Approach to managing patients with HAP who are not improving
In patients with hospital-acquired pneumonia (HAP), if signs and symptoms do not improve as expected with appropriate antibiotic therapy, reassess the diagnosis before escalating antibiotic therapy. Also ensure airway clearance strategies are optimised (eg chest physiotherapy).
Complications of pneumonia and differential diagnoses to consider are listed in Considerations in patients with HAP who are not improving on empirical antibiotic therapy. Review the results of previous diagnostic tests (eg nose and throat swabs, sputum samples). Further imaging studies such as a repeat chest X-ray or chest computed tomography (CT) scan may be considered to investigate for complications or alternative diagnoses. Consider testing for an unrecognised immune system disorder, such as HIV infection. For patients with immune compromise, consider more extensive investigations for a broader range of pathogens. If extensive microbiological testing is needed, discuss the need for bronchoscopy with a respiratory physician.
Seek expert advice on whether to adjust empirical antibiotic therapy in patients with HAP who are not improving.
If a patient is not improving with empirical antibiotic therapy for HAP, consider:
- complications of pneumonia – consider lung abscess or parapneumonic effusion and empyema in patients with persistent symptoms such as fever and chest discomfort
- noninfective causes, such as:
- exacerbations of heart failure or COPD
- acute respiratory distress syndrome
- pulmonary embolus
- undiagnosed HIV infection – consider whether pneumonia is the presenting feature of an undiagnosed HIV infection
- respiratory viruses that can cause pneumonia and pneumonitis such as influenza, parainfluenza, human metapneumovirus, coronavirus (eg SARS-CoV-2), respiratory syncytial virus (RSV) – if suspected, perform nose and throat swabs for nucleic acid amplification testing (eg [PCR])
- unusual bacterial pathogens, such as Legionella species, Nocardia species or Mycobacterium tuberculosis
- anaerobes not adequately treated with standard empirical therapy – especially in patients with severe periodontal disease or putrid sputum, in whom infection with specific anaerobes (eg Bacteroides or Prevotella species) is more likely. For advice on when to adjust therapy to improve anaerobic activity, see Management of aspiration pneumonia in patients who are not improving on empirical therapy for CAP or HAP
- a broader range of pathogens in patients with immune compromise, such as Aspergillus species, Cryptococcus species, cytomegalovirus, or Pneumocystis jirovecii (PJP) – see Aetiology of HAP in patients with immune compromise for more information.
COPD = chronic obstructive pulmonary disease; HAP = hospital-acquired pneumonia; HIV = human immunodeficiency virus; PCR = polymerase chain reaction; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2