Introduction

Lung abscess is defined as a circumscribed area of pus or necrotic debris in lung

parenchima, which leads to a cavity, and after formation of bronchopulmonary fistula, an
air-fluid level inside the cavity.

Lung abscess is in the group of lung infections such as lung gangrene and necrotizing
pneumonia which is characterized with multiple abscesses .

The clinical signs and therapy of lung abscess was described for the first time by
Hippocrates. In pre-antibiotic era, one third of patients with lung abscess would die, the
other third of patients would recover fully, and the rest of them would survive with sequels
such as chronic lung abscess, pleural empyema or bronchiectasis. In that time, surgery was
considered as the only effective therapy, and today most of the patients will be fully
recovered only with antibiotic therapy.

Hundred years ago, mortality from lung abscess was about 75% of patients . Open drainage
of lung abscess decreased mortality on 20-35% and with antibiotic therapy mortality drop
on about 8.7%. At the same time, progress in oral and dental hygiene declined the incidence
of lung abscesses. Today, aspiration from oral cavity is considered the major cause of lung
abscesses as well as poor oral and dental hygiene .

In pre antibiotic era, lung abscess was caused by one type of bacteria, and today almost in
all cases is caused by poly microbial flora .
Lung abscess can be divided on acute (less than 6 weeks) and chronic (more than 6 weeks).
It can be called primary as a result of aspiration of oropharyngeal secretions
(dental/periodontal infection, para nasal sinusitis, disturbance states of consciousness,
swelling disorders, gastro-oesophageal reflux disease, frequent vomiting, necrotizing
pneumonia's or in immunocompromised patients. Secondary lung abscesses occurred in
bronchial obstructions (by tumor, foreign body or enlarged lymph nodes), with coexisting
lung diseases (bronchiectasis, bullous emphysema, cystic fibrosis, infected pulmonary
infarcts, lung contusion), then spreading from extrapulmonary sites-hematogenous
(abdominal sepsis, infective endocarditis, infected canula or central venous catheter, septic
thromboembolisms) or by direct spreading (broncho-oesophageal fistula, subphrenic
abscess) ).

Based on way of spreading, lung abscess can be bronchogenic (aspiration, inhalation) and
haematogenic-dissemination from other infected sites.
Division of lung abscesses:
❖ According to the duration:
Acute (less than 6 weeks);
Chronic (more than 6 weeks);
❖ By etiology:
Primary (aspiration of oropharyngeal secretions, necrotizing pneumonia,
immunodeficiency);
Secondary (bronchial obstructions, haematogenic dissemination, direct spreading from
mediastinal infection, from subphrenium, coexisting lung diseases);
❖ Way of spreading:
Brochogenic (aspiration of oropharyngeal secretions, bronchial obstruction by tumor,
foreign body, enlarged lymph nodes, congenital malformation);
Haematogenic (abdominal sepsis, infective endocarditis, septic thromboembolisms).
Aspiration of oropharyngeal secretions:
Dental/peridental infection;
Para nasal sinusitis;
Disturbance states of consciousness;
Swelling disorders;
Gastro-oesophageal reflux disease;
Frequent vomiting;
Intubated patients;
Patients with tracheostomy;
Nervous recurrent paralysis;
Alcoholism.
Haematogenic dissemination:
Abdominal sepsis;
Infective endocarditis;
Intravenous drug abuse;
Infected cannula or central venous catheter;
Septic thromboembolisms.
Coexisting lung diseases:
Bronchiectasis;
Cystic fibrosis;
Bullous emphysema;
Bronchial obstruction by tumor, foreign body or enlarged lymph nodes;
Congenital malformations (pulmonary sequestration, vasculitis, cystitis);
Infected pulmonary infarcts;
Pulmonary contusion;
Broncho-oesophageal fistula.
Acute lung abscess is usually circumscribed with not so well-defined surrounding to lung
parenchyma, fulfilled with thick necrotic detritus. Histologically, in central parts of abscess
there are necrotic tissue mixed with necrotic granulocytes and bacteria. Around this area
there are preserved neutrophillic granulocytes with dilated blood vessels and inflammatory
oedema .

