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Lung Abscess DX and TX PDF
Lung Abscess DX and TX PDF
of Athens, Greece Lung abscess is defined as a localized collection of pus within the lung
parenchyma, mostly due to bacterial infection, and is characterized by
the presence of a cavity surrounded by necrotic inflammatory lung tissue.
Key words:
Formation of multiple lung abscesses of size less than 2 cm in diameter is
- Lung abscess, commonly referred as necrotizing pneumonia.
- Anaerobic Infection, Lung abscesses are classified as acute or chronic based on symptom
- Cavity, duration ( or <4-6 weeks). They are characterized as primary when they
- Percutaneous Drainage, appear after lung infection in previously healthy persons or in patients
- Surgical Excision
prone to aspiration of nasopharyngeal or oropharyngeal material due
to impaired reflexes of cough and swallowing, especially when bad oral
hygiene or dental disease (e.g. in alcoholics, drug addicts, patients with
reduced level of consciousness, in coma or after epileptic seizures) co-
Correspondence:
exist.1 Abscess formation may occur secondarily in cases of mechanical
Christos F Kampolis
Consultant Pulmonologist bronchial obstruction caused by an endobronchial mass, a foreign body
Second Department of Propaedeutic Surgery, General or extraluminar compression, generalized immunosuppression (e.g. HIV
Hospital Laiko infection), septic pulmonary emboli due to infective endocarditis (mostly
17 Ag. Thoma str., 11527, Athens, Greece
Tel.: +302107456883, Fax: +302107456972 of the tricuspid valve), possible contamination of bullae or bronchiectases,
E-mail: chkamp77@gmail.com mediastinal or subphrenic sepsis with direct transdiaphragmatic extension.
PNEUMON Number 1, Vol. 28, January - March 2015 55
Most studies agree that community lung abscesses are age of the necrotic material, entry of air and creation of
mixed infections, whereas dominant pathogens isolated air-fluid level. Computed tomography (CT) scan has been
(up to 93% in some patient series2) are anaerobic bacteria proven useful in excluding endobronchial obstruction due
found in the normal oral and upper intestinal microbial to malignancy or foreign body and provides additional
flora (e.g. Peptostreptococcus, Bacteroides, Prevotella & information about the size and location of the lesion.
Fusobacterium spp.26). Other less commonly involved Furthermore, it enables distinction between lung abscess
pathogens are Staphylococcus aureus [occasionally methi- and empyema. Lung abscess typically presents as a thick-
cillin resistant (MRSA)], Haemophilus influenzae (type b walled round cavity within the lung parenchyma, without
and c), Streptococcus pyogenes, Nocardia and Actinomy- pressing on the adjacent bronchi, and forms a sharp angle
ces species. In more recent years, higher percentages of with the thoracic wall, whereas empyema is lenticular in
aerobic and microaerophilic Streptococci (Streptococcus shape, causes compression of the adjacent parenchyma
mitis mileri)7,8 and Gram negative bacteria like Klebsiella and forms an obtuse angle with the chest wall.14
pneumoniae have been identified in Asian populations.8 Other conditions that enter the differential diagnosis
Lung abscesses due to hospital-acquired infections caused of lung cavities include pulmonary infarction, vasculitides,
by Staphylococcus aureus and/or gram (-) bacteria like primary or metastatic malignancies, pulmonary seques-
Pseudomonas and Enterobacter, are mostly met in elderly tration, cystic bronchiectasis and pulmonary cysts with
patients with co-morbidities and/or immunosupression. air-fluid level.
