Primary lung abscess

Percutaneous transthoracic catheter drainage for lung abscess: a systematic review and meta-analysis

OBJECTIVES

To evaluate the outcomes of patients receiving image-guided percutaneous catheter drainage (PCD) for lung abscesses in terms of treatment success, major complications, and mortality as well as the predictors of those outcomes.

METHODS

Embase and OVID-MEDLINE databases were searched to identify studies on lung abscesses treated with PCD that had extractable outcomes. The outcomes were pooled using a random-intercept logistic regression model. Multivariate Firth's bias-reduced penalised-likelihood logistic regression analyses were performed to identify predictors of treatment success and complications. Methodological quality was assessed by summing scores of binary responses to items regarding selection, ascertainment of exposure and outcome, causality of follow-up duration, and reporting.

RESULTS

From 26 studies with acceptable methodological quality (median score, 4; range, 3-5), 194 patients were included. The pooled rates of treatment success and major complications were 86.5% (95% confidence interval [CI], 78.5-91.8%; I² = 23%) and 8.1% (95% CI, 4.1-15.3%; I² = 26%), respectively. Four patients eventually died from uncontrolled lung abscesses (pooled rate, 1.5%; 95% CI, 0.2-11.1%; I² = 36%). Malignancy-related abscess (odds ratio [OR], 0.129; 95% CI, 0.024-0.724; p = .022) and the occurrence of a major complication (OR, 0.065; 95% CI, 0.02-0.193; p < .001) were significant predictors of treatment failure. Traversing normal lung parenchyma was the only significant risk factor for major complications (OR, 27.69; 95% CI, 7.196-123.603; p < .001).

CONCLUSION

PCD under imaging guidance was effective for lung abscess treatment, with a low complication rate. Traversal of normal lung parenchyma was the sole risk factor for complications, and malignancy-related abscesses and the occurrence of major complications were predictors of treatment failure.

KEY POINTS

• The pooled treatment success rate of PCD for lung abscess was reasonably high (86.5%); malignancy-related abscesses and the occurrence of a major complication were predictors of treatment failure. • The pooled rate of percutaneous transthoracic catheter drainage-related major complications was 8.1% and traversing normal lung parenchyma by the catheter was the only risk factor. • The pooled mortality rate from uncontrolled lung abscesses with percutaneous transthoracic catheter drainage was low.

[Guidelines for the Management of Community Acquired Pneumonia in Children and Adolescents (Pediatric Community Acquired Pneumonia, pCAP) - Issued under the Responsibility of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Pulmonology (GPP)]

The present guideline aims to improve the evidence-based management of children and adolescents with pediatric community-acquired pneumonia (pCAP). Despite a prevalence of approx. 300 cases per 100 000 children per year in Central Europe, mortality is very low. Prevention includes infection control measures and comprehensive immunization. The diagnosis can and should be established clinically by history, physical examination and pulse oximetry, with fever and tachypnea as cardinal features. Additional signs or symptoms such as severely compromised general condition, poor feeding, dehydration, altered consciousness or seizures discriminate subjects with severe pCAP from those with non-severe pCAP. Within an age-dependent spectrum of infectious agents, bacterial etiology cannot be reliably differentiated from viral or mixed infections by currently available biomarkers. Most children and adolescents with non-severe pCAP and oxygen saturation > 92 % can be managed as outpatients without laboratory/microbiology workup or imaging. Anti-infective agents are not generally indicated and can be safely withheld especially in children of young age, with wheeze or other indices suggesting a viral origin. For calculated antibiotic therapy, aminopenicillins are the preferred drug class with comparable efficacy of oral (amoxicillin) and intravenous administration (ampicillin). Follow-up evaluation after 48 - 72 hours is mandatory for the assessment of clinical course, treatment success and potential complications such as parapneumonic pleural effusion or empyema, which may necessitate alternative or add-on therapy.

Lung Abscess

Lung abscess was successfully treated with percutaneous drainage in 5 of 6 patients. Complete abscess resolution occurred in 4 patients, partial resolution in one, and no response in one. The duration of drainage ranged from 7 to 18 days (mean 15.5 days) in successful cases. The failure of drainage in one neurologically impaired patient was attributed to persistent aspiration. In 2 patients, concurrent pleural empyema was also cured. CT provided the anatomic details necessary for choosing the puncture site and avoiding puncture of the lung parenchyma. Percutaneous catheter drainage is a safe and effective method for treating lung abscess.

