Lung Abscess Treatment & Management
- Author: Nader Kamangar, MD, FACP, FCCP, FCCM; Chief Editor: Ryland P Byrd, Jr, MD more...
The treatment of lung abscess is guided by the available microbiology with consideration of the underlying or associated conditions. No treatment recommendation has been issued by major societies specifically for lung abscess. However, a guideline summary from the Infectious Diseases Society of America, Practice guidelines for outpatient parenteral antimicrobial therapy, is available. Some clinical trials referred to below have included patients with aspiration pneumonia with or without lung abscess.
Standard treatment of an anaerobic lung infection is clindamycin (600 mg IV q8h followed by 150-300 mg PO qid). This regimen has been shown to be superior over parenteral penicillin in published trials. Several anaerobes may produce beta-lactamase (eg, various species of Bacteroides and Fusobacterium) and develop resistance to penicillin; therefore, treatment with a beta-lactamase inhibitor in conjunction with a beta-lactam or carbapenems should be considered.
Although metronidazole is an effective drug against anaerobic bacteria, metronidazole in treating lung abscess has been rather disappointing because these infections are generally polymicrobial. A failure rate of 50% has been reported.[15, 16]
In hospitalized patients who have aspirated and developed a lung abscess, antibiotic therapy should include coverage against S aureus and Enterobacter and Pseudomonas species. When methicillin-resistant S aureus (MRSA) is the source of lung abscesses, vancomycin and linezolid should be considered. Vancomycin 15 mg/kg IV every 12 hours, with a goal trough of 15-20 mcg/mL, is adjusted renally. Linezolid therapy should be started at a dose of 600 mg IV every 12 hours. Once the patient has defervesced once, consider switching to an equivalent PO regimen. Linezolid has been shown to have improved response times over vancomycin, with no difference in mortality overall when compared to vancomycin treatment. Ceftaroline, a fifth-generation cephalosporin, has been shown to have activity against MRSA lung abscesses based on a 2012 study with data from 43 medical centers around the United States. Ceftaroline, however, has not been formally approved by the FDA for the treatment ofMRSAlungabscesses.[17, 18]
Ampicillin plus sulbactam is well tolerated and as effective as clindamycin with or without a cephalosporin in the treatment of aspiration pneumonia and lung abscess.
Moxifloxacin is clinically effective and as safe as ampicillin plus sulbactam in the treatment of aspiration pneumonia and lung abscess.
Actinomyces, Nocardia species, fungal species, and tuberculous abscesses tend to occur mostly in immunocompromised hosts, including chronic glucocorticoid therapy or patients with lung transplants. Data regarding Actinomyces abscesses are limited, but treatment with high-dose penicillin is generally recommended for the treatment of Actinomyces, as penicillin resistance is minimal. Case reports exist of successful treatment of pulmonary Actinomyces with ciprofloxacin.[21, 22]
Treatment of Nocardia species, when suspected as a source of pulmonary abscesses, involves 6-12 months of TMP-SMX, though the clear duration of therapy has not been clearly defined. Additionally, for initial induction therapy TMP-SMX (15 mg/kg IV of the trimethoprim component per day, divided in 2-4 doses) can be used in addition to amikacin at 7.5 mg/kg IV every 12 hours. An alternative regimen involves imipenem 500 mg IV every 6 hours with amikacin.[23, 24] The patient can then be transitioned to TMP-SMX 10 mg/kg of the trimethoprim component, divided into bid or tid doses after IV therapy.
Treatment of fungal abscesses should follow the therapy of each individual fungal organism indicated.
Tuberculous abscesses, especially MAC should follow MAC treatment guidelines.
Duration of therapy
Although the duration of therapy is not well established, most clinicians generally prescribe antibiotic therapy for 4-6 weeks.
Expert opinion suggests that antibiotic treatment should be continued until the chest radiograph has shown either the resolution of lung abscess or the presence of a small stable lesion.
The rationale for extended treatment maintains that risk of relapse exists with a shorter antibiotic regimen.
Response to therapy
Patients with lung abscesses usually show clinical improvement, with improvement of fever, within 3-4 days after initiating the antibiotic therapy. Defervescence is expected in 7-10 days. Persistent fever beyond this time indicates therapeutic failure, and these patients should undergo further diagnostic studies to determine the cause of failure.
Considerations in patients with poor response to antibiotic therapy include bronchial obstruction with a foreign body or neoplasm or infection with a resistant bacteria, mycobacteria, or fungi.
Large cavity size (ie, > 6 cm in diameter) usually requires prolonged therapy. Because empyema with an air-fluid level could be mistaken for parenchymal abscess, a CT scan may be used to differentiate this process from lung abscess.
A nonbacterial cause of cavitary lung disease may be present, such as lung infarction, cavitating neoplasm, and vasculitis. The infection of a preexisting sequestration, cyst, or bulla may be the cause of delayed response to antibiotics.
Surgery is very rarely required for patients with uncomplicated lung abscesses. The usual indications for surgery are failure to respond to medical management, suspected neoplasm, or congenital lung malformation. The surgical procedure performed is either lobectomy or pneumonectomy.
When conventional therapy fails, either percutaneous catheter drainage or surgical resection is usually considered. Endoscopic lung abscess drainage is considered if an airway connection to the cavity can be demonstrated. Endoscopic drainage, however, is not without significant risk to the patient.[26, 27, 28]
Consulting a pulmonary medicine or infectious diseases specialist is often helpful in workup and follow-up of patients with lung abscess.
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