Lung abscess medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

The mainstay of management for lung abscess is: hospital admission for chest drain and systemic antibiotics. Antimicrobial therapy is based on predisposing host factors and local resistance patterns.The standard duration of the treatment of lung abscess is ≥ 4–6 weeks of parenteral antibiotics

Medical Therapy

• Empiric treatment should be commenced after culture samples are obtained.
• The choice of empiric antibiotics should be determined on the basis of the possible risk of multi-drug resistant causative bacteria, and culture results.
• Clinical improvement is reflected in the subsidence of fever (within the first 3-4 days) and complete abatement of fever occurs within 7-10 days. Persistent fever can be explained by treatment failure due to uncommon pathogens (multidrug resistant common bacteria, mycobacteria, fungi) or by the presence of an alternative diagnosis (e.g. endobronchial obstruction, vasculitis) that requires further diagnostic workup (e.g. bronchoscopy or surgical lung biopsy).
• The duration of treatment with antibiotics is not well defined, according to many experts, the optimal duration of antimicrobial therapy is 3-6 weeks, whereas others take the timing of radiological response into consideration.
• In that case, the length of antibiotic treatment depends on complete radiological resolution or stabilization to a small residual lesion.
• Treatment interval may then be prolonged to several months (more than 2),6 especially when the initial lesion is of large size (maximum diameter more than 6cm).

Empiric

• Preferred regimen (1): Ampicillin + Sulbactum  3g IV q6h
• Preferred regimen (2): Imipenem + Cilastin  500 mg IV q6h
• Preferred regimen (3): Meropenem 1-2 g IV q8h
• Alternative regimen (1):Clindamycin  IV 600 mg q8h

Pathogen directed

MSSA

• Preferred regimen (1): Nafcillin 2 g IV q4h
• Preferred regimen (2): Oxacillin 2 g IV q4h
• Preferred regimen (3): Cefazolin 2 g IV q8h

MRSA

• Preferred regimen (1): Linezolid 600 mg q12h IV/PO ± Rifampin 300 mg po/IV bid

Actinomyces

• Preferred regimen (1): Intravenous penicillin G (10 to 20 million units daily in divided doses every four to six hours) for 4 to 6 weeks

Nocardia .spp

• Preferred regimen (1): TMP-SMX 15 mg/kg IV of the trimethoprim component per day in three or four divided doses plusAmikacin 7.5 mg/kg IV every 12 hours 

Fungi

• Preferred regimen (1): Amphotericin B  3-5mg/kg/day/IV

Parasite

• Preferred regimen (1): Albendazole is dosed 10 to 15 mg/kg per day in two divided doses; the usual dose for adults is 400 mg twice daily.one to three months may be appropriate, depending clinical factors; up to six months may be required.

Metronidazole should never be given alone, as it is inactive against microaerophilic strains, aerobic streptococci, and Actinomyces species.
Metronidazole in combination with penicillin is given due to the observed failure of penicillin to cure penicillin-resistant Prevotella melaninogenica, Porphyromonas asaccharolytica, and Bacteroides species.
Patients allergic to penicillin and cephalosporins may be treated with clindamycin combined with aztreonam, ciprofloxacin or levofloxacin for coverage of gram-negative pathogens

Reference

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