Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Lung Abscess Treatment & Management

  • Author: Nader Kamangar, MD, FACP, FCCP, FCCM; Chief Editor: Ryland P Byrd, Jr, MD  more...
 
Updated: Dec 17, 2014
 

Medical Care

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.[13] Some clinical trials referred to below have included patients with aspiration pneumonia with or without lung abscess.

Next

Antibiotic Therapy

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.[14]

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.[19]

Moxifloxacin is clinically effective and as safe as ampicillin plus sulbactam in the treatment of aspiration pneumonia and lung abscess.[20]

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.[25]

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.

Previous
Next

Surgical Care

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]

Previous
Next

Consultations

Consulting a pulmonary medicine or infectious diseases specialist is often helpful in workup and follow-up of patients with lung abscess.

Previous
 
 
Contributor Information and Disclosures
Author

Nader Kamangar, MD, FACP, FCCP, FCCM Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Pulmonary and Critical Care Medicine, Vice-Chair, Department of Medicine, Olive View-UCLA Medical Center

Nader Kamangar, MD, FACP, FCCP, FCCM is a member of the following medical societies: Academy of Persian Physicians, American Academy of Sleep Medicine, American Association for Bronchology and Interventional Pulmonology, American College of Chest Physicians, American College of Critical Care Medicine, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, Association of Pulmonary and Critical Care Medicine Program Directors, Association of Specialty Professors, California Sleep Society, California Thoracic Society, Clerkship Directors in Internal Medicine, Society of Critical Care Medicine, Trudeau Society of Los Angeles, World Association for Bronchology and Interventional Pulmonology

Disclosure: Nothing to disclose.

Coauthor(s)

Jason E Bahk, MD Resident Physician, Department of Internal Medicine, Olive View-UCLA Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Ryland P Byrd, Jr, MD Professor of Medicine, Division of Pulmonary Disease and Critical Care Medicine, James H Quillen College of Medicine, East Tennessee State University

Ryland P Byrd, Jr, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP Thomas H Davis Chair in Pulmonary Medicine, Chief, Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Professor of Internal Medicine, Pediatrics, and Translational Science, Associate Director, Center for Genomics and Personalized Medicine Research, Wake Forest University School of Medicine; Executive Director of the Respiratory Service Line, Wake Forest Baptist Medical Center

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society, Sigma Xi

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Integrity CE, Merck<br/>Received income in an amount equal to or greater than $250 from: – Array Biopharma, AstraZeneca, Aerocrine, Airsonett AB, Boehringer-Ingelheim, Experts in Asthma, Gilead, GlaxoSmithKline, Merck, Novartis, Ono Pharmaceuticals, Pfizer, PPD Development, Quintiles, Sunovion, Saatchi & Saatichi, Targacept, TEVA, Theron.

Acknowledgements

Curtis C Sather, MD Fellow, Divison of Pulmonary/Critical Care Medicine, Cedars-Sinai Medical Center

Curtis C Sather, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, and American Thoracic Society

Disclosure: Nothing to disclose.

Sat Sharma, MD, FRCPC Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association

Disclosure: Nothing to disclose.

References
  1. Bartlett JG, Finegold SM. Anaerobic infections of the lung and pleural space. Am Rev Respir Dis. 1974 Jul. 110(1):56-77. [Medline].

  2. Wang JL, Chen KY, Fang CT, Hsueh PR, Yang PC, Chang SC. Changing bacteriology of adult community-acquired lung abscess in Taiwan: Klebsiella pneumoniae versus anaerobes. Clin Infect Dis. 2005 Apr 1. 40(7):915-22. [Medline].

  3. Takayanagi N, Kagiyama N, Ishiguro T, Tokunaga D, Sugita Y. Etiology and outcome of community-acquired lung abscess. Respiration. 2010. 80(2):98-105. [Medline].

  4. Mwandumba HC, Beeching NJ. Pyogenic lung infections: factors for predicting clinical outcome of lung abscess and thoracic empyema. Curr Opin Pulm Med. 2000 May. 6(3):234-9. [Medline].

  5. Pohlson EC, McNamara JJ, Char C, Kurata L. Lung abscess: a changing pattern of the disease. Am J Surg. 1985 Jul. 150(1):97-101. [Medline].

  6. Hirshberg B, Sklair-Levi M, Nir-Paz R, Ben-Sira L, Krivoruk V, Kramer MR. Factors predicting mortality of patients with lung abscess. Chest. 1999 Mar. 115(3):746-50. [Medline].