Pathology findings with neutrophillic granulocytes with dilated blood vessels and
inflammatory oedema. (HE, ×100).
Chronic lung abscess is usually irregular star-like shape with well-defined surrounding to
lung parenchyma, fulfilled with grayish line or thick detritus (Figure 3). In the centre of
abscess is located pus wit or without bacteria. Around abscess is located pyogenic
membrane through which white blood cells are migrating to abscess cavitation. Around
pyogenic membrane lymphocytes, plasma cells and histiocytes are placed in connective
tissue.

Around pyogenic membrane lymphocytes, plasma cells and histiocytes are placed in
connective tissue. (HE, ×100).
Contributing factors for lung abscess are: elderly, dental/peridental infections (gingivitis-
with bacterial concentration >1011/mL), alcoholism, drug abuse, diabetes mellitus, coma,
artificial ventilation, convulsions, neuromuscular disorders with bulbar dis functions,
malnutrition, therapy with corticosteroids, cytostatics or immunosuppressants, mental
retardation, gastro-oesophageal reflux disease, bronchial obstruction, inability to cough,
sepsis.

In over 90% cases of lung abscess poly microbial bacteria can be found (10). From
anaerobic bacteria in lung abscess predominant isolates being gram-negative Bacteroides
fragilis, Fusobacterium capsulatum and necrophorum, gram-positive anaerobic
Peptostreptococcus and microearophillic streptococci. From aerobic bacteria predominant
isolates in lung abscess being Staphylococcus aureus [including methicillin resistant
staphylococcus aureus (MRSA)], Streptococcus pyogenes and pneumonia, Klebsiella
pneumonia, Pseudomonas aeruginosa, Haemophilus influenza (type B), Acinetobacter spp,
Escherichia coli, and Legionela .
Anaerobic bacteria have been for decades the most dominant type of bacteria in lung
abscess with Streptococcus spp (Streptococcus pneumonia serotype 3 i Streptococcus
anginosus complex). During the last decade the most isolated type bacteria in lung abscess,
especially in Taiwan has been Klebsiella pneumonia, so it is very important to have specific
antibiotic therapy for that type of bacteria. Staphylococcus aureus is the most common
isolated etiologic pathogen of lung abscess in children.
Etiologic pathogen for lung abscess might be, as well Mycobacterium spp, Aspergillus,
Cryptococcus, Histoplasma, Blastomyces, Coccidoides, Entamoeba histolytica, Paragominus
westermani. Actinomyces and Nocardia asteroides are known as important etiologic
pathogens of lung abscess and they require a longer duration (6 months) of antibiotic
administration.

Predictive parts of lung as common sites for lung abscess have been apical segment of lower
lobe of right and sometimes of left lung, then lateral part of posterior segment of right
upper lobe—axillary sub segment, and middle lobe in case of vomiting and aspiration in
prone position—this is typically for alcoholic persons. In 75% of all lung abscesses, they are
located in posterior segment of right upper lobe or in apical segment of lower lobe of both
lungs.

Etiological, abscesses occurred after oropharyngeal aspiration is localized in posterior

segments of the lungs, and there are no patterns for hematological dissemination of lung
abscesses.

Initially, aspiration secretion is localized in distal parts of bronchi causing localized

pneumonitis. In the next 24 to 48 hours (h) a larger area of inflammation with necrotic
debris will develop. Invasive bacterial toxins, vasculitis, venous thrombosis and proteolytic
enzymes from neutrophilic granulocytes will make a colliquative necrotic focus .

If the infective lung tissue affects visceral pleura, a pyopneumothorax or pleural empyema
will develop. In case of adequate antibiotic therapy and good immunologic status of patient,
the chronic inflammatory reaction will circumscribe the process. In case of inadequate or
delayed antibiotic therapy, poor general condition of patient, a sepsis can occur. If there is
connection with the bronchus, necrotic detritus will empty the abscesses cavity and
radiological sign of air-fluid level will occur.

In case of favorable outcome, a necrotic tissue will be eliminated by lysis and phagocytosis
and granulation tissue will make a scar tissue.

In case of adverse outcome, infection will spread around the lung tissue and pleural,
mediastinal or cutaneous fistula can occur. In chronic abscess a necrotic detritus will be
usually reabsorb and fibrosis and calcification can occur.

