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TREATMENT

– pre-1950: surgery.

– However, once certain patterns were noted, shift towards medical therapy emerged. The important concept is that medical treatment of lung abscess is long, and it takes weeks to improve.

– fever can persist for 4 - 7 days (range 4 - 21 days).
– CXR can worsen 3 - 7 days into treatment.
– cavity closure can take 3 - 4 weeks (up to 14 weeks).
– infiltrates can take 8 - 10 weeks to resolve (range 8 - 24 weeks).
– lesions < 3cm resolve faster.
– risk of persistent pneumatoceles or bronchiectasis is directly related to initial cavity size

Cavity size (cm)
Pneumatoceles/Bronchiectasis (%)
0-2
40
2-4
55
4-6
80
>6
100

– penicillin remains a proven therapy for simple cases.
• safe & efficacious
• works desite resistant anaerobic strains
• may have clinical resolution when some, but not necessarily all, organisms are killed (concept of synergy)
• however, some don't respond: clindamycin often necessary for these patients

– therefore, clindamycin is empiric first-line agent of choice.
• better cure rates than with penicillin

PO equivalent to IV antibiotics

– other choices: ticarcillin-clavulinic acid, penicillin + metronidazole, aminoglycosides if gram negatives like Pseudomonas.

– usually need to treat 4 - 6 weeks, but do not determine in advance, rather use conservative approach.

– most conservative approach is to treat until radiographic resolution or stability

– others say to Rx until 7 - 10 days afebrile, and CXR has improved. Then, continue IV for 2-3 more weeks, and complete PO for total of 4-8 weeks.
– assure adequate drainage
• avoid sedation
• cough
• mobilize secretions (chest physio & postural drainage) However, caution re: risk of hemorrhage
• consider cough suppressant if hemoptysis (short-term use)

– surgical treatment is a last resort.
consider if failed medical treatment (e.g. unrelenting sepsis, respiratory failure, metastatic infection, empyema)

– some centers have had success with percutaneous (CT-guided) drainage.
• may leave catheter in place, get faster resolution but risk is increased fistulae

Complications

– recurrent abscess (6%), but less risk with conservative treatment.
– empyema (4%)
– life-threatening hemorrhage (4%)
– mycetomas
– massive aspiration into normal lung (important cause of death)
– more with secondary abscess

References

1. Brook I. Lung Abscess and Pleural Empyema in Children;Advances in Pediatric Infectious Diseases: 1993, vol. 8, p.159-175

2. Davis B, Systrom DM. Lung Abscess: Pathogenesis, Diagnosis and Treatment;Current Clinical Topics in Infectious Diseases: 1993, vol. 8, p.252-273

3. McCarthy VP, Patamasucon P, et al. Necrotizing Pneumococcal Pneumonia in Childhood;Pediatric Pulmonology: 1999, vol. 28, p.217-221

4. Bruckheimer E, Dolberg S, et al. Primary Lung Abscess in Infancy;Pediatric Pulmonolgy: 1995, vol. 19, p.188-191


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