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Journal of Pediatric Infectious Diseases 4 (2009) 27–35 27

DOI 10.3233/JPI-2009-0148
IOS Press

Review Article

Lung abscess in children


Haya Alsubie and Dominic A. Fitzgerald ∗
Department of Respiratory Medicine, The Children’s Hospital at Westmead, Sydney, NSW, Australia

Received 25 July 2008


Revised 30 July 2008
Accepted 4 September 2008

Abstract. Lung abscess is an uncommon but challenging condition to manage. Predisposing factors including pulmonary
aspiration and impaired mucociliary defense mechanisms increase the likelihood of developing a secondary lung abscess.
Aspirating anaerobic organisms from the mouth leading to pneumonia and a secondary lung abscess is more likely to be
seen in children with neuro-cognitive impairment. The more likely anaerobic organisms include Peptostreptococcus species,
Fusobacterium nucleatum and Prevotella melaninogenica. These organisms may be difficult to isolate without specific anaerobic
transport vials and culture media. The rise of interventional radiology, higher positive culture results, better targeted antibiotic
regimes and a greater awareness of hospital acquired pathogens have been significant is decreasing the length of hospitalization
for children with lung abscesses. The morbidity and mortality for lung abscess in children is vastly superior to that in adult
patients because of the lack of co-morbidities in the pediatric population.

Keywords: Lung abscess, pathophysiology, microbiology, anaerobes, interventional radiology, antibiotic therapy

1. Introduction 2. Definition

Lung abscess is an uncommon but important pedi- A lung abscess is a thick-walled cavity that contains
purulent material resulting from suppuration and necro-
atric problem. It is believed to be less common in chil-
sis of the lung parenchyma [1–4]. The lung abscess
dren than adults, although the literature is accordingly
may be primary or secondary. A primary lung abscess
relatively sparse. Lung abscesses may be classified as
occurs in a previously well child with normal lungs,
primary or secondary, depending upon the existence
usually as a complication of pneumonia, and will usu-
of predisposing conditions. Similarly, lung abscesses
ally reach a full recovery without any sequalae. A sec-
may be single or multiple. Those that are secondary
ondary lung abscess occurs in a child with an under-
are far more likely to be caused by anaerobic bacteria. lying airway or lung abnormality, which may be con-
Typically, in children as in adults, it is the existence genital (cystic fibrosis, immunodeficiency or structural
of underlying conditions, which will influence the ap- malformation) or acquired (achalasia or a neurodevel-
proach to management, and the prognosis of a patient opmental abnormality) [1–3].
who presents with a lung abscess [1–3].

3. Epidemiology
∗ Correspondence: Dr. Dominic A. Fitzgerald, Department of Res-
piratory Medicine, The Children’s Hospital at Westmead, Locked
Bag 4001, Westmead, Sydney, NSW, Australia, 2145. Tel.: +61 2 It has been suggested that lung abscesses were more
9845 3397; Fax: +61 2 9845 3396; E-mail: dominif2@chw.edu.au common in previous years [1] before the ability of pre-

1305-7707/09/$17.00  2009 – IOS Press and the authors. All rights reserved
28 H. Alsubie and D.A. Fitzgerald / Lung abscess in children