Signs and symptoms

Early signs and symptoms of lung abscess cannot be differentiate from pneumonia and
include fever with shivering, cough, night sweats, dispnea, weight loss and fatigue, chest
pain and sometimes anemia. At the beginning cough is non-productive, but when
communication with bronchus appears, the productive cough (vomique) is the typical sign).
Cough remains productive, sometimes followed by hemoptysis. In patients with chronic
abscess clubbing fingers can appear.
Differential diagnosis includes excavating tuberculosis and mycosis, but seldom can been
seen radiological sign of gas-liquid level. Pulmonary cystic lesions, such as intrapulmonary
located bronchial cysts, sequestration or secondary infected emphysematous bullae can be
difficult to differentiate, but localization of lesion and clinical signs can indicate the
appropriate diagnosis. Localized pleural empyema can be distinguished by using CT scan or
ultrasound .

Excavating bronchial carcinomas such as squamocellular or microcellular carcinoma are

usually presented with thicker and irregular wall comparing to infectious lung abscess .
Absence of febricity, purulent sputum and leukocytosis can indicate the carcinoma and not
the infective disease . Radiological sign of air-fluid level can be seen and in hydatid cyst of
lung.
CT scan with thicker and irregular wall comparing to infectious lung abscess.
Radiological sign of air-fluid level can be seen and in hydatid cyst of lung.

Differential diagnosis:
Excavating bronchial carcinoma (squamocellular or microcellular);
Excavating tuberculosis;
Localized pleural empyema;
Infected emphysematous bullae;
Cavitary pneumoconiosis;
Hiatus hernia;
Pulmonary hematoma;
Hydatid cyst of lung;
Cavitary infarcts of lung;
Wegener’s granulomatosis.
Diagnostic bronchoscopy is a part of diagnostic protocol for taking the material for
microbiological examination and to confirm intrabronchial cause of abscess-tumor or
foreign body. Sputum examination is useful for identification of microbiological agents or
confirmation of bronchial carcinoma.

Therapy
Standard conservative therapy for lung abscess with anaerobic bacteria is clindamycin (600
mg IV on 8 h), who showed, in several clinical trials superiority to penicillin in terms of
rates of response, duration of fever and time to resolution of putrid sputum. Some types of
Bacteroides species and Fusobacterium species can produce β-lactamase, so they are
resistant to penicillin. About 15-20% of anaerobic bacteria who are responsible for lung
abscess formation are resistant to penicillin only, so alternative is combination of penicillin
and clavulanate or combination of penicillin and metronidazole.
Metronidazole, as a single therapy does not appear to be particularly effective, due to poly
microbial flora, presumably microaerophilic streptococci, such as Streptococcus
milleri.Recommended combinations of antibiotics for lung abscess are combination of β-
lactam with inhibitors of β-lactamase (ticarcilin-clavulanate, ampicillin-sulbactam,
amoxicillin-clavulanate, piperacilin-tazobactam), chloramphenicol, imipenem or
meropenem, second generation of cephalosporins (cefoxitin, cefotetan), newer generation
of fluoroquinolones-moxifloxacin, who shoved to be as effective as combination ampicillin-
sulbactam.

Macrolide (erythromycin, clarithromycin, azithromycin) have very good therapeutic effect

on poli microbial bacteria in lung abscess, except on fusobacterium species. Vancomycin is
very effective for gram-positive anaerobic bacteria.

Aminoglycosides are not recommended in treatment of lung abscess since they poorly pass
through fibrous pyogenic membrane of chronic abscess.

It is recommended to treat lung abscess with broad spectrum antibiotics, due to poly
microbial flora, such as Clindamycin (600 mg IV on 8 h) and then 300 mg PO on 8 h or
combination ampicilin/sulbactam (1.5-3 gr IV on 6 h).

Alternative therapy is piperacilin/tazobactam 3.375 gr IV on 6 h or Meropenem 1 gr IV on 8

h.

For MRSA it is recommended to use linezolid 600 mg IV on 12 h or vancomycin 15 mg/kg

BM on 12 h .

Effective answer to antibiotics therapy can be seen after 3-4 days, general condition will
improve after 4-7 days, but completely healing, with radiographic normalization can be
seen after two months.

If there is no improvement of general condition or radiographic finding, it is necessary to

perform bronchoscopy due to some other etiological factor and change the antibiotics.

The duration of antibiotics therapy depends on the clinical and radiographic response of the
patient. Antibiotics therapy should last at least until fever, putrid sputum and abscess fluid
have resolved, usually between 5-21 days for intravenous application of antibiotics and then
per oral application, in total from 28 to 48 days (14) with periodically radiographic and
laboratory controls. Effects of antibiotic therapy on radiographic finding of lung abscess.

