REVIEW

CURRENT
OPINION Necrotizing pneumonia: a rare complication of
pneumonia requiring special consideration
Yueh-Feng Tsai a and Yee-Huang Ku b

Purpose of review
Necrotizing pneumonia is a rare complication of bacterial lung infection. Its cause is owing to either a
virulence factor of the microorganism or a predisposing factor of the host. This disease may cause
devastating complications such as diffuse pulmonary inflammation, septic shock, and respiratory failure,
making treatment more difficult. In the recent decade, the cause of necrotizing pneumonia and the role of
surgical treatment have raised considerable attention, leading to therapeutically specific suggestions.
Recent findings
Staphylococcus aureus strains that produce Panton–Valentine leukocidin have been reported to cause
rapidly progressive necrosis of the lung tissue in young immunocompetent patients. Furthermore, recent
studies have showed the risk of disease progression is associated with underlying medical conditions.
Although antibiotics are the first choice of treatment for necrotizing pneumonia, it has been emphasized
that surgical treatment is a feasible alternative option in patients who fail to respond to antibiotics and
develop continued deterioration and complications.
Summary
The current knowledge of cause, clinical features, diagnosis, treatment, and prognosis of necrotizing
pneumonia are summarized. Antibiotics remain the mainstay of treatment. Lung resection can be
considered an alternative treatment option in patients who are unresponsive to antibiotic therapy and
develop parenchymal complications. Outcome is affected by the degree of disease progression and
comorbidities.
Keywords
bronchopulmonary fistula, lung resection, necrotizing pneumonia, pneumonia, pulmonary infection

INTRODUCTION the development of bronchopleural fistula, life-

A small number of patients with bacterial lung threatening hemoptysis, septicemia, and respiratory
infection do not follow the usual predictable course failure. Surgical treatment has been considered life-
&&

and develop a necrotic process even with optimal saving in these cases [3 ,4,5].
medical treatment. The process is usually rapidly Articles in the literature describe the predispos-
progressive and these patients tend to present with ing risk factors and surgical outcome of necrotizing
&& &&

acute respiratory distress. The affected extent may
be patchy, segmental, lobar, or even an entire lung
[1]. Necrotizing pneumonia has been characterized
by the finding of pneumonic consolidation with
multiple necrosis of the lung parenchyma. These
necrotic foci may coalesce, resulting in a lung
abscess if localized, or pulmonary gangrene if
involving an entire lobe [2].
Treatment of necrotizing pneumonia consists of
prolonged courses of antibiotics. However, massive
necrotic tissue makes it difficult for the antibiotics to
reach the infected areas, as well as leading to the
progressive destruction and persistent infection of
the pulmonary parenchyma, possibly followed by
pneumonia [1,3 ,6 ,7]. This review summarizes
the current knowledge of cause, clinical charac-
teristics, diagnosis, treatment, and prognosis of
necrotizing pneumonia. Surgical indications and
a
Department of Surgery, St. Martin De Porres Hospital, Chiayi and
b
Department of Medicine, Chi Mei Medical Center, Liouying, Tainan,
Taiwan
Correspondence to Yee-Huang Ku, Department of Medicine, Chi Mei
Hospital, Liouying, No. 201, Taikang, Liouying District, Tainan City 736,
Taiwan (R.O.C). Tel: +886 6 6226999/77604; fax: +886 6 6226999/
77610; e-mail: althrisas@gmail.com
Curr Opin Pulm Med 2012, 18:246–252
DOI:10.1097/MCP.0b013e3283521022

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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

