Etiology of Lung Abscess
Aspiration of oral secretions (most common)
Hematogenous seeding of the lungs (less common)
Most lung abscesses develop after aspiration of oral secretions by patients with gingivitis or poor oral hygiene. Typically, patients have altered consciousness as a result of alcohol, recreational drugs, anesthesia, sedatives, or opioids. Older patients and those unable to handle their oral secretions, often because of neurologic disease, are also at risk.
Lung abscesses can also develop secondary to endobronchial obstruction (eg, due to bronchial carcinoma Lung Carcinoma Lung carcinoma is the leading cause of cancer-related death in men and women worldwide. About 85% of cases are related to cigarette smoking. Symptoms can include cough, chest discomfort or pain... read more ) or to immunosuppression (eg, due to HIV/AIDS Human Immunodeficiency Virus (HIV) Infection Human immunodeficiency virus (HIV) infection results from 1 of 2 similar retroviruses (HIV-1 and HIV-2) that destroy CD4+ lymphocytes and impair cell-mediated immunity, increasing risk of certain... read more or after transplantation and use of immunosuppressive drugs).
A less common cause of lung abscess is necrotizing pneumonia that may develop from hematogenous seeding of the lungs due to suppurative thromboembolism (eg, septic embolism due to IV drug use or Lemierre syndrome Parapharyngeal Abscess A parapharyngeal abscess is a deep neck abscess. Symptoms include fever, sore throat, odynophagia, and swelling in the neck down to the hyoid bone. Diagnosis is by CT. Treatment is with antibiotics... read more ) or right-sided endocarditis Infective Endocarditis Infective endocarditis is infection of the endocardium, usually with bacteria (commonly, streptococci or staphylococci) or fungi. It may cause fever, heart murmurs, petechiae, anemia, embolic... read more . In contrast to aspiration and obstruction, these conditions typically present acutely and cause multiple rather than isolated lung abscesses.
Direct infection (eg, from empyema, subphrenic or mediastinal abscess) rather than hematogenous seeding is possible with certain pyogenic bacteria (eg, Staphylococcus aureus).
The most common pathogens of lung abscesses due to aspiration are anaerobic bacteria, but about half of all cases involve both anaerobic and aerobic organisms (see table Infectious Causes of Cavitary Lung Lesions Infectious Causes of Cavitary Lung Lesions ).
The most common anaerobic pathogens are
The most common aerobic pathogens are
Staphylococci Staphylococcal Infections Staphylococci are gram-positive aerobic organisms. Staphylococcus aureus is the most pathogenic; it typically causes skin infections and sometimes pneumonia, endocarditis, and osteomyelitis... read more —sometimes methicillin-resistant Staphylococcus aureus Antibiotic resistance Staphylococci are gram-positive aerobic organisms. Staphylococcus aureus is the most pathogenic; it typically causes skin infections and sometimes pneumonia, endocarditis, and osteomyelitis... read more (MRSA)
Occasionally, cases are due to gram-negative bacteria, especially Klebsiella Klebsiella, Enterobacter, and Serratia Infections The gram-negative bacteria Klebsiella, Enterobacter, and Serratia are closely related normal intestinal flora that rarely cause disease in normal hosts. Diagnosis is by... read more . Immunocompromised patients with lung abscess are most commonly infected with Pseudomonas aeruginosa Pseudomonas and Related Infections Pseudomonas aeruginosa and other members of this group of gram-negative bacilli are opportunistic pathogens that frequently cause hospital-acquired infections, particularly in ventilator... read more or other gram-negative bacilli but also may have infection with Nocardia Nocardiosis Nocardiosis is an acute or chronic, often disseminated, suppurative or granulomatous infection caused by various aerobic soil saprophytes of the gram-positive bacilli genus Nocardia.... read more , mycobacteria, or fungi.