Radiology in the Intensive Care Unit (Part 2)

This review of intensive care unit (ICU) radiology has been divided into two sections. In Part 1, previously published, the discussion focused on the role of the portable radiograph in the evaluation of the critically ill patient and the impact of the introduction of digital radiography and picture-archiving communications systems on patient care. Part 2 of this review will emphasize the role of computed tomography and the increasing contribution of image-guided interventional procedures in patient management. The deleterious effects of mechanical ventilation due to barotrauma will also be discussed.

Pulmonary Parenchymal Abscess: VATS Approach to Diagnosis and Treatment

Lung abscesses are usually treated with antibiotic regimens and postural drainage. Treatment failure necessitates transbronchial drainage with radiographically guided or open procedures. A patient with a lung abscess remained febrile despite a 2-week course of antibiotics and 3 unsuccessful percutaneous drainage attempts. Video-assisted thoracoscopic exploration localized the abscess and facilitated endoscopic unroofing and debridement of the cavity. Thoracoscopic drainage techniques offer a reliable and expedient option for refractory lung abscesses when compared to standard therapy alone.

The diagnosis and management of empyema in children: a comprehensive review from the APSA Outcomes and Clinical Trials Committee

The aim of this study is to review the current evidence on the diagnosis and management of empyema. The American Pediatric Surgical Association Outcomes and Clinical Trials Committee compiled 8 questions to address. A comprehensive review was performed on each topic. Topics included the distinction between parapneumonic effusion and empyema, the optimal imaging modality in evaluating pleural space disease, when and how pleural fluid should be managed, the first treatment option and optimal timing in the management of empyema, the optimal chemical debridement agent for empyema, therapeutic options if chemical debridement fails, therapy for parenchymal abscess or necrotizing pneumonia and duration of antibiotic therapy after an intervention. The evidence was graded for each topic to provide grade of recommendation where appropriate.

The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America

Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

Aspiration, Bronchial Obstruction, Bronchiectasis, and Related Disorders

The conducting airways play a pivotal role in the spectrum of pulmonary pathology, not only as conduits for injurious agents to enter the lung, but also as an anatomic compartment that is affected by a diverse array of primary or secondary bronchocentric diseases. This chapter discusses aspiration and bronchial obstruction in detail, with emphasis on the aspiration of toxic, infective, or particulate matter. Lung abscess, a frequent complication of obstruction or aspiration, is also reviewed. Both aspiration and lung abscess are reconsidered within the context of pulmonary infectious disease mainly in Chapter 8 on bacterial infections, and to some extent in the chapters on mycobacterial (Chapter 9), fungal (Chapter 10), and parasitic diseases (Chapter 14).

Lung abscess in children

Lung abscess is an uncommon paediatric problem, with a paucity of quality data on the subject in the medical literature. Although the condition has for many years been managed successfully with prolonged courses of intravenous antibiotics, the evolution of interventional radiology has seen the use of percutaneously placed 'pigtail catheters' inserted under ultrasound and computed tomography guidance become the mainstay of therapy where such resources are available. This has been suggested to result in a more rapid defervescence of fever and symptoms, shorter periods of intravenous antibiotics and a decreased length of inpatient care. More invasive procedures, aspiration and drainage, together with improved microbiological diagnostic techniques, including polymerase chain reaction testing, has increased the yield of pathogens identified from abscess fluid samples. Culture results will guide treatment, especially for immunocompromised subjects who may develop a lung abscess as a complication of their underlying condition. The predominant pathogens isolated from primary lung abscesses in children include streptococcal species, Staphylococcus aureus and Klebsiella pneumoniae. Children with a lung abscess, both primary and secondary, have a significantly better prognosis than adults with the same condition.

Percutaneous drainage of pyogenic lung abscess

Although lung abscesses are successfully treated with antibiotics in 80-90% of cases, this conservative approach may occasionally fail. In cases of failure, pulmonary resection is usually advised. Although it remains controversial, an alternative therapy in such situations is percutaneous transthoracic tube drainage (PTTD). Herein we review the medical literature on PTTD from the last 25 y, focusing on its efficacy, indications, technique, complications and mortality. We conclude that PTTD is a safe, simple and efficacious tool for the management of refractory lung abscess. Complications relating to the procedure occurred in 9.7% of cases and included catheter occlusion, chest pain, pneumothorax and hemothorax. The overall mortality rate secondary to lung abscess was acceptable (4.8%).

