From the Guidelines
For a patient with pneumonia who continues to experience symptoms, a thorough work-up is necessary to determine the cause of persistent symptoms and to guide further management. The work-up should start with a comprehensive clinical reassessment, including vital signs, lung examination, and evaluation for any new symptoms.
- Order a chest X-ray to assess for worsening infiltrates or complications like pleural effusion, as recommended by 1 and 1.
- Obtain blood tests including complete blood count, C-reactive protein, and procalcitonin to evaluate the inflammatory response, as suggested by 1.
- Perform blood cultures if not done initially or if the patient is febrile, as recommended by 1 and 1.
- Consider sputum culture and sensitivity testing to identify potential antibiotic-resistant organisms, as recommended by 1 and 1.
- If available, a CT scan of the chest may be warranted to detect complications not visible on X-ray, as suggested by 1.
- Additionally, evaluate for possible empyema with ultrasound if there's clinical suspicion, as recommended by 1 and 1.
- Test for influenza and other respiratory viruses if not previously done, as suggested by 1 and 1.
- In severe cases or those with risk factors, consider bronchoscopy for direct sampling and to rule out obstructive lesions, as recommended by 1 and 1. This work-up helps determine if the current treatment is appropriate or needs adjustment, identifies potential complications, and rules out alternative diagnoses. The persistence of symptoms could be due to antibiotic resistance, inadequate coverage of atypical pathogens, or development of complications like lung abscess or empyema, necessitating this comprehensive approach, as discussed in 1, 1, 1, and 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Diagnostic Approach
The diagnostic approach for a patient with pneumonia who continues to experience symptoms involves a combination of history, physical examination, and imaging studies.
- Chest radiography is routinely used to diagnose pneumonia, but a negative chest radiograph should not replace clinical impression 2.
- Vital sign and physical examination findings are useful screening parameters for community-acquired pneumonia, demonstrating a sensitivity of 95% and a specificity of 56% 3.
- The absence of any vital sign abnormalities or any abnormalities on chest auscultation substantially reduces the likelihood of pneumonia to a point where further diagnostic evaluation may be unnecessary 4.
Risk Scores and Clinical Judgment
Risk scores, such as the CURB-65 decision rule, can help identify high-risk patients, including those who will require ICU admission and critical care intervention 2.
- Clinical scores, including the Pneumonia Severity Index (PSI) and CURB-65, can supplement clinical gestalt and assist in disposition, but should not replace clinical judgment 5.
- Patient socioeconomic status must be considered in disposition decisions 5.
Time to Clinical Stability
The time to clinical stability in patients hospitalized with community-acquired pneumonia can vary, with a median time to stability of 3 days for the most lenient definition of stability and 7 days for the most conservative definition 6.