Pseudomonas aeruginosa, Staphylococcus aureus or Kleb-
siella pneumoniae infections have been associated with
worse prognosis and higher mortality rates.9 In addition, Microbiological diagnosis
patients with variable degrees of immunosupression may Antimicrobial treatment
present lung abscesses due to opportunistic infections Blood cultures, pleural fluid cultures (if available),
(e.g. fungi, mycobacteria). bronchial secretion cultures,15 fiberoptic bronchoscopy
with quantitative cultures of samples obtained by pro-
tected specimen brush and/or bronchoalveolar lavage
Clinical manifestations Chest imaging
(BAL), and cultures of transthoracic needle aspirates are
Clinical findings of lung abscesses caused by anaerobic usually required for targeted antimicrobial treatment of
or mixed bacteria include non-specific symptoms and lower respiratory infections (pneumonia, abscess). It is
signs that last for several weeks and mimic tuberculosis, advisable to collect each specimen before initiation of
such as fever with night sweats, dull chest pain, fatigue, any antimicrobial treatment. Cultures of sputa and up-
anorexia, weight loss and productive cough with fetid per respiratory tract secretions are not suitable for the
and occasionally bloody sputum. On the contrary, when detection of anaerobic pathogens due to their frequent
aerobic microorganisms are the responsible pathogens, contamination from normal flora of the oral cavity. Spu-
clinical progression is more rapid and usually results tum cultures have been proven useful in identifying lung
in non-resolving pneumonia.10 A few years ago (2002), abscesses attributed to aerobic microorganisms such as
a rapidly progressive clinical condition following viral Klebsiella spp., Staphylococcus aureus and Pseudomonas
infection (influenza) was described in younger patients. aeruginosa. Blood cultures and pleural fluid cultures are
It was characterized by cardiovascular instability (shock), usually negative. Generally, bronchoscopic techniques are
neutropenia, lung tissue necrosis with abscess formation employed on suspicion of endobronchial obstruction,16
and high mortality despite antibacterial treatment.11,12 The uncommon pathogens (fungi, mycobacteria, parasites)
responsible isolated pathogen was an MRSA agent with a or immunodeficiency, provided that the physical status
genome mutation for Panton-Valentine toxin. However, of the patient permits it.
the independent role of the toxin was not verified by Therefore, initial management of lung abscess is based
experimental models.13 on empirical therapy with broad-spectrum antibiotics,
Radiological findings consist of solitary or multiple after taking into account the possible risk of multi-drug
thick-walled cavities with abnormal margins that present resistant causative bacteria, and is followed by antibiotic
either isolated or within a consolidation area. Cavitation streamlining driven by microbiological documentation as
occurs when erosion of the lung parenchyma leads to resulted from cultures. Clindamycin (600 mg i.v. every 8
communication with a bronchus, thus resulting in drain- hours followed by 150-300 mg every 6 hours p.o.) is con-
56 PNEUMON Number 1, Vol. 28, January - March 2015
sidered the first-choice antibiotic for therapy of anaerobic abscess cavity, and therefore purulent material is drained
lung infections.17,18 With the emergence of resistance automatically or with the assistance of physiotherapy. How-
of anaerobic bacteria and microaerophilic Streptococci ever, increased bacterial virulence, insufficient antibiotic
mostly to penicillin G and more rarely to clindamycin, concentration inside the abscess cavity and/or a serious
due to -lactamase production, -lactam/-lactamase underlying respiratory disease may lead to failure of drug
inhibitor combinations (amoxicillin/clavulanate, ampicil- treatment.26 When this occurs, surgical intervention may
lin/sulbactam) presented as highly effective agents for be considered a definitive therapy, but it is accompanied
community-acquired lung abscesses.19,20 This antimicrobial by relatively high mortality rates (11%-28%).27 Thus, per-
regimen provides adequate coverage against gram (+), cutaneous and endoscopic drainage techniques have
gram (-) Enterobacteriaceae (e.g. Klebsiella pneumoniae, been gaining ground even as a first-line management,
Enterobacter) and anaerobic bacteria. A possible thera- especially for patients who are not candidates for surgery.