  7. Moreira Jda S, Camargo Jde J, Felicetti JC, Goldenfun PR, Moreira AL, Porto Nda S. Lung abscess: analysis of 252 consecutive cases diagnosed between 1968 and 2004. J Bras Pneumol. 2006 Mar-Apr. 32(2):136-43. [Medline].

  8. Stark DD, Federle MP, Goodman PC, Podrasky AE, Webb WR. Differentiating lung abscess and empyema: radiography and computed tomography. AJR Am J Roentgenol. 1983 Jul. 141(1):163-7. [Medline].

  9. Williford ME, Godwin JD. Computed tomography of lung abscess and empyema. Radiol Clin North Am. 1983 Sep. 21(3):575-83. [Medline].

  10. Bouhemad B, Zhang M, Lu Q, Rouby JJ. Clinical review: Bedside lung ultrasound in critical care practice. Crit Care. 2007. 11(1):205. [Medline].

  11. Bartlett JG. Anaerobic bacterial infections of the lung. Chest. 1987 Jun. 91(6):901-9. [Medline].

  12. Sosenko A, Glassroth J. Fiberoptic bronchoscopy in the evaluation of lung abscesses. Chest. 1985 Apr. 87(4):489-94. [Medline].

  13. [Guideline] Tice AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis. 2004 Jun 15. 38(12):1651-72. [Medline].

  14. Appelbaum PC, Spangler SK, Jacobs MR. Beta-lactamase production and susceptibilities to amoxicillin, amoxicillin-clavulanate, ticarcillin, ticarcillin-clavulanate, cefoxitin, imipenem, and metronidazole of 320 non-Bacteroides fragilis Bacteroides isolates and 129 fusobacteria from 28 U.S. centers. Antimicrob Agents Chemother. 1990 Aug. 34(8):1546-50. [Medline].

  15. Perlino CA. Metronidazole vs clindamycin treatment of anerobic pulmonary infection. Failure of metronidazole therapy. Arch Intern Med. 1981 Oct. 141(11):1424-7. [Medline].

  16. Sanders CV, Hanna BJ, Lewis AC. Metronidazole in the treatment of anaerobic infections. Am Rev Respir Dis. 1979 Aug. 120(2):337-43. [Medline].

  17. Richter SS, Heilmann KP, Dohrn CL, Riahi F, Costello AJ, Kroeger JS, et al. Activity of ceftaroline and epidemiologic trends in Staphylococcus aureus isolates collected from 43 medical centers in the United States in 2009. Antimicrob Agents Chemother. 2011 Sep. 55(9):4154-60. [Medline]. [Full Text].

  18. Wunderink RG, Niederman MS, Kollef MH, Shorr AF, Kunkel MJ, Baruch A, et al. Linezolid in methicillin-resistant Staphylococcus aureus nosocomial pneumonia: a randomized, controlled study. Clin Infect Dis. 2012 Mar 1. 54(5):621-9. [Medline].

  19. Allewelt M, Schuler P, Bolcskei PL, Mauch H, Lode H. Ampicillin + sulbactam vs clindamycin +/- cephalosporin for the treatment of aspiration pneumonia and primary lung abscess. Clin Microbiol Infect. 2004 Feb. 10(2):163-70. [Medline].

  20. Ott SR, Allewelt M, Lorenz J, Reimnitz P, Lode H. Moxifloxacin vs ampicillin/sulbactam in aspiration pneumonia and primary lung abscess. Infection. 2008 Feb. 36(1):23-30. [Medline].

  21. Macfarlane DJ, Tucker LG, Kemp RJ. Treatment of recalcitrant actinomycosis with ciprofloxacin. J Infect. 1993 Sep. 27(2):177-80. [Medline].

  22. Ferreira D, de F, Amado J, Neves S, Taveira N, Carvalho A, et al. Treatment of pulmonary actinomycosis with levofloxacin. J Bras Pneumol. 2008 Apr. 34(4):245-8. [Medline].

  23. Lerner PI. Nocardiosis. Clin Infect Dis. 1996 Jun. 22(6):891-903; quiz 904-5. [Medline].

  24. Clark NM. Nocardia in solid organ transplant recipients. Am J Transplant. 2009 Dec. 9 Suppl 4:S70-7. [Medline].

  25. Sorrell TC, Mitchell DH, Iredell JR. Nocardia species. Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Disease. 6th edition. Philadelphia: Elsevier; 2005. 2916.

