Background

A lung abscess is a subacute inIection in which an area oI necrosis Iorms in the lung
parenchyma. It usually is in a dependent section oI the lung, more oIten involves the right
lung than the leIt, and is most commonly seen aIter aspiration oI oropharyngeal secretions.
Lung abscesses have a slow, insidious presentation and usually develop 1-2 weeks aIter the
initial aspiration event. A lung abscess is shown in the image below.
A thick-walled lung abscess.
Empyema is deIined as pus in the pleural space. It typically is a complication oI pneumonia.
However, it can also arise Irom penetrating chest trauma, esophageal rupture, complication
Irom lung surgery, or inoculation oI the pleural cavity aIter thoracentesis or chest tube
placement. An empyema can also occur Irom extension oI a subdiaphragmatic or
paravertebral abscess.
Pathophysiology
A lung abscess involves the lung parenchyma, whereas an empyema involves the pleural
space. In many patients with pneumonia, a sterile simple parapneumonic eIIusion develops in
the pleural space. II this pleural eIIusion becomes inIected, it is labeled a complicated
parapneumonic eIIusion, whereas the presence oI Irank pus in the pleural space deIines an
empyema.
The development stages oI an eIIusion can be divided into 3 phases: exudative, Iibropurulent,
and organizational. The initial eIIusion develops Irom increased pulmonary interstitial Iluid
along with progressive capillary vascular permeability. A simple eIIusion is Irequently sterile
and resolves with antibiotic treatment oI the underlying pulmonary inIection.
In 5-10 oI the patients with a pleural eIIusion, the eIIusion becomes inIected and
neutrophils buildup. This inIlammatory response, shown in the images below, also causes the
production oI chemokines, cytokines, oxidants, and protease mediators.
Histology oI a lung abscess shows dense inIlammatory
reaction (low power). Histology oI a lung abscess shows
dense inIlammatory reaction (high power).
This more complicated parapneumonic eIIusion needs both antibiotics and some Iorm oI
surgical drainage or alternative treatment modality to remove the purulent eIIusion. In these
more complicated eIIusions, Iibrinolysis and activation oI the coagulation cascade leads to
the production oI Iibrin with subsequent adhesions and loculated Iluid collections. This
process ultimately can cause pleural Iibrosis and impairment oI lung expansion.
pidemiology
Frequency
United States
An estimated 60,000 pleural inIections are diagnosed annually in the United States.
Mortality/Morbidity
The mortality rate Ior lung abscesses is approximately 4-7 but varies with the type oI
material aspirated. Aspiration oI Iluids with mixed gram-negative Ilora has a mortality rate
approaching 20, while aspiration oI acidic materials has an even higher rate. The Iatality
rate Ior complicated parapneumonic eIIusions is estimated to be as high as 15.
Age
Complicated eIIusions and empyema are more common in elderly persons and during
childhood. An increase has occurred in the incidence oI empyema in the pediatric population.
Lung abscess is more common in elderly persons.
History
The patient's history may reveal the Iollowing Iindings:
O #ecent diagnosis and treatment oI pneumonia
O #ecent history oI penetrating chest trauma or diaphragmatic injury (should raise
clinical suspicion Ior empyema)
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O Cough productive oI bloody sputum that Irequently has a Ietid odor or oIIensive
appearance
O ever
O Shortness oI breath
O Anorexia, weight loss
O ight sweats
O !leuritic chest pain
Chalmers et al in a prospective observational study identiIied 6 risk Iactors that were
associated with patients admitted with community-acquired pneumonia who subsequently
developed a complicated parapneumonic eIIusion or empyema. These Iactors include
albumin 30 g/L, sodium 130 mmol/L, platelet count ~400 X 10
9
, C-reactive protein ~100
mg/L, and a history oI alcohol abuse or intravenous drug use.
