Pneumonia Recovery; Discrepancies in Perspectives of the Radiologist, Physician and Patient

Abstract

BACKGROUNDChest radiographs are often used to diagnose community-acquired pneumonia (CAP), to monitor response to treatment and to ensure complete resolution of pneumonia. However, radiological exams may not reflect the actual clinical condition of the patient.OBJECTIVETo compare the radiographic resolution of mild to moderately severe CAP to resolution of clinical symptoms as assessed by the physician or rated by the patient.DESIGNProspective cohort study.PARTICIPANTSOne hundred nineteen patients admitted because of mild to moderately severe CAP with new pulmonary opacities.MAIN MEASURESRadiographic resolution and clinical cure of CAP were determined at day 10 and 28. Radiographic resolution was defined as the absence of infection-related abnormalities; clinical cure was rated by the physician and defined by improvement of signs and symptoms. In addition, the CAP score, a patient-based symptom score, was calculated.KEY RESULTSRadiographic resolution, clinical cure and normalization of the CAP score were observed in 30.8%, 93% and 32% of patients at day 10, and in 68.4%, 88.9% and 41.7% at day 28, respectively. More severe CAP (PSI score >90) was independently associated with delayed radiographic resolution at day 28 (OR 4.7, 95% CI 1.3–16.9). All 12 patients with deterioration of radiographic findings during follow-up had clinical evidence of treatment failure.CONCLUSIONSIn mild to moderately severe CAP, resolution of radiographic abnormalities and resolution of symptoms scored by the patient lag behind clinical cure assessed by physicians. Monitoring a favorable disease process by routine follow-up chest radiographs seems to have no additional value above following a patient's clinical course.

General Principles of Antimicrobial Therapy

“…Although radiologic criteria are commonly used in assessing response to infectious disease therapy, radiologic improvement can frequently lag behind clinical improvement, and routine radiographic follow-up of all infections is not always necessary. For example, in a study of clinical and radiographic follow-up of patients with community-acquired pneumonia, 28 clinical cure was observed in 93% of patients after 10 days of follow-up, whereas radiographic resolution was noted in only 31% of patients. In fact, several weeks or even months may be required before chest radiography or computed tomography shows complete resolution of an infiltrate.…”

Healthcare reconsultation in working-age adults following hospitalisation for community-acquired pneumonia

“…1 Recovery is further prolonged in individuals requiring hospital admission for treatment of their illness. 2,3 Previous studies have shown that between 35-86% of patients report at least one CAP-related symptom 1 month after their index hospital admission.…”

Community acquired pneumonia in the elderly: the Pneumonia in Italian Acute Care for Elderly units (PIACE) study protocol by the Italian Society of Hospital and Community Geriatrics (SIGOT)

“…This sends back to the difficulty in diagnosing pneumonia in elderly patients with comorbid diseases and complex clinical scenarios, due to atypical clinical presentation, low sensitivity of chest radiograph for detecting pulmonary infiltrates, poor correlation between radiological evolution of pulmonary infiltrates and actual clinical conditions. 1,[25][26][27] For instance, it is not always easy to ascertain that a pulmonary infiltrate is new or changed so that it can be unequivocally attributed to a recent-onset pneumonia, rather than to a previous pulmonary infection, congestive heart failure, pulmonary fibrosis or other lung diseases. 25,27 The second issue is the identification of patients who may have MDR pathogens as pneumonia etiology.…”

“…1,[25][26][27] For instance, it is not always easy to ascertain that a pulmonary infiltrate is new or changed so that it can be unequivocally attributed to a recent-onset pneumonia, rather than to a previous pulmonary infection, congestive heart failure, pulmonary fibrosis or other lung diseases. 25,27 The second issue is the identification of patients who may have MDR pathogens as pneumonia etiology. Current guidelines recommend to treat hospitalized patients with either a respiratory fluoroquinolone alone or with a combination of a third-generation cephalosporin plus a macrolide.…”