American Journal of Therapeutics 21, 217–221 (2014)

Lung Abscess: Update on Microbiology

and Management

Moussa F. Yazbeck, MD,1 Maher Dahdel, MD,2 Ankur Kalra, MD,3*

Alexander S. Browne,3 and Melvin R. Pratter, MD2

A lung abscess is a circumscribed collection of pus in the lung as a result of a microbial infection,
which leads to cavity formation and often a radiographic finding of an air fluid level. Patients with
lung abscesses commonly present to their primary care physician or to the emergency department
with ‘‘nonresolving pneumonia.’’ Although, the incidence of lung abscess has declined since the
introduction of antibiotic treatment, it still carries a mortality of up to 10%–20%. This article discusses
in detail the up-to-date microbiology and the management of lung abscesses.

Keywords: lung abscess, necrotizing pneumonia, nonresolving pneumonia, abscess

INTRODUCTION symptoms leading to radiographic testing. These

A lung abscess is a circumscribed collection of pus in the
lung as a result of a microbial infection, which leads to
cavity formation and often a radiographic finding of an
air fluid level.1 Occasionally, it is referred to as
‘‘necrotizing pneumonia’’ or ‘‘lung gangrene’’ in the
setting of multiple lesions (,2 cm).2 Review of 2114 cases
of lung abscesses in the preantibiotic era showed a high
mortality of 30%–40%.1,3 Although, the incidence of lung
abscess has declined since the introduction of antibiotic
treatment, it still carries a mortality of up to 10%–20%.1
Patients with lung abscesses commonly present to their
primary care physician or to the emergency department
with ‘‘nonresolving pneumonia.’’
CLINICAL PRESENTATION
Classically, patients with a lung abscess present with
a constellation of constitutional and respiratory
Divisions of 1Critical Care; 2Pulmonary Diseases; and 3Internal
Medicine, Department of Medicine, Cooper University Hospital,
University of Medicine and Dentistry of New Jersey, Camden, NJ.
The authors have no conflicts of interest.
*Address for correspondence: Department of Medicine, Cooper
University Hospital, University of Medicine and Dentistry of New
Jersey, One Cooper Plaza, Camden, NJ 08103. E-mail: ceo@
kalrahospital.com
1075–2765 Ó 2012 Lippincott Williams & Wilkins
symptoms usually manifest for $2 weeks. A small
prospective study of 26 patients conducted in the early
1970s showed that the duration of symptoms before
presentation ranged between 1 day and 40 weeks with
a mean of 3 weeks. However, less typical presentations
are not uncommon.
Classic symptoms include cough, fever, night sweats,
weight loss, hemoptysis, and pleuritic chest pain.
Putrid sputum with foul-smelling breath occurs in only
50% of cases.4 Of particular interest was the observa-
tion that none of the patients with anaerobic bacterial
infections of the lung complained of shaking chills or
rigor, unlike patients with S. pneumoniae pneumonia.5
Physical examination findings may include fever,
poor dentition, gingival disease, and clubbing.
Amphoric or cavernous breath sounds may be heard,
and the gag reflex may be absent although this is likely
to be an unreliable finding. Anemia of chronic disease
and leukocytosis (;15,000 white blood cells per cubic
millimeters) are usually present. Associated empyema
is present in about one-third of cases.4
DIAGNOSIS
Diagnosis is ultimately made radiographically by plain
chest roentgenogram where a cavitary lesion(s) is seen,
often with an air fluid level (Fig. 1). A computed
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FIGURE 1. Cavity with air fluid level.
tomography (CT) of the chest is the gold standard, and
aids in diagnosing associated malignancy or mass, and
helps in distinguishing parenchymal lesion from
pleural collection. Blood cultures are not usually
helpful, especially in anaerobic infections. Pleural fluid
aspirate could help in the diagnosis if there is an
associated effusion or empyema. Patients have fre-
quently had antibiotics before diagnosis, which com-
plicates isolation of the organism(s). Furthermore, it
may be difficult to isolate anaerobic bacteria since most
respiratory tract specimens (sputum or bronchoscopy
aspirates) are contaminated by upper airway flora.
Therefore, care must be exercised in the interpretation
of culture data because most yield deceptive contam-
inants.2 Finally, routine bronchoscopy is not indicated
in every lung abscess, unless malignancy or atypical
infections are suspected and in those who fail standard
therapy or for a suspected foreign body.2
In this setting, bronchoscopic aspiration using
a quantitative brush catheter or quantization of org-
anisms obtained from bronchoalveolar lavage is usu-
ally performed.
PREDISPOSING FACTORS AND
PATHOPHYSIOLOGY
The most common cause of lung abscess is aspiration
pneumonia secondary to a large inoculum of relatively
virulent bacteria that leads to necrosis of lung paren-
chyma, followed by cavitation. Other recognized
American Journal of Therapeutics (2014) 21(3)
Yazbeck et al
mechanisms are transdiaphragmatic spread of anaerobic
bacteria from subphrenic collections, and hematogenous
seeding commonly associated with right-sided endo-
carditis or septic thrombophlebitis.6
Aspiration invariably is associated with clouding