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Other predispositions to
development oI a parapneumonic eIIusion and empyema include immunosuppression (eg,
HIV, diabetes mellitus, malnutrition), gastrointestinal reIlux, poor dental hygiene, bronchial
aspiration, and chronic lung disease.
Physical
The physical examination may reveal the Iollowing Iindings:
O Temperature Irequently elevated but usually not greater than 102
O Tachypnea
O #ales
O #honchi
O Egophony
O Tubular breath sounds
O ecreased breath sounds
O ullness to percussion
auses
The most common cause oI lung abscess is aspiration. !atients at the highest risk are those
who have the Iollowing:
O !oor dentition
O Seizure disorder
O Alcohol abuse
O Inability to protect their airway because oI an absent gag reIlex (eg, patients who are
comatose, have a change in mentation, or who might be undergoing general
anesthesia)
O !rimary lung disorders, such as septic emboli, vasculitic disorders, cavitating lung
malignancies, or pulmonary cystic disease
O !enetrating chest trauma
The microbiologic organisms involved in lung abscesses typically are polymicrobial oral
Ilora, including Bacteroides, Fusobacterium, and Peptostreptococcus species. Other
organisms include Pseudomonas species, Klebsiella species, Staphylococcus aureus,
Streptococcus pneumoniae, Nocardia species, and less commonly Iungi.
The most common cause oI an empyema is Irom a parapneumonic eIIusion that becomes
inIected; these account Ior about halI oI all empyemas. Other causes oI an empyema include
the Iollowing:
O !enetrating chest trauma
O Contamination oI a wound because oI inadequate skin preparation during procedures
such as needle decompression, chest tube placement, thoracentesis, or lung surgery
Microbiologic organisms that cause an empyema include Streptococcus species such as
Streptococcus milleri (Streptococcus intermedius, Streptococcus constellatus, Streptococcus
mitis), S pneumoniae,Haemophilus influen:ae, and a variety oI gram-negative organisms and
anaerobes.
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One should always consider methicillin-resistant Staphylococcus aureus
(M#SA), enterobacteria, enterococcus, and Mycobacterium tuberculosis as potential
pathogens. osocomial pleural inIections are oIten Irom methicillin-resistant staphylococci,
Klebsiella pneumoniae, gram-negative organisms, and anaerobes.
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In the pediatric
population, S aureus has become the predominant organism associated with empyemas
because oI the widespread use oI the pneumococcal conjugate vaccine.
ifferentials
O !leural EIIusion
O !neumonia, Aspiration
O !neumonia, Bacterial
O !neumonia, Immunocompromised
O !neumonia, Mycoplasma
O !neumonia, Viral
O Tuberculosis
aboratory Studies
O A CBC with diIIerential may reveal a leukocytosis and a leIt shiIt.
O Collect sputum Ior Gram staining, culturing, and sensitivity testing.
O II tuberculosis is suspected, acid-Iast bacilli testing should be obtained.
O Blood culturing is also appropriate.
maging Studies
!erIorm chest radiography to diagnose and diIIerentiate pneumonia, pulmonary abscess, and
empyema. istinction oI these conditions is important because lung abscesses and pneumonia
require medical treatment, while empyema Irequently requires deIinitive surgical therapy.
Several radiographs are shown below.
!neumococcal pneumonia complicated by lung necrosis and
abscess Iormation. A lateral chest radiograph shows air-Iluid
level characteristic oI lung abscess. A 54-year-old patient
developed cough with Ioul-smelling sputum production. A chest radiograph shows lung
abscess in the leIt lower lobe, superior segment. A 42-year-old man
developed Iever and production oI Ioul-smelling sputum. He had a history oI heavy alcohol
use, and poor dentition was obvious on physical examination. Chest radiograph shows lung
abscess in the posterior segment oI the right upper lobe. Chest
radiograph oI a patient who had Ioul-smelling and bad-tasting sputum, an almost diagnostic
Ieature oI anaerobic lung abscess.
On the chest radiograph, a lung abscess appears as a solitary cavitary area with an air-Iluid
level, which typically is present in a dependent portion oI the lung.
