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DOI 10.3233/JPI-2009-0148
IOS Press
Review Article
Abstract. Lung abscess is an uncommon but challenging condition to manage. Predisposing factors including pulmonary
aspiration and impaired mucociliary defense mechanisms increase the likelihood of developing a secondary lung abscess.
Aspirating anaerobic organisms from the mouth leading to pneumonia and a secondary lung abscess is more likely to be
seen in children with neuro-cognitive impairment. The more likely anaerobic organisms include Peptostreptococcus species,
Fusobacterium nucleatum and Prevotella melaninogenica. These organisms may be difficult to isolate without specific anaerobic
transport vials and culture media. The rise of interventional radiology, higher positive culture results, better targeted antibiotic
regimes and a greater awareness of hospital acquired pathogens have been significant is decreasing the length of hospitalization
for children with lung abscesses. The morbidity and mortality for lung abscess in children is vastly superior to that in adult
patients because of the lack of co-morbidities in the pediatric population.
Keywords: Lung abscess, pathophysiology, microbiology, anaerobes, interventional radiology, antibiotic therapy
1. Introduction 2. Definition
Lung abscess is an uncommon but important pedi- A lung abscess is a thick-walled cavity that contains
purulent material resulting from suppuration and necro-
atric problem. It is believed to be less common in chil-
sis of the lung parenchyma [1–4]. The lung abscess
dren than adults, although the literature is accordingly
may be primary or secondary. A primary lung abscess
relatively sparse. Lung abscesses may be classified as
occurs in a previously well child with normal lungs,
primary or secondary, depending upon the existence
usually as a complication of pneumonia, and will usu-
of predisposing conditions. Similarly, lung abscesses
ally reach a full recovery without any sequalae. A sec-
may be single or multiple. Those that are secondary
ondary lung abscess occurs in a child with an under-
are far more likely to be caused by anaerobic bacteria. lying airway or lung abnormality, which may be con-
Typically, in children as in adults, it is the existence genital (cystic fibrosis, immunodeficiency or structural
of underlying conditions, which will influence the ap- malformation) or acquired (achalasia or a neurodevel-
proach to management, and the prognosis of a patient opmental abnormality) [1–3].
who presents with a lung abscess [1–3].
3. Epidemiology
∗ Correspondence: Dr. Dominic A. Fitzgerald, Department of Res-
piratory Medicine, The Children’s Hospital at Westmead, Locked
Bag 4001, Westmead, Sydney, NSW, Australia, 2145. Tel.: +61 2 It has been suggested that lung abscesses were more
9845 3397; Fax: +61 2 9845 3396; E-mail: dominif2@chw.edu.au common in previous years [1] before the ability of pre-
1305-7707/09/$17.00 2009 – IOS Press and the authors. All rights reserved
28 H. Alsubie and D.A. Fitzgerald / Lung abscess in children
Table 1
Factors predisposing to secondary lung abscesses may be seen in
secretions and saliva or gastric contents, aspiration is a
children at increased risk of pulmonary aspiration such as those with common initial step in the progression from pneumoni-
the following predisposing factors tis to pneumonia to lung abscess. Specifically, predis-
Immunocompromised host: posing factors in well children in adolescence include
Chemotherapy anesthesia, head injury with impaired cognition, exces-
Immunosuppressive treatment (corticosteroids)
sive sedation or alcohol ingestion, poor dental hygiene
Nutritional deficiencies
Localized structural lung abnormalities: together with poor gingival status that may be seen in
Congenital cystic adenomatoid malformation children receiving anticonvulsants [1–3]. The signifi-
Bronchogenic cyst cance of the introduction of oral flora into the lung is
Tracheo-esophageal fistula (H-type)
Generalized suppurative lung disease: that the bacteria are predominantly anaerobic and this
Cystic fibrosis will alter the antibiotic approach [3,6]. It is worth not-
Hematogenous spread ing that lung abscess is rare in neonates and also may
Neurodevelopmental abnormalities:
be associated with predisposing factors such as lung
Poorly coordinated swallowing
Neuromuscular condition such as myotonic dystrophy and cyst, pneumonia, cognitive impairment or the presence
Duchenne muscular dystrophy of central venous lines. Again, the early symptoms and
Esophageal motility problems: signs may be non-specific [1–3].