Pyogenic lung infections: factors for predicting clinical outcome of lung abscess and thoracic empyema

Lung abscess and thoracic empyema continue to cause significant morbidity and mortality despite appropriate antibiotic therapy and various options for drainage of empyema. Multiple factors, including the patient's general state of health, the presence of underlying disease, the virulence of the pathogen responsible, and the promptness of drainage of empyema, appear to dictate the clinical outcome. However, the available data are derived from uncontrolled, retrospective studies and the high morbidity and mortality rates underscore the need for large prospective studies to better evaluate factors that may predict the clinical outcome of these conditions.

Percutaneous management of intrapulmonary air and fluid collections

The radiologist's role in the management of intrapulmonary air and fluid collections is becoming more important. Improvements in percutaneous interventional techniques now allow the radiologist to offer patients an alternative treatment option with less morbidity and mortality than surgical resection. The use of CT allows optimal catheter placement and enables safe and effective percutaneous evacuation of intrapulmonary collections. In summary, image-guided percutaneous catheter drainage should (1) be the initial procedure performed to diagnose and treat lung abscesses not responding to conservative therapy; and (2) because of its effectiveness and safety, be considered as a treatment option in the management of symptomatic patients with intrapulmonary mycetomas.

Pyogenic lung infections

Pyogenic lung infections still occur despite the availability of effective antibiotics for the treatment of patients with acute bacterial pneumonia. Our understanding of the pathogenesis and management of these conditions has steadily improved over the past few decades, although some areas remain obscure. The effect of HIV infection on the incidence of pyogenic lung infections remains largely unknown, and large studies are required to evaluate this. Burkholderia (formerly Pseudomonas) cepacia strains are now recognized as important respiratory pathogens in patients with cystic fibrosis, and the high transmissibility of some strains, combined with their inherent multiple antibiotic resistance, are continuing causes for concern.

Computed tomography-guided percutaneous needle aspiration of lung abscesses in neonates and children

Lung abscesses in children often respond to conservative treatment. This is unlikely in children less than 7 years of age and in these surgery is associated with significant morbidity and mortality. We report a neonate and a 2.5 year old child successfully treated with percutaneous computed tomography guided aspiration of lung abscesses.

Cavitating pulmonary infarction in nephrotic syndrome

A 6-year-old boy was admitted with anasarca due to relapse of nephrotic syndrome, non-productive cough, and dyspnea on exertion. On the 8th hospital day he manifested severe right shoulder and chest pain. A nodular opacity in the right lung that transformed into a cavitating lesion was documented by computerized axial tomography. Surgical biopsy of the affected area of the lung documented infarction due to pulmonary embolism. This case highlights the need to consider pulmonary embolism in the evaluation of nephrotic children with a cavitating pulmonary lesion.

Lung abscess: a neglected cause of life threatening haemoptysis

Three cases who presented with life threatening haemoptysis are reported, all of whom required surgery to control the bleeding. In all three patients chronic lung abscess was responsible for the haemoptysis. Even in the absence of typical clinical or radiographic features of an abscess this diagnosis should be considered in any patient presenting with life threatening haemoptysis.

Percutaneous drainage of lung abscess

Most lung abscesses are successfully treated with antibiotics. However, occasional patients with lung abscesses that drain poorly, causing persistent fever and toxic symptoms, may require surgical intervention. Lobectomy is the most frequent surgical procedure. Some patients are debilitated and have underlying medical conditions such as heart disease, chronic pulmonary disease, or liver disease that may render surgical intervention risky. Recently there have been reports of percutaneous drainage of lung abscess with good results. We have successfully carried out percutaneous drainage of lung abscess in 4 patients and an infected bulla in 1. All patients had failed to respond to therapy with antibiotics and postural drainage. There was prompt disappearance of the fluid level in the cavity, decline in temperature, and abatement of toxic symptoms with drainage. The cavities closed gradually over the next 6-12 weeks. The patients tolerated the chest tube well and there were no side effects from the tube drainage. Percutaneous tube drainage is the surgical treatment of choice in the medically complicated patient with a poorly draining lung abscess.

Yield of percutaneous needle lung aspiration in lung abscess

STUDY OBJECTIVE

To evaluate the accuracy of PLA with a thin needle in the bacteriologic diagnosis of patients with lung abscess and in demonstrating possible coexistence of an underlying lung carcinoma, and the influence of this technique in the treatment and outcome of these patients.

