Lung abscess is a localized area of lung destruction caused by infection, typically by aspiration of oropharyngeal bacteria. It appears on imaging as a cavity containing air-fluid levels. The infection can start as necrotizing pneumonia that progresses to microabscesses and larger cavitary lesions over time. Risk factors include dental/sinus infections, impaired swallowing, or pre-existing lung disease. Treatment involves antibiotics targeting common aerobic and anaerobic bacteria. Therapy typically lasts 4-6 weeks until imaging shows resolution, though surgery may be needed for large or resistant abscesses. Complications can include empyema, bronchopleural fistula, or distant infections if not properly treated.
Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities (more than 2 cm) containing necrotic debris or fluid caused by microbial infection.
Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles. Or •Bronchiectasis is characterized by permanent, abnormal dilation of one or more large bronchBronchiectasis.
Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities (more than 2 cm) containing necrotic debris or fluid caused by microbial infection.
Bronchiectasis is a chronic, irreversible dilation of the bronchi and bronchioles. Or •Bronchiectasis is characterized by permanent, abnormal dilation of one or more large bronchBronchiectasis.
Normally, the pleural space contains a small amount of fluid (5 to 15 mL), which acts as a lubricant that allows the pleural surfaces to move without friction.
But if fluid builds up from either increased production or inadequate removal pleural effusion results.
Pleural effusion B/L or unilateral (parapneumonic process)
Refers to any significant collection of fluid within pleural space.
Any imbalance in formation, absorption lead accumulation of pleural fluid. Common condition:
CHF
Bacterial pneumonia
Malignancy(chest tumor)
Pulmonary embolism
Pleura effusion is a condition refers to a collection of fluid in the pleural space. It is almost secondary to other conditions.
Pleural effusion, sometimes referred to as “water on the lungs,” is the build-up of excess fluid between the layers of the pleura outside the lungs. The pleura are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing.
Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi, and viruses.
Pneumonitis is a more general term that describes the inflammatory process in the lung tissue that may predispose and Pneumonia is an inflammation of the lung parenchyma that is caused by a microbial agent.
place the patient at risk for microbial invasion.
Pneumonia is classified into four: community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP), pneumonia in the immunocompromised host, and aspiration pneumonia.
Bronchiectasis
A condition characterized by chronic permanent dilation & destruction of bronchi due to destructive changes in the elastic and muscular layers of bronchial walls.
The common thread in the pathogenesis of bronchiectasis consists of difficulty clearing secretions & recurrent infections with a “vicious circle” of infection and inflammation resulting in airway injury and remodelling.
PLEASE REFER TO REFERENCE TEXTBOOKS FOR CLARITY.
Normally, the pleural space contains a small amount of fluid (5 to 15 mL), which acts as a lubricant that allows the pleural surfaces to move without friction.
But if fluid builds up from either increased production or inadequate removal pleural effusion results.
Pleural effusion B/L or unilateral (parapneumonic process)
Refers to any significant collection of fluid within pleural space.
Any imbalance in formation, absorption lead accumulation of pleural fluid. Common condition:
CHF
Bacterial pneumonia
Malignancy(chest tumor)
Pulmonary embolism
Pleura effusion is a condition refers to a collection of fluid in the pleural space. It is almost secondary to other conditions.
Pleural effusion, sometimes referred to as “water on the lungs,” is the build-up of excess fluid between the layers of the pleura outside the lungs. The pleura are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing.
Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi, and viruses.
Pneumonitis is a more general term that describes the inflammatory process in the lung tissue that may predispose and Pneumonia is an inflammation of the lung parenchyma that is caused by a microbial agent.
place the patient at risk for microbial invasion.
Pneumonia is classified into four: community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP), pneumonia in the immunocompromised host, and aspiration pneumonia.
Bronchiectasis
A condition characterized by chronic permanent dilation & destruction of bronchi due to destructive changes in the elastic and muscular layers of bronchial walls.
The common thread in the pathogenesis of bronchiectasis consists of difficulty clearing secretions & recurrent infections with a “vicious circle” of infection and inflammation resulting in airway injury and remodelling.
PLEASE REFER TO REFERENCE TEXTBOOKS FOR CLARITY.
Pneumonia is an inflammatory condition of the lung affecting primarily the small air sacs known as alveoli. Typically symptoms include some combination of productive or dry cough, chest pain, fever, and trouble breathing. Severity is variable.
Pneumonia is usually caused by infection with viruses or bacteria and less commonly by other microorganisms, certain medications and conditions such as autoimmune diseases. Risk factors include cystic fibrosis, chronic obstructive pulmonary disease (COPD), asthma, diabetes, heart failure, a history of smoking, a poor ability to cough such as following a stroke, and a weak immune system. Diagnosis is often based on the symptoms and physical examination. Chest X-ray, blood tests, and culture of the sputum may help confirm the diagnosis. The disease may be classified by where it was acquired with community, hospital, or health care associated pneumonia.