Following tracheo-esophageal atresia repair
Esophageal strictures In the child with ongoing pulmonary aspiration, it is
Achalasia the impaired mucociliary defense mechanisms, which
increase the likelihood of pulmonary morbidity and
venting aspiration of infected fluid at the time of ton- mortality [6]. These may occur for a variety of reasons,
sillectomy, the widespread availability of antibiotics which begin with pooled oral secretions and poorly co-
to treat chest infections and the more recent evolution ordinated swallow mechanisms. Contributing to this
of better lung imaging to enable earlier treatment of may include: gingival infection, neuromuscular weak-
pneumonia before complications, such as lung abscess ness, structural proximal airway abnormalities (e.g.
and pneumonia arose [1]. Figures from Canada in the cleft larynx), vocal cord palsy, tracheo-bronchomalacia
1980s put the incidence of children hospitalized with and significant thoracic scoliosis [2,3,6]. Converse-
a lung abscess at 0.7 per 100,000 [5]. Lung abscess ly, there may be significant gastro-esophageal reflux
may occur at any age but is thought to be less common of acidic stomach contents and pulmonary aspiration
in the neonatal period [1]. However, this may change of these fluids. Indeed, it is often gastro-esophageal
with the increasing shift of neonatal care to support in- reflux, which is the focus of investigations and inter-
fants at the extreme of viability and the resulting inva- ventions such as gastrostomy tube insertion and fun-
sive techniques (e.g. central venous lines for parenteral doplication of the stomach. The role of fundoplication
nutrition) to support these technology dependent chil- may have been over-emphasized previously as there is
dren, often with significant neurocognitive and physical now a trend toward inserting gastrostomy tubes with-
disabilities [1,2,6]. out fundoplication in the absence of documented evi-
dence of reflux [6]. This is a reasonable approach, but
it is important to consider the possibility of inducing
4. Predisposing factors gastro-esophageal reflux following gastrostomy feeds
at higher volumes (e.g. bolus feeds as opposed to lower
A lung abscess may arise from aspiration of infected volumes given as continuous overnight feeds) [6].
fluid, aspiration of non-infected fluid which triggers a Additional factors to consider in a previously well
chemical irritation (e.g. acidic gastric fluids), a primary child include the case of a bacterial pneumonia which
bacterial lung infection, hematogenous spread of bacte- often follows an otherwise unremarkable viral upper
ria (e.g. bacterial endocarditis of the right sided cham- respiratory tract infection [1,2,4]. The presumed bac-
bers of the heart) or contiguous spread of infection from terial infection may or may not have been treated along
a neighboring organ [1,3]. Pulmonary aspiration may the course of progressing to a lung abscess. Alterna-
be the central factor in the evolution of a lung abscess. tively, the child may have developed bacterial endo-
Whether this occurs acutely in a previously well child carditis, more commonly on an abnormal heart valve
who has inhaled brackish, infected water or in a debil- or in a structurally abnormal heart, which has sent off
itated child with recurrent aspiration of upper airway septic emboli to the lungs (Table 1) [1,2,5–7].
H. Alsubie and D.A. Fitzgerald / Lung abscess in children 29
Table 2
Common pathogens in lung abscesses
tric acid and so it is possible to cause an inflammatory
response without highly acidic fluid [7–10].
Classification Pathogen
It is likely that the number of episodes of aspira-
Aerobic Gram-positive cocci Streptoococcus pneumoniae
Staphylococccus aureus
tion, the volume of aspirated material and any impair-
Aerobic Gram-negative Pseudomonas aeruginosa ment of mucociliary clearance mechanisms contribute
bacilli Klebsiella pneumoniae to the development of a lung abscess [1,2,6,7]. The
Anaerobic cocci Peptostreptococcus, time course for progression from aspiration to pneu-
Microaerophilic streptococci
Anaerobic Gram-negative Bacteroides species monia and abscess is not rapid. Indeed, the course is
bacilli Prevotella, Fusobacterium somewhat insidious, especially in children with chronic
species low-grade cough related to impaired mucociliary clear-
Fungus Candida albicans, Aspergillus ance. Interestingly, it takes days before the symptoms
species
and signs develop even after a known aspiration event
has occurred, because the body’s host defense mecha-
5. Pathophysiology nisms may decrease perfusion to an area of aspiration
and thereby reduce the influx of defense mediators and
Once the lungs are soiled, an inflammatory cascade the egress of infective material [5–7]. Animal work
is triggered giving rise to the chemical pneumonitis, has demonstrated that there is a biphasic response after
which predisposes to infection. Aspiration pneumoni- acid aspiration [10].
