Factors predicting mortality of patients with lung abscess

Aetiology of Adult Community-Acquired Lung Abscess in Hong Kong

BACKGROUND AND OBJECTIVE

Knowing the pattern of pathogens in community-acquired lung abscess (CALA) is important in the choice of initial empiric antibiotics. Early studies established the anaerobes as the predominant pathogen, followed by aerobic streptococci and aerobic Gram-negative bacilli. However, recent reports indicated that Klebsiella pneumoniae and aerobic streptococci predominated.

METHODS

We performed a retrospective study on CALA cases from all public hospitals in Hong Kong over a nine-year period. Only cases with uncontaminated specimens sent for bacterial culture were included. Cases caused by mycobacteria and fungi were excluded.

RESULTS

There were 606 eligible subjects-episodes. Mean age of subjects was 57.7 years and male to female ratio was 3.3:1. Two hundred and thirty-two subjects had at least one positive bacterial culture, with a total of 338 pathogens isolated. Anaerobes were the predominant pathogen group with 103 isolates (30.5% of total). This was followed by aerobic streptococci (90, 26.6%), aerobic Gram-negative bacilli (67, 19.8%), and Staphylococcus aureus (56, 16.6%). Isolation of Staphylococcus aureus was closely linked to intravenous drug abuse, while isolation of Klebsiella pneumoniae (28 cases) was related to extrapulmonary abscesses, particularly of the liver. There were 14 cases of Pseudomonas aeruginosa with underlying chronic lung disease and major organ failure being risk factors.

CONCLUSION

Anaerobes and aerobic streptococci appear to be the major pathogens for primary CALA. Secondary lung abscess caused by haematogenous spread is commonly attributable to Staphylococcus aureus or Klebsiella pneumoniae. Choice of empiric antibiotics should take these into consideration together with local patterns of antibiotic resistance.

Heterogeneity in clinical patterns of adult lung abscess patients: an 8-year retrospective study in a tertiary hospital

BACKGROUND

The widespread use of broad-spectrum antibiotics has led to changes in both the microbiological and clinical characteristics of lung abscesses. It is necessary to re-evaluate the bacterial spectrum associated with these infections. As a novel method for pathogen detection, metagenomic next-generation sequencing (mNGS) is increasingly being applied in clinical practice. There is limited research evaluating the use of mNGS in patients with lung abscesses.

METHODS

A retrospective analysis was conducted on patients with lung abscess who were hospitalized between July 2015 and July 2023 at a teaching hospital in China. Patients who underwent both computerized tomography (CT) imaging and conventional pathogen testing were included in the study. The efficacy of pathogen detection using conventional methods was compared with that of mNGS. Additionally, the clinical and radiological features were analyzed to provide a comprehensive understanding of the disease patterns.

RESULTS

A total of 782 patients with lung abscess were included in the study and hematogenous abscess accounting for 7.16% (56/782) of cases. The overall hospital mortality rate was 1.53%. The mean age of the patients with lung abscess was 60 years, with a male predominance (80.2%). A significant proportion of patients had comorbid conditions, including diabetes (29.7%) and cardiovascular disease (18.2%). Lung abscesses were predominantly located in the right lung, and pleural effusion was more commonly observed in the deceased group. The detection rate of pathogen via conventional test was lower at 41.8% (327/782). Among patients with positive mNGS results, only 51.9% had pathogens identified through conventional testing methods. Klebsiella pneumoniae was the most frequently detected pathogen by conventional culture, while mNGS identified was Parvimonas micra. Infections caused solely by anaerobic bacteria or facultative anaerobes were associated with shorter hospital stays. Patient infected with Gram-negative bacilli (GNB) had a higher proportion of liver abscesses (11.8%).

CONCLUSION

Compared to conventional testing methods, mNGS demonstrates superior performance in detecting anaerobic and facultative anaerobic bacteria. The low detection rate of conventional tests may result in an underestimation of the clinical significance of anaerobic bacteria infections. In patients with lung abscess caused by GNB, hematogenous dissemination, liver abscess and diabetes were more commonly observed and these patients tended to have longer hospital stays.

Percutaneous Drainage of Pediatric Pulmonary Abscesses: An Effective Therapy

INTRODUCTION

Pulmonary abscess is a complication of lung infection with localized necrosis and purulent cavity formation. Pulmonary abscesses are typically managed using antibiotic therapy with anatomic surgical resection reserved as a rescue. Percutaneous drainage is considered relatively contraindicated in some centers due to perceived risk of bronchopleural fistula. However, drain placement has been frequently employed at our institution. The purpose of this study was to review and describe our longitudinal experience.

METHODS

Medical records of children diagnosed with lung abscess and treated with percutaneous drainage from 2005 through 2023 were reviewed. Patient clinical parameters, follow-up imaging, and clinical outcomes were evaluated.