Vaccines to prevent certain types of pneumonia are available. Other methods of prevention include handwashing and not smoking. Treatment depends on the underlying cause. Pneumonia believed to be due to bacteria is treated with antibiotics. If the pneumonia is severe, the affected person is generally hospitalized. Oxygen therapy may be used if oxygen levels are low.
Pneumonia affects approximately 450 million people globally (7% of the population) and results in about four million deaths per year. Pneumonia was regarded by William Osler in the 19th century as "the captain of the men of death". With the introduction of antibiotics and vaccines in the 20th century, survival improved. Nevertheless, in developing countries, and among the very old, the very young, and the chronically ill, pneumonia remains a leading cause of death. Pneumonia often shortens suffering among those already close to death and has thus been called "the old man's friend"
Pneumonia is characterized by the emergence of new lung infiltrates, accompanied by clinical signs such as fever, purulent sputum, leukocytosis, and decreased oxygenation and Nosocomial Pneumonia is a non-incubating lower respiratory infection that presents clinically two or more days after hospitalization. In this presentation "Nosocomial Pneumonias" has been described including their causes, therapy, Principles, diagnosis, symptoms, management, etc. For more information, please contact us: 9779030507.
PNEUMONIA,
DEFINITION
Pneumonia is an infection of the pulmonary parenchyma.
To the pathologist, pneumonia is an infection of the alveoli ,distal airways, and interstitium of the lung that is manifested by increased weight of the lungs, replacement of normal lung’s sponginess by consolidation ,and alveoli filled with white blood cells ,red blood cells and fibrin .To the clinician, pneumonia is a constellation of symptoms and signs in combination with at least one opacity on CXR.
Epidemiology
Between 5 and 10 million cases of infectious pneumonia occur annually in the United States and result in more than 1 million hospitalizations.
Pneumonia is a leading cause of death worldwide, the sixth leading cause of death in the United States, and the most common lethal infectious disease.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
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To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
2. definition
A localized area of destruction of lung
parenchyma in which infection by pyogenic
organisms results in tissue necrosis &
suppuration .
It manifests radiographically as a cavity with an
air – fluid levels.
3. Necrotizing Pneumonia
necrosis with multiple micro abscesses
form a larger cavitary lesion; actually
represents a continuum of the same
process(less than 2cm in diam)
4. Lung Abscess - Classification
May be primary or secondary
Primary = abscess in previously healthy
patient or in a patient at risk for aspiration
Secondary = associated bronchogenic
neoplasm or immunocompromised patient.
7. Etiology
Hematogenous spread from a distal site
• UTI
• Abdominal sepsis
• Pelvic sepsis
• Infective endocarditis
• IV drug abuse
• Infected IV cannulae
• Septic thrombophlebitis
9. Mechanisms of Infection
Commonest cause – Aspiration of
oropharyngeal contents
75% of the abscesses occur in posterior segment
of the Rt. upper lobe or Apical segments of
either lower lobe, these being the segments to
which aspirated material has been shown to
gravitate in the supine subject.
10. Other Mechanisms
The development of lung abscess favoured by
conditions that prevent normal clearance of
pulmonary secretions – lung tumours,
bronchiectasis , inhaled foreign bodies.
Secondary infection – in cong.abn like
bronchopulmonary sequestration & lung cysts
11. Microbiological characteristics
Caused by a wide variety of different organisms
& its common to obtain a mixed bacterial
growth from single abscess when pus is cultured
Anaerobes – 69% of community acquired cases
Anaerobes – 7% hosp acquired cases
Staph aureus, Klebsiella pneumoniae,
Pseudomonas aeruginosa – imp role
12. Anaerobic organisms
Most frequently implicated
Main groups
• Gram negative bacilli – Bacteroides- Bacteroides
fragilis
• Gram positive cocci mainly Peptostreptococcus
• Long & thin gram negative rods –
Fusobacterium – Fusobacterium nucleatum,
Fusobacterium necrophorum
13. Aerobic Organisms
Tend to cause lung abscess as a part of
necrotizing pneumonia
Gram positive aerobes :
• Staph.aureus – pneumonia , lung abscesses ,
pneumatoceles
• Staph.aureus – leading cause of lung abscess in
children
• Strep.pyogenes
• Strep.pneumoniae serotype 3
16. Other causes
Major risk factors for all opportunistic fungal
infections are neutropenia, coticosteroid use,
HIV infection
Single large lung abscess – Actinomyces israeli.