tis is an acute lung injury, which occurs after the in- A lung abscess may arise from embolic phenomena
halation of regurgitated gastric contents [7]. Aspira- such as right-sided bacterial endocarditis, more likely
tion pneumonitis, was originally described as Mendel- in children with right-sided heart valve abnormalities
son’s syndrome from the adult obstetric literature [8], and post-surgery or the placement of a central venous
is a chemical injury caused by the inhalation of sterile line [2,6,7]. Rarely, children with septicemia may have
gastric contents which is seen as distinct from aspira- foci in the lung from hematogenous spread or from
tion pneumonia which is an infectious process resulting thrombophlebitis with septic emboli. In addition, lo-
from the inhalation of oropharyngeal secretions which cal extension from pharyngeal abscesses or abdominal
are colonized by pathogenic bacteria [7]. There is con- collections is also seen [7].
siderable overlap between these conditions and it may In the case of a single small lung abscess, the changes
be difficult to distinguish them in the clinical setting. in ventilation and perfusion may be minimal. As the
Nonetheless, both may contribute to the subsequent de- abscess grows there may be more significant changes
velopment of the relatively uncommon complication of in ventilation and perfusion, resulting in hypoxemia
lung abscess (Table 2). and tachypnea. With the evolution of pleuritic pain
Aspiration pneumonitis is seen in children with a from pleural inflammation, there may be a restrictive
marked disturbance of consciousness which may be component to lung function due to the loss of lung
seen in conditions including: status epilepticus, hypox- volume and reduced lung compliance [1].
ic and metabolic encephalopathies, catastrophic cere-
brovascular events, cerebral trauma as well as patients
with severe neurocognitive impairment of uncertain eti- 6. Clinical presentation
ology, often referred to as having “cerebral palsy” [4,6,
7]. It is a recognized complication of general anesthe- The presentation of lung abscess may be insidious,
sia for any operative procedure and may occur despite typically evolving over two weeks in a child with fever
all appropriate anesthetic precautions [6,7]. Again, in and cough. Other features may include chest pain, dys-
the adult literature, a correlation between the level of pnea, sputum production and hemoptysis (Table 3) [1,
impaired consciousness as measured by the Glasgow 2,5]. The physical findings may range from no de-
Coma Scale and the risk of aspiration was demonstrat- tectable abnormality in the chest to signs of consolida-
ed [9]. It has been suggested that a gastric aspirate pH tion (Table 4). Not infrequently, the diagnosis is made
of less than 2.5 and a volume of greater than 0.3 mL on a chest radiograph as an investigation in a child with
per kilogram of body weight are required for the devel- a persisting cough where a well-circumscribed shadow
opment of aspiration pneumonitis in adults [7]. There is seen containing an air-fluid level [2]. This is more of-
is no corresponding data for children. However, the ten the case in children with a primary lung abscess [1,
stomach contents contain other irritants besides gas- 2,11].
30 H. Alsubie and D.A. Fitzgerald / Lung abscess in children
Table 3
Symptoms reported in several series for children with a lung abscess
Parameters Ho et al. [2] Tan et al. [18] Chan et al. [24] Yen et al. [25]
(n = 23) (n = 23) (n = 27) (n = 23)
Fever 83% 84% 100% 91%
Cough 65% 53% 67% 87%
Dyspnea 36% 35% 19% 35%
Table 4
Clinical signs elicited in children with primary and secondary lung abscess from the Children’s
Hospital at Westmead (1985–2001) [2]
Parameters Primary lung abscess Secondary lung abscess
(n = 29) (n = 14)
Tachypnea 100% 71%
Dull percussion note or reduced air entry 44% 79%
Fever 44% 50%
Localized crepitations 33% 36%
In contrast, a child with a secondary lung abscess is a cohort of 74 children with aspiration pneumonia: 52
more likely to have underlying medical problems. Such with pneumonitis, 12 with necrotizing pneumonia and
problems may include recurrent pulmonary aspiration 10 with a lung abscess [12]. Interestingly, an average
of saliva and upper airway secretions, debilitation, sig- of 4.9 organisms per aspirate was isolated (2.7 anaer-
nificant neuron-cognitive disability, dysphagia, naso- obes and 2.2 aerobes) in that study. It is not uncommon
gastric tube feeding, seizure disorders, altered levels to isolate multiple organisms from lung abscesses and
of consciousness, congenital or acquired immunodefi- more commonly in secondary lung abscesses [12–17].