Rare cases of pulmonary gangrene (extensive necrosis involving a lobe or a lung) or fulminant pneumonia with sepsis have been reported with pathogens such as MRSA, Pneumococcus, and Klebsiella. Some patients are at risk of abscess due to Mycobacterium tuberculosis Tuberculosis (TB) Tuberculosis is a chronic, progressive mycobacterial infection, often with an asymptomatic latent period following initial infection. Tuberculosis most commonly affects the lungs. Symptoms include... read more , and rare cases are due to amebic infection (eg, with Entamoeba histolytica Amebiasis Amebiasis is infection with Entamoeba histolytica. It is acquired by fecal-oral transmission. Infection is commonly asymptomatic, but symptoms ranging from mild diarrhea to severe dysentery... read more ), hydatid cysts, paragonimiasis, or infection with Burkholderia pseudomallei.
Introduction of these pathogens into the lungs first causes inflammation, which, over a week or two, leads to tissue necrosis and then abscess formation. The abscess usually ruptures into a bronchus, and its contents are expectorated, leaving an air- and fluid-filled cavity. In about 10% of cases, direct or indirect extension (via bronchopleural fistula) into the pleural cavity can result in empyema.
Symptoms and Signs of Lung Abscess
Symptoms of abscess due to anaerobic bacteria or mixed anaerobic and aerobic bacteria are usually chronic (eg, occurring over weeks or months) and include productive cough, fever, night sweats, and weight loss. Patients may also present with hemoptysis and pleuritic chest pain. Sputum may be purulent or blood-streaked and classically smells or tastes foul. Patients may have fetid breath.
Symptoms of abscess due to aerobic bacteria develop more acutely and resemble bacterial pneumonia. Abscesses due to organisms other than anaerobes (eg, Mycobacteria, Nocardia) lack putrid respiratory secretions and may be more likely to occur in nondependent lung regions.
Signs of lung abscess, when present, are nonspecific and resemble those of pneumonia: decreased breath sounds indicating consolidation or effusion, temperature ≥ 38° C, crackles over the affected area, egophony, and dullness to percussion in the presence of effusion. Patients typically have signs of periodontal disease and a history of a predisposing cause of aspiration, such as dysphagia or a condition causing impaired consciousness.
Diagnosis of Lung Abscess
Often chest CT for better visualization or if endobronchial obstruction is suspected
Sputum cultures for aerobic bacteria, fungi, and mycobacteria
Bronchoscopy as needed to exclude cancer, detect unusual pathogens such as fungi or mycobacteria, and in immunocompromised patients
Culture of any pleural fluid
Lung abscess is suspected based on history in a patient who is at risk (eg, aspiration-prone due to altered consciousness or dysphagia or who is immunosuppressed) and is confirmed by chest x-ray showing cavitation.
Cavitary pulmonary lesions are not always caused by infection. Noninfectious causes of cavitary pulmonary lesions include the following:
Empyema or bulla with air-fluid level
In an anaerobic infection due to aspiration, chest x-ray classically shows consolidation with a single cavity containing an air-fluid level in portions of the lung that would be dependent when the patient is recumbent (eg, the posterior segments of the upper lobes or the superior or lateral basal segments of the lower lobes). This pattern helps distinguish anaerobic abscess from other causes of cavitary pulmonary disease, because diffuse or embolic pulmonary disease often causes multiple cavitations, and tuberculosis typically involves the apices.
CT is not routinely needed (eg, if cavitation is clear on chest x-ray in a patient who has risk factors for lung abscess). However, CT may be useful when cavitation is suggested but not clearly seen on the chest x-ray, when an underlying pulmonary mass obstructing the drainage of a lung segment is suspected, or when abscess needs to be differentiated from empyema or bulla with an air-fluid level.
Bronchial carcinoma Lung Carcinoma Lung carcinoma is the leading cause of cancer-related death in men and women worldwide. About 85% of cases are related to cigarette smoking. Symptoms can include cough, chest discomfort or pain... read more can lead to obstruction that causes pneumonia and abscess formation. Bronchial carcinoma should be suspected in patients who do not respond to antimicrobial treatment or have atypical findings such as a cavitary lesion and no fever. Bronchoscopy is sometimes done to exclude cancer or the presence of a foreign body or to detect unusual pathogens, such as fungi or mycobacteria. Bronchoscopy is done if patients are immunocompromised.