This infection – lung infiltrate with honey comb
of small abscess cavities that may communicate
with chest wall with bony destruction and sinus
formation
17. Pathology
Most often -as a complication of aspiration pneumonia
Oral anaerobes
“Typical patient” is predisposed to aspiration due to
compromised consciousness
(ie, alcoholism, drug abuse, general anesthesia) or
dysphagia
Periodontal disease, especially gingivitis, with
concentrations of bacteria in the gingival crevice as high as
1011/mL
18. pathology
1. Inoculum from gingival crevice reach lower airways -
while the patient is in the recumbent position.
2. Pneumonitis arises first but progresses to tissue necrosis
after 7-14 days.
3. Necrosis results in lung abscess and/or an empyema; the
latter can be due to a bronchopleural fistula or direct
extension of infection into the pleural space
19. pathology
Lung abscesses begin as areas of pneumonia on which
small zones of necrosis ( microabscesses ) develop
within consolidated lung. Some of these areas coalesce
to form single / sometimes multiple areas of
suppuration and when they reach a size of 1 -2 cm dia –
abscess.
If the natural history of this pathological process is
interupted at an early stage by an appropriate
antimicrobial , then healing may be complete with no
residual radiographic evidence of damage.
20. pathology
If treatment is delayed / inadequate , the inflammatory
process may progress , entering a chronic phase.
Abscesses arising as a result of aspiration usually occur
close to visceral pleural surface in dependent parts of
lungs.
¾ ths of lung abscesses occur in posterior segement of
right upper lobe or apical segement of either lower
lobes, the anatomical disposition of these segmental
bronchi accepting the passage of aspirated liquid in
supine position most readily.
Those d/t haematogenous spread can occur in any part
of lungs
21. Clinical Features - Symptoms
The presenting features of lung abscess vary
considerably .
2. Symptoms progress over weeks to months
3. Fever, cough, and sputum production
4. Night sweats, weight loss & anemia
5. Hemoptysis, pleurisy
22. Clinical Features - Signs
Therea are no signs specific for lung abscess
Digital clubbing – develop within a few weeks if
treatment is inadequate.
Dullness to percussion
Diminished breath sounds if abscess is too large
and situated near the surface of lung.
Amphoric / cavernous breath sounds
23. diagnosis
1. CXR, CT CHEST
2. Difficult to isolate anaerobic bacteria
3. Generally, if symptoms and clinical setting right
for anaerobic infection, generally treat
empirically
4. Gram stain:both +ve &-ve,mixed
5. AFB & Anaerobic culture
24. diagnosis
Transtracheal aspirates (TTA), transthoracic
needle aspirates (TTNA), BAL, pleural fluid, or
blood cultures allow uncontaminated specimens
Bronchoscopy with quantitative cultures
experience with anaerobic lung infections is
limited
Further, none of these specimens likely to yield
anaerobes after antibiotic therapy initiated
25. diagnosis
• For patients presenting less typically,
differential diagnosis is broader and
evaluation should include r/o TB with
AFB sputum smear x 3, possible
bronchoscopy for cx and biopsy
• Blood culture
31. Treatment – antibiotic therapy
1. Ampi / Amoxicillin x orally
2. Metronidazole 400mg TDS –Anaerobes
3. Cry.penicillin & clindamycin +/-
metronidazole IV – in hospitalised pts.
4. Can change – according to sensitivity
32. Duration of treatment
Debated
Some advocate 4-6 weeks
Most treat until radiographic abnormalities resolve ,
generally requiring months of treatment
33. Surgical intervention
• Surgery rarely required
• Indications: failure of medical management, suspected
neoplasm, or hemorrhage.
• Predictors of poor response to antibiotic therapy alone:
abscesses associated-
• with an obstructed bronchus, large abscess (>6 cm in
diameter), relatively resistant organisms, such as P. aeruginosa.
• The usual procedure in such cases is a lobectomy or
pneumonectomy
34. Treatment contd…
• Alternative for patients who are considered
poor operative risks is percutaneous
drainage.
• Bronchoscopy- may be done as a
diagnostic procedure, especially to detect
an underlying lesion, but is of relatively
little use to facilitate drainage
35. Response to treatment
• Usually show clinical improvement with ↓ fever within
3-4 days after beginning antibiotics
Should deffervesce in 7-10 days
Persistent fevers beyond this time indicate delayed
response, and such patients should undergo further
diagnostic tests to define the underlying anatomy and
microbiology of the infection
36. delayed response to treatment
Consider:
• Erroneous microbial diagnosis
• Obstruction with a foreign body or neoplasm
• Large cavity size (>6 cm) which may require
unusually prolonged therapy or empyema
which necessitates drainage
• Non-infectious causes - pulmonary infarcts