Table 1
Factors predisposing to secondary lung abscesses may be seen in
secretions and saliva or gastric contents, aspiration is a
children at increased risk of pulmonary aspiration such as those with common initial step in the progression from pneumoni-
the following predisposing factors tis to pneumonia to lung abscess. Specifically, predis-
Immunocompromised host: posing factors in well children in adolescence include
Chemotherapy anesthesia, head injury with impaired cognition, exces-
Immunosuppressive treatment (corticosteroids)
sive sedation or alcohol ingestion, poor dental hygiene
Nutritional deficiencies
Localized structural lung abnormalities: together with poor gingival status that may be seen in
Congenital cystic adenomatoid malformation children receiving anticonvulsants [1–3]. The signifi-
Bronchogenic cyst cance of the introduction of oral flora into the lung is
Tracheo-esophageal fistula (H-type)
Generalized suppurative lung disease: that the bacteria are predominantly anaerobic and this
Cystic fibrosis will alter the antibiotic approach [3,6]. It is worth not-
Hematogenous spread ing that lung abscess is rare in neonates and also may
Neurodevelopmental abnormalities:
be associated with predisposing factors such as lung
Poorly coordinated swallowing
Neuromuscular condition such as myotonic dystrophy and cyst, pneumonia, cognitive impairment or the presence
Duchenne muscular dystrophy of central venous lines. Again, the early symptoms and
Esophageal motility problems: signs may be non-specific [1–3].
Following tracheo-esophageal atresia repair
Esophageal strictures In the child with ongoing pulmonary aspiration, it is
Achalasia the impaired mucociliary defense mechanisms, which
increase the likelihood of pulmonary morbidity and
venting aspiration of infected fluid at the time of ton- mortality [6]. These may occur for a variety of reasons,
sillectomy, the widespread availability of antibiotics which begin with pooled oral secretions and poorly co-
to treat chest infections and the more recent evolution ordinated swallow mechanisms. Contributing to this
of better lung imaging to enable earlier treatment of may include: gingival infection, neuromuscular weak-
pneumonia before complications, such as lung abscess ness, structural proximal airway abnormalities (e.g.
and pneumonia arose [1]. Figures from Canada in the cleft larynx), vocal cord palsy, tracheo-bronchomalacia
1980s put the incidence of children hospitalized with and significant thoracic scoliosis [2,3,6]. Converse-
a lung abscess at 0.7 per 100,000 [5]. Lung abscess ly, there may be significant gastro-esophageal reflux
may occur at any age but is thought to be less common of acidic stomach contents and pulmonary aspiration
in the neonatal period [1]. However, this may change of these fluids. Indeed, it is often gastro-esophageal
with the increasing shift of neonatal care to support in- reflux, which is the focus of investigations and inter-
fants at the extreme of viability and the resulting inva- ventions such as gastrostomy tube insertion and fun-
sive techniques (e.g. central venous lines for parenteral doplication of the stomach. The role of fundoplication
nutrition) to support these technology dependent chil- may have been over-emphasized previously as there is
dren, often with significant neurocognitive and physical now a trend toward inserting gastrostomy tubes with-
disabilities [1,2,6]. out fundoplication in the absence of documented evi-
dence of reflux [6]. This is a reasonable approach, but
it is important to consider the possibility of inducing
4. Predisposing factors gastro-esophageal reflux following gastrostomy feeds
at higher volumes (e.g. bolus feeds as opposed to lower
A lung abscess may arise from aspiration of infected volumes given as continuous overnight feeds) [6].
fluid, aspiration of non-infected fluid which triggers a Additional factors to consider in a previously well
chemical irritation (e.g. acidic gastric fluids), a primary child include the case of a bacterial pneumonia which
bacterial lung infection, hematogenous spread of bacte- often follows an otherwise unremarkable viral upper
ria (e.g. bacterial endocarditis of the right sided cham- respiratory tract infection [1,2,4]. The presumed bac-
bers of the heart) or contiguous spread of infection from terial infection may or may not have been treated along
a neighboring organ [1,3]. Pulmonary aspiration may the course of progressing to a lung abscess. Alterna-
be the central factor in the evolution of a lung abscess. tively, the child may have developed bacterial endo-
Whether this occurs acutely in a previously well child carditis, more commonly on an abnormal heart valve
who has inhaled brackish, infected water or in a debil- or in a structurally abnormal heart, which has sent off
itated child with recurrent aspiration of upper airway septic emboli to the lungs (Table 1) [1,2,5–7].
H. Alsubie and D.A. Fitzgerald / Lung abscess in children 29