A surrounding patchy area oI inIiltrate aids in diIIerentiating a pulmonary abscess Irom a
cavitary lung cancer.
On the chest radiograph, Iindings that suggest empyema, as opposed to lung abscess, include
extension oI the air-Iluid level to the chest wall, extension oI the air-Iluid level across Iissure
lines, and a tapering border oI the air-Iluid collection.
The costophrenic angle should be closely inspected on the chest radiograph to assess the
presence oI Iluid that suggests eIIusion or empyema.
On the chest radiograph obtained oI the patient in an upright position, blunting oI the
costophrenic angle occurs when approximately 200 mL oI Iluid accumulates.
A lateral chest decubitus radiograph, obtained with the patient on his or her side, reveals
whether the pleural Iluid is mobile and Iorms layers or whether it is loculated.
To better assess any abnormal lung Iindings Iound on a chest radiograph, CT oI the chest or
ultrasonography is usually necessary. Ultrasonography is useIul Ior needle-guided aspiration
and drainage oI a potential pleural eIIusion or empyema. When ultrasonography is not used
to guide needle aspiration, the Iailure rate is 12-15. Color oppler ultrasonography can also
assist in diIIerentiating empyema Irom peripheral air-Iluid pulmonary abscess. Chen et al
reported in a retrospective study that identiIication oI color oppler ultrasonography vessel
signals in pericavitary consolidation was useIul and speciIic Ior identiIying lung abscesses,
with sensitivity oI 94 and speciIicity oI 100.
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CT oI the chest can assess Ior pneumonia, lung abscess, tumor, pleural eIIusions and
septations, other pleural diseases, or pleural thickening. Many clinicians recommend limiting
the use oI CT in children to reduce radiation exposure. JaIIe et al studied the utility oI routine
CT scanning in children and concluded that, while CTs detected more parenchymal
abnormalities, the additional inIormation did not alter management and it did not predict
clinical outcome in patients who were being treated with chest tube drainage and
Iibrinolytics.
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The British Thoracic Society guidelines conclude that chest CT has no role in
the routine identiIication oI pleural collections in children.
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A lung abscess in an adult is
shown in the image below.
A 42-year-old man developed Iever and production oI Ioul-
smelling sputum. He had a history oI heavy alcohol use, and poor dentition was obvious on
physical examination. Lung abscess in the posterior segment oI the right upper lobe was
demonstrated on chest radiograph. CT scan shows a thin-walled cavity with surrounding
consolidation.
ther Tests
O !ulse oximetry - To assess oxygenation
O ABG analysis - To assess respiratory adequacy
O Transtracheal aspiration Ior culturing - II sputum Iindings are nondiagnostic
Procedures
II a pleural eIIusion is present, a diagnostic thoracentesis should be perIormed, and the Iluid
should be analyzed Ior pH, lactate dehydrogenase, and glucose levels; speciIic gravity; and
cell count with diIIerential. luid is also sent Ior Gram stain, culture, and sensitivity.
Gram stain, routine culture, and sensitivity, and acid-Iast bacillus testing should also be
perIormed.
The Iluid should be sent Ior cytology iI cancer is suspected.
The Iollowing Iindings are suggestive oI an empyema or parapneumonic eIIusion that will
need a chest tube Ior complete resolution:
O Grossly purulent pleural Iluid
O pH level less than 7.2
O WBC count greater than 50,000 cells/L (or polymorphonuclear leukocyte count oI
1,000 IU/dL)
O Glucose level less than 60 mg/dL
O Lactate dehydrogenase level greater than 1,000 IU/mL
O !ositive pleural Iluid culture
A pleural Iluid marker currently being studied is tumor necrosis Iactor (T)alpha. In
patients who have pleural eIIusions, a T-alpha level higher than 80 pg/mL is suggestive oI
an empyema or complicated parapneumonic eIIusion.
