Lung Abscess Surgery Treatment & Management

Updated: May 03, 2018
  • Author: Shabir Bhimji, MD, PhD; Chief Editor: Jeffrey C Milliken, MD  more...
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Treatment

Approach Considerations

Current management of lung abscesses focuses on antibiotic therapy that covers gram-positive, gram-negative, and anaerobic organisms. The majority of lung abscesses can be treated successfully with antibiotics alone. Any patient who shows no response to antibiotic therapy after 7-10 days should be reevaluated for resistant organisms or airway obstruction.

It is important to note that surgery is required for only a minor percentage of lung abscesses. Only cases that have failed to respond to antibiotics or the organism is resistant are considered for surgery. Surgery is also considered when there is a complication associated with the abscess (eg, bleeding).

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Medical Therapy

Antibiotic therapy

Because effective broad-spectrum antibiotics are available, primary or nonspecific abscesses can frequently be arrested in the early stage of suppurative pneumonitis. Whereas penicillin was long the antibiotic of choice, trials subsequently showed clindamycin to be superior. [7] Intravenous (IV) therapy is appropriate for adults until an initial clinical response is observed, after which time oral therapy is safe. Although the overall efficacy of penicillin seems to diminish with time, it remains a practical drug for most patients, especially if clindamycin is contraindicated.

Tetracycline is considered inadequate therapy because most anaerobes are resistant to it. Similarly, metronidazole is ineffective in approximately 50% of patients, presumably because of the contribution of aerobic bacteria. Therefore, if this agent is to be used, it should be combined with either a penicillin derivative or a cephalosporin. [7]

After initial antibiotic therapy, the clinical and radiographic response is gradual. The fever generally subsides in 4-7 days, but normalization of the chest radiograph may require 2 months. The optimal duration of treatment is 4-6 weeks or until the chest x-ray shows complete resolution.

More specifically, antibiotics used to treat lung abscesses caused by anaerobic organisms include the following [7] :

  • First choice - Clindamycin
  • Alternative - Penicillin
  • Oral therapy - Clindamycin, metronidazole, amoxicillin

Antibiotics used to treat lung abscesses caused by gram-negative organisms include the following:

  • First choices - Cephalosporins, aminoglycosides, quinolones
  • Alternatives - Penicillins, cephalexin
  • Oral therapy - Trimethoprim-sulfamethoxazole

Antibiotics used to treat lung abscesses caused by pseudomonal organisms include the following:

  • First choices - Aminoglycosides, quinolones, cephalosporins

Antibiotics used to treat lung abscesses caused by gram-positive organisms include the following:

  • First choices - Oxacillin, clindamycin, cephalexin, nafcillin, amoxicillin
  • Alternatives - Cefuroxime, clindamycin
  • Oral therapy - Vancomycin
  • Macrolides (erythromycin, azithromycin and clarithromycin) have a good success rate

Aminoglycosides are not recommended for treatment of lung abscesses because they usually have poor penetrability past the fibrotic membrane that is formed in chronic cases.

Antibiotics used to treat lung abscesses caused by nocardial organisms include the following:

  • First choices - Trimethoprim-sulfamethoxazole, tetracycline

Postural drainage

Most lung abscesses communicate with the tracheobronchial tree early in the course of the infection and drain spontaneously during the course of therapy. Dependent drainage (with appropriate positions based on the pulmonary segment) is commonly advocated, using chest physical therapy and sometimes bronchoscopy. Bronchoscopy can also facilitate abscess drainage by aspirating the appropriate bronchus through the bronchoscope. [8] Transbronchial drainage by catheterization of the appropriate bronchus under fluoroscopy has been successfully performed. Overall, drainage is required for fewer than 10% of lung abscess.

Generally, augmenting this passive drainage with invasive procedures is unnecessary. In fact, attempts at therapeutic bronchoscopy may sometimes produce adverse consequences. Reports have been received of bronchoscopy-induced release of large amounts of purulent material from the involved lung segment into other parts of the lung, occasionally inducing acute respiratory failure, acute respiratory distress syndrome (ARDS), or both.

Lasers have also been used for endobronchial drainage of lung abscess. They can perforate the wall through the airways and provide a route for catheter drainage. [9]

Course of treatment

If treatment is started in the acute stage of the disease and is continued for 4-6 weeks, approximately 85-95% of patients with anaerobic lung abscesses respond to medical management alone. Successful medical therapy resolves symptoms with no radiographic evidence or only a residual thin-walled cystic cavity (<2 cm after 4-6 weeks of antibiotic therapy).