Table 2
Common pathogens in lung abscesses
tric acid and so it is possible to cause an inflammatory
response without highly acidic fluid [7–10].
Classification Pathogen
It is likely that the number of episodes of aspira-
Aerobic Gram-positive cocci Streptoococcus pneumoniae
Staphylococccus aureus
tion, the volume of aspirated material and any impair-
Aerobic Gram-negative Pseudomonas aeruginosa ment of mucociliary clearance mechanisms contribute
bacilli Klebsiella pneumoniae to the development of a lung abscess [1,2,6,7]. The
Anaerobic cocci Peptostreptococcus, time course for progression from aspiration to pneu-
Microaerophilic streptococci
Anaerobic Gram-negative Bacteroides species monia and abscess is not rapid. Indeed, the course is
bacilli Prevotella, Fusobacterium somewhat insidious, especially in children with chronic
species low-grade cough related to impaired mucociliary clear-
Fungus Candida albicans, Aspergillus ance. Interestingly, it takes days before the symptoms
species
and signs develop even after a known aspiration event
has occurred, because the body’s host defense mecha-
5. Pathophysiology nisms may decrease perfusion to an area of aspiration
and thereby reduce the influx of defense mediators and
Once the lungs are soiled, an inflammatory cascade the egress of infective material [5–7]. Animal work
is triggered giving rise to the chemical pneumonitis, has demonstrated that there is a biphasic response after
which predisposes to infection. Aspiration pneumoni- acid aspiration [10].
tis is an acute lung injury, which occurs after the in- A lung abscess may arise from embolic phenomena
halation of regurgitated gastric contents [7]. Aspira- such as right-sided bacterial endocarditis, more likely
tion pneumonitis, was originally described as Mendel- in children with right-sided heart valve abnormalities
son’s syndrome from the adult obstetric literature [8], and post-surgery or the placement of a central venous
is a chemical injury caused by the inhalation of sterile line [2,6,7]. Rarely, children with septicemia may have
gastric contents which is seen as distinct from aspira- foci in the lung from hematogenous spread or from
tion pneumonia which is an infectious process resulting thrombophlebitis with septic emboli. In addition, lo-
from the inhalation of oropharyngeal secretions which cal extension from pharyngeal abscesses or abdominal
are colonized by pathogenic bacteria [7]. There is con- collections is also seen [7].
siderable overlap between these conditions and it may In the case of a single small lung abscess, the changes
be difficult to distinguish them in the clinical setting. in ventilation and perfusion may be minimal. As the
Nonetheless, both may contribute to the subsequent de- abscess grows there may be more significant changes
velopment of the relatively uncommon complication of in ventilation and perfusion, resulting in hypoxemia
lung abscess (Table 2). and tachypnea. With the evolution of pleuritic pain
Aspiration pneumonitis is seen in children with a from pleural inflammation, there may be a restrictive
marked disturbance of consciousness which may be component to lung function due to the loss of lung
seen in conditions including: status epilepticus, hypox- volume and reduced lung compliance [1].
ic and metabolic encephalopathies, catastrophic cere-
brovascular events, cerebral trauma as well as patients
with severe neurocognitive impairment of uncertain eti- 6. Clinical presentation
ology, often referred to as having “cerebral palsy” [4,6,
7]. It is a recognized complication of general anesthe- The presentation of lung abscess may be insidious,
sia for any operative procedure and may occur despite typically evolving over two weeks in a child with fever
all appropriate anesthetic precautions [6,7]. Again, in and cough. Other features may include chest pain, dys-
the adult literature, a correlation between the level of pnea, sputum production and hemoptysis (Table 3) [1,
impaired consciousness as measured by the Glasgow 2,5]. The physical findings may range from no de-
Coma Scale and the risk of aspiration was demonstrat- tectable abnormality in the chest to signs of consolida-
ed [9]. It has been suggested that a gastric aspirate pH tion (Table 4). Not infrequently, the diagnosis is made
of less than 2.5 and a volume of greater than 0.3 mL on a chest radiograph as an investigation in a child with
per kilogram of body weight are required for the devel- a persisting cough where a well-circumscribed shadow
opment of aspiration pneumonitis in adults [7]. There is seen containing an air-fluid level [2]. This is more of-
is no corresponding data for children. However, the ten the case in children with a primary lung abscess [1,
stomach contents contain other irritants besides gas- 2,11].
30 H. Alsubie and D.A. Fitzgerald / Lung abscess in children