RESULTS

Percutaneous drainage (n = 24) or aspiration alone (n = 4) under imaging guidance was performed by interventional radiologists for 28 children with lung abscesses. A single catheter (8-12 Fr) was deployed in the pulmonary abscess cavity and remained for a median of 6 days (IQR: 6-8 days). The median hospital stay was 10 days (IQR: 8.8-14.8 days). The technical success rate for percutaneous drainage or aspiration of primary pulmonary abscesses was 100% (26/26). Two children were later diagnosed with secondarily infected congenital pulmonary airway malformations that were both successfully drained and ultimately surgically resected. The abscess cavities resolved in all patients and catheters were removed upon clinical, radiographic, and laboratory improvement. Complications included the presence of two bronchopleural fistula, both of which were treated with immediate pleural drain placement.

CONCLUSION

Percutaneous drainage of pulmonary abscesses is an effective therapeutic option in children and can be considered alongside antibiotics as part of the initial treatment for pulmonary abscesses. Bronchopleural fistula can occur, but at a lower frequency than previously reported.

LEVEL OF EVIDENCE

Level V.

Lung abscess: an update on the current knowledge and call for future investigations

PURPOSE OF REVIEW

Lung abscess is a severe and complex respiratory infection. The purpose of this review is to discuss recent publications on lung abscess, covering topics such as epidemiology, clinical presentation, diagnosis, and treatment and prevention.

RECENT FINDINGS

Risk factors associated with lung abscess include structural lung disease, poor dental hygiene, and ventilator-associated pneumonia, while concerns are now raised regarding the potential of electronic cigarettes use as a risk factor. The complexity of lung abscess is reflected by the relative high number of case reports describing rare and complex cases. Early transthoracic drainage could improve in-hospital outcomes, while next-generation sequencing could become an important tool in diagnostics and future clinical studies.

SUMMARY

High-quality evidence and guidelines to support treatment of lung abscess are lacking. Despite advancements, we call for prospective studies to evaluate the use of invasive procedures and antibiotic treatment regimens.

Epidemiology and Clinical Patterns of Lung Abscesses in ICU: A French Multicenter Retrospective Study

BACKGROUND

Data are scarce regarding epidemiology and management of critically ill patients with lung abscesses.

RESEARCH QUESTION

What are the clinical and microbiological characteristics of critically ill patients with lung abscesses, how are they managed in the ICU, and what are the risk factors of in-ICU mortality?

STUDY DESIGN AND METHODS

This was a retrospective observational multicenter study, based on International Classification of Diseases, 10th Revision, codes, between 2015 and 2022 in France. In-ICU mortality-associated factors were determined by multivariate logistic regression.

RESULTS

We analyzed 171 ICU patients with pulmonary abscesses. Seventy-eight percent were male, with a mean age of 56.5 ± 16.4 years; 20.4% misused alcohol, 25.2% had a chronic lung disease (14% COPD), and 20.5% had a history of cancer. Overall, 40.9% were immunocompromised and 38% qualified for nosocomial infection. Presenting symptoms included fatigue or weight loss in 62%, fever (50.3%), and dyspnea (47.4%). Hemoptysis was reported in 21.7%. A polymicrobial infection was present in 35.6%. The most frequent pathogens were Enterobacteriaceae in 31%, Staphylococcus aureus in 22%, and Pseudomonas aeruginosa in 19.3%. Fungal infections were found in 10.5%. Several clusters of clinicoradiologic patterns were associated with specific microbiological documentation and could guide empiric antibiotic regimen. Percutaneous abscess drainage was performed in 11.7%; surgery was performed in 12.7%, and 12% required bronchial artery embolization for hemoptysis. In-ICU mortality was 21.5%, and age (OR: 1.05 [1.02-1.91], P = .007], renal replacement therapy during ICU stay (OR, 3.56 [1.24-10.57], P = .019), and fungal infection (OR, 9.12 [2.69-34.5], P = .0006) were independent predictors of mortality after multivariate logistic regression, and drainage or surgery were not.

INTERPRETATION

Pulmonary abscesses in the ICU are a rare but severe disease often resulting from a polymicrobial infection, with a high proportion of Enterobacteriaceae, S aureus, and P aeruginosa. Percutaneous drainage, surgery, or arterial embolization was required in more than one-third of cases. Further prospective studies focusing on first-line antimicrobial therapy and source control procedure are warranted to improve and standardize patient management.

Diagnostic performance of the metagenomic next-generation sequencing in lung biopsy tissues in patients suspected of having a local pulmonary infection

Purpose

This study aims to evaluate the diagnostic application and performance of the metagenomic next-generation sequencing (mNGS) in patients suspected of local pulmonary infection by comparing it to the traditional pathogen detection methods in lung tissue specimens obtained by a computerized tomography-guided biopsy (CT-guided biopsy).

Methods

We retrospectively reviewed patients, admitted to the First Affiliated Hospital of Wenzhou Medical University, China from May 2018 to December 2020, who were suspected of local pulmonary infection. All cases received a CT-guided lung biopsy, tissue samples were sent both for conventional examinations (CE) and mNGS tests. The sensitivity and specificity of the two diagnostic approaches were compared.

