Pneumonia is a very common clinical condition with significant morbidity and mortality. Although many patients respond to first line therapy a minority of patients fail to improve and provide a challenge for the clinician. C reactive protein (CRP) is a useful test in managing pneumonia. One study done in 1996 showed that only 5% of patients admitted with community acquired pneumonia had a CRP concentration <50 mg/l.1
Although the initial concentration does not correlate with disease severity it is useful to observe response to treatment. If CRP has not fallen by 50% by day 4 of treatment, this suggests treatment failure or development of a complication.2,3
Elderly patients will often have a slower clinical response and this should be taken into consideration.
Misdiagnosis is one possibility and if a patient has not improved the history, examination and radiology should be carefully reviewed and repeat/further imaging should be considered.
Pneumonia can lead to secondary complications which may explain failure to improve. These can be divided into pulmonary (eg, empyema, parapneumonic effusion or abscess formation) and intrapulmonary (eg, renal failure or sepsis).
Finally, the antibiotic may be inappropriate or the pathogen unexpected. The antibiotic dose and route of administration should be reviewed as should patient compliance. All microbiology samples should be reviewed and further samples should be sent to rule out less common infection, such as Legionella. Always remember that some patients will have a mixed infection and to consider tuberculosis and fungal infections.
A literature review revealed a similar case published in 2004.4
- It is vital to establish good rapport with a patient so that they will be more likely to divulge sensitive information to you.
- Always take a detailed occupational history in a patient presenting with respiratory symptoms.
- Not all occupational respiratory patients worked in shipyards!