Table 3.

Potential reasons for treatment failure for WHO-defined pneumonia at 72 h and possible solutions

	Frequency*	Possible solution†
Wrong diagnosis
Reactive airways/asthma	Common	Physician referral
Malaria	Geographically focused	Hospital for blood smear
Foreign body	Rare	Hospital assessment
Anaemia	Rare	Hospital assessment
Cardiac disease	Rare	Hospital assessment
Others	Rare	Hospital assessment
Host failure
HIV/AIDS	Geographically focused	Hospital for HIV test
Malnutrition	Geographically focused	Hospital for intensive treatment
Pulmonary maldevelopment	Rare	Hospital assessment
Others	Rare	Hospital assessment
Complication
Empyema	Uncommon	Hospital for drainage
Abscess	Rare	Hospital for radiography
Others	Rare	Hospital assessment
Non-susceptible pathogen
Viral infection (respiratory syncytial virus, influenza, others)	Common	Observation or hospital
Tuberculosis	Geographically focused	Four drugs and hospital assessment
Mycoplasma, Chlamydophila	Uncommon	Appropriate antibiotics (eg, macrolide, doxycycline, or fluroquinolone)
Non-susceptible S pneumoniae	Uncommon	Appropriate antibiotics (eg, high-dose amoxicillin, ceftriaxone)
Beta-lactamase-producing Haemophlus influenzae	Uncommon	Appropriate antibiotics (eg, amoxicillin–clavulanic acid, ceftriaxone)
Non-typhoidal salmonellae	Geographically focused	Appropriate antibiotics in hospital
Staphylococcus aureus	Rare	Appropriate antibiotics in hospital
Strongyloides, other parasites	Rare	Ivermectin etc, in or out of hospital
Endemic fungi	Rare	Hospital assessment and anti-fungal therapy
Others	Rare	Hospital assessment

^*Common agents may be responsible for at least a third of outpatient pneumonia treatment failures; uncommon agents may be responsible for a minor fraction; rare agents are probably responsible for only occasional treatment failures; globally uncommon agents may be common in certain geographic areas, although they are uncommon as causes for pneumonia treatment failure globally. Based on data from Heffelfinger et al⁷¹ and discussions of the panel based on their clinical experience.

^†Note that referral to the next level facility instead of a hospital may occasionally be appropriate, depending on the resources at the facility and the suspected condition.