Lung Abscess in adults - Guideline for the management of

Publication: 01/03/2009  --
Last review: 15/11/2016  
Next review: 15/11/2019  
Clinical Guideline
CURRENT 
ID: 1741 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2016  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the management of lung abscess in adults

Summary
Lung Abscess in adults

Pertinent aspects of history and examination
Key diagnostic criteria

  • The diagnosis of lung abscess is usually made from the history along with the appearance of a cavity with an associated air fluid level on chest x-ray.
  • Lung abscesses often have an insidious onset. See main guideline for symptoms on presentation.

Investigations required

  • Chest X-ray, CT scanning
  • Blood cultures, respiratory secretions
  • CT or Ultrasound-guided transthoracic percutaneous needle aspiration.
  • Radiology

Non-Antimicrobial Management

  • Postural drainage and physiotherapy to aid the production of purulent sputum.
  • Referral for surgery. Very rarely required if appropriate antibiotics are given. See main guidelines for details.

Empirical (initial) antimicrobial treatment
IV Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g three times a day

Allergy to penicillin
IV Clindamycin electronic Medicines Compendium information on Clindamycin 600mg four times a day + oral Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 750mg twice a day*

*Age over 65 – replace this regimen with IV Levofloxacin electronic Medicines Compendium information on Levofloxacin 500mg twice a day and IV Metronidazole electronic Medicines Compendium information on Metronidazole 500mg three times a day

Referral criteria for specialist input

  • Fever and other symptoms persist after 10-14 days of treatment
  • Chest x-rays indicate that the abscess is not shrinking.

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Clinical Diagnosis

Criteria for use of this guideline

  • A lung abscess is a localized, suppurative, necrotizing process within the pulmonary parenchyma, with or without cavity formation.
  • Primary abscesses result from necrosis in an already existing pathology, often a complication of aspiration of the stomach contents or upper respiratory tract secretions. A secondary abscess may result from septic vascular emboli, bronchial obstruction, spread from a liver abscess, as complication of pneumonia, or a neoplastic process.
  • The diagnosis is usually made from the history along with the appearance of a cavity with an associated air fluid level on chest x-ray.
  • Lung abscesses often have an insidious onset. Symptoms on presentation may include:
    • Productive cough ± haemoptysis
    • Breathlessness
    • Fevers
    • Night sweats
    • Foul sputum, or purulent pleural fluid
    • Non-specific features of chronic infection (anaemia, weight loss, malaise)

[Evidence Level C]

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Investigation
    • Radiology
  • Chest x-ray, may show consolidation, cavitation, air-fluid level.
  • CT scanning may assist in the diagnosis and guide management in patients who are not responding to treatment and who have a complex CXR.
  • A CT scan can help define the exact position of the abscess, which may be useful for physiotherapy.
  • Review gum and dental hygiene

    • Specimens
  • Blood cultures, preferably before antibiotic treatment is commenced.
  • Respiratory secretions e.g. sputum, bronchial washings for culture (including AFB), preferably before antibiotic treatment is commenced.
  • CT or Ultrasound-guided transthoracic percutaneous needle aspiration. However there is a risk of bleeding, pneumothorax and seeding of the infection to the pleural space, if abscess is not adjacent to the pleura.

[Evidence Level C]

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Treatment
Non-Antimicrobial Treatment

Non-Antimicrobial Management

  • Postural drainage and physiotherapy to aid the production of purulent sputum.
  • Referral for surgery. Very rarely required if appropriate antibiotics are given. May be needed if:
      • Failure to respond after at least 6 weeks of treatment
      • Very large abscess (>6cm diameter)
      • Resistant organisms
      • Haemorrhage
      • Recurrent disease

[Evidence Level C]

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Empirical Antimicrobial Treatment

Antimicrobial treatment
Note that the suggested doses and frequency assume normal renal and hepatic function

Empirical therapy
IV Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 1.2g three times a day

Allergy to penicillin
IV Clindamycin electronic Medicines Compendium information on Clindamycin 600mg four times a day + oral Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 750mg twice a day*

*Age over 65 – replace this regimen with IV Levofloxacin electronic Medicines Compendium information on Levofloxacin 500mg twice a day and IV Metronidazole electronic Medicines Compendium information on Metronidazole 500mg three times a day

[Evidence Level C]

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Directed Antimicrobial Treatment (when microbiology results are known)

These empirical agents should be reviewed in the light of culture results and clinical progress and amended accordingly.

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Duration of Treatment

Duration of treatment

  • IV therapy maybe required until the patient shows signs of improvement (1 week)
  • Prolonged treatment over several weeks is typically required. Oral antibiotics are often required.
  • Treatment should continue until the cavity has resolved.

NB. Intravenous therapy should be discontinued as soon as clinically indicated.
[Evidence Level C]

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Switch to oral agent(s)

IV antibiotics should be given for at least 1 week in absence of these features.

The following criteria may be considered when deciding to switch from intravenous to oral therapy:

    • Resolution of fever.
    • Pulse rate <100 beats/min
    • Resolution of tachypnoea
    • Clinically hydrated and taking oral fluids
    • Resolution of hypotension
    • Absence of hypoxia
    • Improving white cell count
    • Non-bacteraemic infection
    • No microbiological evidence of legionella, staphylococcal or Gram negative enteric bacilli infection
    • No concerns over gastrointestinal absorption

The choice of oral agent can be determined by a number of factors, including susceptibility of isolated pathogen(s), drug allergy, tolerability, etc. If no obvious alternative is apparent, please contact microbiology for further advice.
[Evidence Level C]

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Treatment Failure

Treatment Failure

Consider the following explanations:

  • Incorrect diagnosis
  • Resistant or unusual organism (e.g. Mycobacterium tuberculosis, Nocardia, fungi)
  • Antibiotic hypersensitivity reaction
  • Complication e.g. empyema
  • Underlying lung disease e.g. lung cancer
  • Immunosuppresion (known or unexpected)
  • Large cavity (>6cm) may require drainage
  • Non-bacterial cause e.g. Wegener’s granulomatosis

[Evidence Level C]

Please note that these are guidelines. On some occasions you may be advised to manage patients differently, depending on clinical circumstances, microbiology results, etc.

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Referral Criteria
  • Fever and other symptoms persist after 5 days of treatment
  • Chest x-rays indicate that the abscess is not shrinking.

[Evidence Level C]

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Provenance

Record: 1741
Objective:
  • To provide evidence-based recommendations for appropriate diagnosis and investigation of lung abscess
  • To provide evidence-based recommendations for appropriate non-antimicrobial management of lung abscess
  • To provide evidence-based recommendations for appropriate empirical and directed antimicrobial therapy of lung abscess
  • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
  • To advise in the event of antimicrobial allergy.
  • To set-out criteria for referral to specialists.
Clinical condition:

Lung abscess

Target patient group: See guideline
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

British Society for Antimicrobial Chemotherapy. Treatment of Hospital Infections: Lung abscesses. British Society for Antimicrobial Chemotherapy. Available at: http://www.bsac.org.uk/pyxis/RTI/Lung abscess/Lung%20abscessf.htm (Accessed 9th March 2009)

Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

Not supplied

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