Results

106 patients enrolled, 76 patients were diagnosed with a pulmonary infection. Among 49 patients with identified pathogens, CE confirmed pathogenic infections in 32 cases. Mycobacterium spp. and fungi accounted for 37.5% (12/32) and 28.1% (9/32), respectively, with bacteria 34.4% (11/32). The mNGS examination detected extra pathogenic microorganisms in 22 patients that were consistent with the patients' clinical and radiographic pictures. The sensitivity of mNGS was 53.9% vs. 42.1% for the CE, while the specificity was 56.7% versus 96.7%. For detection rate, mNGS was significantly superior to CE in bacterial (96.3% vs. 40.7%, p < 0.05), and mixed infections (100% vs. 50%, p < 0.05), but inferior to CE in fungal (60% vs. 90%, p > 0.05) and Mycobacterium spp. infections (66.7% vs. 100%, p > 0.05) with no significant difference. Among 31 cases diagnosed with lung abscess, the diagnostic performance of the detection rate was 67.7% (21/31) in favour of mNGS compared to 29.0% (9/31) for CE (p < 0.05). Most polymicrobial infections were induced by anaerobic species that coexisted with Streptococcus constellatus. And Klebsiella pneumoniae was the most common isolated monomicrobial infection.

Conclusions

The most commonly detected causative pathogens for local pulmonary infections were bacteria, Mycobacterium spp. and fungi. Compared with the CE, the advantages of mNGS in the pathogens detection lie in the discovery of bacterial and mixed infections, as well as in the detection of lung abscess. Conversely, mNGS is not good enough to be recommendable for the detection of Mycobacterium spp. and fungi.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01912-4.

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.

Lung abscess secondary to lung cancer with a coinfection of Granulicatellaadiacens and other bacteria: a case report

Background

Granulicatella adiacens is facultative anaerobic Gram-positive bacteria, which mainly involve bacterial endocarditis and bacteremia, but there are few reports of local suppurative infection. A case of lung abscess with a coinfection of Granulicatella adiacens and other bacteria in a lung cancer patient will be reported in this paper. To our knowledge, this is the first case report describing lung abscess due to G.adiacens.

Case presentation

A 52-year-old Chinese woman was admitted to the hospital, She complained of coughing and expectoration for 1 month, shortness of breath for half a month, and dyspnea for 1 day. After a series of examinations, she was diagnosed with lung abscess, pleural effusion, and bronchogenic carcinoma. Draining pus culture demonstrated Granulicatella adiacens. After more than 5 weeks of antibiotic therapies in total, she gradually recovered to fight against lung cancer.

Conclusion

This is the first reported lung abscess caused by G.adiacens. In immunosuppressed hosts, G.adiacens is a virulent pathogen associated with a spectrum of intrathoracic suppurative. Earlier diagnosis and proper drainage surgery with effective antibiotics treatment are very important, and antimicrobial treatment should be more than 5 weeks. When complex pulmonary infection interferes with the CT diagnosis, clinical suspicion of lung cancer should be increased if G.adiacens or Eikenella corrodens is detected from a pulmonary infection.

Pyogenic lung abscess in an infectious disease unit: a 20-year retrospective study

Background:

Pyogenic lung abscesses are rare and poorly described infections. This study aimed to describe their prognostic factors.

Methods:

We retrospectively included all patients hospitalized between 1 January 1998 and 1 June 2018, with an International Classification of Diseases, version 10 (IDC-10) diagnosis of pyogenic lung abscess, from the Diamm based medical records (Micro6, Nancy, France). Parasitic, fungal, or mycobacterial lung abscesses were excluded.

Results:

A total of 64 patients were included. Abscesses were associated with immunosuppression in 28 patients, including HIV infection and immunosuppressive therapy for eight and 12 patients, respectively. Bacterial identification was obtained for 36 patients. Nine patients (14%) developed lung abscesses after hematogenous dissemination. They differed from bronchogenic abscesses by their younger age (p = 0.03), the absence of smoking or emphysema (p = 0.05), Staphylococcus aureus (p = 0.001) or Streptococcus spp. (p = 0.05) isolation, and the smaller size of their abscess (p = 0.02). Overall, evolution was marked by radiological sequelae (46.9%), relapse (12.5%), and death (4.8%). Radiological sequelae occurred more frequently during the course of bronchogenic abscesses (p = 0.02), particularly when they spontaneously discharged (p = 0.04). Relapses were more frequent in patients with emphysema (p = 0.04) and when Haemophilus influenzae was isolated (p = 0.04). In multivariate analysis, poor outcomes, including death, sequelae, and relapse occurred more frequently in patients who had bronchogenic abscess (p = 0.02), and in those who received antibiotics during less than 6 weeks (p = 0.05).

Conclusion:

A duration of antibiotic treatment of less than 6 weeks and bronchogenic presentation were globally associated with poor outcome of pyogenic lung abscesses. These data should be considered when proposing guidelines for the care of pyogenic lung abscesses.

The reviews of this paper are available via the supplemental material section.

