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com %2F AUTHOR INFORMATION Authored by Mark Zwanger, MD, MBA, Program Director, Assistant Professor, Department of Surgery, Division of Emergency Medicine, Thomas Jefferson University Coauthored by Patti Purpura, MD, Consulting Staff, Department of Emergency Medicine, Virginia Mason Hospital Mark Zwanger, MD, MBA, is a member of the following medical societies: American College of Emergency Physicians Edited by Mark S Slabinski, MD, Director, Department of Emergency Medicine, Southeastern Ohio Regional Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Paul Blackburn, DO, Program Director, Department of Emergency Medicine, Maricopa Medical Center; Assistant Professor, Department of Surgery, University of Arizona; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Robert O'Connor, MD, MPH, Program Director, Associate Professor, Thomas Jefferson University, Program Director, Department of Emergency Medicine, Christiana Care Health System Editor's Email: Mark S Slabinski, MD eMedicine Journal, April 24 2002, Volume 3, Number 4 INTRODUCTION Background: A lung abscess is a subacute infection in which an area of necrosis forms in the lung parenchyma. It usually is in a dependent section of the lung, more often involves the right lung than the left, and is most commonly seen after aspiration of oropharyngeal secretions. Lung abscesses have a slow, insidious presentation and usually develop 1-2 weeks after the initial aspiration event. Empyema is defined as pus in the pleural space. It typically is a complication of pneumonia. However, it can also arise from penetrating chest trauma, esophageal rupture, or inoculation of the pleural cavity after thoracentesis or chest tube placement. An empyema can also occur from extension of a subdiaphragmatic or paravertebral abscess. Pathophysiology: Lung abscesses involve the lung parenchyma, while empyema involves the pleural space. Mortality/Morbidity: The mortality rate for lung abscesses is approximately 4-7% but varies with the type of material aspirated. Aspiration of fluids with mixed gram-negative flora has a mortality rate approaching 20%, while aspiration of acidic materials has an even higher rate. Age: These conditions occur more commonly in the elderly. CLINICAL History: The patient's history may reveal the following findings: Many patients give a history of a recent diagnosis and treatment for pneumonia. A recent history of penetrating chest trauma should raise clinical suspicion for empyema. Patients report a cough productive of bloody sputum that frequently has a fetid odor or offensive appearance. Fever Shortness of breath Anorexia, weight loss Night sweats Pleuritic chest pain Physical: The physical examination may reveal the following findings: Temperature frequently elevated but usually not greater than 102F Tachypnea Rales Rhonchi Egophony Tubular breath sounds

 Decreased breath sounds Dullness to percussion Causes: The most common cause of lung abscess or empyema is aspiration. Patients at the highest risk are those who have the following: Poor dentition Seizure disorder Alcohol abuse Inability to protect their airway because of an absent gag reflex (eg, patients who are comatose, have a change in mentation, or who might be undergoing general anesthesia) Patients with primary lung disorders, such as septic emboli, vasculitic disorders, cavitating lung malignancies, or pulmonary cystic disease A cause of lung abscess or empyema is penetrating chest trauma. Empyema secondary to chest penetration is caused by primary contamination of the trauma wound or inadequate skin preparation before needle decompression, chest tube placement, or thoracentesis. The microbiologic organisms involved in lung abscesses and empyema typically are polymicrobial oral flora, including Bacteroides species, Fusobacterium species, and Peptostreptococcus species. Pseudomonas species, Klebsiella species, Staphylococcus aureus, Streptococcus pneumoniae, Nocardia species, and fungal species are less commonly seen. The microbiologic organisms involved in empyema caused by chest penetration typically are skin flora, such as S aureus or Staphylococcus epidermis. DIFFERENTIALS Pleural Effusion Pneumonia, Aspiration Pneumonia, Bacterial Pneumonia, Immunocompromised Pneumonia, Mycoplasma Pneumonia, Viral Tuberculosis Other Problems to be Considered: Sarcoidosis WORKUP Lab Studies: A CBC with differential may reveal a leukocytosis and a left shift. Collect sputum for Gram staining, culturing, and sensitivity testing. If tuberculosis is suspected, acid-fast bacilli testing should be ordered. Blood culturing Imaging Studies: Perform chest radiography to diagnose and differentiate pneumonia, pulmonary abscess, and empyema. Distinction of these conditions is important because lung abscesses and pneumonia require medical treatment, while empyema frequently requires definitive surgical therapy. On the chest radiograph, a lung abscess appears as a solitary cavitary area with an air-fluid level, which typically is present in a dependent portion of the lung. A surrounding patchy area of infiltrate aids in differentiating a pulmonary abscess from a cavitary lung cancer. On the chest radiograph, findings that suggest empyema, as opposed to lung abscess, include extension of the air-fluid level to the chest wall, extension of the air-fluid level across fissure lines, and a tapering border of the air-fluid collection.