  26. Herth F, Ernst A, Becker HD. Endoscopic drainage of lung abscesses: technique and outcome. Chest. 2005 Apr. 127(4):1378-81. [Medline].

  27. Kelogrigoris M, Tsagouli P, Stathopoulos K, Tsagaridou I, Thanos L. CT-guided percutaneous drainage of lung abscesses: review of 40 cases. JBR-BTR. 2011 Jul-Aug. 94(4):191-5. [Medline].

  28. Taniguchi M, Morita S, Ueno E, Hayashi M, Ishikawa M, Mae M. Percutaneous transhepatic drainage of lung abscess through a diaphragmatic fistula caused by a penetrating liver abscess. Jpn J Radiol. 2011 Nov. 29(9):663-6. [Medline].

  29. Bandt PD, Blank N, Castellino RA. Needle diagnosis of pneumonitis. Value in high-risk patients. JAMA. 1972 Jun 19. 220(12):1578-80. [Medline].

  30. Bartlett JG. HIV infection and surgeons. Curr Probl Surg. 1992 Apr. 29(4):197-280. [Medline].

  31. Bartlett JG, Gorbach SL, Tally FP, Finegold SM. Bacteriology and treatment of primary lung abscess. Am Rev Respir Dis. 1974 May. 109(5):510-8. [Medline].

  32. Chung G, Goetz MB. Anaerobic Infections of the Lung. Curr Infect Dis Rep. 2000 Jun. 2(3):238-244. [Medline].

  33. Finegold SM, George WL, Mulligan ME. Anaerobic infections. Part II. Dis Mon. 1985 Nov. 31(11):1-97. [Medline].

  34. Finegold SM, Rolfe RD. Susceptibility testing of anaerobic bacteria. Diagn Microbiol Infect Dis. 1983 Mar. 1(1):33-40. [Medline].

  35. Howe C, Sampath A, Spotnitz M. The pseudomallei group: a review. J Infect Dis. 1971 Dec. 124(6):598-606. [Medline].

  36. La Scola B, Michel G, Raoult D. Isolation of Legionella pneumophila by centrifugation of shell vial cell cultures from multiple liver and lung abscesses. J Clin Microbiol. 1999 Mar. 37(3):785-7. [Medline]. [Full Text].

  37. Mansharamani N, Balachandran D, Delaney D, Zibrak JD, Silvestri RC, Koziel H. Lung abscess in adults: clinical comparison of immunocompromised to non-immunocompromised patients. Respir Med. 2002 Mar. 96(3):178-85. [Medline].

  38. Mansharamani NG, Koziel H. Chronic lung sepsis: lung abscess, bronchiectasis, and empyema. Curr Opin Pulm Med. 2003 May. 9(3):181-5. [Medline].

  39. Narushima M, Suzuki H, Kasai T, et al. Pulmonary nocardiosis in a patient treated with corticosteroid therapy. Respirology. 2002 Mar. 7(1):87-9. [Medline].

  40. Senecal JL, St-Antoine P, Beliveau C. Legionella pneumophila lung abscess in a patient with systemic lupus erythematosus. Am J Med Sci. 1987 May. 293(5):309-14. [Medline].

  41. Weissberg D. Percutaneous drainage of lung abscess. J Thorac Cardiovasc Surg. 1984 Feb. 87(2):308-12. [Medline].

 
Previous
Next
 
Histology of a lung abscess shows dense inflammatory reaction (low power).
A thick-walled lung abscess.
Pneumococcal pneumonia complicated by lung necrosis and abscess formation.
A lateral chest radiograph shows air-fluid level characteristic of lung abscess.
A 54-year-old patient developed cough with foul-smelling sputum production. A chest radiograph shows lung abscess in the left lower lobe, superior segment.
A 42-year-old man developed fever and production of foul-smelling sputum. He had a history of heavy alcohol use, and poor dentition was obvious on physical examination. Chest radiograph shows lung abscess in the posterior segment of the right upper lobe.
A 42-year-old man developed fever and production of foul-smelling sputum. He had a history of heavy alcohol use, and poor dentition was obvious on physical examination. Lung abscess in the posterior segment of the right upper lobe was demonstrated on chest radiograph. CT scan shows a thin-walled cavity with surrounding consolidation.
Chest radiograph of a patient who had foul-smelling and bad-tasting sputum, an almost diagnostic feature of anaerobic lung abscess.
Histology of a lung abscess shows dense inflammatory reaction (high power).
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.