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Definition:
Necrosis of the pulmonary tissue & formation of
cavities containing necrotic debris or fluid caused
by microbial infection.

The formation of multiple small (< 2 cm) abscesses is

occasionally referred to as necrotizing pneumonia
or lung gangrene.

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Failure to recognize & treat lung abscess is associated
with poor clinical out-come.

Lung abscess was a devastating disease in the pre-

antibiotic era, when 1/3 of the patients died,
another 1/3 recovered, & the remainder developed
debilitating illnesses [i.e. recurrent abscesses,
chronic empyema, bronchiectasis].

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In the early post-antibiotic period, sulfonamides didnt
improve the out-come of patients with lung abscess
until the penicillin's & tetracycline's were available.

Although resectional surgery was often considered a

treatment option in the past, the role of surgery has
greatly diminished over time coz most patients with
un-complicated lung abscess eventually respond to
prolonged antibiotic therapy.

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Lung abscesses can be classified based on the duration
& the likely etiology.

Acute abscesses are less than 4-6 wks old, whereas

chronic abscesses are of longer duration.

Primary abscess is infectious in origin, caused by

aspiration or pneumonia in the healthy host.

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Secondary Abscess is caused by:
- Pre-existing condition (obstruction).
- Spread from an extra-pulmonary site.
- Bronchiectasis.
- An immuno-compromised state.

Lung abscesses can be further characterized by the

responsible pathogen, such as Staphylococcus lung
abscess & anaerobic or Aspergillus lung abscess.

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Lung abscess arises as a complication of aspiration
pneumonia caused by mouth anaerobes.

A bacterial inoculums from the gingival crevice

reaches the lower airways, & infection is initiated
coz the bacteria arent cleared by the patients
host defense mechanism.

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Abscesses generally develop in the right lung and
involve the posterior segment of the right upper
lobe, the superior segment of the lower lobe, or
both. This is due to gravitation of the infectious
material from the oropharynx into these dependent
areas.

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Initially, the aspirated material settles in the distal
bronchial system and develops into a localized
pneumonitis. Within 24-48 hours, a large area of
inflammation results, consisting of exudate, blood,
and necrotic lung tissue. The abscess frequently
connects with a bronchus and partially empties.

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Other mechanisms for lung abscess formation include :
Septic emboli to the lung ,caused by:
1) Bacteremia.
2) Tricuspid valve endocarditis.

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Anaerobes are recovered in up to 89% of the patients,
46% of patients with lung abscess had only a
mixture of anaerobes isolated from sputum cultures
while 43% of patients had a mixture of anaerobes &
aerobes.

The most common anaerobes are Peptosretococcus,

Bacteroids, Fusobacterium species &
Microaerophilic streptococcus.

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Other organisms that may infrequently cause lung
abscess include Staphylococcus aureus,
Streptococcus pyogens, Streptococcus pneumoniae
(rarely), Klebsiella pneumoniae, Hemophilus
influenza, Actinomyces species, Nocardia species, &
Gm negative bacilli.

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Non-bacterial pathogens may also cause lung
abscesses .

Theses micro-organisms include:

1) Parasites [Paragonimus , Entamoeba].
2) Fungi [Aspergillus , Cryptococcus ,
Histoplasma , Blastomyces , Coccidioides].
3) Mycobacterium.

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Anaerobic infection:
1) Patients often present with indolent symptoms that
evolve over a period of weeks to months.

2) The usual symptoms are fever , cough with sputum

production , night sweats , anorexia & weight loss.

3) The expectorated sputum characteristically is foul

smelling & bad tasting.

4) Patients may develop hemoptysis or pleurisy.

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Other bacterial pathogens:
1) These patients generally present with conditions
that are more emergent in nature & are usually
treated while they have bacterial pneumonia.

2) Cavitation occurs subsequently as parenchymal

necrosis ensues.

3) Abscesses from fungi, Nocardia & Mycobacteria

tend to have an indolent course & gradually
progressive symptoms.

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Patients may have low-grade fever in anaerobic
infections & temperature > 38.5 C in other
infections.

Generally, evidence of gingival disease is present.

Clinical findings of consolidation may be present:

[decreased breath sounds, dullness to percussion,
bronchial breath sounds, course inspiratory
crackles].

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Evidence of pleural friction rub signs of associated
pleural effusion, empyema & pyo-pneumothorax
may be present. Signs include :
[dullness to percussion, contralateral mediastinal
shifting & absent breath sounds over the effusion].

Digital clubbing may develop rapidly.

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The bacterial infection may reach the lungs in
several ways .that most common is aspiration of
oro-pharyngeal contents.

