, MD, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Dana A Stearns, MD, Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital
Dana A Stearns, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Paul Blackburn, DO, FACOEP, FACEP, Program Director, Department of Emergency Medicine, Maricopa Medical Center; Assistant Professor, Department of Surgery, University of Arizona
Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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