Lung Abscess

43 Users are discussing this topic

PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

See also: Bacterial Vaginosis written for patients

Synonyms: pyogenic lung infection/pneumonia, necrotising pneumonia

Severe, localised suppurative infection in the substance of the lung, associated with necrotic cavity formation. The process is usually surrounded by a fibrous reaction, forming the abscess wall. Multiple small abscess formation may occur and is sometimes referred to as necrotising pneumonia.

The most frequent cause is aspiration of anaerobic organisms from the mouth in those predisposed to pulmonary aspiration, with impaired immune defences and cough reflex. A pneumonitis develops which progresses to abscess formation over a period of days or weeks.

These include:

NB: lung abscesses may present acutely or more chronically.[1]

NEW - log your activity

  • Notes
    Add notes to any clinical page and create a reflective diary
  • Track
    Automatically track and log every page you have viewed
  • Print
    Print and export a summary to use in your appraisal
Click to find out more »

Types of lung abscesses

  • Primary abscess - occurs in previously normal lungs and may follow aspiration.
  • Secondary abscess - occurs in patients with an underlying lung abnormality.

Common pathogens causing lung abscess include anaerobes, Staphylococcus aureus and enteric Gram-negative rods like Klebsiella pneumoniae.[2] 

Anaerobes

  • Peptostreptococcus spp.
  • Bacteroides spp.
  • Fusobacterium spp.
  • Microaerophilic streptococci

Aerobes

  • S. aureus
  • Streptococcus pyogenes
  • Haemophilus influenzae
  • Pseudomonas aeruginosa
  • K. pneumoniae - becoming more prevalent[3]
  • Burkholderia cepacia - particularly associated with cystic fibrosis
  • Streptococcus pneumoniae
  • Legionella pneumonia[2] 
  • Actinomyces spp.
  • Nocardia spp.
  • Proteus mirabilis
  • Pasteurella multocida - zoonotic infection from cats/dogs/cattle[4]
  • Burkholderia pseudomallei - soil-borne Asian/Australian infection; cases occurred following the tsunami disaster in 2004[5]

Other organisms

  • Mycobacterial infections - predominantly tuberculosis (TB)
  • Fungal lung infections such as Aspergillus, Cryptococcus, Histoplasma, Blastomyces, Coccidioides species
  • Parasites such as Entamoeba histolytica, Paragonimus spp.

Incidence and prevalence figures have not been established.

Risk factors

  • Alcoholism or drug misuse.
  • Following general anaesthesia.
  • Diabetes mellitus.
  • Severe periodontal disease.
  • Stroke/cerebral palsy/cognitive impairment/impaired consciousness leading to increased risk of aspiration.
  • Immunosuppression, particularly chronic granulomatous disease in children.
  • Congenital heart disease.
  • Chronic lung disease, particularly cystic fibrosis.

Symptoms

  • Onset of symptoms is often insidious (more acute if following pneumonia)
  • Spiking temperature with rigors and night sweats
  • Cough ± phlegm production (frequently foul-tasting and foul-smelling and often blood-stained)
  • Pleuritic chest pain
  • Breathlessness

Signs

  • Tachypnoea
  • Tachycardia
  • Finger clubbing in chronic cases
  • Dehydration
  • High temperature
  • Localised dullness to percussion (if consolidation is also present or effusion)
  • Bronchial breathing and/or crepitations (if consolidation is present)
  • Also look for signs of severe periodontal disease and infective endocarditis
  • FBC - normocytic anaemia or neutrophilia.
  • Renal function.
  • Liver function tests.
  • Blood cultures and sputum cultures (including AAFB).
  • ESR/CRP usually elevated.
  • CXR - shows walled cavity, usually with a fluid level; may also be presence of an empyema or effusion.
  • Tapping or draining of fluid or empyema with microbiology and cytology of samples.
  • CT scan of the thorax - may detect multiple small abscesses.
  • Fibre-optic bronchoscopy can exclude obstruction and provide samples for culture.
  • Trans-thoracic biopsy/aspiration (usually with ultrasound guidance) or trans-tracheal biopsy.