Prehospital are
O Supplemental oxygen should be given and an intravenous line started.
O Appropriate airway management, including intubation, should be perIormed
depending on the patient's clinical condition.
mergency epartment are
All patients should undergo pulse oximetry and evaluation oI their respiratory status. II
respiratory Iailure is Iound or likely to occur, intubation and mechanical ventilation is
necessary. Supplemental oxygen should be started Ior any patient who is acutely short oI
breath or who is hypoxic based on pulse oximetric Iindings.
Once the diagnosis oI a lung abscess is made, parenteral antibiotics should be started. Ideally,
sputum and blood culture Iindings should be obtained prior to the initiation oI antibiotics.
AIter the diagnosis oI empyema is made, prompt drainage by means oI tube thoracostomy
with use oI parenteral antibiotics should be initiated.
onsultations
Treatment oI lung abscesses or empyema is perIormed in-hospital, with consultations
involving internists, pulmonologists, thoracic surgeons, and/or interventional radiologists.
Treatment should be individualized.
Many clinicians advocate the administration oI intrapleural Iibrinolytics in patients with
empyemas. Intrapleural Iibrinolytics assist in the breakdown oI Iibrin bands that can cause
loculation oI the empyema and allow Ior better chest tube drainage oI the inIected material. A
recent meta-analysis that included 761 patients showed that intrapleural Iibrinolytic therapy
conIers signiIicant beneIit in reducing the requirement Ior surgical intervention Ior patients.
|7|
However, some randomized clinical trials have reported opposite results, with these studies
suggesting no beneIit in outcomes with Iibrinolytic therapy.
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II chest tube drainage and
Iibrinolytic treatment are unsuccessIul, many authors recommend video-assisted thoracic
surgery (VATS) next rather than the more traditional open thoracotomy. VATS is less
invasive and well tolerated with outcomes that compare Iavorably with open thoracotomy.
In the pediatric population, the American !ediatric Surgery Association ew Technology
committee oIIers the Iollowing algorithm. Children with parapneumonic eIIusions and/or
empyema must be treated with antibiotics along with chest tube drainage iI there are
respiratory symptoms Irom compressive eIIects oI the Iluid. II the illness progresses beyond
3-4 days, a loculated collection may be present and treatment with Iibrinolytics or VATS
would be the next step.
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One study advocated the use oI VATS pleural evacuation as the
initial intervention.
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VATS was associated with a shorter hospital length oI stay. umerous
children who were treated with tube thoracostomy still required VATS.
Lung abscesses typically respond well to antibiotic therapy, but when that therapy is
unsuccessIul, the consulting clinician might consider percutaneous catheter drainage or
endoscopic surgical resection oI the involved area oI the lung (see Lung Abscess, Surgical
!erspective).
Medication Summary
Lung abscesses are treated with a prolonged course oI parenteral antibiotics that target
organisms Iound in aspiration pneumonia. The initial choice oI antibiotics Irequently is
empiric, beginning with clindamycin, ceIoxitin, ticarcillin, or piperacillin/tazobactam,
although penicillin has been very eIIective when the organism is sensitive. Some authors
advocate adding coverage Ior Klebsiella as well. Subsequent therapy should be based on
sputum or blood culture results.
An empyema is treated with parenteral antibiotics and prompt chest tube drainage. Empiric
therapy Ior an empyema is Irequently with imipenem or piperacillin/tazobactam until a
deIinitive organism is identiIied on pleural Iluid cultures and sensitivities are obtained.
Antibiotic coverage Ior anaerobic organisms is also recommended since anaerobes Irequently
coexist but are more diIIicult to isolate. or an empyema secondary to aspiration pneumonia
or a parapneumonic process, choose antibiotics that are active against mouth Ilora, S aureus
and Streptococcus species. or an empyema secondary to penetrating chest trauma,
administer antibiotics that have coverage Ior skin Ilora. II M#SA is suspected, include
vancomycin in the treatment plan. !leural Iluids or sputum specimens that are obtained
should be cultured Ior M tuberculosis as well.
