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