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Beatriz Rosón, MD; Jordi Carratalà, MD; Núria Fernández-Sabé, MD; Fe Tubau, MD; Frederic Manresa, MD; Francesc Gudiol, MD

Arch Intern Med. 2004;164:502-508.

Background  Early failure is a matter of great concern in the treatment of community-acquired pneumonia. However, information on its causes and risk factors is lacking.

Methods  Observational analysis of a prospective series of 1383 nonimmunosuppressed hospitalized adults with community-acquired pneumonia. Early failure was defined as lack of response or worsening of clinical or radiologic status at 48 to 72 hours requiring changes in antibiotic therapy or invasive procedures. Concordance of antimicrobial therapy was examined for cases with an etiologic diagnosis.

Results  At 48 to 72 hours, 238 patients (18%) remained febrile, but most of them responded without further changes in antibiotic therapy. Eighty-one patients (6%) had early failure. The main causes of early failure were progressive pneumonia (n = 54), pleural empyema (n = 18), lack of response (n = 13), and uncontrolled sepsis (n = 9). Independent factors associated with early failure were older age (>65 years) (odds ratio [OR], 0.35), multilobar pneumonia (OR, 1.81), Pneumonia Severity Index score greater than 90 (OR, 2.75), Legionella pneumonia (OR, 2.71), gram-negative pneumonia (OR, 4.34), and discordant antimicrobial therapy (OR, 2.51). Compared with treatment responders, early failures had significantly higher rates of complications (58% vs 24%) and overall mortality (27% vs 4%) (P<.001 for both).

Conclusions  Early failure is infrequent but is associated with high morbidity and mortality rates. Its detection and management require careful clinical assessment. Most cases occur because of inadequate host-pathogen responses. Discordant therapy is a less frequent cause of failure, which may be preventable by rational application of the current antibiotic guidelines.

From the Infectious Disease Service (Drs Rosón, Carratalà, Fernández-Sabé, and Gudiol), the Microbiology Service (Dr Tubau), and the Respiratory Service (Dr Manresa), Hospital Universitari de Bellvitge, University of Barcelona, L'Hospitalet, Barcelona, Spain. The authors have no relevant financial interest in this article.

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