LUNG ABSCESS

PRESENTED BY
DR B. HANUMA
SRINIVAS
PG

UNDER GUIDANCE OF
DR SUDHAKAR MS MCH
(CT SURGEON)
DEFINITION
Lung abscess is defined as necrosis of the
pulmonary tissue and formation of cavities
containing necrotic debris or fluid caused by
microbial infection.

The formation of multiple small (<2 cm)

abscesses is occasionally referred to as necrotizing
pneumonia or lung gangrene.
INTRODUCTON
Lung abscess was a devastating disease in the
preantibiotic era 1/3 of pts died,
1/3 recovered,
the remaining 1/3 developed debilitating illnesses
such as recurrent abscesses, chronic empyema,
bronchiectasis, or other consequences of chronic
pyogenic infections.
CLASSIFICATION
BASED ON DURATION
1.Acute abscesses -less than 4-6 weeks old,

2.chronic abscesses -longer duration >6 weeks

BASED ON ETIOLOGY

1. Primary abscess

2. secondary abscess
Primary abscess
is infectious in origin,

caused by
Aspiration
or
pneumonia in the healthy host
secondary abscess
is caused by a preexisting condition (eg,
obstruction),

spread from an extrapulmonary site,

bronchiectasis, and/or an
immunocompromised state..
Pathophysiology
Most frequently, the lung abscess arises as a
complication of aspiration pneumonia caused by
mouth anaerobes.
The patients who develop lung abscess are
predisposed to aspiration and commonly have
periodontal disease. A bacterial inoculum from
the gingival crevice reaches the lower airways,
and infection is initiated because the bacteria are not
cleared by the patient's host defense mechanism
 This results in aspiration pneumonitis and
progression to tissue necrosis 7-14 days later, resulting
in formation of lung abscess.
 
Other mechanisms
include
bacteremia
tricuspid valve endocarditis, causing septic emboli
(usually multiple) to the lung.
an acute oropharyngeal infection followed by 
septic thrombophlebitis of the internal jugular vein, is
a rare cause of lung abscesses.
The oral anaerobe F necrophorum is the most common
pathogen.
 
RISK FACTORS
Patients at the highest risk for
developing lung abscess have the
following risk factors:
Periodontal disease
Seizure disorder
Alcohol abuse
Dysphagia
INFECTIOUS AGENTS
Anaerobic bacteria are the most significant
pathogens in lung abscess.
MC anaerobes are
Peptostreptococcus species,
Bacteroides species,
Fusobacterium species, and
microaerophilic streptococci.
Aerobic bacteria that may infrequently cause lung
abscess include
Staphylococcus aureus,
Streptococcus pyogenes,
Streptococcus pneumoniae (rarely),
Klebsiella pneumoniae,
Haemophilus influenzae,
Actinomyces species,
 Nocardia species, and gram-negative bacilli.
 
 Nonbacterial and atypical bacterial pathogens may
also cause lung abscesses, usually in the
immunocompromised host.
These include
parasites (eg, Paragonimus and Entamoeba species)

fungi (eg, Aspergillus, Cryptococcus, Histoplasma,

Blastomyces, and Coccidioides species), and

Mycobacterium species
Histology of a lung abscess shows dense
inflammatory reaction
INCIDENCE
Sex - Male predominance

Age -MC in elderly patients because of the

increased incidence of periodontal disease
prevalence of dysphagia and aspiration

SIDE - MC in right lung

CLINICAL FEATURES
Symptoms depend on whether the abscess is caused by
anaerobic or other bacterial infection.

Anaerobic infection in lung abscess

 Patients often present with indolent symptoms that evolve
over a period of weeks to months.
 The usual symptoms are fever, cough with sputum
production, night sweats, anorexia, and weight loss.
The expectorated sputum
characteristically is foul smelling and
bad tasting.
 Patients may develop hemoptysis or pleurisy
Physical
 Generally, patients with in lung abscess have evidence of gingival
disease.

 Clinical findings of concomitant consolidation may be present

(eg, decreased breath sounds, dullness to percussion, bronchial
breath sounds, course inspiratory crackles).

