infectious

Pneumonia Not Improving in the ICU

A progressive bedside problem for apparent pneumonia with persistent hypoxemia, fever or shock despite initial therapy.

Failure to improve should trigger diagnostic reassessment rather than automatic antibiotic broadening. Confirm that the syndrome is pneumonia, reconsider the host and exposure context, and look for complications or a source that requires a procedure.

Phase 1 — Recheck the Phenotype

Reassess CAP/HAP/VAP timing, aspiration risk, viral disease, immunocompromise, necrotizing/cavitary disease and noninfectious mimics such as edema, hemorrhage, organizing inflammation or pulmonary embolism.

Phase 2 — Recheck Microbiology

Review specimen quality, prior antibiotics, cultures and local resistance. Use invasive sampling selectively when it is likely to change management rather than as a routine reflex.

Phase 3 — Search for a Complication

Use imaging and bedside assessment to look for empyema, abscess/necrosis, airway obstruction or another source of sepsis. Drainage or other source control may matter more than broader antibiotics.

Reassessment

Evidence status

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Actionable Clinical Workflows (6)

Step-by-step ICU Processes

Noninvasive Respiratory Support Escalation & Intubation Decision

From initial noninvasive modality selection to ROX index tracking and timely intubation triggers.

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Acute Hypoxemia

From confirming true hypoxemia to identifying the underlying mechanism.

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Sepsis Recognition, Source Control & De-escalation

From SSC 2026 infection-likelihood/shock-based early treatment and source control to reassessment, de-escalation, and fluid stewardship.

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Fever / Suspected Sepsis

From recognizing organ dysfunction to source identification and time-sensitive empiric therapy.

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Deep-Dive Topic Destinations (5)

Reference Knowledge

Pneumonia Variants in the ICUrespiratory

Pattern-based ICU pneumonia approach: severe CAP, HAP/VAP, aspiration, viral, necrotizing, immunocompromised and nonresolving pneumonia.

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Severe Community-Acquired Pneumonia (Severe CAP)respiratory

IDSA/ATS severe CAP criteria, rapid microbiology, targeted empiric antimicrobial regimens, and landmark adjunctive hydrocortisone evidence (CAPE COD).

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Ventilator-Associated Pneumonia (VAP)infectious-disease

Quantitative lower tract sampling (ETA vs BAL), rapid multiplex PCR panels and stewardship interpretation, PK/PD extended beta-lactams, 7-day duration, and the SHEA prevention bundle.

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Pleural Infection / Empyemarespiratory

Diagnosis and source control of complicated parapneumonic effusion and empyema with drainage, tPA/DNase and surgical escalation

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Bronchoscopy in the ICUrespiratory

Safe diagnostic and therapeutic bronchoscopy in hypoxemic, mechanically ventilated and bleeding ICU patients

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