[Management of Lung Abscess - Diagnostics and Treatment]

Lung abscess is a localized infectious pus-filled cavity of the lung tissue by viral, bacterial, mycotic or parasitic pathogens. Currently, there are different classifications, which are based primarily on the genesis and duration of symptoms. Important steps for diagnosis are in addition to clinical examination, laboratory and chest X-ray especially bronchoscopy with microbiological examinations and computed tomography. Treatment of lung abscesses continues to be a domain of conservative antibiotic therapy. The vast majority of cases can be cured with this. Interventional procedures such as transthoracic or endobronchial abscess drainage with subsequent irrigation can effectively support the healing process. Thoracic surgery is particularly important in cases of failure of conservative and interventional therapy as well as secondary abscesses on the basis of a lung carcinoma. Mostly anatomical resections are required. Alternatively, VAC therapy (vacuum-assisted closure therapy) may be considered in seriously ill, old, immunosuppressed, and multimorbid patients with complicated abscesses (e.g. perforation in the pleural cavity and sero-pneumothorax).

Efficacy and safety of percutaneous tube drainage in lung abscess: a systematic review and meta-analysis

Objectives: Lung abscess is an infectious lung disease. The main objective of this review was to assess the efficacy and safety of percutaneous tube drainage (PTD) in patients with lung abscess by systematic review and meta-analysis of published data. Methods: We searched all literature published between 1 January 2010, and 6 August 2019, in the PubMed, Cochrane Central Library, EMBASE, Wanfang, Chinese National Knowledge Infrastructure, and Chinese Biomedical Literature databases for relevant reports. The data from these studies were pooled for statistical analysis, and sensitivity analysis and risk-of-bias analysis was performed. Results: Meta-analysis revealed that percutaneous tube drainage (PTD) was superior to conservative treatment in terms of the total effectivity rate (P < 0.01). Moreover, length of hospital stay and number of fever days were reduced for the PTD group than for the group receiving conservative treatment (P < 0.01). There was no significant difference between PTD and conservative treatment in terms of complication rate (P = 0.43). Conclusion: Lung abscess drainage is a safe and effective method for treating lung abscesses. Based on the principle that as much drainage as possible should be performed as treatment of abscess diseases, drainage should be promoted as treatment for lung abscess.

Fluid-filled Cystic Lesions of the Lungs

A pulmonary cyst usually refers to an air-filled space with a smooth, thin wall. Fluid-filled cystic lesions of the lungs include a range of etiologies such as true cysts, congenital malformations, infections, and benign and malignant neoplasms. With relatively little solid component, these lesions often have similar imaging appearances to one another. This article focuses on key imaging features and clinical characteristics that can be used to narrow the differential diagnosis.

[Lung abscess: Diagnosis and management]

Lung abscesses are necrotic cavitary lesions of the lung parenchyma. They are usually caused by anaerobic bacteria or mixed flora and typically occur after aspiration. Primary lung abscesses occur in previously healthy patients with no underlying medical disorders and are usually solitary. Secondary lung abscesses occur in patients with underlying or predisposing conditions and may be multiple. The initial diagnosis is usually made by chest radiography showing a lung cavity with an air-fluid level. Typically, the cavity wall is thick and irregular, and a surrounding pulmonary infiltrate is often present. The differential diagnosis of pulmonary cavitation is wide, including different types of possible infections, neoplasia and malformations of the bronchial tree. Management is usually based on prolonged antibiotic treatment. Failure of conservative management, manifested by the persistence of sepsis and/or other abscess complications, may necessitate drainage with invasive techniques (percutaneous, endoscopic or surgical) or open surgical removal of the lung lesion in patients with good performance status and sufficient respiratory reserve.

Unusual case of a giant lung abscess initially misdiagnosed and treated as an empyema

We report the case of a 66-year-old man with dental infection who presented to our emergency department complaining of a 3-month medical history of chest pain and productive cough, in association with malaise, fever, weight loss and anaemia. His chest radiograph showed a nearly total opacification of the right hemithorax and chest ultrasound findings were suggestive of empyema, subsequently confirmed by a chest CT. The patient started appropriate treatment. A follow-up chest CT performed to rule out bronchopleural fistula revealed a large lung abscess. The patient had the final diagnosis of a giant lung abscess, which was initially thought to be an empyema because of the clinical and radiologic similarities with this entity. The initial misdiagnosis led to prompt percutaneous drainage of the lung abscess in addition to antibiotherapy and respiratory physiotherapy with a good final outcome, which suggests the efficacy of this approach in similar cases.

Post-resection complications: abscesses, empyemas, bronchopleural fistulas

The role of thoracic surgeons in the management of pulmonary infection has evolved over time as the medical treatments have improved. We herein review historical and current management for surgically-treated pulmonary infections-lung abscesses, empyemas, and bronchopleural fistulas. In particular, we review when the surgeons need to be involved for infectious cases, our algorithm/approach to empyemas, and summary of post-operative bronchopleural fistula in tuberculosis cases.

