Added to Saved items
This article is for Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find one of our health articles more useful.

Read COVID-19 guidance from NICE

Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.

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 formations may occur - sometimes referred to as necrotising pneumonia.

The most frequent cause is aspiration of anaerobic organisms from the mouth in those predisposed to aspiration pneumonia, with immunodeficiency 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[2].

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[3].


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


  • S. aureus.
  • Streptococcus pyogenes.
  • Haemophilus influenzae.
  • Pseudomonas aeruginosa.
  • K. pneumoniae - becoming more prevalent[4].
  • Burkholderia cepacia - particularly associated with cystic fibrosis.
  • Streptococcus pneumoniae.
  • Legionella pneumonia[5].
  • Actinomyces spp.
  • Nocardia spp.
  • Proteus mirabilis.
  • Pasteurella multocida - zoonotic infection from cats/dogs/cattle[6].
  • Burkholderia pseudomallei - a soil-borne Gram-negative infection which causes a condition called melioidosis. It affects animals and humans, especially in Southeast Asia and northern Australia[7].

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.


  • 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.


  • 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.
  • LFTs.
  • 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.


Most lung abscesses (80-90%) are now successfully treated with antibiotics[8].

  • 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[9].
  • 15-20% of anaerobic bacteria are resistant to penicillin only, so a combination of penicillin and clavulanate or a combination of penicillin and metronidazole should be considered as alternatives[2].
  • Regimen should be altered once the organism is known.


  • If the condition fails to resolve with conservative measures, drainage via a bronchoscope, CT-guided percutaneous drainage or cardiothoracic surgical intervention may be required[10].
  • Surgery is associated with a number of complications, such as empyema and bronchoalveolar air leak - especially so in children[11, 12]

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

These include:

  • Empyema.
  • Pneumatocele.
  • Bronchopleural fistula.
  • Distant complications from haematogenous spread (eg, brain abscess).
  • There is an overall 90% cure rate with antibiotic therapy[13].
  • 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[14].
  • Other poor prognostic factors include pneumonia, reduced level of consciousness, anaemia and infection with P. aeruginosa, S. aureus and K. pneumoniae[15].

Further reading and references

  • Mohapatra MM, Rajaram M, Mallick A; Clinical, Radiological and Bacteriological Profile of Lung Abscess - An Observational Hospital Based Study. Open Access Maced J Med Sci. 2018 Sep 236(9):1642-1646. doi: 10.3889/oamjms.2018.374. eCollection 2018 Sep 25.

  • Wojsyk-Banaszak I, Krenke K, Jonczyk-Potoczna K, et al; Long-term sequelae after lung abscess in children - Two tertiary centers' experience. J Infect Chemother. 2018 May24(5):376-382. doi: 10.1016/j.jiac.2017.12.020. Epub 2018 Feb 15.

  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 Jun38(3):183-8.

  2. Kuhajda I, Zarogoulidis K, Tsirgogianni K, et al; Lung abscess-etiology, diagnostic and treatment options. Ann Transl Med. 2015 Aug3(13):183. doi: 10.3978/j.issn.2305-5839.2015.07.08.

  3. Chirtes IR, Marginean CO, Gozar H, et al; Lung Abscess Remains a Life-Threatening Condition in Pediatrics - A Case Report. J Crit Care Med (Targu Mures). 2017 Aug 193(3):123-127. doi: 10.1515/jccm-2017-0023. eCollection 2017 Jul.

  4. An S, Li X, Wei S, et al; An unusual case of lung abscess secondary to round pneumonia caused by recurrent Klebsiella pneumoniae strain and the role of occult metastases tumor. Respir Med Case Rep. 2018 Feb 323:107-109. doi: 10.1016/j.rmcr.2018.01.008. eCollection 2018.

  5. Yu H, Higa F, Koide M, et al; Lung abscess caused by Legionella species: implication of the immune status of hosts. Intern Med. 200948(23):1997-2002. Epub 2009 Dec 1.

  6. Zurlo J; Pasteurella species. Infectious Diseases Advisor, 2018.

  7. Melioidosis; Centers for Disease Control and Prevention, 2018

  8. Ko Y, Tobino K, Yasuda Y, et al; A Community-acquired Lung Abscess Attributable to Streptococcus pneumoniae which Extended Directly into the Chest Wall. Intern Med. 201756(1):109-113. doi: 10.2169/internalmedicine.56.7398. Epub 2017 Jan 1.

  9. Schiza S, Siafakas NM; Clinical presentation and management of empyema, lung abscess and pleural effusion. Curr Opin Pulm Med. 2006 May12(3):205-11.

  10. Izumi H, Kodani M, Matsumoto S, et al; A case of lung abscess successfully treated by transbronchial drainage using a guide sheath. Respirol Case Rep. 2017 Mar 245(3):e00228. doi: 10.1002/rcr2.228. eCollection 2017 May.

  11. Wali SO; An update on the drainage of pyogenic lung abscesses. Ann Thorac Med. 2012 Jan7(1):3-7. doi: 10.4103/1817-1737.91552.

  12. Madhani K, McGrath E, Guglani L; A 10-year retrospective review of pediatric lung abscesses from a single center. Ann Thorac Med. 2016 Jul-Sep11(3):191-6. doi: 10.4103/1817-1737.185763.

  13. Huang HC, Chen HC, Fang HY, et al; Lung abscess predicts the surgical outcome in patients with pleural empyema. J Cardiothorac Surg. 2010 Oct 205:88. doi: 10.1186/1749-8090-5-88.

  14. Monteiro R, Alfaro TM, Correia L, et al; Lung abscess and thoracic empyema: retrospective analysis in an internal medicine department. Acta Med Port. 2011 Dec24 Suppl 2:229-40. Epub 2011 Dec 31.

  15. Patradoon-Ho P, Fitzgerald DA; Lung abscess in children. Paediatr Respir Rev. 2007 Mar8(1):77-84. Epub 2007 Feb 14.