Approach to a non-

resolving pneumonia
 Definition
Non resolving pneumonia is defined as a clinical syndrome in which
focal infiltrates begin with some clinical association of acute
pulmonary infection and despite a minimum of 10 days of appropriate
antibiotic therapy patients either does not improve or worsens or
radiological opacities fail to resolve within 12 weeks
 Non responding pneumonia absence of clinical response after 3-5
days of antibiotic therapy
Progressive pneumonia increase in radiological abnormalities and
clinical deterioration during first 72 hours of treatment
 Rate of resolution
Abnoramlities Duration
Fever 2 4 days
Cough 4-9 days
Crackles 3-6 days
Leucocytosis 3-4 days
C-reactive protein 1-3 days
Chest x-ray 4-12 weeks
Oxygen Saturation 2-6 days
Halms criteria (assess resolution )

Temperature < 37.8

Heart rate < 100
Respiratory rate < 24
Systolic Bp > 90
Saturation /arterial O2 tension 90%/> 60mmHg
Mental state Baseline mental status
Oral intake Normal oral intake
Cause of non- resolution
Inappropriate antibiotic therapy
Complication of initial pneumonia
Host factors
Presence of resistant organisms
Defect in defence
Disease mimicking pneumonia
Inappropriate antibiotic therapy
Patient no receiving or taking prescribed antibiotics
Inadequate dose
Poor absorption of oral antibiotics
Antibiotic hypersensitivity
Use of antibiotics organisms are resitant to
Complications of initial pneumonia
Pulmonary
Para pneumonic effusion
Empyema
Lung abscess
Adult respiratory distress syndrome
Extra-pulmonary
Metastatic focus of infection e.g. endocarditis
Phlebitis at cannula site
Septicaemia
End organ sequelae of sepsis
Host factors
Age > 50 yrs.
Immunosuppression
Co-morbid illnesses- Diabetes, COPD
Alcoholism
Intubated patients
Defect in defences
Local
Bronchiectasis
Endobronchial obstruction
Aspiration
Impaired cough (sedatives, stroke, neuromuscular disease)
Systemic immune deficiency
HIV
Hypogammaglobinaemia
myeloma
Resistant organisms
Pathogens always resistant to common antibiotic
Atypical organisms
Pathogens with acquired resistance
MRSA
Disease mimicking pneumonia
Tuberculosis
Atypical Mycobacteria
Fungal
Norcardia
Incorrect diagnosis
Common
Pulmonary embolism
Pulmonary oedema
Bronchial carcinoma
Bronchiectasis
Uncommon
Cryptogenic organising pneumonia
Pulmonary eosinophilia
Pulmonary alveolar haemorrhage
Foreign body
Congenital pulmonary abnormality
Delayed radiological recovery
Patients with clinical recovery but have a radiological lag behind

Causative agent Time to clearance

Pneumococcus 1-3 months
legionella 2-6 months
Mycoplasm 1-2 months
Chlamydia 1-3 months
Diagnostic evaluation
Re-evaluate host factors
Possibility of antimicrobial failure
Patient compliance
Dosage
Review sensitivity
Unusual pathogens
Pneumonia complications
Local
Systemic
Radiological
Repeat chest x-ray
Chest CT scan
Bronchoscopy
Bronchoalveolar Lavage
Transbronchial lung biopsy