Effects of antibiotic therapy on radiographic finding of lung abscess.

Bronchoscopy should be the integral part of the algorithm for diagnostic and therapy of
lung abscess. General supporting measures include hyper caloric diet, correction of fluids
and electrolytes and respiratory rehabilitation with postural drainage. Drainage procedures
include percussion and positioning to increase drainage through the airways. Lung abscess
often will rupture spontaneously into the airways, which aids in clearing the infection, but
also may result in spread of the infection to other parts of the lung.

Abscess greater than 6 cm in diameter or if symptoms lasts more than 12 weeks with
appropriate therapy, have little chances for only conservative healing, and surgical therapy
should be considered, if general condition allows. Options for surgery are: chest tube
drainage or surgical resection of lung abscess with surrounding tissue.

Endoscopic drainage of lung abscesses is described as an alternative to chest tube drainage

and is performed during the bronchoscopy with usage of laser. It was recommended for the
patients with poor general condition, coagulopathies and for the abscesses with central
locations in lungs. One of the possible complication of these technique is a spillage of
necrotic detritus in other parts of the lungs.

Per cutaneous trans thoracic tube drainage is easy to do surgical procedure in local
anaesthesia, and nowadays it is recommended to perform it ultrasound or computerized
tomography (CT) scan control). The first one was described in 1938 for treatment of
tuberculosis lung cavities. It was later used routinely in the management of lung abscesses,
before the antibiotic era and became the treatment of choice (39). Per cutaneous chest tube
drainage of lung abscess is indicated in about 11-21% patients after failure of antibiotics
therapy.

Chest tube drainage, as a definitive therapy for lung abscess is present in about 84% of
patients, with complication rate of drainage about 16% and mortality about 4%.
Complications of tube drainage are spillage the necrotic detritus and infection in pleura
with formation of pyopneumothorax, empyema or bronchopleural fistula or bleeding.

Per cutaneous trans thoracic tube drainage of lung abscess is performed in local anesthesia
with or without ultrasound. tube drainage with trocar is highly effective surgical procedure,
but Seldinger technique ) is recommended due to lesser complications. Chest tube drainage
with trocar is recommended for thoracic surgeons, especially if during the procedure trocar
passes through lung tissue.

Chest tube drainage with Seldinger technique.

The usage of intra-cavitary fibrinolytic agents (streptokinase, urokinaze) is not
recommended, due to possibility of bronchopulmonary or bronchopleural fistula can occur .
Average duration for tube drainage of lung abscess is about 10-16 days, and in case of
prolong air leak, tube can be attach to Heimlich valve.

In case of pleural space obliteration, with peripheral localisation of lung abscess, it is

possible to perform pneumostomy or cavernostomy-open drainage of abscess (Monaldi
procedure) but due to its invasiveness seldom is performed .

Surgical resection of lung abscess is the therapy of choice for about 10% of patients.
Indications for surgical resection of lung abscess can be divided on acute and chronic.

Acute indications are: hemoptysis, prolonged sepsis and febricity, bronchopleural fistula,
rupture of abscess in pleural cavity with pyopneumothorax/empyema.

Chronic indications are: unsuccessfully treated lung abscess more than 6 weeks, suspicion
on cancer, cavitary larger than 6 cm, leukocytosis in spite of antibiotics.

Lobectomy is the resection of choice for large or central position of abscess. Atypical
resection or segmentectomy are satisfactory procedures, if it is possible to remove complete
abscess and if necessary surrounding lung tissue with necrotizing pneumonia.

Results of surgical treatment depend mostly of general condition and immunity of patient.
Elderly patients, malnutrition and alcoholism are poor prognostic factors. Mortality rate
after surgical resections is about 11-28% .

Minimal invasive surgical procedures, such as video assisted thoracoscopy is a method of

choice for peripheral localization of lung abscess and without pleural adhesions and
fibrothorax. Results of this surgical procedure are satisfactory, but this intervention
requires general anesthesia, double lumen endotracheal tube or single-lumen endotracheal
tube with insufflation of carbon dioxide. One of the possible complications is spillage of
necrotic detritus in pleural cavity .
Overall mortality in lung abscess treatment is about 2.0-38.2% with important role of
patient age, malnutrition, comorbidity, immunity, appropriate and timely antibiotics and
supportive therapy.