peutic alternative is the combination of a 2nd (cefuroxime,
cefoxitin) or 3rd generation cephalosporin (ceftriaxone) Percutaneous drainage
with clindamycin or metronidazole. Monotherapy with Percutaneous drainage of lung abscesses has been
metronidazole should be avoided due to inadequate established as treatment of choice for patients who have
coverage for aerobic and microaerophilic Streptococci, failed to respond to antibiotic therapy and have an im-
such as Streptococcus milleri.4,21,22 Linezolide (initial i.v. paired cough reflex (thus resulting in difficult self-drainage
administration 600 mg twice daily and subsequent oral of the abscess), and/or are unsuitable for surgical interven-
administration after clinical improvement) is preferred tion (e.g. due to severe immunodeficiency or mechanical
in cases of lung abscess caused by MRSA.23 An alterna- ventilation).28 However, this technique have demonstrated
tive choice is vancomycin (15 mg/kg x2 i.v., with dose benefits even in patients without contraindications to
adapted according to optimal serum levels (15-20 mcg/ surgery. More specifically, 14% of total cases of primary
ml) and renal function). Low daptomycin concentrations lung abscess (n=48) that were treated by Yellin A et al
achieved in lung tissue renders daptomycin inadequate during a 5-year period (1978-1982) underwent success-
for lower respiratory infections.24 ful percutaneous drainage, without any complications
Clinical improvement is reflected in the subsidence of or relapse after 2-5 years of monitoring.29
fever (within the first 3-4 days) and complete defervescence The percutaneous procedure is usually selected for
within 7-10 days.25 Persistent fever can be explained by lung abscesses with diameters greater than 4-8 cm and is
treatment failure due to uncommon pathogens (multi- performed under fluoroscopic, ultrasound or computed
drug resistant common bacteria, mycobacteria, fungi) tomography guidance. Computed tomography is gener-
or by the presence of an alternative diagnosis (e.g. en- ally preferred due to additional information provided
dobronchial obstruction, vasculitis) that requires further about location, content and wall-thickness of the abscess.
diagnostic work-up (e.g. bronchoscopy, transdermal or In addition, it has been proven useful in differentiation
surgical lung biopsy). between empyema and abscess and in exclusion of
The duration of treatment with antibiotics is not widely endobronchial lesions. Either the trocar or the Seldinger
accepted. According to many experts optimal duration of technique are used for abscess drainage, with no differ-
antimicrobial therapy is 3-6 weeks, whereas others take ence found when evaluating their respective therapeutic
the timing of radiological response into consideration. effectiveness. The Seldinger technique is considered to
In that case, the length of antibiotic treatment depends be safer since it permits greater control in the position-
on complete radiological resolution or stabilization to ing of the drainage tube and thus is accompanied by
a small residual lesion. Treatment interval may then be fewer complications.28,30 Silvermann et al argue that the
prolonged to several months (more than 2),6 especially Seldinger technique increases the risk of pneumothorax,
when the initial lesion is of large size (maximum diameter and furthermore, advancing of the guidewire through
more than 6cm). the thicked-wall abscess may cause bending or rupture
of the guidewire or the catheter.31 The ultimate selection
of the procedure depends on the level of training and
Drainage
preferences of the radiologist.
In the early stages of lung abscess, there exists direct Drainage duration varies but usually 4-5 weeks are
communication of the tracheobronchial tree with the required. Chest tubes should not be flushed, in order to
PNEUMON Number 1, Vol. 28, January - March 2015 57
avoid bronchogenic spreading of pus. Drainage accord- of the day, thus ensuring the drainage of the abscess.
ing to radiographic findings is successful in up to 83% In a small number of patients with recurrent lung
of cases.32 Percutaneous drainage failure and indication abscesses, endoscopic drainage was performed in com-
for surgery may arise when the abscess is multilocu- bination with laser.39 The catheter is inserted through a
lated, organized and/or thick-walled. Technique-related bronchoscope and laser is used in order to perforate the
complications occur in nearly 16% of patients. The most wall of the abscess through the airway and to lead the
significant complications are hemothorax, hemoptysis, catheter inside the cavity. The catheter is removed after
pyopneumothorax and fistula formation between the 4-6 days with immediate improvement of clinical status
pleural cavity and the abscess resulting in empyema. Less and radiological imaging within the first 24 hours.
significant complications are those related to bending or
leaking of the drainage catheter.