Table 3
Symptoms reported in several series for children with a lung abscess
Parameters Ho et al. [2] Tan et al. [18] Chan et al. [24] Yen et al. [25]
(n = 23) (n = 23) (n = 27) (n = 23)
Fever 83% 84% 100% 91%
Cough 65% 53% 67% 87%
Dyspnea 36% 35% 19% 35%

Table 4
Clinical signs elicited in children with primary and secondary lung abscess from the Children’s
Hospital at Westmead (1985–2001) [2]
Parameters Primary lung abscess Secondary lung abscess
(n = 29) (n = 14)
Tachypnea 100% 71%
Dull percussion note or reduced air entry 44% 79%
Fever 44% 50%
Localized crepitations 33% 36%

In contrast, a child with a secondary lung abscess is a cohort of 74 children with aspiration pneumonia: 52
more likely to have underlying medical problems. Such with pneumonitis, 12 with necrotizing pneumonia and
problems may include recurrent pulmonary aspiration 10 with a lung abscess [12]. Interestingly, an average
of saliva and upper airway secretions, debilitation, sig- of 4.9 organisms per aspirate was isolated (2.7 anaer-
nificant neuron-cognitive disability, dysphagia, naso- obes and 2.2 aerobes) in that study. It is not uncommon
gastric tube feeding, seizure disorders, altered levels to isolate multiple organisms from lung abscesses and
of consciousness, congenital or acquired immunodefi- more commonly in secondary lung abscesses [12–17].
ciency states and congenital abnormalities of proximal This is not only related to how the specimen is col-
airway structures [11]. In vulnerable individuals, the lected, percutaneous or trans-tracheal versus purulent
presence of poor oral hygiene predisposes to aspiration sputum or unprotected bronchial brushings where con-
pneumonia, lung abscess and empyema with anaerobic tamination with oral flora may occur [12–14]. Anaer-
organisms [7]. obes are more common in patients who are predisposed
to aspiration, such as with dental caries, seizure dis-
orders and impaired co-ordination of swallowing [13–
7. Microbiology 16]. In a cohort of adults presenting with acute lung
abscess in South Africa in the early 1990s, 29 of 34
The pathogens causing a lung abscess may be classi- patients had predisposing factors for lung abscess (i.e.
fied as being aerobic, anaerobic or fungal. More com- secondary lung abscess). In these subjects, anaerobes
monly isolated pathogens are listed in Table 1. In addi- accounted for 74% of the bacterial yield, and apart from
tion to Staphylococcus aureus, one should also consider those subjects with tuberculosis, the bacterial cultures
group B Streptococcus, Escherichia coli and Klebsiella obtained consisted of anaerobes alone in 52% and of
pneumoniae in young infants [1]. However, with age, aerobes alone in only 22% [17]. In a pediatric sample
the likelihood of predisposing factors to lung abscess of patients presenting with an acute lung abscess from
increases and therefore the likelihood of an anaerobic Zimbabwe in 1992, more aerobic organisms were cul-
pathogen increases. From the work in the 1970s, us- tured, especially S. aureus, reflecting different risk fac-
ing trans-tracheal aspiration, studies demonstrated that tors for lung abscess (e.g. post-viral lower respiratory
anaerobic bacteria accounted for 60–80% of lung ab- tract infection) and the higher proportion of primary
scess, with Peptostreptococcus species, Fusobacterium lung abscesses seen [17].
nucleatum and Prevotella melaninogenica predominat- Importantly, the key issues are to consider the likeli-
ing [12–15]. These bacteria matched known oral flora, hood of anaerobic pathogens, to attempt to obtain un-
which had been implicated by Dr David Smith at Duke contaminated purulent material from the abscess cavity,
University in the pre-antibiotic era of the 1920s [15]. culture the pus in appropriate anaerobic media and treat
In children with aspiration pneumonia,the likelihood accordingly. The sensitivity of some obligate anaer-
of yielding an anaerobic organism was reported to be obes to die when exposed to air will undermine attempts
as high as 90% in trans-tracheal aspirates evaluated in to isolate causal anaerobic bacteria and so a liquid spec-
H. Alsubie and D.A. Fitzgerald / Lung abscess in children 31

imen of pus is best injected directly after aspiration into


an oxygen-free (anaerobic) transport vial [11].