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Oral cavity disease
Periodontal disease
Gingivitis

Altered consciousness[ inability to protect their airways

coz of an absent gag reflex]
Alcoholism
Coma
Drug abuse
Anesthesia
Seizures

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Immunocompromised host
Steroid chemotherapy
Malnutrition
Multiple trauma

Esophageal disease
Achalasia
Reflux disease
Depressed cough and gag reflex
Esophageal obstruction
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Bronchial obstruction
Tumor
Foreign body
Stricture

Generalized sepsis

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patients with 1ry lung disorders
Septic emboli from tricuspid endocarditis.
Vasculitic disorders.
Cavitating lung malignancies.
Pulmonary cystic diseases.

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The following infectious etiologies of pneumonia
infrequently progress to parenchymal necrosis & lung
:abscess formation
.Pseudomonas aerugenosa-
.Klebsiella pneumoniae -
.Staph. aureus (may result in multiple abscesses) -
.Strept. Pneumonia -
.Nocardia species -
.Fungal species - 23
An abscess may occur 2ry to bronchial carcinoma,
the bronchial obstruction causes post-obstructive
pneumonia which may lead to abscess formation.

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1) Alcoholism 7) Pneumocystis Carnii
2) Pleuro-pulmonary pneumonia.
Empyema. 8) Aspiration pneumonia.
3) Hydatid Cysts. 9) Bacterial pneumonia.
4) Lung Cancer. 10) Fungal pneumonia.
5) Mycobacterium. 11) Pulmonary embolism.
6) Pneumococcal 12) Sarcoidosis.
infections. 13) T.B.

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- CBC
- Sputum for gram stain, culture & sensitivity.
- If T.B. is suspected, acid fast bacilli stain &
mycobacterial culture is requested.
- Blood culture may be helpful in establishing the
etiology.
- Obtain sputum for ova & parasite whenever a
parasitic cause for lung abscess is suspected.

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CXR:
- Irregularly sharp cavity with an air-fluid level inside.

- Lung abscess as a result of aspiration most frequently

occur in the posterior segments of the upper lobes or
the superior segments of the lower lobe.

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- The wall thickness of a lung abscess progresses from
thick to thin and from ill-defined to well-
circumscribed as the surrounding lung infection
resolves.

- The cavity wall can be smooth or ragged but is less

commonly nodular, which raises the possibility of
cavitating carcinoma.

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- The abscess may extend to the pleural surface, in
which case it forms acute angles with the pleural
surface.

- - Up to one third of lung abscesses may be

accompanied by an empyema.

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- CT scan:
- Better in lung anatomy visualization to identify
empyema from lung infarction.
- An abscess is rounded radio-lucent lesion with a think
wall & ill-defined irregular margins.

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- Trans-tracheal aspirate or trans-thoracic needle
aspiration may provide microbiologic diagnosis,
obtaining pleural fluid and blood cultures in patients
with lung abscess is easier.

- Flexible fiberoptic bronchoscopy is performed to

exclude bronchogenic carcinoma whenever
bronchial obstruction is suspected.

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Antibiotic therapy:
- Anaerobic lung infection = Clindamycin [shown to be
superior over parenteral penicillin coz several anaerobes
may produce B-lactamase & therefore develop penicillin
resistance].

- Although metronidazole is an effective drug against

anaerobic bacteria, a failure rate of 50% has been
reported.

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- In hospitalized patients who have aspirated and
developed a lung abscess, antibiotic therapy should
include coverage against S aureus and Enterobacter
and Pseudomonas species.

- Cefoxitin is a second-generation cephalosporin that

has gram-positive, gram-negative, and anaerobic
coverage. This agent may be used when a
polymicrobial infection is suspected as cause of
lung abscess.
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Duration of therapy:
- Most clinicians prescribe antibiotic therapy generally
for 4-6 weeks.

- Current recommendations are that antibiotic treatment

should be continued until the chest radiograph has
shown either the resolution of lung abscess or the
presence of a small stable lesion.

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Response to therapy:

- Patients show clinical improvement, with

improvement of fever, within 3-4 days after
initiating the antibiotic therapy.

- Patients with poor response to antibiotic therapy

include bronchial obstruction with a foreign body or
neoplasm or infection with a resistant bacteria,
Mycobacteria, or fungi.

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Surgery is very rarely required for patients with
uncomplicated lung abscesses. The usual indications
for surgery are failure to respond to medical
management, suspected neoplasm, or congenital
lung malformation. The surgical procedure
performed is either lobectomy or pneumonectomy.

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1) Rupture into pleural space causing empyema.
2) Pleural fibrosis.
3) Trapped lung.
4) Respiratory failure.
5) Bronchopleural fistula.
6)Pleural cutaneous fistula.

In a patient with coexisting empyema and lung abscess,

draining the empyema while continuing prolonged
antibiotic therapy is often necessary.

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The prognosis for lung abscess following antibiotic
treatment is generally favorable. Over 90% of lung
abscesses are cured with medical management alone,
unless caused by bronchial obstruction secondary to
carcinoma.

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Thank You

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