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Necrotizing pneumonia
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CURRENT
OPINION Necrotizing pneumonia: a rare complication of
pneumonia requiring special consideration
Yueh-Feng Tsai a and Yee-Huang Ku b
Purpose of review
Necrotizing pneumonia is a rare complication of bacterial lung infection. Its cause is owing to either a
virulence factor of the microorganism or a predisposing factor of the host. This disease may cause
devastating complications such as diffuse pulmonary inflammation, septic shock, and respiratory failure,
making treatment more difficult. In the recent decade, the cause of necrotizing pneumonia and the role of
surgical treatment have raised considerable attention, leading to therapeutically specific suggestions.
Recent findings
Staphylococcus aureus strains that produce Panton–Valentine leukocidin have been reported to cause
rapidly progressive necrosis of the lung tissue in young immunocompetent patients. Furthermore, recent
studies have showed the risk of disease progression is associated with underlying medical conditions.
Although antibiotics are the first choice of treatment for necrotizing pneumonia, it has been emphasized
that surgical treatment is a feasible alternative option in patients who fail to respond to antibiotics and
develop continued deterioration and complications.
Summary
The current knowledge of cause, clinical features, diagnosis, treatment, and prognosis of necrotizing
pneumonia are summarized. Antibiotics remain the mainstay of treatment. Lung resection can be
considered an alternative treatment option in patients who are unresponsive to antibiotic therapy and
develop parenchymal complications. Outcome is affected by the degree of disease progression and
comorbidities.
Keywords
bronchopulmonary fistula, lung resection, necrotizing pneumonia, pneumonia, pulmonary infection
and develop a necrotic process even with optimal saving in these cases [3 ,4,5].
medical treatment. The process is usually rapidly Articles in the literature describe the predispos-
progressive and these patients tend to present with ing risk factors and surgical outcome of necrotizing
&& &&
acute respiratory distress. The affected extent may pneumonia [1,3 ,6 ,7]. This review summarizes
be patchy, segmental, lobar, or even an entire lung the current knowledge of cause, clinical charac-
[1]. Necrotizing pneumonia has been characterized teristics, diagnosis, treatment, and prognosis of
by the finding of pneumonic consolidation with necrotizing pneumonia. Surgical indications and
multiple necrosis of the lung parenchyma. These
necrotic foci may coalesce, resulting in a lung a
Department of Surgery, St. Martin De Porres Hospital, Chiayi and
abscess if localized, or pulmonary gangrene if b
Department of Medicine, Chi Mei Medical Center, Liouying, Tainan,
involving an entire lobe [2]. Taiwan
Treatment of necrotizing pneumonia consists of Correspondence to Yee-Huang Ku, Department of Medicine, Chi Mei
prolonged courses of antibiotics. However, massive Hospital, Liouying, No. 201, Taikang, Liouying District, Tainan City 736,
necrotic tissue makes it difficult for the antibiotics to Taiwan (R.O.C). Tel: +886 6 6226999/77604; fax: +886 6 6226999/
reach the infected areas, as well as leading to the 77610; e-mail: althrisas@gmail.com
progressive destruction and persistent infection of Curr Opin Pulm Med 2012, 18:246–252
the pulmonary parenchyma, possibly followed by DOI:10.1097/MCP.0b013e3283521022
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Necrotizing pneumonia Tsai and Ku
Although the pathogenesis of necrotizing pneumo- Other identified organisms were Staphylococcus
nia is not clearly defined, most studies believe that epidermidis, Escherichia coli, Acinetobacter baumannii,
tissue necrosis occurs as a result of inflammatory Haemophilus influenzae and Pseudomonas aeruginosa
&&
response due to the toxins produced by the invasive [1,3 ,25]. P. aeruginosa pneumonia is not common
pathogen or the associated vasculitis and venous in healthy persons but usually presents with a ful-
&&
thrombosis [6 ,8–11]. The most common patho- minant and lethal course [25]. It is well recognized
gens are Staphylococcus aureus, Streptococcus pneumo- to invade blood vessels and cause a thrombotic
&& &&
niae, and Klebsiella pneumoniae [1,3 ,6 ,7,12,13]. endarteritis, therefore leading to tissue necrosis
S. aureus is responsible for about 2% of cases [7]. Rarely, anaerobes such as Clostridia species
of community-acquired pneumonia [9]. S. aureus and Bacteroides species are reported. They are
strains, often methicillin-resistant, that produce thought to play a synergistic role in causing necrot-
cytotoxin Panton–Valentine leukocidin (PVL) are izing pneumonia, which is usually a delayed process
associated with causing progressive and hemorrha- [26].