DESIGN

Case series.

SETTING

Tertiary university referral center.

PATIENTS

Consecutive sample of 50 patients with clinical picture suggestive of pulmonary infection and single or multiple cavitation of at least 1 cm in diameter on chest x-ray films, and lack of clinical suspicion of active pulmonary tuberculosis. One patient was excluded from the study after demonstration of tuberculosis by PLA.

INTERVENTIONS

Lung aspirates were obtained under fluoroscopic guidance by introduction of a 22-gauge disposable spinal needle within the abscess cavity and were immediately transported to the bacteriology laboratory and pathology department for processing. All patients were initially treated with clindamycin. Tobramycin was added in all those patients with hospital-acquired infection, lack of foulness of sputum, and those who were initially severely ill. Definite treatment was based on the results of bacteriologic cultures.

MEASUREMENTS AND MAIN RESULTS

Cultures of LAs were positive in 82 percent (40/49) of patients. In 20 cases the isolates were monobacterial (13 aerobic bacteria and seven anaerobic). In the remaining 20 cases, cultures grew more than one kind of bacteria (four exclusively aerobic, five exclusively anaerobic, and 11 mixed), with an average of 3.25 types of bacteria per case. Anaerobes were found as a single bacteria or associated with other aerobic bacteria in only 58 percent (23/40). The results of LA cultures led to change in the initial antibiotic trial in 23 patients (47 percent). Of ten cases in which bronchogenic carcinoma was demonstrated, cytologic study of LA was done in nine, and eight had positive cytologic yield. Pneumothorax occurred in seven cases (14 percent) as the sole complication.

CONCLUSIONS

(1) Percutaneous lung aspiration had a high diagnostic yield and accuracy in our series, with a relatively low incidence of complications. (2) Anaerobic bacteria were less frequently implicated in our cases than previously reported. This finding led to significant changes in the initial empiric antibiotic treatment.

Fatal hemoptysis due to lung abscess and pulmoaortic fistula

A 79-year-old man was hospitalized because of staphylococcal sepsis, and subsequently died from massive hemoptysis. Autopsy revealed a lung abscess which had eroded into the aorta. Severe atherosclerosis of the aorta may have been an important contributing factor.

Indwelling transbronchial catheter drainage of pulmonary abscess

Adequate cavitary drainage is of paramount importance in the treatment of pulmonary abscesses. Occasionally this cannot be achieved despite vigorous chest physical therapy and the utilization of bronchoscopy. Intermittent transbronchial catheterization under fluoroscopic guidance has been suggested as a method to facilitate drainage. We have modified this technique by placing an indwelling intracavitary catheter, which allows irrigation and drainage over a prolonged period. This report describes this technique and our experience with 3 patients managed in this fashion.

Percutaneous small bore catheter drainage in the management of lung abscesses

For patients with pyogenic lung abscesses who do not respond to medical therapy, thoracotomy with pulmonary resection is the widely-accepted treatment of choice. Six patients with lung abscess who failed to respond to conservative medical management were treated by percutaneous catheter drainage using small catheters (10 Fr or smaller). Five patients showed prompt clinical improvement and the sixth improved after a modification in antibiotic therapy. All patients recovered with radiographic resolution of the abscess and were well at followup periods from two months to two years. In such patients, percutaneous drainage with small catheters provides an excellent clinical result with minimal risk and trauma.

The radiology of aseptic cavitation in pulmonary infarction

Eight patients with aseptic cavitation of sterile pulmonary infarcts are described. All except one had left ventricular failure and/or chronic airflow obstruction. Infarcts with cavities were commonly single (75%) and right-sided (69%) and usually followed a sizeable area of consolidation (larger than 4 cm) after about 2 weeks. Of the 62% that could be localised to a segment, all were in the apical or posterior segment of an upper lobe or the apical segment of a lower lobe and the majority (85%) had scalloped inner margins and cross cavity band shadows. At the time of cavitation, 38% had additional features on the chest radiograph that were suggestive of pulmonary embolic disease. A number of cavities developed a tertiary infection and an air-fluid level but the latter feature was non-specific. Aseptic cavitation of a sterile pulmonary infarct should be considered in the differential diagnosis of any cavitating lung lesion, particularly if it shows the above features.

