Page 9 / Case 01/01
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
THANK YOU FOR JOINING US FOR THE CROSS-CANADA PAEDIATRIC RESPIRATORY ROUNDS. HOPE TO SEE YOU NEXT TIME.
Thank you to AstraZeneca for their support
of this program and website.