Antibiotics
lass Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens
in the context oI the clinical setting.
View Iull drug inIormation
lindamycin (leocin)

Lincosamide Ior the treatment oI serious skin and soIt-tissue staphylococcal inIections. Also
eIIective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial
growth, possibly by blocking dissociation oI peptidyl t#A Irom ribosomes causing #A-
dependent protein synthesis to arrest.
View Iull drug inIormation
efoxitin (Mefoxin)

Second-generation cephalosporin indicated Ior inIections with gram-positive cocci and gram-
negative rod. InIections caused by cephalosporin- or penicillin-resistant gram-negative
bacteria may respond.
View Iull drug inIormation
Penicillin G (Pfizerpen)

InterIeres with synthesis oI cell wall mucopeptide during active multiplication, resulting in
bactericidal activity against susceptible microorganisms; traditional drug Ior the treatment oI
lung abscess, but its spectrum oI activity is narrow.
View Iull drug inIormation
Ticarcillin/clavulanate (Timentin)

Inhibits biosynthesis oI cell wall mucopeptide and is eIIective during active growth stage.
Antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most
gram-positive bacteria, most gram-negative bacteria, and most anaerobes.
View Iull drug inIormation
Piperacillin/tazobactam (Zosyn)

Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis oI cell wall
mucopeptide and is eIIective during stage oI active multiplication.
View Iull drug inIormation
mipenem and cilastatin (Primaxin)

or treatment oI multiple organism inIections in which other agents do not have wide-
spectrum coverage or are contraindicated because oI potential Ior toxicity.
View Iull drug inIormation
Vancomycin (Vancoled, Vancocin, yphocin)

!otent antibiotic directed against gram-positive organisms and active against nterococcus
species. UseIul in the treatment oI septicemia and skin structure inIections. Indicated Ior
patients who cannot receive or whose conditions are unresponsive to penicillins and
cephalosporins or have inIections with resistant staphylococci. or abdominal-penetrating
injuries, it is combined with an agent active against enteric Ilora and/or anaerobes. To avoid
toxicity, current recommendation is to assay vancomycin trough levels aIter third dose drawn
0.5 h prior to next dosing. Use CrCl to adjust dose in patients with renal impairment.
Further npatient are
O Inpatient care is mandatory Ior the management and assistance oI the patient's
respiratory status, continuation oI intravenous antibiotics, and drainage oI the lung
abscess or empyema as needed.
npatient & utpatient Medications
O Outpatient therapy Ior lung abscess or empyema is not indicated or advised; inpatient
care is mandatory.
O Antimicrobial therapy should be continued empirically until therapy can be guided
with culture results.
Transfer
O TransIer oI these patients usually is not indicated unless advanced respiratory
management or surgical drainage is not available without transIer.
O !atients should be transIerred only aIter stabilization oI their respiratory status and
administration oI intravenous antibiotics.
eterrence/Prevention
O !revention oI aspiration is important to minimize the subsequent risk oI lung abscess.
O Early intubation should be perIormed in patients who do not have a gag reIlex.
O !osition the patient in a manner that minimizes the risk oI aspiration. or example, a
patient who is vomiting should be placed on his or her side.
O Immediately suction the patient's orotracheal area iI he or she aspirates in the E.
omplications
O Complications oI pulmonary abscess include pleural Iibrosis, trapped lung, restrictive
ventilatory deIect, bronchopleural Iistula, and pleurocutaneous Iistula.
Prognosis
O The prognosis Ior both lung abscess and empyema generally is good. inety percent
oI lung abscesses are cured with medical management alone.
Patient ducation
O or excellent patient education resources, visit eMedicine's InIections Center, Lung
and Airway Center, and !neumonia Center. Also, see eMedicine's patient education
articles Bacterial !neumonia, Abscess, and Antibiotics.