gic necrotizing pneumonia especially in young
&&
immunocompetent patients [9,11,14 ]. Although
most studies reported that PVL served as the CLINICAL FEATURES
mediator of tissue necrosis [9,11], other studies Necrotizing pneumonia tends to occur in adult
also suggested that a-hemolysin and possibly other males with concomitant medical illness such as
cytotoxins are responsible for the pathogenesis of diabetes mellitus, alcohol abuse, and corticosteroid
&& &&
pulmonary disease [15]. therapy [3 ,14 ]. In contrast, the pediatric patients
Streptococci are considered important patho- are predominantly composed of healthy female
&&
gens too. S. pneumoniae is the most common cause children [6 ,13,19,20]. Common presenting symp-
of bacterial pneumonia in children and an increase toms include fever, cough, chest pain, and shortness
&& &&
in necrotizing pneumonia has been observed since of breath [4,6 ,14 ]. These patients may have
1990 [8,13,16,17]. Nonvaccine S. pneumoniae purulent sputum and sometimes present with
serotype 3 has become a significant contributor confusion [27,28]. Duration of symptoms prior to
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Infectious diseases
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Necrotizing pneumonia Tsai and Ku
TREATMENT
Treatment of necrotizing pneumonia is primarily
medical. However, when the disease deteriorates
or complications occur in spite of optimal medical
treatment, surgical intervention should be con-
sidered an alternative treatment.
Antibiotics
Intravenous antibiotic therapy remains the main-
stay treatment of necrotizing pneumonia. The
choice of initial antibiotics should be directed at
broad coverage with commonly implicated patho-
gens (S. aureus, streptococci, K. pneumoniae, etc) [7].
Additional empirical anaerobic antibiotic should be
considered in patients with lung abscesses. Once the
causative pathogens and sensitivities are known,
antibiotics can be modified accordingly. However,
the patients’ clinical information and the local
susceptibility pattern of the possible pathogen such
as the incidence of penicillin-nonsusceptible or
ceftriaxone-nonsusceptible Streptococcus pneumoniae
and community-acquired methicillin-resistant
Staphylococcus aureus (MRSA), also determine the
FIGURE 2. Extensive consolidation and collapse with a choice of antibiotics.
pneumothorax in a 78-year-old-woman with corticosteroid Empiric penicillins or ceftriaxone (if penicillin-
therapy. 700 ml of pus was drained and there was persistent nonsusceptible S. pneumoniae was considered) or
air leak. glycopeptide (if ceftriaxone-nonsusceptible S. pneu-
moiae was considered) are recommended. Clinda-
mycin or metronidazole can be used in combination
to cover possibly involved anaerobes. Respiratory
quinolones, such as levofloxacin or moxifloxacin
(which can also cover anaerobic infection), are an
alternative choice especially for those patients aller-
gic to penicillins or cephalosporins. Glycopeptide or
linezolid is recommended in treating community-
&&
acquired MRSA infection [14 ]. Linezolid and clin-
damycin have been reported to have better result
in treating staphylococcal necrotizing pneumonia
&&
as a result of inhibiting PVL production [14 ].
In hospital-acquired infection, antipseudomonas
b-lactams or/and quinolones, or both, are recom-
mended if pseudomonas is considered, and even
carbepenem if a multidrug resistant organism is
considered. If the culture results are negative, the
adjustment of antibiotics may depend on the treat-
ment response of clinical parameters (e.g. symptoms
and signs, inflammatory markers, chest radio-
graphs).
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Infectious diseases
into the pleural space because an inflammatory tolerate pneumonectomy [1,4,7]. In addition, a con-
pleural adhesion commonly occurs. Even if success- siderable number of patients have pleural collec-
ful, the result of drainage is unsatisfactory, as pleural tions at the time of surgery. Thus, decortication
fluid frequently becomes loculated. Furthermore, should also be undertaken to facilitate expansion
a retrospective study in children showed pleural of the remaining lung.