KEY POINTS
 The most common pathogens associated with
necrotizing pneumonia are Staphylococcus aureus,
Streptococcus pneumoniae, and Klebsiella pneumoniae.
 Patients developing necrotizing pneumonia usually
have concomitant medical illness, the most common
being diabetes mellitus and alcohol abuse.
 Contrast-enhanced chest computed tomography is the
standard procedure for the diagnosis of necrotizing
pneumonia and is helpful in evaluating the
parenchymal complications.
 Pulmonary resection is a feasible treatment option in
patients who have no response to antibiotic therapy
and develop parenchymal complications such as
persistent pulmonary sepsis, bronchopleural fistula,
hemoptysis, and necrotic parenchyma that is associated
with impaired respiratory function.
 Outcome depends on the degree of disease
progression and underlying medical conditions.
techniques with particular attention to lung resec-
tion for necrotic parenchyma are highlighted in
this article.
CAUSE
Although the pathogenesis of necrotizing pneumo-
nia is not clearly defined, most studies believe that
tissue necrosis occurs as a result of inflammatory
response due to the toxins produced by the invasive
pathogen or the associated vasculitis and venous
&&
thrombosis [6 ,8–11]. The most common patho-
gens are Staphylococcus aureus, Streptococcus pneumo-
&& &&
niae, and Klebsiella pneumoniae [1,3 ,6 ,7,12,13].
S. aureus is responsible for about 2% of cases
of community-acquired pneumonia [9]. S. aureus
strains, often methicillin-resistant, that produce
cytotoxin Panton–Valentine leukocidin (PVL) are
associated with causing progressive and hemorrha-
gic necrotizing pneumonia especially in young
&&
immunocompetent patients [9,11,14 ]. Although
most studies reported that PVL served as the
mediator of tissue necrosis [9,11], other studies
also suggested that a-hemolysin and possibly other
cytotoxins are responsible for the pathogenesis of
pulmonary disease [15].
Streptococci are considered important patho-
gens too. S. pneumoniae is the most common cause
of bacterial pneumonia in children and an increase
in necrotizing pneumonia has been observed since
1990 [8,13,16,17]. Nonvaccine S. pneumoniae
serotype 3 has become a significant contributor
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Necrotizing pneumonia Tsai and Ku
following the introduction of the 7-valent pneumo-
coccal conjugate vaccine (PCV-7) in 2000 [8,16–19].
It has been hypothesized that S. pneumoniae serotype
3 leading to necrosis is probably related to the
inflammatory response to the capsular polysacchar-
ides and its ability to resist phagocytosis [8]. In
addition, other nonvaccine S. pneumoniae serotypes
have also been reported in the post-PCV-7 era, such
as 1, 14, 15, 19A, and 33 [8,19]. Other streptococci
that have been reported include b-hemolytic strep-
tococci such as group A streptococci and Streptococ-
cus viridans. Group A streptococci are notorious for
invasive infection and childhood pneumonia, and
are well known to be preceded by a varicella infec-
tion [20,21]. It has been suggested that M protein, a
virulence factor associated with tissue necrosis, con-
tributes to intravascular thrombosis and rapid tissue
destruction [10]. S. viridans are frequently isolated in
patients with underlying immune suppression and
comorbidities such as corticosteroid therapy and
alcoholism [3 ].
&&
K. pneumoniae has long been documented as the
principal cause of pneumonia. Patients in extreme
age groups and with compromised immune status
such as in diabetes mellitus and alcoholism are
susceptible infection. Recent studies report that var-
ious virulence factors, including hypermucoviscos-
ity, K1/K2 capsular serotype, and other virulence-
associated genes, contribute to the pathogenesis of
K. pneumoniae infection [22,23,24 ].
&
Other identified organisms were Staphylococcus
epidermidis, Escherichia coli, Acinetobacter baumannii,
Haemophilus influenzae and Pseudomonas aeruginosa
&&
[1,3 ,25]. P. aeruginosa pneumonia is not common
in healthy persons but usually presents with a ful-
minant and lethal course [25]. It is well recognized
to invade blood vessels and cause a thrombotic
endarteritis, therefore leading to tissue necrosis
[7]. Rarely, anaerobes such as Clostridia species
and Bacteroides species are reported. They are
thought to play a synergistic role in causing necrot-
izing pneumonia, which is usually a delayed process
[26].
CLINICAL FEATURES
Necrotizing pneumonia tends to occur in adult
males with concomitant medical illness such as
diabetes mellitus, alcohol abuse, and corticosteroid
&& &&
therapy [3 ,14 ]. In contrast, the pediatric patients
are predominantly composed of healthy female
&&
children [6 ,13,19,20]. Common presenting symp-
toms include fever, cough, chest pain, and shortness
&& &&
of breath [4,6 ,14 ]. These patients may have
purulent sputum and sometimes present with
confusion [27,28]. Duration of symptoms prior to
www.co-pulmonarymedicine.com 247
 Infectious diseases