Lung abscess caused by Streptococcus pneumoniae serotype 6B

Lung abscess has been considered to be a rare complication of pneumococcal infection, and most cases are reported to be Streptococcus pneumoniae serotype 3. A 67-year-old man presented with fever and was diagnosed to have lung abscess caused by S. pneumoniae serotype 6B. The minimal inhibitory concentration (MIC) of penicillin for the isolate was 1 μg/mL. He was treated with high-dose intravenous sulbactam/ampicillin as definitive therapy based on susceptibility testing for S. pneumoniae and recovered successfully without surgical intervention. S. pneumoniae serotype 6B can cause lung abscess.

Streptococcus Gordonii Empyema: A Case Report and Review of Empyema

Streptococcus gordonii (S. gordonii) is a pioneer oral bacteria that is recognized as an agent of bacterial endocarditis. However, an extensive review of the literature revealed no reported case of S. gordonii causing empyema. We present a case of a 65-year-old male who presented with respiratory distress. Physical examination revealed several dental caries with decreased breath sounds in the bibasilar regions. A computed tomography (CT) scan of the chest and abdomen demonstrated left-sided pleural effusion and a 4.3 cm x 2.8 cm splenic abscess. He received intravenous (IV) antibiotics, and his blood cultures remained negative. Drainage of the splenic abscess grew S. gordonii. A CT-guided thoracentesis yielded 450 ml of exudative fluid. Pleural fluid cultures grew S. gordonii. A CT scan of the head and neck ruled out an intra-oral abscess. He received six weeks of IV penicillin with a follow-up CT scan showing resolution of both the splenic abscess and the left parapneumonic effusion.

The Clinical Courses of Patients with Congenital Cystic Adenomatoid Malformation Complicated by Pneumonia

PURPOSE

We evaluated the clinical characteristics and courses of patients with congenital cystic adenomatoid malformation (CCAM) complicated by pneumonia.

MATERIALS AND METHODS

We retrospectively reviewed the records of 19 adult patients with surgically confirmed CCAM between March 2005 and July 2013.

RESULTS

Eighteen of nineteen patients presented with acute pneumonia symptoms and signs, and inflammatory markers were elevated. On chest computed tomography, all 18 patients had parenchymal infiltration around cystic lesions, 17 (94%) had an air-fluid level, and 2 (11%) had pleural effusion. After antibiotics treatment for a median of 22 days prior to surgery, all acute pneumonia symptoms and signs disappeared in 17 (94%) patients at a median of 10 days. Improvements and normalization of inflammatory marker levels, occurred in 17 (94%) and 9 (50%) patients at medians of 8 and 17 days, respectively. Radiological improvement was evident in 11 (61%) patients, at a median of 18 days, of these patients, partial radiological improvement occurred in 10 (56%) and complete radiological resolution in only 1 (6%). One patient (6%) did not improve in terms of clinical, laboratory, or radiological findings despite antibiotic treatment for 13 days. Consequently, after 17 (94%) elective and 1 (6%) emergency surgeries, all patients improved without development of complications.

CONCLUSION

We described the clinical characteristics and courses of patients with CCAM complicated by pneumonia, and showed that surgery may be performed safely after clinicolaboratory improvement is attained upon antibiotic treatment, even in the absence of complete radiological resolution.

Clinical evaluation of the need for carbapenems to treat community-acquired and healthcare-associated pneumonia

Carbapenems have an overall broad antibacterial spectrum and should be protected against from the acquisition of drug resistance. The clinical advantages of carbapenem in cases of pneumonia have not been certified and the need for antipseudomonal antimicrobial agents to treat healthcare-associated pneumonia (HCAP) remains controversial. We introduced an antimicrobial stewardship program for carbapenem and tazobactam/piperacillin use and investigated the effects of this program on the clinical outcomes of 591 pneumonia cases that did not require intensive care unit management, mechanical ventilation or treatment with vasopressor agents [221 patients with community-acquired pneumonia (CAP) and 370 patients with HCAP]. Compared with the pre-intervention period, age, comorbidities and the severity and etiology of pneumonia did not differ during the intervention period. Carbapenems were rarely used during the intervention period in cases of pneumonia (CAP: 12% vs. 1%, HCAP: 13% vs. 1%), while antipseudomonal beta-lactam use was reduced from 33% to 8% among cases with HCAP. This reduction in the rate of carbapenem administration did not have an impact on the prognosis in the cases of CAP, and the in-hospital mortality was lower among the patients with HCAP during the intervention period (15% vs. 5%, p = 0.013). The causes of death in the cases of HCAP were not directly related to pneumonia during the intervention period. The current study shows that carbapenem use can be avoided in cases of CAP or HCAP that are not in a critical condition. The frequent use of antipseudomonal beta-lactams does not improve the clinical outcomes of HCAP.

Lung abscess: update on microbiology and management

A lung abscess is a circumscribed collection of pus in the lung as a result of a microbial infection, which leads to cavity formation and often a radiographic finding of an air fluid level. Patients with lung abscesses commonly present to their primary care physician or to the emergency department with "nonresolving pneumonia." Although, the incidence of lung abscess has declined since the introduction of antibiotic treatment, it still carries a mortality of up to 10%-20%. This article discusses in detail the up-to-date microbiology and the management of lung abscesses.