of consciousness or dysphagia. This includes but is not
limited to alcoholics (70%), drug users, patients after
general anesthesia, and patients with seizures. Men
outnumber women by a ratio of 5:1. The term
aspiration could be a little misleading, because nearly
all healthy persons periodically aspirate their secre-
tions. It is believed that patients who develop anaerobic
infections of the lung or abscesses are the ones who
are prone to aspiration of large quantities of fluids from
the upper airways. Dental disease with gingivitis or
pyorrhea usually provides the inoculum. The organ-
isms that are predominant in anaerobic infections of the
lung normally colonize the gingival crevices. The
association of lung abscess with aspiration pneumonia
makes the dependent lung segments most vulnerable.
It is more frequently found on the right side, perhaps
reflecting the angle of takeoff of the right main-stem
bronchus. The dependent pulmonary segments
favored by gravitational flow in the recumbent position
are the superior segments of the lower lobes or the
posterior segments of the upper lobes; the favored
segments with aspiration in the upright or semi-
recumbent position are the basal segments of the lower
lobes.6 Infection in the basal segments was common
when oral surgery and tonsillectomy were performed
in the sitting position.
 Bronchogenic neoplasms and bronchiectasis are
associated with an increased risk of developing
lung abscesses through impairment of mucus
clearance. Chronic obstructive pulmonary disease
does not seem to be a predisposing factor.
 Intravenous drug use predisposes patients to
right-sided endocarditis, which in turn can lead
to the passage of clots laden with bacteria into the
pulmonary circulation. These could be solitary but
are most commonly multiple necrotizing lesions.
Indwelling venous catheters or medical device
infection can also cause septic emboli. Similarly,
Lemierre syndrome is an infection of the lateral
pharyngeal space of the neck resulting in septic
thrombophlebitis of the internal jugular vein,
which can cause septic pulmonary emboli. This
syndrome was originally described in 1936 by
Lemierre. In the majority of cases, Lemierre
syndrome typically results from an infection of
the pharynx and subsequent local tissue invasion
by the anaerobic gram-negative bacterium Fuso-
bacterium necrophorum. Therefore, this entity
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Lung Abscess
should be considered in the differential diagnosis
of septic emboli especially if a history of pharyn-
gitis or neck pain is present.7
 A multitude of cases of lung abscesses were
diagnosed after the 2004 tsunami in Asia and the
New Orleans hurricane, when infections occurred
due to aspiration of soil-contaminated water.
These grew an unusual spectrum of microbes such
as Burkholderia pseudomallei, mostly contaminants
from the soil. Similarly, near drowning can lead to
aspiration of water and therefore formation of
abscesses.
DIFFERENTIAL DIAGNOSIS
Differential diagnosis of lung abscess is as follows:
 infectious: Tuberculosis, Melioidosis,
 empyema with air fluid level,
 bullae or cysts with air fluid level,
 bronchiectasis,
 neoplasm,
 vasculitis,
 Bland embolism with infarction.
MICROBIOLOGY
Studies of primary lung abscesses in the preantibiotic
era implicated a variety of microorganisms, particu-
larly anaerobes. The availability of surgical and
autopsy specimens from patients not treated with
antimicrobials offered excellent sources for bacterio-
logic study. Earlier studies showed that anaerobic
bacteria were found in 90% of lung abscesses and were
the only organisms present in about half of the cases.
These bacteria reflect the anaerobic flora of the gingival
crevice. The most frequently isolated anaerobes are
Peptostreptococcus spp (now Finegoldia magna), Prevotella
melaninogenica, Bacteroides spp, and F. nucleatum.
Abscesses are often polymicrobial and contain multiple
anaerobic species. Microaerophilic streptococci and
viridans streptococci are often present as well. Less
frequently, monomicrobial aerobic bacteria such as
Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas
aeruginosa, B. pseudomallei, Legionella spp, Actinomyces
spp, and Nocardia spp can be the causative organisms.
S. aureus pneumonia and associated lung abscess
usually present as a fulminant disease—frequently
a superinfection with influenza and carry a high
mortality. It occurs frequently in adolescents and
young adults, with high rates of methicillin resistance
(methicillin-resistant S. aureus). There is also an
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219
association with intravenous drug use. A study
conducted in 2005 in Taiwan that included 90 adults
with community-acquired lung abscesses suggested
that the bacteriology of lung abscesses has changed,
because they recovered anaerobes in only 31% of cases.
K. pneumoniae seemed to be the predominant bacterium
to be isolated (33%). Therefore, the study
further suggested that antibiotic selection for treatment
of lung abscesses should include coverage for
K. pneumoniae.8 Unfortunately, there are no recent
similar studies in the United States, and therefore, the
Taiwanese study results should not be extrapolated to
the United States mostly because of the geographic
