From the Guidelines
The recommended workup for recurrent pneumonia should include a comprehensive clinical evaluation, chest imaging, and targeted testing to identify underlying causes, as outlined in the most recent guidelines 1. Begin with a detailed medical history focusing on frequency and pattern of infections, followed by a complete physical examination. Obtain a chest X-ray and consider high-resolution CT scan to identify structural abnormalities, bronchiectasis, or other chronic changes, as recommended by the American College of Radiology Appropriateness Criteria 1. Laboratory testing should include:
- Complete blood count with differential
- Comprehensive metabolic panel
- Inflammatory markers like ESR and CRP, which can help reflect the clinical course and severity of pneumonia 1 Sputum cultures with sensitivity testing and blood cultures during acute episodes are essential to identify pathogens. Pulmonary function tests should be performed to assess for obstructive or restrictive patterns. Consider bronchoscopy with bronchoalveolar lavage to obtain samples for microbiological analysis and to evaluate for anatomical abnormalities. Immunological evaluation including immunoglobulin levels (IgG, IgA, IgM, IgE), antibody response to vaccines, and lymphocyte subset analysis can identify immunodeficiencies. Additional testing may include:
- Sweat chloride test for cystic fibrosis
- Alpha-1 antitrypsin levels
- HIV testing
- Evaluation for gastroesophageal reflux disease or aspiration This comprehensive approach is necessary because recurrent pneumonia often indicates an underlying condition such as immunodeficiency, anatomical abnormality, or chronic disease that requires specific treatment beyond antibiotics to prevent further recurrences. The initial empirical treatment should follow an approach according to the individual risk of mortality, taking into account general patterns of expected pathogens, regional and local patterns of microbial resistance, and considerations of tolerability and toxicity of antimicrobial agents in the individual patient 1.
From the Research
Recommended Workup for Recurrent Pneumonia
The workup for recurrent pneumonia involves identifying the underlying etiologies, which can include:
- Structural abnormalities
- Underlying medical conditions
- Immunological abnormalities, including infection by the human immunodeficiency virus (HIV) 2
Patient Evaluation
Evaluation of patients with recurrent pneumonia should include:
- Detailed history and physical examination to identify risk factors and underlying conditions 3
- Laboratory studies to rule out immunodeficiency diseases 3
- Screening for modifiable risk factors, such as the use of proton-pump inhibitors and systemic and inhaled corticosteroids 4
High-Risk Populations
Certain populations are at higher risk for recurrent pneumonia, including:
- Elderly patients (age ≥65-years-old) with impaired functional status 4
- Patients with primary antibody deficiency, particularly those with chronic and structural lung disease, splenomegaly, and allergies 5
- Immune-suppressed patients, such as those with immunoglobulin deficiencies 4
Diagnostic Considerations
When evaluating patients with recurrent pneumonia, consider the following: