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Right Middle Lobe Syndrome Medication

  • Author: Nemr S Eid, MD, FAAP, FCCP; Chief Editor: Michael R Bye, MD  more...
 
Updated: Apr 17, 2015
 

Medication Summary

The role of antibiotic therapy in the treatment of right middle lobe syndrome (RMLS) is not well studied. Antibiotics are usually administered during acute exacerbations and when bronchiectasis is well established. In this latter instance, long-term rotation of antibiotics (ie, 3 weeks on and 1 week off, then change antibiotic) is advocated. Base the choice of antibiotic on culture and sensitivity results of either sputum or bronchoaveolar lavage (BAL) fluid. When this is not available, select a broad-spectrum antibiotic to cover S pneumoniae, other streptococci, H influenzae, and Moraxella catarrhalis. Antibiotics can be orally or intravenously administered. The use of nebulized antibiotics has not been studied in right middle lobe syndrome. Also see Asthma for relevant treatment information.

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Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Cefuroxime (Ceftin, Zinacef)

 

Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have; adds activity against Proteus mirabilis, H influenzae, Escherichia coli, Klebsiella pneumoniae, and M catarrhalis.

Cefpodoxime proxetil (Vantin)

 

Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins; bacteria eventually lyse because of ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.

Cefprozil (Cefzil)

 

Binds to one or more of the penicillin-binding proteins, which, in turn, inhibits cell wall synthesis and results in bactericidal activity.

Erythromycin and sulfisoxazole (Pediazole)

 

Erythromycin is a macrolide antibiotic with a large spectrum of activity. Erythromycin binds to the 50S ribosomal subunit of the bacteria, which inhibits protein synthesis.

Sulfisoxazole expands erythromycin's coverage to include gram-negative bacteria. Sulfisoxazole inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic acid.

Azithromycin (Zithromax)

 

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Clarithromycin (Biaxin)

 

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Amoxicillin and clavulanic acid (Augmentin)

 

Drug combination treats bacteria resistant to beta-lactam antibiotics. For children >3 months, base dosing protocol on amoxicillin content. Due to different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250 mg chewable-tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.

Sulfamethoxazole and trimethoprim (Bactrim, Septra, Cotrim)

 

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.

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Contributor Information and Disclosures
Author

Nemr S Eid, MD, FAAP, FCCP Professor of Pediatrics, University of Louisville School of Medicine; Director of Pediatric Pulmonary Medicine, Director of The Childhood Asthma Care and Education Center and the Cystic Fibrosis Center, Medical Director of Pediatric Respiratory Therapy, Kosair Children's Hospital

Nemr S Eid, MD, FAAP, FCCP is a member of the following medical societies: Kentucky Chapter of The American Academy of Pediatrics, Kentucky Pediatric Society, American College of Chest Physicians, American Thoracic Society, Kentucky Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Michelle Eckerle University of Louisville School of Medicine

Michelle Eckerle is a member of the following medical societies: Kentucky Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of Medicine; Attending Physician, Pediatric Pulmonary Division, Women's and Children's Hospital of Buffalo

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

Thomas Scanlin, MD Chief, Division of Pulmonary Medicine and Cystic Fibrosis Center, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School

Thomas Scanlin, MD is a member of the following medical societies: American Association for the Advancement of Science, Society for Pediatric Research, American Society for Biochemistry and Molecular Biology, American Thoracic Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Acknowledgements

Heidi Connolly, MD Associate Professor of Pediatrics and Psychiatry, University of Rochester School of Medicine and Dentistry; Director, Pediatric Sleep Medicine Services, Strong Sleep Disorders Center

Heidi Connolly, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

References
  1. Springer C, Avital A, Noviski N, et al. Role of infection in the middle lobe syndrome in asthma. Arch Dis Child. 1992 May. 67(5):592-4. [Medline].

  2. Liu J, Chen SW, Liu F, Li QP, Kong XY, Feng ZC. The diagnosis of neonatal pulmonary atelectasis using lung ultrasonography. Chest. 2015 Apr 1. 147(4):1013-9. [Medline].

  3. [Guideline] Institute for Clinical Systems Improvement (ICSI). Diagnosis and management of asthma. 2008 Jan. [Full Text].

  4. Priftis KN, Mermiri D, Papadopoulou A, et al. The role of timely intervention in middle lobe syndrome in children. Chest. 2005 Oct. 128(4):2504-10. [Medline].

  5. Halliday HL, Ehrenkranz RA, Doyle LW. Early (< 8 days) postnatal corticosteroids for preventing chronic lung disease in preterm infants. Cochrane Database Syst Rev. 2009 Jan 21. CD001146. [Medline].

  6. Ayed AK. Resection of the right middle lobe and lingula in children for middle lobe/lingula syndrome. Chest. 2004 Jan. 125(1):38-42. [Medline]. [Full Text].

  7. Brown M, Lemen R. Bronchiectasis. Kendig's Disorders of the Respiratory Tract in Children. Philadelphia, Pa: WB Saunders Co; 1998. 150-2.

  8. Priftis KN, Anthracopoulos MB, Mermiri D, et al. Bronchial hyperresponsiveness, atopy, and bronchoalveolar lavage eosinophils in persistent middle lobe syndrome. Pediatr Pulmonol. 2006 Sep. 41(9):805-11. [Medline].

  9. Torkian B, Kanthan R, Burbridge B. Diagnostic pitfalls in fine needle aspiration of solitary pulmonary nodules: two cases with radio-cyto-histological correlation. BMC Pulm Med. 2003 Sep 8. 3(1):2. [Medline]. [Full Text].

 
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Posteroanterior chest radiograph demonstrating right middle lobe collapse and infiltrate. Note blurred right heart border.
Lateral view chest radiograph showing a wedge-shaped density extending from the hilum anteriorly and inferiorly.
Chest CT scan showing extensive bronchiectasis of both medial and lateral segments of the right middle lobe.
 
 
 
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