drainage increased the incidence of ongoing air leak Necrotizing pneumonia often leaves the inter-
through a bronchopleural fistula [31]. lobar fissure densely fused and the involved paren-
chyma tends to become heavy and firm, making
pulmonary resection very difficult. Recent studies
Surgery recommend the key technique is to ligate and sever
Surgical debridement or resection may be con- the pulmonary veins first. This procedure permits
&&
sidered for patients who fail to improve with the lung to be retracted more easily [1,3 ]. When a
medical management. However, the optimal indica- densely fused fissure is encountered, direct dissec-
tions and timing of surgery are unclear. It is recom- tion of the pulmonary artery in the fissure is risky
mended that a surgical approach should be and not suggested. Alternatively, the fissure can be
considered if patients develop continued deteriora- divided between clamps in small steps from both
tion or have complications despite the use of anti- ends but sparing the central area within which the
biotic therapy and less invasive procedures. pulmonary arteries lay. The central fused paren-
Accordingly, the primary indications include per- chyma is further divided vertically by electrocautery
sistent fever and leukocytosis, occurrence of without injuring the artery until a TA 60 stapler
empyema, bronchopleural fistula and hemoptysis, (4.8 mm, green cartridge) can be applied. The
and necrotic parenchyma that is responsible for remaining tissues between the involved and healthy
&& &&
impaired respiratory function [1,3 ,6 ,7,12]. lobes are temporarily clamped with the stapling
Furthermore, for patients with respiratory failure device in atelectasis. The healthy lung is inflated
and septic shock who are stabilized after medical to confirm that the proposed line of transection is
treatment, surgical intervention can be an option if correct. Then the staples are advanced, and the
&&
parenchymal complications occur [1,3 ,7]. On the involved lobe is resected. The resection margin of
contrary, a higher risk of postoperative death and the left lung is reinforced with continuous mono-
&&
ventilator dependency is observed in patients with filament absorbable sutures [3 ]. Several authors
bilateral diffuse disease and preexisting organ failure advocated covering the bronchial stump with tissue
such as liver cirrhosis, renal failure, and chronic flaps to reduce the risk of stump leak, particularly
&&
obstructive pulmonary disease [1,3 ,7]. Extensive after pneumonectomy [1,7,12]. However, a recent
lung resection should be avoided in such cases. investigation with 26 patients undergoing pulmon-
The operation can be performed with single- ary resection for necrotizing pneumonia showed
lung anesthesia using a double-lumen endobron- lobectomies and bilobectomies can be safely per-
&&
chial tube to facilitate exposure. To prevent the formed without the use of a flap [3 ].
spread of secretions to the contralateral lung, the The main postoperative complications include
airway must be frequently suctioned during surgical persistent air leak, empyema, and ventilator
manipulation. Patients may not tolerate one-lung dependency. A recent publication with 20 children
ventilation, which increases the surgical difficulty. reported that postoperative persistent air leak
Alternative use of one-lung and two-lung venti- occurred in 20% of patients, all of whom received
&&
lation is a way to maintain adequate saturation of segmentectomy [6 ]. Prolonged chest tube drainage
&&
oxygen during the whole course of surgery [3 ]. is required in these cases and the chest tube ulti-
The type of surgical resection is based on the mately can be safely removed as a result of post-
extent of the pulmonary necrosis and is always as operative pleural symphysis. A residual space after
conservative as possible. If the necrotic parenchyma lobectomy or pneumonectomy may increase the
is confined to the periphery, it can be treated by risk of postoperative empyema. A pleural irrigation
debridement, wedge resection, or segmentectomy. system or obliteration of the space with a muscle
When the affected parenchyma is too extensive to flap seems to reduce the incidence of postoperative
completely remove the infected tissue using partial pleural infection [1,7]. Once this complication
resection of a lobe, lobectomy is indicated occurs, it is usually localized and can be managed
&& && &&
[1,3 ,6 ]. The necrotizing process can possibly by percutaneous drainage [3 ,12]. Patients with
involve multiple lobes. A significantly more invasive bilateral diffuse disease tend to become ventilator
procedure such as bilobectomy and pneumonec- dependent following lung resection [1]. Debride-
tomy may be required. Literature demonstrates that ment of necrotic parenchyma is an alternative
patients with unilateral involvement can well approach [7].
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Necrotizing pneumonia Tsai and Ku
3. Tsai YF, Tsai YT, Ku YH. Surgical treatment of 26 patients with necrotizing
PROGNOSIS && pneumona. Eur Surg Res 2011; 47:13–18.
The mortality of necrotizing pneumonia is difficult In this study, authors describe the common comorbidities and complications of
necrotizing pneumonia. They also highlight the indications and techniques of
to assess because of its rarity, but is likely to be high. surgical resection for necrotic lung tissue and conclude that pulmonary resection
There are also not enough data to compare the is a feasible treatment option for patients who have no response to antibiotic
therapy and develop parenchymal complications.
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alone because it is not possible to select those pulmonary gangrene. Ann Thorac Surg 2009; 87:310–311.
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tory to medical therapy ranges between 80 and 95% && necrotizing pneumonia. J Bras Pneumol 2010; 36:716–723.
&& &&
Authors emphasize chest CT should be performed in pneumonia children with
[1,3 ,6 ,7,29]. Bilateral diffuse disease and preex- persistent fever, worsening of clinical status, or pleural complications despite
isting organ failure appear to be important predic- appropriate antibiotic therapy. They advocate surgical resection is indicated in
&&
cases of septicemia, bronchopleural fistula, or acute respiratory failure that are
tors of surgical outcome [1,3 ,7]. Moreover, Li et al. refractory to medical treatment.
&&
[14 ] suggest that necrotizing pneumonia due to S. 7. Karmy-Jones R, Vallières E, Harrington R. Surgical management of necrotizing
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