Utility of pneumonotomy in the treatment of cavitary lung disease

Three patients were judged to be prohibitive operative risks despite the need for urgent drainage of cavitary pulmonary lesions. Cavernostomy was performed in each case, with a satisfactory long-term outcome in two patients. The third patient recovered from his pulmonary insult, but died much later, secondary to an unrelated illness. One patient had a purulent lung abscess due to aspiration, one had atypical tuberculosis resistant to all antibiotics, and the third patient experienced massive hemoptysis from a tuberculous cavity. Two-stage procedures were utilized in the first two patients, while urgent operation in the third patient was facilitated by adhesions from a previous thoracotomy and pleural infection. Care must be taken to minimize endobronchial and pleural contamination by meticulous attention to detail during the performance of percutaneous tube drainage. There are relatively few indications for percutaneous drainage of cavitary pulmonary lesions in this antibiotic era. However, certain clinical situations should prompt consideration for a pneumonotomy. These include a severely septic or debilitated patient who is unresponsive to medical management, the presence of resistant pathogens in a compromised host, and the presence of severe adhesive pleuritis which may prohibit an expeditious thoracotomy and resection for massive hemoptysis.

Fiberoptic bronchoscopy in the evaluation of lung abscesses

To define the results of flexible fiberoptic bronchoscopy (FFB) in patients with lung abscess and to characterize those patients most likely to have an underlying carcinoma, we retrospectively studied the records of 52 consecutive patients undergoing FFB at our institution between 1975 and 1982. Nineteen patients (36.5 percent) had an associated bronchogenic carcinoma (group 1); 33 (63.5 percent) had no malignancy (group 2). The FFB aided in diagnosing 73.7 percent of group 1 patients, but added no information in group 2 patients. Group 1 and 2 patients differed significantly with respect to prevalence of systemic symptoms (15.8 percent vs 51.5 percent, p less than 0.01); predisposition to aspiration pneumonia (26.3 percent vs 60.6 percent, p less than 0.01); mean presenting white blood cell count (10.9 vs 14.2, p less than 0.05); mean oral temperature at presentation (37.5 vs 38.3 degrees C, p less than 0.05); and the prevalence of extensive infiltrates on the initial chest roentgenogram (17.0 percent vs 83.6 percent, p less than 0.05). Based on these data, we believe that by carefully considering the available clinical information, it is possible to identify those patients whose lung abscesses are likely to be related to bronchogenic carcinoma. Such individuals should be promptly evaluated. It is not necessary, however, to routinely order bronchoscopy for all patients with lung abscess.

Percutaneous tube drainage: the treatment of choice for refractory lung abscess

During the years 1978 to 1982, 48 patients with primary lung abscess were seen in the Sheba Medical Center in Israel. Seven of them (14%) did not respond to conservative treatment and were candidates for operation. All were successfully treated by percutaneous tube drainage initiated under local anesthesia, and all recovered completely. There were no relapses after a follow-up period of 2 to 5 years. During this period, we did not perform pulmonary resection for primary lung abscess. Three patients with malignant abscesses were also treated initially by transthoracic drainage but eventually required surgical intervention. We conclude that percutaneous transthoracic drainage is an efficient and safe mode of treatment, and we recommend transthoracic drainage as the treatment of choice for long-standing, refractory primary lung abscesses.

Lung abscess caused by Streptococcus pneumoniae type 3. The importance of counterimmunoelectrophoresis in laboratory diagnosis

We are reporting the case of an 18-month-old girl with a post-pneumonic lung abscess. The counterimmunoelectrophoresis (CIE) of the patient's urine during the bacteremic phase of the disease gave a precipitation line with pneumococcal antiserum. Later in the course of the disease, after the diagnosis of lung abscess had been established, the pus drained from the abscess gave positive reactions with pneumococcal omnivalent serum and type 3 pneumococcal antiserum. At this stage, the pus was sterile and blood cultures were negative. This case demonstrates that the CIE test is a simple procedure which gives a rapid and exact diagnosis up to the serotype level.

Alcohol and the respiratory tract

Possible mechanisms by which alcohol may adversely affect the respiratory system are considered. Alcohol ingestion impairs glottic reflexes, and alcoholics are predisposed to pneumonias and lung abscesses from aspiration of oropharyngeal bacteria. Alcohol intoxication also increases the frequency of sleep apnea and may result in respiratory failure from oversedation.

Pneumonostomy in the management of pediatric lung abscess

Emergency pneumonostomy was curative in a critically ill child with acute lung abscess. This procedure may be indicated for the rare acute lung abscess which fails to respond to medical therapy.