Lung abscess combined with chronic osteomyelitis of the mandible successfully treated with video-assisted thoracoscopic surgery

With the progress of antibiotic therapy, the mortality of lung abscess has been improved, and surgical intervention has declined. However, surgery is still required in selected cases that are intractable to antibiotic treatment. Video-assisted thoracoscopic surgery (VATS) is beneficial for treatment and/or diagnosis of pulmonary disease as it provides a less invasive surgical technique and reduces prolongation of post-operative recovery. However, the indication of VATS lobectomy for lung abscess is controversial as a result of particular complications, i.e. wet lung, intrapleural adhesion and ease of bleeding. We herein report a rare combination of lung abscess and osteomyelitis of mandible resulting from the same pathogen successfully treated with VATS lobectomy. We propose VATS lobectomy for lung abscess. This procedure might be the best treatment candidate for selected cases of lung abscess.

An update on the drainage of pyogenic lung abscesses

Most lung abscesses (80-90%) are now successfully treated with antibiotics; however, this conservative approach may occasionally fail. When medical treatment fails, pulmonary resection is usually advised. Alternatively, percutaneous transthoracic tube drainage or endoscopic drainage can be considered, though both remain controversial. In this communication, the medical literature focusing on percutaneous tube drainage efficacy, indications, techniques, complications, and mortality, as well as available data regarding endoscopic drainage are reviewed.

[Lung abscess and necrotizing pneumonia: chest tube insertion or surgery?]

Lung abscesses and necrotizing pneumonia are rare complications of community-acquired pneumonia since the advent of antibiotics. Their management leans first of all on the antibiotic treatment adapted on the informed germs. However, in 11 to 20% of the cases of lung abscesses, this treatment is insufficient, and drainage, either endoscopic or percutaneous, must be envisaged. In first intention, we shall go to less invasive techniques: endoscopic or percutaneous radio-controlled. In case of failure of these techniques, a percutaneous surgical drainage by minithoracotomy will be performed. In the necrotizing pneumonia, because of the joint obstruction of the bronchus and blood vessels corresponding to a lung segment, the systemic antibiotic treatment will be poor effective. In case of failure of this one we shall propose, a percutaneous surgical drainage, especially if the necrosis limits itself to a single lobe. The surgical treatment will be reserved: in the failures of the strategy of surgical drainage, in the necroses extending in several lobes.

Segurança e efetividade da fisioterapia respiratória em abscesso pulmonar: estudo de casos

O abscesso pulmonar é uma lesão necrótica geralmente devida a germes piogênicos. A fisioterapia respiratória (FR) é indicada, porém há poucos relatos na literatura, não havendo consenso quanto ao uso e às técnicas de FR para esse caso. O objetivo deste estudo de dois casos foi verificar a segurança e efetividade da FR no tratamento do abcesso pulmonar. O caso 1 foi um paciente de 30 anos, internado; a terapia consistiu em posicioná-lo em Trendelenburg semi-lateral direito para ventral por 30 minutos, três vezes ao dia, com saída de grande quantidade de secreção. Após 5 dias, o radiograma de tórax demonstrou redução de 90% do nível hidroaéreo, verificando-se o esvaziamento completo do abscesso após 14 dias de internação. O caso 2 foi uma paciente de 28 anos igualmente com diagnóstico de abscesso pulmonar, também tratada com drenagem postural, nos mesmos posicionamento e freqüência que o caso 1, sendo drenada grande quantidade de secreção amarelada e fluida. Após 7 dias de tratamento evidenciou-se redução importante do nível líquido do abscesso pulmonar. Conclui-se que a drenagem postural isoladamente é uma técnica de fisioterapia efetiva e segura no tratamento do abcesso pulmonar.

[Prognostic lung abscess factors]

BACKGROUND

Lung abscess, although curable when caught early and treated appropriately, still may recur repeatedly or require surgery. We retrospectively assessed prognostic lung abscess factors and predictive recurrence factors. We evaluated comorbidity using the Charson comorbidity index (CCI).

METHODS

Subjects numbered 44 hospitalized for lung abscesses between June 2004 and May 2009 and classified as; elderly (over 65 years) or non-elderly and cured treatment failed.

RESULTS

Mean age and the CCI of failed treatment were statistically higher than in cures at 80.8 years and 3.25 vs 64.1 years and 1.25 (p < 0.05). Abscess location, smoking habits, symptoms, white blood cell count and C-reactive protein did not differ on day 1. The causative organism, fistula presence at 65.6% vs 45.5% (p = 0.30) and lesion size at 59.8 mm vs 71.6 mm (p = 0.14) did not differ between groups, but the degree of lesion size reduction in treatment failures was lower than cures at 24.9% vs 69.1% (p < 0.05).

CONCLUSIONS

Lung abscess prognosis is thus adversely affected by age and comorbidity. In Japan, subjects having multiple comorbidities are expected to increase with aging. The degree of lesion size reduction appears to be a predictive factor in recurrence, underscoring the importance of follow-up in imaging, including chest computed tomography.

