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Lung Abscess

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Lung Abscess

ETIOLOGY AND PATHOPHYSIOLOGY

para>Staphylococcus is the most common organism in children. пїЅ пїЅ

Antibiotics according to culture and sensitivity results; for presumed anaerobes, clindamycin 600 mg q6 " пїЅ8h IV followed by 300 mg q6h PO for 4 weeks пїЅ пїЅ

Admission Criteria/Initial Stabilization

Activity reduced until radiographic evidence of clearing пїЅ пїЅ

Serial radiographs until resolution of cavity пїЅ пїЅ

11 Munthe-Fog пїЅ пїЅL, Hummelsh пїЅ пїЅj пїЅ пїЅT, Honore пїЅ пїЅC, et al. Immunodeficiency associated with FCN3 mutation and ficolin-3 deficiency. N Engl J Med. 2009;360(25):2637 " пїЅ2644.22 Chirinos пїЅ пїЅJA, Garcia пїЅ пїЅJ, Alcaide пїЅ пїЅML, et al. Septic thrombophlebitis: diagnosis and management. Am J Cardiovasc Drugs. 2006;6(1):9 " пїЅ14.33 Mawdsley пїЅ пїЅJE, Maleki пїЅ пїЅN, Benjamin пїЅ пїЅE, et al. Oesophageal perforation with asymptomatic lung abscess formation. Lancet. 2006;368(9552):2104.44 O 'Connor пїЅ пїЅJV, Chi пїЅ пїЅA, Joshi пїЅ пїЅM, et al. Post-traumatic empyema: aetiology, surgery and outcome in 125 consecutive patients. Injury. 2012;44(9):1153 " пїЅ1158.55 Velagapudi пїЅ пїЅP, Turagam пїЅ пїЅM, Are пїЅ пїЅC, et al. "A forgotten disease " пїЅ: a case of Lemierre syndrome. ScientificWorldJournal. 2009;9:331 " пїЅ332.66 Chen пїЅ пїЅCH, Chen пїЅ пїЅW, Chen пїЅ пїЅHJ, et al. Transthoracic ultrasonography in predicting the outcome of small-bore catheter drainage in empyemas or complicated parapneumonic effusions. Ultrasound Med Biol. 2009;35(9):1468 " пїЅ1474.77 Nagasawa пїЅ пїЅKK, Johnson пїЅ пїЅSM. Thoracoscopic treatment of pediatric lung abscesses. J Pediatr Surg. 2010;45(3):574 " пїЅ578.

  • May be due to aspiration of anaerobic oral flora (most common); 24 to 48 hours after aspiration, lung abscess forms.
  • Less commonly, septic emboli from endocarditis and others (1)[B],(2,3)[C]
  • Usually mixed flora with predominance of anaerobes
  • Oral flora anaerobes (60 " пїЅ75% of cases)PeptostreptococcusPrevotellaFusobacteriumBacteroides sp.
  • Aerobes (10 " пїЅ20%)Staphylococcus aureusStreptococcus pyogenesKlebsiella sp.Pseudomonas aeruginosaStreptococcus milleri
  • Atypical aerobesLegionellaNocardia
  • Actinomyces
  • Peptostreptococcus
  • Prevotella
  • Fusobacterium
  • Bacteroides sp.
  • Staphylococcus aureus
  • Streptococcus pyogenes
  • Klebsiella sp.
  • Pseudomonas aeruginosa
  • Streptococcus milleri
  • Legionella
  • Nocardia
  • No known genetic pattern
  • Immunodeficiency associated with FCN3 mutation and ficolin-3 deficiency may predispose patients to lung infections (1)[B].

RISK FACTORS

  • Periodontal disease (gingivitis), dental abscess, dental surgery
  • Risk for aspirationAlcohol intoxication (loss of consciousness) is the most common cause of aspiration.EpilepsyCerebrovascular accident with oropharyngeal dysfunctionSinusitisGeneral anesthesia with surgeryDysphagiaTracheal/nasogastric tubeSevere gastroesophageal reflux diseaseCerebral palsy
  • Large bacterial burdenNecrotizing pneumoniaBacteremia (especially Staphylococcus)Septic embolism (especially in endocarditis)Disseminated septic phlebitis
  • Airway obstructionBronchial stenosisPulmonary embolismCavitary infarctionLung neoplasiaEnlarged lymph nodeForeign body: stent-associated respiratory tract infection
  • ImmunocompromisedDiabetes mellitusHIV infectionChronic steroid use
  • Amoebic lung abscess: most often from direct extension from liver abscess through the diaphragm to the right lower lobe
  • Alcohol intoxication (loss of consciousness) is the most common cause of aspiration.
  • Epilepsy
  • Cerebrovascular accident with oropharyngeal dysfunction
  • Sinusitis
  • General anesthesia with surgery
  • Dysphagia
  • Tracheal/nasogastric tube
  • Severe gastroesophageal reflux disease
  • Cerebral palsy
  • Necrotizing pneumonia
  • Bacteremia (especially Staphylococcus)
  • Septic embolism (especially in endocarditis)
  • Disseminated septic phlebitis
  • Bronchial stenosis
  • Pulmonary embolism
  • Cavitary infarction
  • Lung neoplasia
  • Enlarged lymph node
  • Foreign body: stent-associated respiratory tract infection
  • Diabetes mellitus
  • HIV infection
  • Chronic steroid use