hospitalization is extremely variable, ranging from

several days to 1 week [4,20,27].
Necrotizing pneumonia may associate with high
inflammatory markers such as high levels of white
blood cells, erythrocyte sedimentation rate, and
C-reactive protein. In addition, signs of complicated
clinical prognosis, including longer duration of
symptoms, higher ratio and longer duration of
hospitalization, increased number of febrile days,
longer normalization period of C-reactive protein
levels, and higher cost of treatment are reported [29].
The necrotic process can occur at any lobe of
the lung but involvement of the right lower,
right middle, and left lower lobes is more fre-
&&
quent [1,3 ,13,29]. A parapneumonic effusion or
empyema is a common complication of necrotizing
&&
pneumonia [1,3 ]. The patient’s condition can be
further complicated by the development of high-
output bronchopleural fistula, massive hemoptysis,
&&
and bilateral diffuse pneumonia [1,3 ,12,29]. Septic
shock and respiratory failure may subsequently
occur, leading to the necessity for vasopressor
&&
therapy and ventilator support [3 ,4,20].

FIGURE 1. Consolidation and collapse in the right lung with

DIAGNOSIS
Confirming the etiologic pathogens responsible for
severe, rapidly progressive pneumonia is important
to direct antibiotic treatment. However, a positive
microbiology result is not always obtainable.
Sputum Gram’s stain can be quickly obtained but
usually shows large concentrations of Gram-positive
and Gram-negative bacteria [7]. The result of spu-
tum culture is also not reliable owing to contami-
nation from normal oropharyngeal flora. Cultures
of peripheral blood (if bacteremia is suspected),
pleural fluid (when pleural effusion coexists), and
infected lung tissue (obtained at the time of surgery)
give the most reliable results to establish a bacter-
iologic diagnosis of necrotizing pneumonia. The
overall positive percentage variably ranges between
&& &&
40 and 100% [1,3 ,6 ,12,13].
The diagnosis of necrotizing pneumonia is made
generally according to chest imaging studies, includ-
ing a series of radiography and contrast-enhanced
&&
computed tomography (CT) [3 ,13,19]. Early in the
disease course, necrotizing pneumonia typically
appears as consolidation on the chest radiograph.
Repeated radiographic evaluation every 3–4 days is
advocated to determine the effects of antibiotic
therapy and detect the occurrence of complications
&&
[3 ]. As the disease is associated with empyema or
bronchopleural fistula, a pleural effusion (Fig. 1) or
pneumothorax (Fig. 2) can be seen. However, it is
common for chest radiography to underestimate the
degree of parenchymal destruction [1,30].
a large loculated effusion. This is a 46-year-old-man with
diabetes mellitus and alcoholism. Mild left pulmonary
infiltrates are noted.
Contrast-enhanced chest CT is the standard
procedure in making the diagnosis of necrotizing
pneumonia and is helpful in evaluating the paren-
chymal complications that are not appreciated on
chest films. Any delay in confirming the diagnosis is
probably due to the delay in performing the chest
CT [29]. When chest radiography shows progressive
pneumonia, the occurrence of a pleural effusion or
hydropneumothorax, or when patients develop
hemoptysis, respiratory distress or septic shock
despite appropriate medical treatment, chest CT
&&
scan should be performed promptly [3 ,13]. Pneu-
monic consolidation with multiple areas of necrotic
low attenuation on CT is suggestive of necrotizing
&&
pneumonia (Fig. 3) [1,3 ,29].
Proximal endobronchial obstructing lesions,
which present with fever, cough, and pulmonary
consolidation, may mimic the clinical and radio-
graphic features of necrotizing pneumonia. These
lesions include a foreign body and endobronchial
malignancy. CT can help identify most endobron-
chial foreign bodies. Complete consolidation of a
lobe, however, may possibly mask the presence of an
underlying carcinoma. Bronchoscopy is useful to
differentiate necrotizing pneumonia from proximal
endobronchial obstruction.

