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  • • Localized collection of pus

    • Acute: < 6 wks

    • Chronic: > 6 wks

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Primary

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  • • Aspiration of oropharyngeal contents

    • Acute necrotizing pneumonia (Staph, Klebsiella)

    • Chronic pneumonia due to fungi, TB

    • Opportunistic infection in immunocompromised person

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Secondary

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  • • Bronchial obstruction (cancer, foreign body)

    • Cavitating pulmonary lesions (cancer)

    • Direct extension (amebiasis, subphrenic abscess)

    • Hematogenous dissemination

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Epidemiology

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  • • Increased incidence with AIDS, transplantation, and chemotherapy

    • Pathogens typically found in cultures include:

    • -Staphylococcus

      -Streptococcus

      -Klebsiella

      -E coli

      -Pseudomonas

      -Clostridium

      -Bacteroides

    • Pathogens found in immunocompromised patients:

    • -Candida

      -Legionella

      - Pneumocystis carinii

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Symptoms and Signs

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  • • Cough, fever, dyspnea, pleuritic chest pain

    • Malaise, weight loss if chronic

    • On exam: Clubbing; signs of pleural effusion; cachexia; and rarely, draining chest wound (empyema necessitatis)

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Laboratory Findings

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  • • Elevated WBC, with left shift

    • Positive sputum culture

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Imaging Findings

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  • Chest film: Area of intense consolidation or rounded density; with or without air-fluid level

    CT scan: Helpful in cases of suspected bronchial obstruction

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  • • Evaluate for primary structural diseases of lungs, including cancer

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  • • WBC, sputum culture

    • Chest x-ray and chest CT scan

    • Bronchoscopy in patients with unexplained reason for lung abscess

    • Fine-needle aspiration (FNA) of abscess cavity identifies pathogens in 94% of cases

    • -Bronchoalveolar lavage (BAL) identifies organism in only 3%

    • FNA important to identify unusual organisms in immunocompromised patients

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  • • Antibiotics mainstay of treatment

    • Penicillin and clindamycin commonly used

    • Trimethoprim-sulfamethoxazole, pentamidine, erythromycin, or amphotericin B often indicated in immunocompromised patients

    • Continue antibiotics until complete resolution (3-6 mos)

    • Chest physiotherapy, bronchoscopy with drainage may be necessary

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Surgery

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Indications

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  • • Poor response to above medical regimen, percutaneous drainage

    • Tense abscess (mediastinal shift, shift of diaphragm, etc)

    • Evidence of contralateral lung contamination

    • Signs of sepsis after 72 hrs of antibiotic therapy

    • Abscess size > 4 cm or enlarging

    • Rising fluid level

    • Persistent ventilatory dependency

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Complications

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  • • Rupture into bronchus

    • Rupture into pleural space resulting in pyopneumothorax

    • Massive hemoptysis

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Prognosis

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  • Percutaneous drainage: 1.5% mortality, 10% morbidity

    Overall mortality rate: 5-20%

    Medical therapy success: 75-88%

    Operative patients: Cured 90% of time, 1% mortality

    Mortality in immunocompromised patients: 28%

++

References

Schiza S. Siafakas NM. Clinical presentation and management of empyema, lung abscess and pleural effusion. Current Opinion in Pulmonary Medicine. 2006, 12(3):205-11.  [PubMed: 16582676]
Puligandla PS. Laberge JM. Respiratory infections: pneumonia, lung abscess, and empyema. Seminars in Pediatric Surgery. 2008, 17(1):42-52.  [PubMed: 18158141]

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