bias. In fact, K. pneumoniae in Taiwan is notably more
virulent from most other parts of the world. This belief
is reinforced by the fact that K. pneumonia is the
primary cause of liver abscesses in countries in Asia. In
patients with impaired cell-mediated immunity (AIDS,
transplant), opportunistic pathogens such as mycobac-
teria, Aspergillus, Rhodococcus, and Nocardia are
important causes of cavitary lung lesions. Specifically,
Nocardia spp seems to have an association with long-
term steroid use. In patients with impaired host
defenses caused by granulocytopenia (leukemia, che-
motherapy), aerobic bacteria such as P. aeruginosa,
S. aureus, and fungi including Aspergillus and
Zygomycetes are important pathogens.4 Finally, par-
asitic infections, and mycobacteria can also cause
lung abscesses.
TREATMENT
Antibiotics remain the main stay of treatment for
lung abscesses. Early studies showed that penicillin
and clindamycin were equally effective, but with
the increasing surge of anaerobic beta-lactamase
activity, clindamycin became superior in terms of
response rate, fever duration, and time to resolution
of putrid sputum.9 The recommended dose of
clindamycin is 600 mg administered intravenously
every 8 hours if hospitalized, followed by 150–
300 mg orally 4 times daily. It is important to keep in
mind that if we were to extrapolate the findings of
Wang et al8 that pneumoniae has become a more
common cause of lung abscesses than before, clin-
damycin alone may no longer be appropriate. At this
point, there are no other studies to support such
an extrapolation.
As stated in the microbiology section, the causative
agents of lung abscesses are often polymicrobial
and therefore carry different degrees of resistance
to antibiotics; but in general, all anaerobes and
most of the facultative organisms isolated from
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the respiratory samples have been susceptible to
beta-lactam/beta-lactamase combinations such as
amoxicillin-clavulanate.10
Although several antibiotics are recommended for
the treatment of aspiration pneumonia, including
third-generation cephalosporins, fluoroquinolones,
and piperacillin,11 there are not enough data to support
the use of these regimens for the treatment of lung
abscesses.
Metronidazole does not seem to be particularly
effective, presumably because of the important role of
microaerophilic streptococci, such as Streptococcus
milleri.12,13 Therefore, if used at all, it should be in
combination with a beta-lactam such as ceftriaxone.
The duration of therapy is controversial. Some
authors recommend treatment for 3 weeks regard-
less of the clinical improvement, whereas others
favor continuing antibiotic treatment until the chest
x-ray clears or shows a smaller, stable residual
lesion.14 This can be achieved primarily on an
outpatient basis or initial in-patient treatment
followed by oral regimen. Frequently, patients who
get hospitalized initially are those who failed out-
patient treatment for a presumptive diagnosis of
pneumonia, patients with secondary causes of lung
abscess (bronchogenic carcinoma or immunosup-
pression), when diagnosis is in doubt, and/or ill and
toxic-appearing patients.
In 20% of cases, drainage of the collection may be
necessary. Despite the absence of accurate clear guide-
lines for invasive approaches, the primary indications
would be failure to respond to medical therapy alone,
and in circumstances such as significant hemoptysis or
suspected neoplasm. The available options are percu-
taneous drainage under CT guidance, which carries
a risk of soiling the pleural space.15 Another method is
endoscopic drainage, which requires an experienced
operator, and is performed by placing a catheter into
the abscess cavity under bronchoscopic visualization,
and leaving the catheter in place until the cavity is
drained.16 Bronchopleural fistula is not an uncommon
complication in this setting.
Patients with lung abscesses usually respond to
treatment within days with defervescence and
improvement in the clinical status. If fever persists
beyond 7–10 days, this is usually an indication of
a delayed response. In such circumstances, further
diagnostic tests are warranted to identify any
underlying anatomic abnormalities, resistant micro-
biology, or unusual agents such as mycobacteria or
fungi.17
Surgery, which used to be indicated for large-sized
abscesses (.6 cm), and in nonresponders to medical
treatment, is seldom done anymore.
American Journal of Therapeutics (2014) 21(3)
Yazbeck et al
PROGNOSIS
The incidence of lung abscesses has declined since
the introduction of antibiotics; however, prognosis
remains poor for the elderly, debilitated, malnour-
ished, and immunocompromised. Lung abscess still
causes significant mortality of up to 10%–20%, and
significant morbidity. A retrospective study of 75
patients by Hirshberg et al found an association
between certain predisposing factors and worse
outcomes. These included large abscess size, right
lower lobe location, low albumin, anemia, and
infections with S. aureus, K. pneumoniae, and partic-
ularly P. aeruginosa. It could also be argued that those
predisposing factors reflect a poor basic physical
condition.1
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