Lung abscess in adults with tetralogy of fallot and pulmonary atresia

We describe 5 adults with tetralogy of Fallot and pulmonary atresia who developed lung abscesses, including some infected with atypical microbial pathogens, with important morbidity. We hypothesize that patients with such anatomy are at risk for chronic pulmonary infection due to hypo-perfusion of the pulmonary parenchyma. This previously unreported clinical association should be considered in the differential diagnosis of patients with tetralogy of Fallot and pulmonary atresia who alter their respiratory state.

[Pulmonary abcess, a revision]

Lung abscesses are cavitating lesions containing necrotic debris caused by microbial infection. Patients with chronic lung disease, bronchial obstruction secondary to cancer, a history of aspiration or risk of aspiration caused by alcoholism, altered mental status, structural or physiologic alterations of the pharynx and esophagus, neuromuscular disorders, anesthesia, are among others at higher risk of developing lung abcess. The main bacteriological characteristics, the diagnosis, therapy and prognosis are considered. The problem of antimicrobial resistance is also referred.

Sudden death due to aortic rupture in acromegaly

Acromegaly, when left untreated, is associated with premature mortality which is chiefly related to cardiovascular complications. We report on a 50-year-old acromegalic woman, resistant to therapy, who died suddenly because of thoracic aortic rupture and massive bleeding into the left pleural space. The postmortem examination disclosed, nearby the point of rupture, a pulmonary abscess as well as extensive intrinsic alteration of arteries originating from the aortic arch and aorta itself, which featured microscopic cystic medial necrosis. We discussed how these aspects could be related to long-term exposition to growth hormone excess. In particular, this case gives further evidence of vascular system frailty in acromegaly.

Pneumonotomy: an alternative way for managing lung abscess

BACKGROUND

Surgical resection (SR) is the most effective strategy in the management of patient with lung abscess who have failed medical treatment. Surgical drainage (SD) of lung abscess is an alternative in high-risk patients. There are limited findings in comparing the two procedures. The aim of this study was to compare surgical outcomes in patients who underwent SR versus SD.

METHODS

We retrospectively reviewed 61 patients receiving surgical intervention for lung abscess in our hospital from 1994 to 2002. The patients were divided into two groups according to different surgical procedure. They are patients who received SR (lobectomy, pneumonectomy or wedge resection) and patients who underwent SD (pneumonotomy) of lung abscess.

RESULT

There were 33 patients enrolled in SD and 28 patients in the SR for lung abscess. There was no significant difference between the two groups in number of risk factors or size or location of abscess. The operation time and blood loss seemed to be less in SD, although they did not reach statistic difference. Postoperative major complications were more frequent for SD than for SR (36.3 vs 32.1%, P = 0.038). The mortality rate and total complication rate were similar.

CONCLUSION

When surgery is indicated for lung abscess, SR is the preferred procedure. Whenever there are great difficulties during SR or patients are unable to tolerate major pulmonary resection, SD can be an alternative choice. The techniques were relatively easy and effective. The surgical outcomes in short term was favourable and can be comparable to that of standard SR.

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.

Clinical presentation and management of empyema, lung abscess and pleural effusion

PURPOSE OF REVIEW

Pleural effusions, lung abscess and empyema remain a commonly encountered clinical problem and a significant source of morbidity. The aim of this review is to summarize recent developments with emphasis on controlled trials.

RECENT FINDINGS

There is wide variation in the management of infectious pleural effusions, partly because of the relative lack of randomized controlled trials. The recent MRC/BTS UK controlled trial of interapleural streptokinase for pleural infection assessed the efficacy of intrapleural streptokinase compared with placebo in complicated parapneumonic effusions. The study showed no difference in the primary end point, mortality, or in the need for surgery or length of the hospital stay among patients with pleural infection. The first large report published for over a decade has suggested that the bacteriological characteristics of lung abscess have changed.

SUMMARY

The major recent development in the management of pleural infections is the finding that we should dampen the ardor for the routine use of fibrinolytic agents in all patients with pleural infections. We strongly recommend the necessity for additional, well-designed trials to help determine optimal care for these seriously ill patients.

Changing bacteriology of adult community-acquired lung abscess in Taiwan: Klebsiella pneumoniae versus anaerobes

BACKGROUND

Most literature regarding lung abscess focuses on anaerobic bacterial lung abscess, and aerobic gram-negative bacillary infection is less frequently discussed. This study was conducted to investigate the bacteriology of community-acquired lung abscess and to improve the empirical therapeutic strategy for adults with community-acquired lung abscess.

METHODS

We reviewed and analyzed data on 90 consecutive adult cases of bacteriologically confirmed community-acquired lung abscess treated during 1995-2003 at a tertiary university hospital in Taiwan.