The costophrenic angle should be closely inspected on the chest radiograph to assess the presence of fluid that suggests effusion or empyema. On the chest radiograph obtained with the patient upright, blunting of the costophrenic angle occurs when approximately 175 mL of fluid accumulates. A lateral chest decubitus radiograph, obtained with the patient on his or her side, reveals whether the pleural fluid is mobile and forms layers or whether it is loculated. If the chest radiograph does not adequately distinguish between lung abscess and empyema (versus mass or tumor), CT of the chest or ultrasonography will be required. Other Tests: Pulse oximetry - To assess oxygenation ABG analysis - To assess respiratory adequacy Transtracheal aspiration for culturing - If sputum findings are nondiagnostic Procedures: If a pleural effusion is present, a diagnostic thoracentesis should be performed, and the fluid should be analyzed for pH, lactate dehydrogenase, and glucose levels; specific gravity; and cell count with differential. Gram staining, cultures, and acid-fast bacillus and sensitivity tests should also be ordered. The fluid should be sent for cytology if cancer is suspected. The following findings are suggestive of an empyema or a parapneumonic effusion, which resolves only with a chest tube: Grossly purulent pleural fluid pH less than 7.2 WBC greater than 50,000 cells/mm3 (or polymorphonuclear leukocyte count of 1,000 IU/dL) Glucose less than 60 mg/dL Lactate dehydrogenase level greater than 1,000 IU/mL TREATMENT Prehospital Care: Supplemental oxygen should be given and an intravenous line started. Appropriate airway management, including intubation, should be performed depending on the patient's clinical condition. Emergency Department Care: All patients should undergo pulse oximetry and evaluation of their respiratory status. If respiratory failure is found or likely to occur, intubation and mechanical ventilation is necessary. Supplemental oxygen should be started for any patient who is acutely short of breath or who is hypoxic based on pulse oximetric findings. Once the diagnosis of a lung abscess is made, parenteral antibiotics should be started. Ideally, sputum and blood culture findings should be obtained prior to the initiation of antibiotics. After the diagnosis of empyema is made, prompt drainage by means of tube thoracostomy with use of parenteral antibiotics should be initiated. Consultations: Treatment of lung abscesses and empyema is performed in-hospital, with consultations with internists and/or thoracic surgeons. MEDICATION Lung abscesses are treated with a prolonged course of parenteral antibiotics that target organisms found in aspiration pneumonia. The initial choice of antibiotics frequently is empiric, beginning with clindamycin, cefoxitin, or penicillin. Subsequent therapy should be based on sputum or blood culture results. An empyema is treated with prompt chest tube drainage with use of parenteral antibiotics. For an empyema secondary to aspiration pneumonia or a parapneumonic process, choose antibiotics that are active against mouth flora. For an empyema secondary to penetrating chest trauma, administer antibiotics that have coverage for skin flora.

Drug Category: Antibiotics -- Empiric antimicrobial therapy must be comprehensive and

should cover all likely pathogens in the context of the clinical setting. Clindamycin (Cleocin) -- Lincosamide for the treatment of serious skin and soft-tissue staphylococcal infections. Also effective against Drug Name aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. Adult Dose 600 mg IV q6-8h Pediatric Dose 25-40 mg/kg/d IV divided tid/qid Documented hypersensitivity; regional enteritis; ulcerative colitis; Contraindications hepatic impairment; antibiotic-associated colitis Increases duration of neuromuscular blockade, induced by Interactions tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption Pregnancy B - Usually safe but benefits must outweigh the risks. Adjust dose in severe hepatic dysfunction; no adjustment necessary Precautions in renal insufficiency; associated with severe and possibly fatal colitis Cefoxitin (Mefoxin) -- Second-generation cephalosporin indicated for infections with gram-positive cocci and gram-negative rod. Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond. 2 g IV q6-8h 80-160 mg/kg/d IV divided q4-6h Documented hypersensitivity Probenecid may increase effects; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function) B - Usually safe but benefits must outweigh the risks. Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis Penicillin G (Pfizerpen) -- Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms; traditional drug for the treatment of lung abscess, but its spectrum of activity is narrow. 2 million U IV q4h 150,000 U/kg/d IV divided q4h Documented hypersensitivity Probenecid can increase effects; coadministration of tetracyclines can decrease effects B - Usually safe but benefits must outweigh the risks. Caution in impaired renal function