The success of medical therapy is dependent on the duration of symptoms and the size of the cavity before the initiation of therapy. Antibiotic therapy is rarely successful if symptoms are present for longer than 12 weeks before the initiation of antibiotic therapy or if the original diameter of the cavity is greater than 4 cm. When patients with lung abscesses do not respond to proper medical therapy, the probability of an underlying malignancy must be considered.

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Surgical Therapy

Surgical treatment is now rarely necessary and is almost never the initial choice in the management of lung abscesses. In current practice, fewer than 15% of patients need surgical intervention for the unchecked disease and for complications that occur in both the acute and chronic stages of the disease. When surgery is performed, lobectomy is commonly done.

Surgical management is reserved for specific indications such as the following:

  • Little or no response to medical treatment
  • Inability to eliminate a carcinoma as a cause
  • Critical hemoptysis
  • Complications of lung abscess (eg, empyema, bronchopleural fistula)

In addition, if after 4-6 weeks of medical treatment a notable residual cavity remains and the patient is symptomatic, surgical resection is advocated.

Several important factors must be considered before surgery is undertaken. Because of the high risk of spillage of the abscess into the uninvolved contralateral lung, it is almost essential that a double-lumen tube be used to protect the airway during anesthesia. If this is not available, surgery poses a very high risk of abscess in the other lung and a risk of ARDS. In such cases, postponing the surgical procedure is a wise decision.

Another, less satisfactory method of dealing with this problem is to position the patient in the prone position. The surgeon must be skilled in resecting the abscess and in rapid clamping of the bronchus to prevent spillage into the trachea. These factors are extremely important in dealing with the surgical aspects of treating a lung abscess. If doubt persists, it is best to postpone the surgical procedure.

Percutaneous drainage of a complicated abscess (ie, one associated with fever and signs of sepsis) is beneficial in selected patients who do not respond to adequate medical therapy. [10, 11] These are ventilator-dependent patients who are not candidates for extensive thoracic procedures.

Other indications for drainage include the following:

  • Ongoing sepsis despite adequate antimicrobial therapy
  • Progressively enlarging lung abscess in imminent danger of rupture
  • Failure to wean from mechanical ventilation
  • Contamination of the opposite lung

In current practice, most of these lung abscesses are drained under computed tomography (CT) guidance. [10]

Results achieved with percutaneous drainage show it to be safe and effective in comparison with surgery. Percutaneous drainage is rarely complicated by empyema, hemorrhage, or bronchopleural fistula. Although a few patients who undergo percutaneous drainage develop bronchopleural fistulas, most of these fistulas close spontaneously with resolution of the abscess cavity. Percutaneous drainage may be used to stabilize and prepare critically ill patients for surgery. [12, 13]

In rare cases where a patient has bleeding associated with a lung abscess, angiographic embolization may also be used. [14]

Intrathoracic vacuum-assisted closure has also been reported as a means of managing complex lung abscesses. [15, 16]

Bronchoscopy is an invaluable part of the treatment of lung abscess. In individuals who are not responding to antibiotic therapy, bronchoscopy can help determine the patency of the bronchus and aid with specimen collection. Bronchoscopy should not be used to drain the lung abscess, in that there is a real potential risk of spillage of pus into the other lung.

Abscess from gram-negative and opportunistic bacteria

Hospital-acquired gram-negative infections are usually due to nosocomial organisms (eg, Pseudomonas, Enterobacter, or Proteus). Patients with these infections are often elderly, debilitated with numerous major medical disorders, or have sustained multiple trauma. These patients are typically treated in a critical care unit.

The infection is usually with a resistant organism originating from a single source. The lung abscess appears rapidly as an area of pneumonitis with associated pleural involvement. These patients often require percutaneous drainage as an emergency procedure. Unfortunately, the infection is systemic and often out of control, and the pulmonary pathology represents only one aspect of a multiorgan involvement with a rapidly deteriorating course.

Among fungal infections, Candida albicans has become a major organism in lung abscesses. Fungal infections are difficult to treat, and amphotericin/fluconazole and surgical drainage remain the only modalities of treatment; however, at best, they have had only limited success.

Results

The results of surgical treatment are difficult to assess because of the varying patient population and the tremendous increase in illicit drug abuse, alcoholism, AIDS, and infections by gram-negative and opportunistic organisms. These factors have increased the incidence of lung abscess and the associated morbidity.

A study by Nagasawa et al showed that thoracoscopic surgery can lead to effective drainage of pediatric lung abscess without major complications. [17] In addition, other benefits of thoracoscopy include rapid recovery, less pain, and minimal morbidity. [18]

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