Anaerobic bacteria are rarely identifiable on culture because uncontaminated specimens are difficult to obtain and because most laboratories do not culture anaerobes well or often. If sputum is putrid, then anaerobic infection is assumed to be the cause. However, if empyema is present, pleural fluid provides a good source for anaerobic culture.
When clinical findings make anaerobic infection less likely, aerobic, fungal, or mycobacterial infection should be suspected, and attempts should be made to identify a pathogen. Cultures of sputum, bronchoscopic aspirates, or both are helpful.
Treatment of Lung Abscess
IV antibiotics or, for less seriously affected patients, oral antibiotics
Percutaneous, endobronchial, or surgical drainage of any abscess that does not respond to antibiotics or of any empyema
The primary choice is a combination beta-lactam/beta-lactamase inhibitor, for example, ampicillin/sulbactam 1.5 g (1 g ampicillin plus 0.5 g sulbactam) to 3 g (2 g ampicillin plus 1 g sulbactam) IV or IM every 6 hours; the dose should not exceed 12 g per day . Alternatives include a carbapenem (eg, imipenem/cilastatin 500 mg IV every 6 hours) or combination therapy with metronidazole 500 mg every 8 hours plus penicillin 2 million units IV every 6 hours. In patients who are allergic to penicillin, clindamycin 600 mg IV every 8 hours, moxifloxacin 400 mg once daily, or combination therapy with levofloxacin 750 mg once daily with metronidazole 500 mg every 8 hours are alternative choices.
Less seriously ill patients may be given oral antibiotics such as amoxicillin/clavulanic acid 1 g (875/125 mg) orally every 12 hours or, in patients allergic to penicillin, clindamycin 300 mg orally every 6 hours. IV regimens can be converted to oral ones when the patient defervesces.
For very serious infections involving MSRA, the best treatment is linezolid or vancomycin.
If gram-negative bacilli are cultured in significant concentrations from sputum or blood and are identified on gram stain, the antibiotic regimen should be modified to cover the specific pathogen in addition to anaerobes.
Clindamycin 600 mg IV every 6 to 8 hours was the drug of choice because it has excellent activity against streptococci and anaerobic organisms; however, it has become a second-line drug because of concern for the substantial rate of Clostridioides (formerly, Clostridium) difficile infection if clindamycin therapy is prolonged. It is still a useful choice in penicillin-allergic patients.
Optimal duration of treatment is unknown, but common practice is to treat until the chest x-ray shows complete resolution or a small, stable, residual scar, which generally takes 3 to 6 weeks or longer. In general, the larger the abscess, the longer it will take for x-rays to show resolution.
Most authorities do not recommend chest physical therapy and postural drainage because of the potential for spillage of infection into other bronchi with extension of the infection or acute obstruction.
An accompanying empyema must be drained. Surgical removal or drainage of lung abscesses is necessary in the roughly 10% of patients in whom lesions do not respond to antibiotics, and in those who develop pulmonary gangrene. Resistance to antibiotic treatment is most common with large cavities and with post-obstructive abscesses. 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, and noninfectious causes of cavitation.
When surgery is necessary, lobectomy is the most common procedure; segmental resection may suffice for small lesions (< 6 cm diameter cavity). Pneumonectomy 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 under ultrasound guidance of a pigtail catheter can help facilitate drainage. .
Lung abscesses are most often caused by aspiration of oral secretions by patients who have impaired consciousness; thus, anaerobic bacteria are among the common pathogens.
Suspect lung abscess in patients prone to aspiration, who have subacute constitutional and pulmonary symptoms, and whose chest x-ray shows compatible lesions such as cavities.
Treat initially with antibiotics; if patients do not respond within 7 to 10 days, evaluate them for unusual or resistant pathogens, bronchial obstructive lesions, and noninfectious causes of lung cavitation.
Drain empyemas and consider surgical removal or drainage of lung abscesses that do not respond to drug therapy and for pulmonary gangrene.