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Adult Dose Pediatric Dose Contraindications Interactions Pregnancy Precautions

FOLLOW-UP Further Inpatient Care: Inpatient care is mandatory for the management and assistance of the patient's respiratory status, continuation of intravenous antibiotics, and drainage of the abscess or empyema as needed. In/Out Patient Meds: Outpatient therapy for these conditions is not indicated or advised; inpatient care is mandatory. Antimicrobial therapy should be continued empirically until therapy can be guided with culture results.

Transfer: Transfer of these patients usually is not indicated unless advanced respiratory management or surgical drainage is not available without transfer. The patient should be transferred only after stabilization of their respiratory status and administration of intravenous antibiotics. Deterrence/Prevention: Prevention of aspiration is important to minimize the subsequent risk of lung abscess. Early intubation should be performed in patients who do not have a gag reflex. Position the patient in a manner that minimizes the risk of aspiration. For example, a patient who is vomiting should be placed on their side. Immediately suction the patient's orotracheal area if he or she aspirates in the ED. Complications: Complications of pulmonary abscess include pleural fibrosis, trapped lung, restrictive ventilatory defect, bronchopleural fistula, and pleurocutaneous fistula. Prognosis: The prognosis for both lung abscess and empyema generally is good. Ninety percent of lung abscesses are cured with medical management alone. MISCELLANEOUS Medical/Legal Pitfalls: Failure to suspect the diagnosis Failure to perform thoracentesis for a pleural effusion: The fluid results assist in the treatment of the patient by allowing differentiation of an empyema and parapneumonic effusion. Empyema requires chest tube placement. On the contrary, an effusion can be treated with intravenous antibiotics alone. BIBLIOGRAPHY Bartlett JG: Anaerobic bacterial infections of the lung. Chest 1987 Jun; 91(6): 901-9[Medline]. Bartlett JG: Anaerobic bacterial infections of the lung and pleural space. Clin Infect Dis 1993 Jun; 16 Suppl 4: S248-55[Medline]. Benjamin GC: Aspiration pneumonia, lung abscess and empyema. Emerg Med 1992; 276-8. Cowen ME, Johnston MR: Thoracic empyema: causes, diagnosis, and treatment. Compr Ther 1990 Oct; 16(10): 40-5[Medline]. Houston MC: Pleural fluid pH: diagnostic, therapeutic, and prognostic value. Am J Surg 1987 Sep; 154(3): 333-7[Medline]. Huang HC, Chang HY, Chen CW: Predicting factors for outcome of tube thoracostomy in complicated parapneumonic effusion for empyema. Chest 1999 Mar; 115(3): 751-6[Medline]. Hughes CE, Van Scoy RE: Antibiotic therapy of pleural empyema. Semin Respir Infect 1991 Jun; 6(2): 94-102[Medline]. Light RW: Pleural Diseases. Dis Mon 1992; 38: 261[Medline]. Miller KS, Sahn SA: Chest tubes. Indications, technique, management and complications. Chest 1987 Feb; 91(2): 258-64[Medline]. Pennza PT: Aspiration pneumonia, necrotizing pneumonia, and lung abscess. Emerg Med Clin North Am 1989 May; 7(2): 279-307[Medline]. Richardson JD, Carrillo E: Thoracic infection after trauma. Chest Surg Clin N Am 1997 May; 7(2): 401-27[Medline]. Sanford JP, Gilbert DN, Moellering RC: Guide to Antimicrobial Therapy. 1997: 28-9. Wiedemann HP, Rice TW: Lung abscess and empyema [published erratum appears in Semin Thorac Cardiovasc Surg 1995 Oct;7(4):247]. Semin Thorac Cardiovasc Surg 1995 Apr; 7(2): 119-28[Medline].