NIV Congres

Moderator:
Mw. dr. H.A.H. Kaasjager, Arnhem

Panelleden
Mw. dr. P.C. Oldenburg, Amersfoort
Mw. W.E.M. Schouten, Amsterdam
Dr. F.L.J. Visseren, Utrecht


Background: Community acquired pneumonia is a common health problem and affects 5-10 individuals per 1000 persons per year in the Netherlands. After hospital admission due to a community acquired pneumonia a chest X-ray of the thorax is often part of routine follow-up procedures in the outpatient clinic to ensure that a pulmonary malignancy is not missed. However, there is little research evidence to support this practice. The purpose of this critical appraisal of literature is to search for evidence of benefit of a routine follow-up chest X-ray, taken into account the costs and radiation exposure.

Methods: A structured search in PubMed was conducted using the following search terms: 'Pneumonia'[Mesh] AND follow-up AND chest radiography. Limits were set to the English language, humans and adults. The search yielded 132 articles that were screened by title and abstract for relevance. This led to selection of 5 relevant articles that were critically appraised. Furthermore the guidelines of The Canadian Community-Acquired Pneumonia Working Group, the Infectious diseases society of America, the American Thoracic society, the Dutch Association of Physicians for Pulmonary Diseases and Tuberculosis and The Dutch Working Party on Antibiotic Policy were reviewed.

Results: All articles targeted on the new diagnosis of a pulmonary malignancy as benefit of follow-up. Holmberg et al. conducted a retrospective study of 1011 hospitalized patients with pneumonia where pulmonary carcinoma was found by convalescent chest radiography in 2/88 patients not feeling well and in 2/524 patients feeling well at follow-up. They suggested that if signs or symptoms of respiratory disease persisted, chest radiography should be performed but that it could be omitted if the patient has completely recovered 1 month after the acute onset of illness.[1] Marrie et al. found in a prospective study in 1269 patients admitted with a pneumonia that 4 patients were newly diagnosed with a pulmonary malignancy due to a follow-up chest radiograph.[2] Soyseth et al. compared the incidence of lung cancer among patients admitted for pneumonia with a general population and showed that patients admitted with a pneumonia had an increased incidence of lung cancer compared with the general population. This risk persisted for 6 years after the onset of the lung infection.[3]Mortensen et al. showed that of 40,744 patients hospitalized with pneumonia, 3760 (9.2%) patients were diagnosed with pulmonary malignancy after their index pneumonia admission. Only 27% was diagnosed within 90 days of admission. They identified factors significantly associated with a new diagnosis of pulmonary malignancy like history of chronic pulmonary disease, any prior malignancy, white race, being married and tobacco use.[4] Tang et al. conducted a population-based cohort study of 3398 patients with chest radiography-confirmed pneumonia. The incidence of new lung cancer was approximately 1% within 90 days and 2% over 5 years. They suggested that only patients 50 years or older should be targeted for radiographic follow-up.[5] The Canadian and American guidelines recommended a follow-up chest X-ray 4-8 weeks after discharge. In the Dutch guidelines it was not mentioned.

Conclusion: There are no randomised studies regarding this topic. However, according to the existing literature, routine follow-up chest X-ray after admission with pneumonia seems to be obsolete and should only be performed when a pulmonary malignancy is suspected. There is some evidence that certain patient groups with risk factors still could benefit from routine follow-up, but more research is needed.