RESULTS

We found that a high proportion (21%) of cases of lung abscess were due to Klebsiella pneumoniae infection, which differs from the findings of previous studies. Lung abscess due to K. pneumoniae was associated with underlying diabetes mellitus (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.0-18.4; P = .039) and negatively correlated with a time from onset of symptoms to diagnosis of >30 days (OR, 0.2; 95% CI, 0.1-0.7; P = .008). A higher percentage of patients with K. pneumoniae lung abscess had concomitant bacteremia (OR, 9.4; 95% CI, 1.1-81.9; P = .032), delayed defervesence (OR, 9.2; 95% CI, 1.8-47.8; P = .004), and multiple cavities noted on radiographs (OR, 11.0; 95% CI, 1.3-94.9; P = .015), compared with patients with anaerobic bacterial lung abscess. The rate of nonsusceptibility to clindamycin and penicillin among anaerobes and Streptococcus milleri group isolates increased.

CONCLUSION

K. pneumoniae has become a more common cause of lung abscess than before, and a high proportion of anaerobes and S. milleri strains have become resistant to penicillin and clindamycin. A beta-lactam/beta-lactamase inhibitor or second- or third-generation cephalosporin with clindamycin or metronidazole is suggested as empirical antibiotic therapy for community-acquired lung abscess.

Ampicillin + sulbactam vs. clindamycin ± cephalosporin for the treatment of aspiration pneumonia and primary lung abscess

Aspiration pneumonia, necrotising pneumonia and primary lung abscess are complications arising from the aspiration of infectious material from the oral cavity or stomach. There is limited information on optimal antibacterial therapeutic regimens. Patients with pulmonary infection following aspiration (n = 95) were included in a prospective, open, randomised, comparative multicentre trial to compare the safety, clinical and bacteriological efficacy of ampicillin + sulbactam vs. clindamycin +/- cephalosporin. Treated patients (n = 70) received sequential antibiotic therapy with either ampicillin + sulbactam (n = 37) or clindamycin (n = 33), with or without a second- or third-generation cephalosporin, administered until the complete resolution of clinical and radiological abnormalities. Definite or presumptive pathogens were isolated from 58 patients. Mean duration of therapy was 22.7 days for ampicillin + sulbactam and 24.1 days for clindamycin. In patients treated with ampicillin + sulbactam, the clinical response was 73.0% at the end of therapy and 67.5% 7-14 days after therapy. For clindamycin, the rates were 66.7% and 63.5%, respectively. Bacteriological response was similar in both treatment arms. Nine patients died (12.9%), with a Simplified Acute Physiology Score of > 30 points being the only significant predictive factor for therapeutic failure. Ampicillin + sulbactam and clindamycin +/- cephalosporin were both well-tolerated and proved equally effective in the treatment of aspiration pneumonia and lung abscess.

Chronic lung sepsis: lung abscess, bronchiectasis, and empyema

Chronic lung infections including lung abscess, bronchiectasis, and empyema remain serious medical diseases despite the availability of antimicrobial agents. Recent publications contribute to our understanding of disease pathogenesis and management of these entities. The microbial pathogen of lung abscess may be different comparing immunocompetent with immunocompromised patients, supporting a concept for aggressive diagnostic investigations and targeting of specific potential pathogens. The use of surgery in bronchiectasis may be declining, but surgical intervention remains an important strategy with favorable outcomes, especially in cases of focal bronchiectasis. For empyema, maintaining a high index of clinical suspicion may allow for diagnostic thoracentesis in patients with pleural effusions and allow initiation of appropriate tube thoracotomy drainage and use of fibrinolytics. With appropriate management, morbidity and mortality may be limited and outcomes generally favorable.

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%).

Lung abscess in adults: clinical comparison of immunocompromised to non-immunocompromised patients

Information related to the clinical characteristics and isolated microbes associated with lung abscesses comparing immunocompromised (IC) to non-immunocompromised (non-IC) patients is limited. A retrospective review for 1984-1996 identified 34 consecutive adult cases of lung abscess (representing 0.2% of all cases of pneumonia), including 10 non-IC and 24 IC patients. Comparison of age, gender, tobacco use, pre-existing pulmonary disease or recognized aspiration risk factors were not significantly different between the two groups. Upper lobe involvement accounted for the majority of cases, although multi-lobe involvement was limited to IC patients. There were no differences in the need for surgical intervention, and mortality was very low for both groups. Anaerobes were the most frequent isolates for non-IC patients (30%), whereas aerobes were the most frequent isolate for IC patients (63%). Importantly, certain organisms were exclusively isolated in the IC group and multiple isolates were obtained only from the IC patients.Thus, comparing non-IC to IC patients, clinical characteristics may be similar whereas important differences may exist in the microbiology associated with lung abscess. These findings have important implications for the clinical management of these patient groups, and support a strategy to aggressively identify microbial agents in abscess material.

Lobectomy for cavitating lung abscess with haemoptysis: strategy for protecting the contralateral lung and also the non-involved lobe of the ipsilateral lung

We describe the anaesthetic management of a patient undergoing lobectomy for cavitating lung abscess complicated by haemoptysis. Surgery for lung abscess is one of the absolute indications for the use of a double-lumen tube (DLT). Because pus or blood could impede fibreoptic-assisted DLT placement, a traditional, blind placement of the DLT was performed. To protect the uninvolved parts of the operated lung, ventilation of the lung with the abscess was not performed until the resection of the involved lobe had been completed.