ciency states and congenital abnormalities of proximal This is not only related to how the specimen is col-
airway structures [11]. In vulnerable individuals, the lected, percutaneous or trans-tracheal versus purulent
presence of poor oral hygiene predisposes to aspiration sputum or unprotected bronchial brushings where con-
pneumonia, lung abscess and empyema with anaerobic tamination with oral flora may occur [12–14]. Anaer-
organisms [7]. obes are more common in patients who are predisposed
to aspiration, such as with dental caries, seizure dis-
orders and impaired co-ordination of swallowing [13–
7. Microbiology 16]. In a cohort of adults presenting with acute lung
abscess in South Africa in the early 1990s, 29 of 34
The pathogens causing a lung abscess may be classi- patients had predisposing factors for lung abscess (i.e.
fied as being aerobic, anaerobic or fungal. More com- secondary lung abscess). In these subjects, anaerobes
monly isolated pathogens are listed in Table 1. In addi- accounted for 74% of the bacterial yield, and apart from
tion to Staphylococcus aureus, one should also consider those subjects with tuberculosis, the bacterial cultures
group B Streptococcus, Escherichia coli and Klebsiella obtained consisted of anaerobes alone in 52% and of
pneumoniae in young infants [1]. However, with age, aerobes alone in only 22% [17]. In a pediatric sample
the likelihood of predisposing factors to lung abscess of patients presenting with an acute lung abscess from
increases and therefore the likelihood of an anaerobic Zimbabwe in 1992, more aerobic organisms were cul-
pathogen increases. From the work in the 1970s, us- tured, especially S. aureus, reflecting different risk fac-
ing trans-tracheal aspiration, studies demonstrated that tors for lung abscess (e.g. post-viral lower respiratory
anaerobic bacteria accounted for 60–80% of lung ab- tract infection) and the higher proportion of primary
scess, with Peptostreptococcus species, Fusobacterium lung abscesses seen [17].
nucleatum and Prevotella melaninogenica predominat- Importantly, the key issues are to consider the likeli-
ing [12–15]. These bacteria matched known oral flora, hood of anaerobic pathogens, to attempt to obtain un-
which had been implicated by Dr David Smith at Duke contaminated purulent material from the abscess cavity,
University in the pre-antibiotic era of the 1920s [15]. culture the pus in appropriate anaerobic media and treat
In children with aspiration pneumonia,the likelihood accordingly. The sensitivity of some obligate anaer-
of yielding an anaerobic organism was reported to be obes to die when exposed to air will undermine attempts
as high as 90% in trans-tracheal aspirates evaluated in to isolate causal anaerobic bacteria and so a liquid spec-
H. Alsubie and D.A. Fitzgerald / Lung abscess in children 31
8. Imaging
Table 5
Antibiotic treatment doses∗
Intravenous antibiotics Dose [26]
Benzylpenicillin (30 mg/kg up to) 1.2 g 4 to 6 hourly
Di/Flucloxacillin (50 mg/kg up to) 2 g 6 hourly
Cefotaxime 50 mg/kg 8 hourly
Ceftriaxone 50 mg/kg once daily
Clindamicin (10 mg/kg up to) 450 mg 8 hourly
Vancomycin (10 mg/kg up to) 500 mg 6 hourly
Metronidazole (12.5 mg/kg up to) 500 mg 8 to 12 hourly
Meropenem (20 mg/kg up to) 1 g 8 hourly
∗ Derived from the Children’s Hospital at Westmead Handbook [26].
Table 6
Complications of lung abscess
whereas in children the mortality is significantly lower,
probably of the order of less than 5% and occurs pre-
Spontaneously rupture into adjacent compartment
Empyema, pyothorax or pneumothorax
dominantly in those with a secondary lung abscess [21].
The connection between the abscess cavity and the pleural space It is the co-morbidity of the predisposing conditions in
Bronchopleural fistula both adults and children that contributes to the worse
Hematogenous spread leading to multiple abscesses prognosis and higher mortality rate. Consequently, al-
Anesthesia complication:
Aspiration, reaction, post-op nausea and fever
most all immunologically competent children with a
Radiation exposure: primary lung abscess would be expected to recover,
Computerized tomography scans, chest radiographs whereas those with predisposing conditions, predom-
Reaction to antibiotics: inantly immunocompromised states, would expect to
Fever, rash or anaphylaxis
Site scar fare significantly worse [1,2,18,21,24,25].
[18] T.Q. Tan, D.K. Seilheimer and S.L. Kaplan, