History

Fact Explanation
Fever with night sweats After organisms enter into the lungs, first it causes inflammation, leads to tissue necrosis and then abscess formation. [2] The abscess usually ruptures into a bronchus, and its contents are expectorated, leaving an air- and fluid-filled cavity. Inflammation results in formation of pyrogens (cytokines) which causes fever. [1]
Productive cough with foul smelling sputum When the abscess ruptures into a bronchus, and its contents are expectorated, it can presents with productive cough. [1] It is foul smelling, as bacteria from the mouth or throat tend to produce foul odors.
Haemoptysis Erosion into a blood vessel can result in haemoptysis. [3]
Pleuritic chest pain Inflammation of the pleura can results in pleuritic chest pain. [1]
Fatigue This may be due to the production of cytokines. Chronic abscesses, can be associated with these constitutional symptoms. [1]
Loss of apetite Due to the production of cytokines. [1]
Weight loss This usually happens with the chronic abscesses. [2]
Shortness of breath Shortness of breath [1] associated with fever, cough and pleuritic chest pain suggests an infection in the lung.
Duration of the symptoms Lung abscesses can be classified as acute or chronic based upon the duration of symptoms prior to presentation for medical care; symptoms present for one month or more are considered chronic. [1] Many people have these symptoms for weeks or months before seeking medical attention. [2] These people have chronic abscesses and, in addition to the other symptoms, lose a substantial amount of weight and have daily fever and night sweats. In contrast, lung abscesses caused by Staphylococcus aureus or MRSA can be fatal within days, sometimes even hours. Abscess less than 6 weeks of duration are considered as acute abscess. [1]
Risk factors:-unconscious or very drowsy because of sedation, anesthesia, alcohol or drug abuse, or a disease of the nervous system. [1] Acute altered mental status (AMS) is associated with aspiration of the contents. Sedation during anesthesia can also lead to AMS. Certain drugs are known to interfere with swallowing reflex causing the pharyngeal contents to be aspirated. Disease of the nervous system can directly affect the swallowing.[5]
Risk factors:- history of dental decay (periodontal) disease A lung abscess is usually caused by bacteria that normally live in the mouth or throat and that are aspirated into the lungs, [1] resulting in an infection. Often, periodontal disease [1] is the source of the bacteria that cause a lung abscess.
Risk factors:- Immunodefficiency Immunodeficient conditions like hypogammaglobulinemia, sickle cell anemia, human immunodeficiency virus [HIV], malnutrition, diabetes mellitus and splenectomy are vulnerable for lung abscess [1] and may be caused by organisms that are not typically found in the mouth or throat, such as fungi (Aspergillus, Cryptococcus, Histoplasma, Blastomyces, and Coccidioides species), Mycobacterium tuberculosis, parasites (eg:- Paragonimus and Entamoeba species
Risk factors:- History of air way obstruction Obstruction of the airways also can lead to abscess formation. If the bronchi are blocked by a tumor or a foreign object, an abscess can form because secretions can accumulate behind the tumor. [1] Bacteria sometimes enter these secretions. The obstruction prevents the bacteria-laden secretions from being coughed back up through the airway.Usually, people develop only one lung abscess as a result of aspiration or airway obstruction.If several abscesses develop, they are usually in the same lung.
Risk factors:- History of intravenous drug use Usually they develop single abscesses. If several abscesses develop, they are usually in the same lung. [2]
Risk factors:- History of chronic lung diseases Chronic lung diseases such as chronic obstructive pulmonary disease, bronchiectasis are vulnerable for abscess formation. [4]
If complicated with empyema [1] The abscess usually ruptures into a bronchus, and its contents are expectorated, leaving an air- and fluid-filled cavity. [1] In about one third of cases, direct or indirect extension (via bronchopleural fistula) into the pleural cavity results in empyema. Patient may be presenting with fever, cough, shortness of breath and pleurisy.
If complicated with bacteremia [1] Invasion of bacteria to blood can occur as a result of lung abscess. Some patients are asymptomatic or have only mild fever. But, symptoms such as shaking chills, persistent fever, altered sensorium, GI symptoms (abdominal pain, nausea, vomiting, diarrhea)t may occur in sepsis or septic shock. [1]
If complicated with respiratory failure [1] Type I respiratory failure is characterized by low Pa O2 < 60 mm Hg with a normal or low Pa CO2. Confusion or loss of consciousness, lethargy, fatigue and shortness of breath are the presenting symptoms. [1]
If complicated with bronchiectasis If complicated with bronchiectasis [3] , they present with a history of long-term sputum production, which sometimes increase over the baseline producing thick foul smelling sputum. They can also develop clubbing and weight loss. [4]
If complicated with metastatic infections like brain abscess Can present with fever, headache, drowsiness and focal weakness. [1]
If complicated with dehydration Thirst, loss of appetite, fatigue, [1] weakness, chills and decreased urination may be present.
References
  1. HAGAN JL, HARDY JD. Lung abscess revisited. A survey of 184 cases. Ann Surg [online] 1983 Jun, 197(6):755-762 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1352910
  2. Lung abscess. West J Med [online] 1976 Jun, 124(6):476-482 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1130102
  3. PHILPOTT NJ, WOODHEAD MA, WILSON AG, MILLARD FJ. Lung abscess: a neglected cause of life threatening haemoptysis. Thorax [online] 1993 Jun, 48(6):674-675 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC464615
  4. WAYBURN E, BERNE CJ. CLINICAL SYMPOSIUM--TREATMENT OF BRONCHIECTASIS AND CHRONIC LUNG ABSCESS Calif Med [online] 1948 Jul, 69(1):55-57 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1643311
  5. DIBARDINO DAVID M., WUNDERINK RICHARD G.. Aspiration pneumonia: A review of modern trends. Journal of Critical Care [online] 2015 February, 30(1):40-48 [viewed 30 March 2015] Available from: doi:10.1016/j.jcrc.2014.07.011

Examination

Fact Explanation
Febrile Low-grade fever in anaerobic infections and temperatures higher than 38.5°C in other infections. [1,2]
Periodantal disease This is a risk factor for the development of lung abscess. [1,2]
Tachycardia May be due to fever and sepsis. [1]
Features of dehydration Dry skin, dry mouth, skin flushing, tachycardia, tachypnoea, increased body temperature and hypotension [1] can be signs of dehydration.
Clubbing Hypoxia can cause vasodialataion, increased blood supply to the distal parts of the digits can be a reason for the clubbing. But in most cases the cause is not known. [3,4]
Reduced chest moments on affected side This is due to the consolidation. [3]
Reduced chest expansion on affected side Due to the consolidation. [3]
Dull on percussion Due to the consolidation. [3]
Decreased breath sounds Normal vesicular breathing is not present. [3]
Bronchial breath sounds Bronchial breath sound [3] is a harsh breath sound,made by air moving in the large bronchi where the duration and the pitch of the expiratory sound is higher. May be heard over a consolidated lung and over the cavitations.
Coarse inspiratory crackles Coarse, loud, low pitched, scanty, gravity independent sounds, that resolve with coughing and cannot be differentiated by posture.[3]
Pleural friction rub This is a creaking sound heard on auscultation of the chest wall. It indicates, that pleura and the chest wall are rubbing together. Pleural rub is usually associated with pleuritic pain and may be heard over areas of inflamed pleura. [5]
If complicated with pleural effusion Reduced chest expansion and moments on affected side, Dull percussion node, absent breath sounds over the area of effusion and mediastinal shift to contralateral side (large effusion). [1]
If complicated with empyema Empyema can occur as a complication of the disease. [1] Tachypnea, decreased breath sounds, dullness to percussion and rhonchi may be present.
If complicated with bacteremia/ sepsis Tachypnoea and hypotension may suggests sepsis or septic shock. [1]
If complicated with respiratory failure Dyspnoea [1] ,tachypnoea , cyanosis and arrhythmia may be present on examination.
If complicated with bronchiectasis Clubbing, cachexia and anaemia may be present. [4]
If complicated with metastatic infections like brain abscess Can present with focal neurological signs. [1]
References
  1. HAGAN JL, HARDY JD. Lung abscess revisited. A survey of 184 cases. Ann Surg [online] 1983 Jun, 197(6):755-762 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1352910
  2. Lung abscess. West J Med [online] 1976 Jun, 124(6):476-482 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1130102
  3. PHILPOTT NJ, WOODHEAD MA, WILSON AG, MILLARD FJ. Lung abscess: a neglected cause of life threatening haemoptysis. Thorax [online] 1993 Jun, 48(6):674-675 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC464615
  4. WAYBURN E, BERNE CJ. CLINICAL SYMPOSIUM--TREATMENT OF BRONCHIECTASIS AND CHRONIC LUNG ABSCESS Calif Med [online] 1948 Jul, 69(1):55-57 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1643311
  5. AMPOFO K, BYINGTON C. Management of Parapneumonic Empyema Pediatr Infect Dis J [online] 2007 May, 26(5):445-446 [viewed 17 September 2014] Available from: doi:10.1097/01.inf.0000261011.23728.dd

Differential Diagnoses

Fact Explanation
Primary or metastatic lung carcinoma [8] Malignancy is associated with low-grade fever, loss of apetite and loss of weight. Haemoptysis is commonly associated with bronchogenic carcinoma. History of smoking and exposure to chemicals like asbestos may be present. [8] On examination patient may be pale which might also be present in chronic lung abscesses .There will be no leukocytosis,There will be no response to antibiotics within 10 days,
Tuberculosis [6] Postprimary tuberculosis may present with cavitating lung lesions. A patient having tuberculosis [5] usually has a history of an exposure to a person with tuberculosis. He/She will also have systemic symptoms of anorexia, weight loss , fatigue, malaise and as well as a low-grade fever with night sweats. The lesions mostly affect the posterior or apical lung segments of the upper lobes or the superior lung segments of the lower lobes, bilateral upper lobe disease is very common. [6] The cavity is usually thin-walled, smooth on the inner margin with no air-fluid level. The tuberculoma is a round or oval lesions with small, discrete shadows may occur in either primary or postprimary disease.
Pneumonia [7] This is an acute, often fulminant infection. Has a usually short duration before recognition. Causative organisms include Staphylococcus aureus, Streptococcus pyogenes, Klebsiella pneumoniae, and Pseudomonas species. Examination findings may be same as in lung abscess. Hypotension, tachypnea, confusion, uremia, and avance dage are the risk factors fo rdeveloping the complications. [7]
Empyema Patient may be presenting with fever, cough, shortness of breath and pleurisy. On chest x-ray, abscess is usually thich waled, irregular margin whereas empyema is lentiform, well defined with a smooth surface. [1] On CT scan; abscesses will abruptly interrupt bronchovascular structures, but empyema will usually distort and compress adjacent lung, split pleura sign-thickening and separation of visceral and parietal pleura is a sign of empyema, [2] abscesses have thick irregular walls but empyema are usually smoother, angle with pleura- abscesses usually have an acute angle (claw sign) and empyema have obtuse angles.
Fungal infection History will contain a residence or travel to an endemic area, or even an occupational exposure. This is more prevalent in patients those who have impaired cell-mediated immunity (e.g. malignancies, AIDS, transplant immunosuppression, ) or granulocytopenia. [9]
Rheumatoid lung nodule [4] Patient is having other features of rheumatoid arthritis such as distal symetrical polyarthritis [4] mainly involving the hands, subcutaneous nodules, joint abnormalities( Z thumb, swan neck deformity, ulnar deviation of the wrist) together with other multi-systemic manifestations. ESR will be elevated. Rheumatoid factor and anti nuclear antibodies may be positive. [4]
Septi emboli [3] Patient may be having an evidence of infective foci elsewhere in the body such as tricuspid valve endocarditis, [3] thrombophlebitis, infected venous catheter or pacemker, arteriovenous shunts for hemodialysis, peritonsillar abscess and osteomyelitis. [3] Patient will be having high fever with chills, chest pain, dyspnoea and severe sinus tachycardia. Multiple cavitating masses are there on chest x-ray, usually thin-walled, migratory , old ones clear and new ones arise. Pleural effusion is rare. Hilar and mediastinal adenopathy can occur.
References
  1. HAGAN JL, HARDY JD. Lung abscess revisited. A survey of 184 cases. Ann Surg [online] 1983 Jun, 197(6):755-762 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1352910
  2. AMPOFO K, BYINGTON C. Management of Parapneumonic Empyema Pediatr Infect Dis J [online] 2007 May, 26(5):445-446 [viewed 17 September 2014] Available from: doi:10.1097/01.inf.0000261011.23728.dd
  3. STAWICKI SP, FIRSTENBERG MS, LYAKER MR, RUSSELL SB, EVANS DC, BERGESE SD, PAPADIMOS TJ. Septic embolism in the intensive care unit Int J Crit Illn Inj Sci [online] 2013, 3(1):58-63 [viewed 17 September 2014] Available from: doi:10.4103/2229-5151.109423
  4. CHHAKCHHUAK CL, KHOSRAVI M, LOHR KM. Role of 18F-FDG PET Scan in Rheumatoid Lung Nodule: Case Report and Review of the Literature Case Rep Rheumatol [online] 2013:621340 [viewed 17 September 2014] Available from: doi:10.1155/2013/621340
  5. SANDHU GK. Tuberculosis: Current Situation, Challenges and Overview of its Control Programs in India J Glob Infect Dis [online] 2011, 3(2):143-150 [viewed 17 September 2014] Available from: doi:10.4103/0974-777X.81691
  6. DOOLEY KE, CHAISSON RE. Tuberculosis and diabetes mellitus: convergence of two epidemics Lancet Infect Dis [online] 2009 Dec, 9(12):737-746 [viewed 17 September 2014] Available from: doi:10.1016/S1473-3099(09)70282-8
  7. LIM W, VAN DER EERDEN MM, LAING R, BOERSMA W, KARALUS N, TOWN G, LEWIS S, MACFARLANE J. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study Thorax [online] 2003 May, 58(5):377-382 [viewed 17 September 2014] Available from: doi:10.1136/thorax.58.5.377
  8. MOLINA JR, YANG P, CASSIVI SD, SCHILD SE, ADJEI AA. Non-Small Cell Lung Cancer: Epidemiology, Risk Factors, Treatment, and Survivorship Mayo Clin Proc [online] 2008 May, 83(5):584-594 [viewed 17 September 2014] Available from: doi:10.4065/83.5.584
  9. CASADEVALL A. Antibody immunity and invasive fungal infections. Infect Immun [online] 1995 Nov, 63(11):4211-4218 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC173598

Investigations - for Diagnosis

Fact Explanation
Chest X-ray Usually single cavity, cavities typically have a thick-wall, smooth inner margin and an air-fluid level. [1] More frequent in superior segments of lower lobes or posterior segments of lower lobes. [1] Unlike pleural collections, lung abscesses frequently have a fluid level [2] which is approximately the same length on both the frontal and lateral projection. About 1/3 may have an associated empyema. [1] Sometimes the appearance of an abscess is similar to other conditions, such as cancer, sarcoidosis, or Wegener's granulomatosis.
Chest CT Cavity may be seen as rounded with a thick wall and an air-fluid level Sometimes, an abscess is only found on CT of the chest. CT is needed in cases of uncertain cause and cases that do not respond to antibiotics. Abscess will have a relatively thick wall cavity [1], with a irregeular inner margin and an air-fluid level. [1] There is an inflammatory reaction in the surrounding lung. Also helpful in differentiating between a lung abscess and an empyema.
Sputum culture Cultures of sputum may help to identify the organism causing the abscess, [1] but this test is usually not useful except for excluding MRSA, tuberculosis, and fungal infections. Most common anaerobes ncludes bacteroides species, peptostreptococcus species, [2] microaerophilic streptococci and fusobacterium species. Aerobes infrequently causing lung abscess include Staphylococcus aureus, Streptococcus pneumoniae (rarely), Streptococcus pyogenes, Haemophilus influenzae, Klebsiella pneumoniae, Nocardia and Actinomyces species, and gram-negative bacilli. [2]
Full blood count Patients with lung abscess may be having abnormally high white blood cell counts (leukocytosis) indicating a posibility of a bacterial infection.[3] Usually blood tests are not much helpful in making a diagnosis of lung abscess, but they can be useful in ruling out other conditions and to see the response to treatment.
ESR andCRP Elevated ESR and CRP, as a marker of inflammation. [3]
References
  1. HAGAN JL, HARDY JD. Lung abscess revisited. A survey of 184 cases. Ann Surg [online] 1983 Jun, 197(6):755-762 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1352910
  2. Lung abscess. West J Med [online] 1976 Jun, 124(6):476-482 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1130102
  3. MACDONALD KS, DE CARVALHO VM, LIEBERT L, EMBREE JE. Streptococcus pneumoniae: A cause of primary lung abscess in a child Can J Infect Dis [online] 1993, 4(4):232-234 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3250795

Investigations - Fitness for Management

Fact Explanation
Full blood count [1] Leukocytosis and anemia common with chronic abscess. Leukopenia or leukocytosis may be seen with MRSA. [1]
References
  1. Lung abscess. West J Med [online] 1976 Jun, 124(6):476-482 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1130102

Investigations - Followup

Fact Explanation
Bronchoscopy This is needed in cases of uncertain cause and cases that do not respond to antibiotics to see any obstruction [1] in the air way, usually after 3-6 weeks of successful therapy.
Chest X-ray This investigation is very valuable in follow up as the treatment with IV antibiotics is given until sufficient clinical improvement or until a chest X-ray is clear or shows a small, stable residual lesion, which generally takes 3 to 6 wk or longer. [1]
References
  1. HAGAN JL, HARDY JD. Lung abscess revisited. A survey of 184 cases. Ann Surg [online] 1983 Jun, 197(6):755-762 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1352910

Investigations - Screening/Staging

Fact Explanation
Bronchoscopy Bronchoscopy is often done when the abscess is thought to be the result of a tumor or a foreign object blocking the airway. [1,2]
Chest X-ray Chest X-ray can used to evaluate the complications such as empyema particularly if they are not responding to the antibiotics. [1]
References
  1. HAGAN JL, HARDY JD. Lung abscess revisited. A survey of 184 cases. Ann Surg [online] 1983 Jun, 197(6):755-762 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1352910
  2. Lung abscess. West J Med [online] 1976 Jun, 124(6):476-482 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1130102

Management - General Measures

Fact Explanation
Antipyretics Patients may be having fever which might be discomforting. [1]
Fluid management Patient might be having anorexia, less fluid input and dehydration. [2]
Monitoring for complications Patient must be carefully monitered for the development of complications empyema, respiratory failure, massive haemorrhage and bacteremia. [1] If there is any accompanying empyema, it must be drained. [2]
Evaluation for no response If patients fail to defervesce or to improve clinically after 7 to 10 days, they should be evaluated for resistant or unusual pathogens, airway obstruction, [1] and noninfectious causes of cavitation. [3]
References
  1. HAGAN JL, HARDY JD. Lung abscess revisited. A survey of 184 cases. Ann Surg [online] 1983 Jun, 197(6):755-762 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1352910
  2. PHILPOTT NJ, WOODHEAD MA, WILSON AG, MILLARD FJ. Lung abscess: a neglected cause of life threatening haemoptysis. Thorax [online] 1993 Jun, 48(6):674-675 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC464615
  3. WAYBURN E, BERNE CJ. CLINICAL SYMPOSIUM--TREATMENT OF BRONCHIECTASIS AND CHRONIC LUNG ABSCESS Calif Med [online] 1948 Jul, 69(1):55-57 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1643311

Management - Specific Treatments

Fact Explanation
Antibiotics Most common anaerobic pathogens causing lung abscess are Peptostreptococcus, Fusobacterium, Prevotella, and Bacteroides. [1] The most common aerobic pathogens are streptococci, staphylococci and sometimes methicillin-resistant Staphylococcus aureus (MRSA). Gram-negative bacteria, especially Pseudomonas aeruginosa in immunocompromised patients, Klebsiella and other gram-negative bacilli may also be the causative organisms. Occasionally Nocardia, Mycobacteria sp. or fungi are also responsible. Proper therapy for anaerobic infections often requires intensive antimicrobial therapy for a prolonged period. Several classes of antimicrobial agents such as penicillins [1] , cephalosporin, [5] tetracyclines, chloramphenicol [2] and clindamycin are useful in the treatment of infections due to anaerobic bacteria.
Clindamycin Clindamycin is used for the treatment of serious infections caused by anaerobic bacteria, [2] such as Bacteroides spp, Peptostreptococcus, anaerobic streptococci, Clostridium spp, and microaerophilic streptococci. It is very useful in polymicrobic infections such as intra-abdominal or pelvic infections, osteomyelitis, diabetic foot ulcers, aspiration pneumonia, lung abscess and dental infections.This may be bacteriostatic or bactericidal depending on the organism and drug concentration. Clindamycin inhibits protein synthesis of bacteria by binding to the ribosomal subunits of the bacteria. Kidney disease, liver disease, stomach or intestinal disease are some cautions for usage. Side effects include abdominal pain, diarrhea, nausea, vomiting, fungal overgrowth, pseudomembranous colitis, hypersensitivity, and stevens-Johnson syndrome. Some contraindications are hypersensitivity to clindamycin or tartrazine dye, ulcerative colitis, regional enteritis and pseudomembranous colitis. eg:- Clindamycin 600mg IV 8H, then clindamycin 300mg PO four times a day until CXR shows small stable lesion or is clear.
Penicillin [1] Penicillins are effective [1] against many different bacteria including H. influenzae, N. gonorrhoea, E. coli, Pneumococci, Streptococci, and certain strains of Staphylococci. Some common side effects are diarrhea, headache, sore mouth or tongue, vaginal itching and discharge, less common side effects include fast or irregular breathing, fever, joint pain, light headedness or fainting, shortness of breath,and skin rash. [7] Bacteroides fragilis is responsible for most anaerobic infections in man. Most of them show resistance to beta-lactam antibiotics which may be due to beta-lactamase production or permeability barrier in the cell wall. Studies also have shown the that the time for response after antibiotics is less in the case of clindamycin compared to penicillin.Therefore penicillin are not the first choice in lung abscess. eg:- Ampicillin/sulbactam 1.5-3g IV 6H, then amoxicillin/clavulanate 875mg PO twice daily or clindamycin 300mg PO four times a day as above. Alternatives: Piperacillin/tazobactam 3.375gm IV 6H, then amoxicillin/clavulanate 875mg PO twice daily or clindamycin 300mg PO four times a day.
Metranidazole [8] Metronidazole is currently approved for use against Trichomonas infection and amebiasis. [8] It is also effective against giardiasis , "nonspecific vaginitis," and anaerobic infections and bactericidal against almost all obligately anaerobic organisms. Though metranidazole is effective against anaerobes, studies have shown that metronidazole treatment of anaerobic pulmonary infections is less effective than clindamycin.
Tetracycline Tetracyclines are broad-spectrum antibiotics that act as such at the ribosomal level where they interfere with protein synthesis. [6] They have the activity against a wide range of microorganisms including gram-positive and gram-negative bacteria, chlamydiae, mycoplasmas, rickettsiae, and protozoan parasites. Use of the tetracycline is limited in lung abscess as there is resistance against it by some organisms.
Carbapenam [5] Carbapenam is a class of β-Lactam antibiotics with a broad spectrum of antibacterial activity. Their structure is highly resistant to most β-lactamases. But development of resistance is now becoming a problem. [5] eg:- Imipenem 0.5-1g IV 6-8H or meropenem or doripenem, then clindamycin 300mg PO four times a day or amoxicillin/clavulanate 875mg PO twice-daily. [1]
Vancomycin Inhibits cell-wall biosynthesis. Used against Staphelococcus aureus and Methicillin resistant staphelococcus aureus(MRSA) has to be covered with vancomycin. [4] eg:- vancomycin 15mg/kg IV 12H
Duration of treatment Most non-specific lung abscesses are treated empirically with clindamycin and respond, but may require 3 months, or longer course. [1,2] Treat with IV antibiotics until sufficient clinical improvement, then receive oral antibiotics for 2-3 months or until a CXR is clear or shows a small, stable residual lesion which generally takes 3 to 6 wk or longer.
Drainage [1] Most patients have already drained the abscess spontaneously via bronchus and need only above treatment. Bronchoscopic drainage or physical therapy not generally useful. [1] Postural drainage probably plays no role in treatment and may be dangerous. Indications for percutaneous drainage: failure to respond to above treatment; usually due to abscess cavity >6cm diameter, complicated/serious associated diseases or atypical organisms.
Surgery [1] Lobectomy [1] or pneumonectomy, may be used for patients who fail to respond to medical therapy. Indications for surgical resection same as for percutaneous drainage. [1] Segmental resection may suffice for small lesions (<6 cm diameter cavity). [1] Pneumonectomy [1] may be necessary for multiple abscesses unresponsive to drug therapy or for pulmonary gangrene. In patients likely to have difficulty tolerating surgery, percutaneous drainage or, rarely, bronchoscopic placement of a pigtail catheter can help facilitate drainage. [1]
References
  1. HAGAN JL, HARDY JD. Lung abscess revisited. A survey of 184 cases. Ann Surg [online] 1983 Jun, 197(6):755-762 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1352910
  2. Lung abscess. West J Med [online] 1976 Jun, 124(6):476-482 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1130102
  3. PHILPOTT NJ, WOODHEAD MA, WILSON AG, MILLARD FJ. Lung abscess: a neglected cause of life threatening haemoptysis. Thorax [online] 1993 Jun, 48(6):674-675 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC464615
  4. GARBATI MA, TLEYJEH IM, ABBA AA. Complicated Community-Acquired Staphylococcus Endocarditis and Multiple Lung Abscesses: Case Report and Review of Literature Case Rep Infect Dis [online] 2011:981316 [viewed 17 September 2014] Available from: doi:10.1155/2011/981316
  5. KOKKONOUZIS I, CHRISTOU I, ATHANASOPOULOS I, SARIDIS N, SKOUFARAS V. Multiple lung abscesses due to acinetobacter infection: a case report Cases J [online] :9347 [viewed 17 September 2014] Available from: doi:10.1186/1757-1626-2-9347
  6. ROCCARO AS, BLANCO AR, GIULIANO F, RUSCIANO D, ENEA V. Epigallocatechin-Gallate Enhances the Activity of Tetracycline in Staphylococci by Inhibiting Its Efflux from Bacterial Cells Antimicrob Agents Chemother [online] 2004 Jun, 48(6):1968-1973 [viewed 17 September 2014] Available from: doi:10.1128/AAC.48.6.1968-1973.2004
  7. BHATTACHARYA S. THE FACTS ABOUT PENICILLIN ALLERGY: A REVIEW J Adv Pharm Technol Res [online] 2010, 1(1):11-17 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3255391
  8. NARCISI EM, SECOR WE. In vitro effect of tinidazole and furazolidone on metronidazole-resistant Trichomonas vaginalis. Antimicrob Agents Chemother [online] 1996 May, 40(5):1121-1125 [viewed 17 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC163276