8. Imaging

The basic diagnostic test for lung abscess is the chest


radiography, which typically demonstrates an air-fluid
level within a spherical area of consolidation (Fig. 1).
The possibility of lung abscess is greater in the de-
pendent areas of lung, which are more prone to reflect
pulmonary aspiration, specifically the posterior upper
lobe or the superior lower lobe [11]. In one series of
45 lung abscesses in subjects aged from 1 month to 28
years, the distribution was as follows: right upper lobe Fig. 1. Chest radiograph of a lung abscess in the right upper lobe.
(36%), right lower lobe (33%), right middle lobe (24%)
and left upper lobe (9%). Eleven of the 45 subjects had 8.1. The role and type of interventional approach
involvement of more than one lobe and in 16% of all
cases; a pleural effusion was demonstrated [18]. This The traditional mode of therapy has involved intra-
important data was gathered from one large US centre venous antibiotic treatment with a lengthy hospital stay
over nearly 14 years (1982–1993). The data present- followed by several weeks of enteral antibiotics [1,3,
20]. The alternative was surgery, usually with a lobec-
ed, when contrasted with current practice, highlights
tomy or segmentectomy where possible [1,5]. Howev-
how the role of interventional radiology has come to
er, this was not a simple procedure and came with sig-
the fore in the role of management of lung abscess, the
nificant morbidity and some mortality, particularly in
role of computerized tomography (CT) guided imaging patients with predisposing conditions for a secondary
has improved and the duration of inpatient stay has re- lung abscess [1]. Consequently, the involvement of
duced. Today, not withstanding concerns about the use interventional procedures in the management of lung
of ionizing radiation, low dose, contrast-enhanced CT abscess became established [4].
scans are usually considered to be the investigation of The aspiration of lung abscesses with or without an
choice to distinguish lung abscess from an empyema, external drain under CT guidance for large, peripheral-
necrotizing pneumonia with a pneumatocele, seques- ly located abscesses has been used in the pediatric pop-
tration or underlying congenital abnormality such as ulation since the 1980s, with reports of improved suc-
bronchogenic cyst [2–4]. This is particularly relevant cess rates, reduced morbidity and mortality [2]. Nee-
if image guided drainage is considered to distinguish dle aspiration under image guidance has been used for
between necrotizing pneumonia and lung abscess [4]. many years with success for diagnostic and therapeutic
The characteristic appearance of a lung abscess on purposes, but lacks the utility of a small percutaneous
a CT image is shown in Figs 2a and 2b. In particular, drain (pigtail catheter) which may drain the collection
for several days if required. Originally, the concept
the thick-walled cavity contains mobile, central fluid
of CT-guided drainage and the insertion of a pigtail
occurring in the midst of an area of consolidated lung.
catheter for lung abscess and empyema were consid-
An air-fluid level is often apparent on the CT scan,
ered when medical therapy had failed or for rapid di-
even when it may not be evident on the plain chest agnostic and therapeutic benefit in patients considered
radiograph [19]. Magnetic resonance imaging scans too unwell for surgery [21–23]. With experience, the
offer no diagnostic advantage over CT scans and are practice has broadened to the point where intervention-
not routinely used in most centers for investigation and al radiology is considered the standard of care where
treatment of lung abscess as the resolution provided is, such expertise is available [2]. This has been suggest-
at present in clinical practice, not as helpful as the CT ed to result in more rapid defervescence of fever and
imaging [19]. symptoms, shorter periods of intravenous antibiotics
32 H. Alsubie and D.A. Fitzgerald / Lung abscess in children