GENERAL PREVENTION

  • Treatment of predisposing diseases
  • Aspiration precautions
  • Treatment of periodontal diseases

COMMONLY ASSOCIATED CONDITIONS

  • Periodontal disease
  • Pneumonia
  • Alcoholism
  • Empyema (if necrosis of the abscess wall allows entry into pleural space)
  • Posttraumatic empyema (4)[B]
  • Tuberculosis
  • Immunocompromised patient

DIAGNOSIS

HISTORY

  • Fever
  • Malaise
  • Diaphoresis
  • Night sweats
  • Anorexia
  • Weight loss
  • Dyspnea
  • Chest pain/pleurisy
  • Cough with purulent, foul-smelling, putrid, sour-tasting sputum
  • Hemoptysis

PHYSICAL EXAM

  • Vital signs: tachypnea, tachycardia
  • Lung examDecreased breath soundsCavernous breath soundsCracklesWheezingDullness to percussionConsolidation by auscultationClubbing of digits
  • Decreased breath sounds
  • Cavernous breath sounds
  • Crackles
  • Wheezing
  • Dullness to percussion
  • Consolidation by auscultation
  • Clubbing of digits

The posterior segment of the right upper lobe is the most common location for a lung abscess.

DIFFERENTIAL DIAGNOSIS

  • Bronchogenic carcinoma
  • Bronchiectasis
  • Empyema with bronchopulmonary fistula
  • Tuberculosis
  • Mycotic lung infections
  • Vasculitis
  • Parasitic lung infections
  • Infected pulmonary bulla
  • Wegener granulomatosis
  • Pulmonary sequestration
  • Subphrenic or hepatic abscess with perforation into a bronchus
  • Bronchogenic or parenchymal cyst
  • Aspirated foreign body

DIAGNOSTIC TESTS & INTERPRETATION

  • CBC shows leukocytosis and anemia.
  • Hypoalbuminemia
  • Sputum smear: neutrophils, mixed bacteria
  • Sputum culture: often grows normal respiratory flora; may help in atypical presentations
  • Blood culture: often negative in anaerobic abscess
  • Drugs that may alter lab results: prior antibiotics
  • Chest x-rayLung cavity with air " пїЅfluid levelConsolidation with radiolucency, infiltrates, pleural effusion, mediastinal adenopathy
  • Ultrasound (US)Color Doppler US: Great sensitivity, specificity, positive predictive value, and negative predictive value when identification of vessel signals in a pericavitary consolidation is achieved.
  • Computed tomography scanDefines location and extent (typical location depends on segments such as posterior segments of upper lobes or superior segments of lower lobes)May detect obstructing lesionMay demonstrate cavitary opacitiesMay show multiple thrombus of neck vessels (infectious thrombophlebitis) (5)[B]
  • Lung cavity with air " пїЅfluid level
  • Consolidation with radiolucency, infiltrates, pleural effusion, mediastinal adenopathy
  • Color Doppler US: Great sensitivity, specificity, positive predictive value, and negative predictive value when identification of vessel signals in a pericavitary consolidation is achieved.
  • Defines location and extent (typical location depends on segments such as posterior segments of upper lobes or superior segments of lower lobes)
  • May detect obstructing lesion
  • May demonstrate cavitary opacities
  • May show multiple thrombus of neck vessels (infectious thrombophlebitis) (5)[B]
  • Bronchoscopy if obstruction is suspected
  • Bronchoscopic brushing
  • Bronchoalveolar lavage
  • Transthoracic needle aspiration (rarely done)
  • Percutaneous catheter " пїЅguided drainage (6)[B]
  • Solitary abscess
  • Multiple abscesses
  • Cavitation with necrosis
  • Effusion/empyema

TREATMENT

GENERAL MEASURES

  • Postural drainage
  • Nasotracheal suctioning if needed
  • Prolonged course of antibiotics
  • Pulmonary physiotherapy
  • Bronchoscopy with selective therapeutic lavage (rarely done)
  • In general, 10% require surgical intervention, such as drainage of abscess or empyema.

