Bacterial Lung Abscess

Bren F.
Dagoc, MD
ID Fellow in-Training
San Lazaro Hospital
OBJECTIVES:
1. To define lung abscess.

2. To present the pathophysiology of lung abscess.
3. To present the different causative organisms isolated in bacterial lung
abscess.
4. To discuss the clinical manifestation, diagnosis and treatment of
bacterial lung abscess
Source: Mandell, Douglas, and Bennett’s Principle and Practice of Infectious Disease 8th ed
Mandell, Douglas, and Bennett’s Principle and Practice of Infectious Disease 8th ed
Primary Lung Abscess Secondary Lung Abscess
 Develops in individuals prone to Obstructive airway neoplasm as a
aspiration or in general good health complication of thoracic surgery or
 80% of lung abscess (50% associated systemic condition/treatment that
with putrid sputum) compromises host immune defense
mechanism
Complication of aspiration pneumonia
Dependent portions of the lung
Occurs in a reclining or supine position
Right main stem bronchus
• Larger in diameter
• Shorter
• Less angulated from the trachea
Unilateral
• Posterior segment RUL
• Posterior segment LUL
• Superior segments of lower lobes
Complication of aspiration pneumonia
Dependent portions of the lung
Occurs in a reclining or supine position
Right main stem bronchus
• Larger in diameter
• Shorter
• Less angulated from the trachea
Unilateral
• Posterior segment RUL
• Posterior segment LUL
• Superior segments of lower lobes
occur as a complication of aspiration pneumonia
Direct chemical injury

• Aspirated stomach acid
• Obstruction by aspirated particulate
matter e.g food
Secondary bacterial infection Tissue necrosis w/ lung abscess formation

min 1 week and usually 2 weeks to
develop
Risk Factors
• Predisposition to aspiration Alcoholism (~70%), Seizures, Drug overdose
General anesthesia, Dysphagia, Respiratory muscle dysfunction
Tooth extraction, Mechanical interference with anatomic and
physiologic barriers to aspiration
• Poor dentition with gingivitis
• Airway obstruction Neoplasm, foreign bodies, extrinsic compression (enlarged lymph
nodes)
• others Bronchiectasis, GERD, secondary infection from bland pulmonary
infarction from PE, septic emboli from TV endocarditis, suppurative
phlebitis
Risk Factors
• Lemierre Septic phlebitis of the neck veins
Syndrome
Fusobacterium necrophorum
Embolic infection in the lung may
complicate an oropharyngeal
infection e.g peritonsillar abscess
Polymicrobial
Anaerobes 90%
Fusobacterium nucleatum
Prevotella melaninogenica
Finegoldia magna (Peptostreptococcus
magnus)
Polymicrobial
Anaerobes 90%
Polymicrobial
Anaerobes 90%
Polymicrobial
Anaerobes 90%
Finegoldia magna (Peptostreptococcus
magnus)
Monomicrobial
Staphylococcal aureus Legionella spp.
Klebsiella spp. Rhodococcus equi
Pseudomonas aeruginosa Actinomyces spp.
Burkholderia pseudomallei Nocardia spp.
Pasteurella multocida Streptococcus pneumoniae type 3
Group A streptococcus
Haemophillus influenza types b and c
others
fungi Coccidioidomycosis, blastomycosis, cryptococcosis,
histoplamosis
mycobacterium
parasites Paragonimus westermani
Entamoeba histolytica
Subacute or indolent Sputum: putrid smell 50%
Several weeks or longer Foul sputum smell of patients breath
Physical Examination
Amphoric or cavernous breath

sounds
Clubbing of digits
Gag reflex may be absent
Labs:
Anemia of chronic disease
WBC ~ 15,000/mm3
Empyema 1/3 of cases
Necrotizing pneumonia:
within 1 week of symptom
> 20,000/mm3
Pulmonary gangrene
Chest radiograph
Thick
Irregular
Pulmonary infiltrate is
present
Computed tomography
More sensitive
Detect small cavities
Provide evidence for
obstructing endobronchial
lesions
Putrid odor on expectorated sputum and aspirated pleural
fluid -> pathognomonic for anaerobic infection
Special techniques are needed to confirm the presence of

anaerobes in sputum
transtracheal aspiration
transthoracic aspiration
fiberoptic bronchoscopy
bronchoalveolar lavage
culture of empyema fluid by thoracentesis
Antimicrobial Therapy
Penicillin
Clindamycin
Metronidazole
inferior to Clindamycin
not active on microaerophilic streptococci and some anaerobic cocci
Penicillin + B-lactamase inhibitors / carbapenems / quinolones

Oral therapy: Amoxicillin + Clavulanate 500mg q8h
Clindamycin 300-600 mg q8h
Moxifloxacin 400mg/day
Duration of Therapy 6 – 8 weeks
Weekly or biweekly chest radiograph
Bronchoscopy reserve for patients who do not respond to medical

management or in endobronchial tumor is suspected
Clinical features asstd w/ malignancy
anterior lobar segment
lack of aspiration risk
edentulous patient
age >50 years w/strong smoking history
lack of systemic symptoms
Surgical Intervention reserved for 10-15% of patients who do not improve medical
management
Drainage
Indications: > 8cm
caused by Pseudomonas aeruginosa
obstructing neoplasm
massive hemorrhage
Response to Therapy defervescence 7-10 days

Fever > 2 weeks: diagnostics test to R/O complications,
obstructions
Medical management fails: undrained pleural collections,
endobronchial obstruction, resistant organisms, cavity > 8cm

Bacterial Lung Abscess

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Bacterial Lung Abscess

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Bren F.

1. To define lung abscess.

Direct chemical injury

Secondary bacterial infection Tissue necrosis w/ lung abscess formation

Amphoric or cavernous breath

Special techniques are needed to confirm the presence of

Penicillin + B-lactamase inhibitors / carbapenems / quinolones

Bronchoscopy reserve for patients who do not respond to medical

Response to Therapy defervescence 7-10 days

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