Table 5
Antibiotic treatment doses∗
Intravenous antibiotics Dose [26]
Benzylpenicillin (30 mg/kg up to) 1.2 g 4 to 6 hourly
Di/Flucloxacillin (50 mg/kg up to) 2 g 6 hourly
Cefotaxime 50 mg/kg 8 hourly
Ceftriaxone 50 mg/kg once daily
Clindamicin (10 mg/kg up to) 450 mg 8 hourly
Vancomycin (10 mg/kg up to) 500 mg 6 hourly
Metronidazole (12.5 mg/kg up to) 500 mg 8 to 12 hourly
Meropenem (20 mg/kg up to) 1 g 8 hourly
∗ Derived from the Children’s Hospital at Westmead Handbook [26].

higher prevalence anaerobes, a reduced proportion of


S. aureus and Haemophilus influenzae type b (since the
introduction of routine immunization in 1992) and a
(a)
shorter length of hospital stay than reported in previ-
ous series [2]. Most interestingly, for the 19 patients
managed exclusively in our institution (mean age 8.3
years; range 20 days to 19.5 years) between 1985 and
2000 with a primary lung abscess (n = 9), the average
length of stay in our institution was 12.4 days [95%
confidence interval (CI) 8.4, 16.5] and for those with
secondary lung abscess (n = 10) it was 25.1 days (95%
CI 14.6, 35.6), giving an overall average of 19.1 days
(95% CI 13.0, 25.2) [2]. Subsequently, over the past 5
years, the length of hospital stay has decreased in our
institution. Current practice at the Children’s Hospital
at Westmead in Sydney sees children presenting with
primary lung abscess managed routinely undergoing
placement of a CT-guided pigtail catheter at presenta-
(b)
tion, with 2–3 days of drainage, intravenous antibiotics
Fig. 2. (a) Computerized tomography scan image of a lung abscess, and discharge within 7 days on a course of oral (enteral
(b) Computerized tomography scan imaging assisting in the place- for those managed with gastrostomy feeds and medi-
ment of a pigtail catheter drain. cations) antibiotic therapy to complete a month of total
antimicrobial therapy guided by culture results [1,2,6,
and a decreased length of inpatient care [2]. However, 13,20].
there does remain a role for surgery in selected cases.
In a recent series of 27 cases (eight primary and 19
secondary lung abscesses occurring between 1987 and
9. Antibiotics
2003) from Taiwan, lobectomy was needed in five of
27 patients (18.5%) [24]. In this series, surgical in-
terventions were required in eight (42%) of 19 of pa- The choice of antibiotics (Table 5) varies somewhat
tients with secondary lung abscess. In the cohort, 10/27 between institutions and is guided by a number of fac-
had ultrasound-guided aspiration of their abscesses and tors, including the ability to isolate organisms through
only one had CT guided aspiration [24]. aspiration and drainage of the abscess, whether the ab-
By way of contrast, at the Children’s Hospital at scess is believed to be a primary or secondary phe-
Westmead in Sydney, the rise in interventional radiolo- nomenon, the likelihood of penicillin resistance, cost
gy over the past 20 years has resulted in routine use of and local practices [1,2,6,13,20,25,26]. At our in-
CT-guided aspiration for abscesses and, in more recent stitution, we initially prefer to use a third-generation
years, in the use of CT-guided pigtail drainage catheters cephalosporin and flucloxacillin (or clindamicin) un-
at the time of presentation. This has translated into a til the aspirated lung abscess fluid culture results are
higher proportion of positive cultures overall, with a available to rationalize therapy.
H. Alsubie and D.A. Fitzgerald / Lung abscess in children 33