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FIGURE 2. Extensive consolidation and collapse with a
pneumothorax in a 78-year-old-woman with corticosteroid
therapy. 700 ml of pus was drained and there was persistent
air leak.
FIGURE 3. Contrast-enhanced chest CT reveals pneumonic
consolidation with multiple areas of necrotic low attenuation
involving the whole left lower lobe. This is a 56-year-old-man
with diabetes mellitus.
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Necrotizing pneumonia Tsai and Ku
TREATMENT
Treatment of necrotizing pneumonia is primarily
medical. However, when the disease deteriorates
or complications occur in spite of optimal medical
treatment, surgical intervention should be con-
sidered an alternative treatment.
Antibiotics
Intravenous antibiotic therapy remains the main-
stay treatment of necrotizing pneumonia. The
choice of initial antibiotics should be directed at
broad coverage with commonly implicated patho-
gens (S. aureus, streptococci, K. pneumoniae, etc) [7].
Additional empirical anaerobic antibiotic should be
considered in patients with lung abscesses. Once the
causative pathogens and sensitivities are known,
antibiotics can be modified accordingly. However,
the patients’ clinical information and the local
susceptibility pattern of the possible pathogen such
as the incidence of penicillin-nonsusceptible or
ceftriaxone-nonsusceptible Streptococcus pneumoniae
and community-acquired methicillin-resistant
Staphylococcus aureus (MRSA), also determine the
choice of antibiotics.
Empiric penicillins or ceftriaxone (if penicillin-
nonsusceptible S. pneumoniae was considered) or
glycopeptide (if ceftriaxone-nonsusceptible S. pneu-
moiae was considered) are recommended. Clinda-
mycin or metronidazole can be used in combination
to cover possibly involved anaerobes. Respiratory
quinolones, such as levofloxacin or moxifloxacin
(which can also cover anaerobic infection), are an
alternative choice especially for those patients aller-
gic to penicillins or cephalosporins. Glycopeptide or
linezolid is recommended in treating community-
&&
acquired MRSA infection [14 ]. Linezolid and clin-
damycin have been reported to have better result
in treating staphylococcal necrotizing pneumonia
&&
as a result of inhibiting PVL production [14 ].
In hospital-acquired infection, antipseudomonas
b-lactams or/and quinolones, or both, are recom-
mended if pseudomonas is considered, and even
carbepenem if a multidrug resistant organism is
considered. If the culture results are negative, the
adjustment of antibiotics may depend on the treat-
ment response of clinical parameters (e.g. symptoms
and signs, inflammatory markers, chest radio-
graphs).
Chest tube drainage
Chest tube drainage may be undertaken for symp-
tomatic relief in necrotizing pneumonia with large
pleural fluid collections or pyopneumothorax. It
may be technically difficult to insert the chest tube
www.co-pulmonarymedicine.com 249
 Infectious diseases
into the pleural space because an inflammatory
pleural adhesion commonly occurs. Even if success-
ful, the result of drainage is unsatisfactory, as pleural
fluid frequently becomes loculated. Furthermore,
a retrospective study in children showed pleural
drainage increased the incidence of ongoing air leak
through a bronchopleural fistula [31].
Surgery
Surgical debridement or resection may be con-
sidered for patients who fail to improve with
medical management. However, the optimal indica-
tions and timing of surgery are unclear. It is recom-
mended that a surgical approach should be
considered if patients develop continued deteriora-
tion or have complications despite the use of anti-
biotic therapy and less invasive procedures.
Accordingly, the primary indications include per-
sistent fever and leukocytosis, occurrence of
empyema, bronchopleural fistula and hemoptysis,
and necrotic parenchyma that is responsible for
&& &&
impaired respiratory function [1,3 ,6 ,7,12].
Furthermore, for patients with respiratory failure
and septic shock who are stabilized after medical
treatment, surgical intervention can be an option if
&&
parenchymal complications occur [1,3 ,7]. On the
contrary, a higher risk of postoperative death and
ventilator dependency is observed in patients with
bilateral diffuse disease and preexisting organ failure
such as liver cirrhosis, renal failure, and chronic
&&
obstructive pulmonary disease [1,3 ,7]. Extensive
lung resection should be avoided in such cases.
The operation can be performed with single-
lung anesthesia using a double-lumen endobron-
chial tube to facilitate exposure. To prevent the
spread of secretions to the contralateral lung, the
airway must be frequently suctioned during surgical
manipulation. Patients may not tolerate one-lung
ventilation, which increases the surgical difficulty.
Alternative use of one-lung and two-lung venti-
lation is a way to maintain adequate saturation of
&&
oxygen during the whole course of surgery [3 ].
The type of surgical resection is based on the
extent of the pulmonary necrosis and is always as
conservative as possible. If the necrotic parenchyma
is confined to the periphery, it can be treated by
debridement, wedge resection, or segmentectomy.
When the affected parenchyma is too extensive to
completely remove the infected tissue using partial
resection of a lobe, lobectomy is indicated
&& &&
[1,3 ,6 ]. The necrotizing process can possibly
involve multiple lobes. A significantly more invasive
procedure such as bilobectomy and pneumonec-
tomy may be required. Literature demonstrates that
patients with unilateral involvement can well
250 www.co-pulmonarymedicine.com
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tolerate pneumonectomy [1,4,7]. In addition, a con-
siderable number of patients have pleural collec-
tions at the time of surgery. Thus, decortication
should also be undertaken to facilitate expansion
of the remaining lung.
Necrotizing pneumonia often leaves the inter-
lobar fissure densely fused and the involved paren-
chyma tends to become heavy and firm, making
pulmonary resection very difficult. Recent studies
recommend the key technique is to ligate and sever
the pulmonary veins first. This procedure permits
&&
the lung to be retracted more easily [1,3 ]. When a
densely fused fissure is encountered, direct dissec-
tion of the pulmonary artery in the fissure is risky
and not suggested. Alternatively, the fissure can be
divided between clamps in small steps from both
ends but sparing the central area within which the
pulmonary arteries lay. The central fused paren-
chyma is further divided vertically by electrocautery
without injuring the artery until a TA 60 stapler
(4.8 mm, green cartridge) can be applied. The
remaining tissues between the involved and healthy
lobes are temporarily clamped with the stapling
device in atelectasis. The healthy lung is inflated
to confirm that the proposed line of transection is
correct. Then the staples are advanced, and the
involved lobe is resected. The resection margin of
the left lung is reinforced with continuous mono-
&&
filament absorbable sutures [3 ]. Several authors
advocated covering the bronchial stump with tissue
flaps to reduce the risk of stump leak, particularly
after pneumonectomy [1,7,12]. However, a recent
investigation with 26 patients undergoing pulmon-
ary resection for necrotizing pneumonia showed
lobectomies and bilobectomies can be safely per-
&&
formed without the use of a flap [3 ].
The main postoperative complications include
persistent air leak, empyema, and ventilator
dependency. A recent publication with 20 children
reported that postoperative persistent air leak
occurred in 20% of patients, all of whom received
&&
segmentectomy [6 ]. Prolonged chest tube drainage
is required in these cases and the chest tube ulti-
mately can be safely removed as a result of post-
operative pleural symphysis. A residual space after
lobectomy or pneumonectomy may increase the
risk of postoperative empyema. A pleural irrigation
system or obliteration of the space with a muscle
flap seems to reduce the incidence of postoperative
pleural infection [1,7]. Once this complication
occurs, it is usually localized and can be managed
&&
by percutaneous drainage [3 ,12]. Patients with
bilateral diffuse disease tend to become ventilator
dependent following lung resection [1]. Debride-
ment of necrotic parenchyma is an alternative
approach [7].
Volume 18  Number 3  May 2012

