Follow-Up Chest X-Rays After Pneumonia?

Summary and Comment |
August 23, 2011

Follow-Up Chest X-Rays After Pneumonia?

  1. Allan S. Brett, MD

Follow-up imaging probably can be limited to older patients.

  1. Allan S. Brett, MD

Older guidelines recommended routine follow-up chest x-rays at about 6 weeks after episodes of community-acquired pneumonia, presumably to screen for malignancy after an acute infiltrate has cleared. More recent U.S. guidelines don't address this issue (Clin Infect Dis 2007; 44(Suppl 2):S27), and a recent U.K. guideline recommends this practice only for patients with persistent symptoms or those “at higher risk of underlying malignancy (especially smokers and those aged >50 years)” (Thorax 2009; 64(Suppl 3):iii1).

In this population-based cohort study, Canadian researchers identified all 3398 patients without known cancer who received inpatient or outpatient treatment for pneumonia between 2000 and 2002 in metropolitan Edmonton. The incidence of newly diagnosed lung cancer was 1.1% at 90 days and 1.7% at 1 year. Only 40% of patients had follow-up chest x-rays performed within 90 days. All but 1 of the 57 patients in whom cancer was diagnosed within 1 year were 50 or older; thus, the authors conclude that routine follow-up chest x-rays should be restricted to people in that age group.


Because less than half the patients underwent follow-up chest x-rays and, because this study was not a randomized comparison of imaging versus no imaging, the benefit of routine radiography after pneumonia remains unclear. However, the low 1-year incidence of lung cancer provides reassurance that a selective approach — limiting follow-up chest x-rays to middle-aged and older adults — is reasonable. Obviously, patients of any age who remain symptomatic also should undergo follow-up imaging. (Read the case history of a pneumonia patient, and decide if you would order a follow-up x-ray.)


Reader Comments (17)

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Julie Anderson Other Healthcare Professional, Other, Lutheran Medical

Of course he should have had a follow up. 1 in 57 is too many. How would you like it to be your loved one? He had problems and had to be admitted to the hospital. Unbelievable that you did not do a followup.

CM, BSN, PhD Nurse/NP/PA

Due to the complexity of the patient's condition, I'd recommend a followup chest xray when symptoms subside to ensure that no other etiologies are involved.

Terry Pontino Other Healthcare Professional, Family Medicine/General Practice, Cardiopulmonary, Primary care office

Yes I would to check for a malignancy. You never know.

bimlesh pandey

I would get CXR for reasons

In endemic country or region like India, Bangladesh, Pakistan you may CAP like presentation with Tuberculosis. These region also has high prevalence of Drug resistance to usual organisms

For these 2 reasons we require few more CXR than our counterpart in Europe or America.

Competing interests: None declared

Angela Crowell

Given that pt presented with a difficult pneumonia and was unresponsive to first treatment, thus needing to be hospitalized I would have ordered a chest x-ray to rule out late stage lung cancer. The fact that he was not a smoker and feeling better should not have been a deciding factor in not ordering an x-ray. We all know that a large majority of lung cancer patients have never smoked and many never present symptons until cancer has become metatasis.

Competing interests: None declared

hassan ayoub

i think that it should be an indication for graphy follow up post pneumonia,i.e. in critical pneumonia : unresponsive for treatment,diabetic,imunnocompromized,corton using,etc... patients. this should undergo a trial of cost benefit and treatment outcome. thanks.

Competing interests: None declared

Gerson Luiz Penna Bastos

I'd start with amoxicillin-clavulanate and, with >/= 50 yo I'd add azythromicin.

We cannot infer his CURB-65 risk but probably was low, when he was examined for the first time.

Given that he felt himself 100% better, I would not order a followup CXR.

Competing interests: None declared

Amine El Eid

I would have done an Xray after 6 weeks but not in this case, the CT scan eliminated the presence of tumour, the patient is symptom free & physical examination is normal. I would have used Ampicilline & clavulanic acid combination to start with.

Competing interests: None declared

Martie J. Lynch

Because all of my patients are older than 65, my decision making paradigm considers the usual standards of care along with "softer" factors such as level of frailty pre and post CAP. Even in the absence of quantitative markers of fever, cough and fatigue, hospitalization for any reason can be the first domino to fall in an otherwise medically stable 76 yr old. The benefit of a post CAP xray at 6 weeks far outweighs the risk.

Competing interests: None declared

Barbara H Chaffee MD

I would do the 6 week Xray but would not have done the CT scan in the setting of acute pneumonia when the interpretation would be difficult in terms of finding an occult mass. The 6 week study would be cheaper and would give the needed information.

Competing interests: None declared

chris graviss MD Physician, Radiology, VA

It's so hard to teach this to the clinicians

Susan M Womeldorf

While not routinely needed, I would have gotten a follow up chest x- ray on the patient described in the case history. His course was complicated enough that, despite imaging done while ill, I would still want a CXR after recovery.

Competing interests: None declared

Abdulrazak A Ahmad

I would have used combination of amicillin and azithromycin or amoxycillin and clavulanate to start with. Having had CT chest and bronchoscopy done I don't think a follow up chest Xray will be more informative any way if this is taking with symptomatic relief and no history of smoking I will not go further.

Competing interests: None declared

Michael F Bone

Lovely example of right middle lobe pneumonia. In the first instance I would probably have used co-amoxyclavulanic acid unless patient allergic. The CT scan showed no obstructive lesion so I'm not sure I would have performed a bronchoscope at that time. Remember the natural history of pneumonic resolution usually takes 3 weeks with the phases of red and the successive grey hepatisation. i would have performed a repeat CXR. Follow up CXR is not only indicated for the exclusion of lung cancer especially in a 75 year old man. It would be reassuring to know that there had been no sequelae such as empyema or bronchiectasis

Competing interests: None declared

Ashley E

I do not feel that a follow up chest x-ray is necessary for the majority of people with pneumonia.

Competing interests: None declared

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