For primary lung abscess, antibiotic choice should


cover likely organisms including S. aureus, Streptococ-
cus pneumoniae and other streptococcal species and
gram-negative bacilli that are normally found in the up-
per respiratory tract. Therefore, the use of flucloxacillin
and cefotaxime/ceftriaxone would be appropriate start-
ing points. With the increasing threat of multiply resis-
tant S. aureus (MRSA), the role of vancomycin is likely
to increase. For patients at risk of a hospital acquired in-
fection with Klebsiella spp. or Enterobacter spp., these
are resistant to penicillin and there is an increasing risk
of antibiotic resistance to third and fourth generation
cephalosporins owing to the production of plasmid-
mediated extended-spectrum beta-lactamases. Conse-
quently, most isolates are sensitive to fluoroquinolones,
trimethoprim/ sulfamethoxazole, aminoglycosides and
carbapenems (e.g. meropenem) and a combination of
a carbapemem (or fluoroquinolone) with an aminogly-
coside may be appropriate [20].
For patients at risk of secondary lung abscess through
aspiration, it is important to cover anaerobes normally
found in the upper airway, with clindamicin provid-
ing coverage against these organisms as well as S. au-
reus. Alternatives could include benzylpenicillin and
metronidazole. For an immunocompromised host, an- Fig. 3. Transcutaneous drain in situ in treatment of a lung abscess
tibiotic coverage is broader and likely to include con- (Photo courtesy of Dr David Lord).
sideration of fungal pathogen. Once the child has de-
fervesced, an oral antibiotic would replace the intra- The rate of resolution of the abscess cavity lags be-
venous therapy and the child would be discharged on hind the clinical resolution of the abscess. In fact,
an oral antibiotic to complete a four-week course of whilst children would routinely receive another 3 weeks
treatment [1,2,13,20,25,26]. of oral antibiotics after discharge, the abscess cavity
on the chest radiograph may persist for months to even
years after appropriate therapy [1]. Pulmonary function
typically returns to baseline [5].
10. Clinical course
10.1. Complications
If intravenous antibiotics alone are used, the fever
may resolve in seven to ten days and the illness resolves In the pre-antibiotic era, a lung abscess was fatal in
within a further two weeks [1,5]. It is our experience 30% to 40% of cases [1]. In contrast, whilst deaths
that the use of interventional radiology has since ap- due to lung abscess still occur in children, they are be-
proximately halved the length of hospitalization from lieved to be infrequent for primary lung abscess but
our figures from 1985 to 2000 of 12.4 days for a pri- more common in secondary lung abscess. Deaths are
mary lung abscess and 25 days for a secondary lung more commonly reported in cases of secondary lung
abscess [2]. The use of percutaneous aspiration or pig- abscess where host factors (e.g. malnutrition in patients
tail catheter drainage (Fig. 3) shortens the course of in the developing world; immunodeficiencies or malig-
the illness considerably and probably has an associated nancies) are more likely to determine the outcome in
cost saving allowing for the costs of anesthesia and in- cases [1]. In our experience, there have been no deaths
terventional procedures given the costs of intravenous from lung abscess in the last 20 years [2], yet in a sim-
therapies and hospital bed days [2]. More importantly, ilar time period from Taiwan there were 5/27 (18.5%)
a shorter hospital stay is better for the children and their of patients who died due to the severity of their under-
families [1,2]. lying conditions [21]. The series from Taiwan reported
34 H. Alsubie and D.A. Fitzgerald / Lung abscess in children

Table 6
Complications of lung abscess
whereas in children the mortality is significantly lower,
probably of the order of less than 5% and occurs pre-
Spontaneously rupture into adjacent compartment
Empyema, pyothorax or pneumothorax
dominantly in those with a secondary lung abscess [21].
The connection between the abscess cavity and the pleural space It is the co-morbidity of the predisposing conditions in
Bronchopleural fistula both adults and children that contributes to the worse
Hematogenous spread leading to multiple abscesses prognosis and higher mortality rate. Consequently, al-
Anesthesia complication:
Aspiration, reaction, post-op nausea and fever
most all immunologically competent children with a
Radiation exposure: primary lung abscess would be expected to recover,
Computerized tomography scans, chest radiographs whereas those with predisposing conditions, predom-
Reaction to antibiotics: inantly immunocompromised states, would expect to
Fever, rash or anaphylaxis
Site scar fare significantly worse [1,2,18,21,24,25].

a complication rate of 41%, which included respiratory


failure (6/27), pneumothorax (3/27), shock (1/27), os- References
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