 Evidence of pleural friction rub and signs of associated pleural

effusion, empyema, and pyopneumothorax may be present.

Signs include dullness to percussion, contralateral shift of the

mediastinum, and absent breath sounds over the effusion.

 Digital clubbing may develop rapidly.

Differential Diagnoses

Alcoholism
Pneumococcal Infections Pulmonary Embolism
Empyema, Tuberculosis
Pneumocystis Carinii Mycobacterium Kansasii
Pneumonia Wegener Granulomatosis
Hydatid Cysts Infective Endocarditis
Pneumonia, Aspiration Pneumonia, Bacterial
Lung Cancer, Non-Small
Cell
MANAGEMENT
Laboratory Studies
CBP&DC -may reveal leukocytosis and a left shift.

sputum for Gram stain, culture, and sensitivity.

(If tuberculosis is suspected, acid-fast bacilli stain

and mycobacterial culture is requested. )

Blood culture may be helpful

Obtain sputum for ova and parasite whenever a

parasitic cause for lung abscess is suspected.
Chest radiography
A typical chest radiographic appearance of a lung
abscess is an irregularly shaped cavity with an air-
fluid level inside. Lung abscesses as a result of
aspiration most frequently occur in the posterior
segments of the upper lobes or the superior segments
of the lower lobes.
The wall thickness of a lung abscess progresses from
thick to thin and from ill-defined to well-
circumscribed as the surrounding lung infection
resolves. The cavity wall can be smooth or ragged but
is less commonly nodular, which raises the possibility
of cavitating carcinoma.
Anaerobic infection may be suggested by cavitation
within a dense segmental consolidation in the
dependent lung zones.
 Ultrasonography

Lung abscess appears as a

rounded hypoechoic lesion
with an outer margin
CT scanning of the lungs may help visualize
the anatomy better than chest radiography
Treatment
MEDICAL

SURGICAL
 Medical

Most abscesses develop secondary to aspiration and are

caused by anaerobes.

USE OF Antibiotics
 Clindamycin (Cleocin)
Adult
600 mg IV q8h, followed by 150-300 mg PO qid
Pediatric
25-40 mg/kg/d IV divided tid/qid-

Ampicillin plus sulbactam is well tolerated and as

effective as clindamycin with or without a
cephalosporin in the treatment of aspiration
pneumonia and lung abscess.
Cefoxitin (Mefoxin)
Adult
2 g IV q6-8h
Pediatric
80-160 mg/kg/d IV divided q4-6h
Penicillin G (Pfizerpen)
Adult
2 million U IV q4h
Pediatric
150,000 U/kg/d IV divided q4h

Metronidazole is an effective drug against

anaerobic bacteria
SURGICAL
Surgery is very rarely required for patients with
uncomplicated lung abscesses.
Indications for surgery
a.failure to respond to medical management,
b.suspected neoplasm, or
c.congenital lung malformation.
Although resectional surgery was often considered a
treatment option in the past, the role of surgery has
greatly diminished over time because most patients
with uncomplicated lung abscess eventually respond
to prolonged antibiotic therapy.
 
The surgical procedure performed is either
lobectomy
or
pneumonectomy

When conventional therapy fails, either

percutaneous catheter drainage or surgical
resection is usually considered
Pneumococcal pneumonia complicated by lung
necrosis and abscess formation.
A lateral chest radiograph shows air-fluid level characteristic of
lung abscess.
A 54-year-old patient developed cough with foul-smelling sputum
production. A chest radiograph shows lung abscess in the left lower
lobe, superior segment.
A 42-year-old man developed fever and production of foul-smelling sputum. He had a
history of heavy alcohol use, and poor dentition was obvious on physical examination.
Chest radiograph shows lung abscess in the posterior segment of the right upper lobe.
Chest radiograph of a patient who had foul-smelling and bad-
tasting sputum, an almost diagnostic feature of anaerobic lung
abscess.
Mortality/Morbidity

Most patients with primary lung

abscess improve with antibiotics, with
cure rates documented at 90-95%.