PROGNOSIS
The mortality of necrotizing pneumonia is difficult
to assess because of its rarity, but is likely to be high.
There are also not enough data to compare the
results of surgical resection with medical therapy
alone because it is not possible to select those
patients with a poor prognosis who may benefit
from earlier surgical treatment. The survival rate
of lung resection for necrotizing pneumonia refrac-
tory to medical therapy ranges between 80 and 95%
&& &&
[1,3 ,6 ,7,29]. Bilateral diffuse disease and preex-
isting organ failure appear to be important predic-
&&
tors of surgical outcome [1,3 ,7]. Moreover, Li et al.
&&
[14 ] suggest that necrotizing pneumonia due to S.
aureus has a worse prognosis when flu-like symp-
toms, hemoptysis, and leukopenia are present.
CONCLUSION
Antibiotics remain the mainstay of treatment for
necrotizing pneumonia. Once patients have contin-
ued deterioration or develop associated compli-
cations despite appropriate antibiotic therapy,
contrast-enhanced CT must be performed promptly
to confirm the diagnosis of necrotizing pneumonia
and evaluate the extent of involvement. Pulmonary
resection is reserved for patients who have no
response to antibiotic therapy and develop paren-
chymal complications. Outcome is affected by the
degree of disease progression and underlying
medical conditions. Further studies to determine
the mechanism of pulmonary necrosis are needed.
In addition, because necrotizing pneumonia is rare
and because the precise indications of lung resection
remain unclear, large-scale, randomized controlled
trials are required to guide treatment and define the
requirement for pulmonary resection.
Acknowledgements
None.
Conflicts of interest
There are no conflicts of interest.
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Volume 18  Number 3  May 2012