Acute severe community-acquired pneumonia: recovery and follow-up

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Target exams

Red flags

• Non-resolving pneumonia on CXR at 6 weeks: investigate malignancy, TB, immunodeficiency, bronchiectasis, foreign body
• Radiographic resolution lags behind clinical recovery — in severe CAP only ~25% of infiltrates clear by day 7 and ~53% by day 28, versus 56% clinical improvement and 78% clinical cure; persistence >6 weeks mandates workup
• Bronchoscopy indicated if pneumonia fails to improve by 6 weeks, or earlier if an endobronchial obstruction (cancer, foreign body) is suspected
• PICS is the rule, not the exception — about a third of ICU CAP survivors still screen positive for cognitive impairment at 1 year; persistent physical and psychological morbidity is common
• ICU follow-up clinic at 2-3 months: assess physical, cognitive, psychological function
• Vaccinate: pneumococcal (Prevenar 13 + Pneumovax 23) and annual influenza — prevents recurrence (CAPITA trial)
• Post-extubation dysphagia in up to 50% of long-intubated patients — silent aspiration drives recurrent pneumonia; SLT assessment before oral intake