MEDICATION

  • Historically, standard therapy had been penicillin G 1 to 2 million units IV q4h until improvement, followed by 1.2 million units (750 mg) PO q6h times for 3 to 4 weeks; now, many relevant pathogens produce пїЅ пїЅ-lactamase.
  • Cefoxitin 2 g IV q6 " пїЅ8h
  • Piperacillin-tazobactam 3.375 g IV q6h
  • Ticarcillin-clavulanate 3.1 g IV q6h
  • Metronidazole has not proven as effective as clindamycin but often is recommended for use as an adjunctive therapy (500 mg IV q6h).
  • Full course of therapy may be needed for up to 8 weeks.

SURGERY/OTHER PROCEDURES

  • Antibiotic treatment is successful in most patients; surgical options are considered when medical therapy fails.
  • Endoscopic drainage
  • Tube thoracostomy with medical failure or prohibitive operative risk
  • Thoracoscopic drainage (7)[B]
  • Percutaneous catheter " пїЅguided drainage (6)[B]
  • Pulmonary resection only if complications occur or if patient fails therapy (mortality 11 " пїЅ16%)
  • Vacuum-assisted closure may be used in debilitated patients.

INPATIENT CONSIDERATIONS

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

DIET

PATIENT EDUCATION

  • Pulmonary physiotherapy techniques
  • American Academy of Family Physicians at http://www.aafp.org/home.html
  • American Lung Association: possible complications of pneumonia: http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/pneumonia/learn-about-pneumonia.html

PROGNOSIS

  • Clinical improvement with decrease in fever expected 3 to 4 days after starting antibiotics
  • Defervescence is expected in 7 to 10 days.
  • Prognosis depends on the underlying disease or immunosuppression.
  • Patients with primary abscess (otherwise healthy, typical aspiration) have cure rates of 90 " пїЅ95%.
  • Certain factors tend to have worse prognosis:Large abscess (>6 cm)Anatomic obstructionRight lower lobe locationCertain bacteriologic species: S. aureus, Klebsiella, Pseudomonas
  • Overall mortality 15 " пїЅ20%
  • Patients with secondary abscess (underlying neoplasm, obstruction, HIV) have 75% mortality.
  • Large abscess (>6 cm)
  • Anatomic obstruction
  • Right lower lobe location
  • Certain bacteriologic species: S. aureus, Klebsiella, Pseudomonas

Mortality higher in the elderly

COMPLICATIONS

  • Extension
  • Empyema
  • Massive hemoptysis
  • Pneumothorax
  • Brain abscess

REFERENCES

ADDITIONAL READING

  • Bartlett пїЅ пїЅJG. How important are anaerobic bacteria in aspiration pneumonia: when should they be treated and what is optimal therapy. Infect Dis Clin North Am. 2013;27(1):149 " пїЅ155.
  • Desai пїЅ пїЅH, Agrawal пїЅ пїЅA. Pulmonary emergencies: pneumonia, acute respiratory distress syndrome, lung abscess, and empyema. Med Clin North Am. 2012; 96(6):1127 " пїЅ1148.
  • Huang пїЅ пїЅCT, Chen пїЅ пїЅCY, Ho пїЅ пїЅCC, et al. A rare constellation of empyema, lung abscess, and mediastinal abscess as a complication of endobronchial ultrasound-guided transbronchial needle aspiration. Eur J Cardiothorac Surg. 2011;40(1):264 " пїЅ265.
  • Medford пїЅ пїЅAR, Bennett пїЅ пїЅJA, Free пїЅ пїЅCM, et al. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): applications in chest disease. Respirology. 2010;15(1):71 " пїЅ79.
  • Sziklavari пїЅ пїЅZ, Ried пїЅ пїЅM, Hofmann пїЅ пїЅHS. Vacuum-assisted closure therapy in the management of lung abscess. J Cardiothorac Surg. 2014;9(1):157.

SEE ALSO

CODES

ICD10

  • J85.2 Abscess of lung without pneumonia
  • J85.1 Abscess of lung with pneumonia
  • A06.5 Amebic lung abscess
  • J85.3 Abscess of mediastinum

ICD9

  • 513.0 Abscess of lung
  • 006.4 Amebic lung abscess
  • 513.1 Abscess of mediastinum

SNOMED

  • Abscess of lung (disorder)
  • abscess of lung with pneumonia (disorder)
  • Amebic lung abscess (disorder)
  • Abscess of mediastinum
  • Tuberculous abscess of lung (disorder)
  • Abscess of lung and mediastinum

CLINICAL PEARLS

  • Bacteria are carried to the dependent portions of the lung, with the posterior segment of the right upper lobe being the most common location for abscess.
  • Percutaneous drainage and surgical resection could be considered treatment options when medical therapy fails. Endoscopic drainage techniques show promise as an alternative.
  • Lemierre syndrome is a complication of Fusobacterium necrophorum oropharyngeal infection (usually pharyngitis). The infection extends to the internal jugular vein, causing thrombophlebitis. The thrombophlebitis, in turn, produces septic emboli, including emboli that produce lung abscess or pneumonia (2)[C].