In conclusion, percutaneous drainage of lung abscesses Surgical intervention
is characterized by high therapeutic effectiveness and Until 1920s, mortality rate from acute lung abscesses
preservation of functional lung tissue, is a minimally- was around 75%.40 The first open surgical drainage was
invasive method with fewer complications and lower performed by Harold Neuhof, a pioneer of thoracic sur-
mortality rates (approximately 4%) in comparison to gery, and lead to remarkable reduction of morbidity
surgical management.33 and mortality (2.5%).41 Percutaneous drainage of lung
abscesses was considered as the first choice treatment
Endoscopic drainage in the pre-antibiotic era.42 The discovery of antibiotics
Percutaneous drainage of lung abscesses should be (in the late 1940s) rendered conservative drug approach
avoided in cases of coagulation disorders, when a large effective in 80-95% of the cases.43 In the 40s and 50s,4447
amount of lung tissue must be traversed or when adja- surgical resection of the involved part of the lung (seg-
cent anatomical areas hinder direct access to the cavity. mentectomy, lobectomy or rarely pneumonectomy) was
Furthermore, the risk for contamination of the pleural acknowledged as the most effective method in prevent-
space and consequent empyema is not negligible. ing complications or relapses, when medical treatment
In the abovementioned cases, an alternative thera- alone failed to cure multiple and/or chronic abscesses.
peutic approach is endoscopic drainage of the cavity, a Although 11% of 182 patients that were treated by Hagan
technique described initially by Metras H. and Chapin J. & Hardy between 1960 and 19821 underwent surgery, total
in 195434 and subsequently in three publications between mortality per decade remained unchanged (>20%). The
1975 and 1988.3537 Until that time, this technique had persisting high mortality was attributed to the increased
been performed in a small number of patients with a number of patients with co-morbidities such as malignan-
success rate of approximately 70%. In 2005, Henry F. et al cies and diabetes mellitus and to the administration of
presented a further larger group of patients (n=38), with immunosuppressive drugs. In a subsequent publication
100 % successful drainage after catheter placement with (1986) of a large series of patients by Postma & Le Roux,
a bronchoscope.38 At first, a guidewire is inserted into the total mortality was initially comparably high (15.4%)
cavity through the working channel of a flexible bron- despite surgical resection of the lesions. Mortality was
choscope. Once guidewire location has been ascertained then minimized (0.9%) by restoring the classical technique
by fluoroscopy, a 7 French pigtail catheter is advanced. of open surgical drainage and by implementing lung
If infusion of contrast medium via the catheter confirms tissue removal only for more complex cases (e.g. large
its proper positioning, the guidewire and bronchoscope hemoptysis, uncertain diagnosis or lung gangrene).48
are withdrawn and the catheter tip is stabilized at the Patients who are referred to a thoracic surgeon are
nasal wall. Bronchography may be selectively performed usually in a serious septic situation due to chronic absces-
to identify the airway that leads into the abscess, thus sive lesions not responding to pharmaceutical treatment
permitting the insertion of the guidewire via the catheter either alone or combined with transcutaneous drainage.
used for the bronchography. Subsequently, the cavity is These patients usually present with extensive necrosis
flushed daily with normal saline solution through the of lung parenchyma (abscess size >6 cm), bronchial
catheter, while antibiotic infusions (e.g. gentamicin or obstruction due to a mass or a foreign body, empyema,
amphotericin in confirmed fungal infections) may also bronchopleural fistula,40 or infection due to multi-drug
be administered.38 The catheter remains open for the rest resistant microrganisms [e.g. gram(-)]. In most cases,
58 PNEUMON Number 1, Vol. 28, January - March 2015