Supportive measures

  • Analgesia
  • Oxygen if required
  • Rehydration if indicated
  • Postural drainage with chest physiotherapy

Antibiotics

Most lung abscesses (80-90%) are now successfully treated with antibiotics.[6] 

  • Begin with intravenous treatment, usually for about 2-3 weeks, and follow with oral antibiotics for a further 4-8 weeks.
  • Recommended first-line therapy includes beta-lactam/beta-lactamase inhibitor or cephalosporin (second- or third-generation) plus clindamycin.[3]
    Previously, therapy with a broad-spectrum penicillin and clindamycin was used. Clindamycin had also been used alone (covers S. aureus and anaerobes and both oral and intravenous preparations exist); however, in the 1990s it was discovered that some anaerobes were resistant to both penicillin and clindamycin.
  • An alternative regimen is to begin with a broad-spectrum cephalosporin and flucloxacillin.[7]
  • Regimen should be altered once the organism is known.

Surgery

  • If the condition fails to resolve with conservative measures, bronchoscopy, CT-guided percutaneous drainage or cardiothoracic surgical intervention may be required.[8] 
  • Surgery is associated with a number of complications, such as empyema and bronchoalveolar air leak - especially so in children.[7]

Where slow resolution occurs, the possibility of malignancy or unusual organisms must be considered.

These include:

  • Empyema
  • Pneumatocele
  • Bronchopleural fistula
  • There is an overall 90% cure rate with antibiotic therapy.[9] 
  • Morbidity and mortality are more likely to be associated with underlying pathology such as bronchial carcinoma.
  • Prognosis is adversely affected by older age and multiple comorbidities.[10] 
  • Other poor prognostic factors include pneumonia, reduced level of consciousness, anaemia and infection with P. aeruginosa, S. aureus and K. pneumoniae.[7]

Further reading & references

  1. Chan PC, Huang LM, Wu PS, et al; Clinical management and outcome of childhood lung abscess: a 16-year experience. J Microbiol Immunol Infect. 2005 Jun;38(3):183-8.
  2. Yu H, Higa F, Koide M, et al; Lung abscess caused by Legionella species: implication of the immune status of hosts. Intern Med. 2009;48(23):1997-2002. Epub 2009 Dec 1.
  3. Schiza S, Siafakas NM; Clinical presentation and management of empyema, lung abscess and pleural effusion. Curr Opin Pulm Med. 2006 May;12(3):205-11.
  4. Umemori Y, Hiraki A, Murakami T, et al; Chronic lung abscess with Pasteurella multocida infection. Intern Med. 2005 Jul;44(7):754-6.
  5. Chierakul W, Winothai W, Wattanawaitunechai C, et al; Melioidosis in 6 tsunami survivors in southern Thailand. Clin Infect Dis. 2005 Oct 1;41(7):982-90. Epub 2005 Sep 1.
  6. Wali SO; An update on the drainage of pyogenic lung abscesses. Ann Thorac Med. 2012 Jan;7(1):3-7. doi: 10.4103/1817-1737.91552.
  7. Patradoon-Ho P, Fitzgerald DA; Lung abscess in children. Paediatr Respir Rev. 2007 Mar;8(1):77-84. Epub 2007 Feb 14.
  8. Kelogrigoris M, Tsagouli P, Stathopoulos K, et al; CT-guided percutaneous drainage of lung abscesses: review of 40 cases. JBR-BTR. 2011 Jul-Aug;94(4):191-5.
  9. Huang HC, Chen HC, Fang HY, et al; Lung abscess predicts the surgical outcome in patients with pleural empyema. J Cardiothorac Surg. 2010 Oct 20;5:88. doi: 10.1186/1749-8090-5-88.
  10. Monteiro R, Alfaro TM, Correia L, et al; [Lung abscess and thoracic empyema: retrospective analysis in an internal medicine department]. Acta Med Port. 2011 Dec;24 Suppl 2:229-40. Epub 2011 Dec 31.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Gurvinder Rull
Current Version:
Peer Reviewer:
Dr Adrian Bonsall
Document ID:
2406 (v22)
Last Checked:
03/02/2014
Next Review:
02/02/2019

Did you find this health information useful?

Yes No

Thank you for your feedback!

Subcribe to the Patient newsletter for healthcare and news updates.

We would love to hear your feedback!

 
 
Patient Access app - find out more Patient facebook page - Like our page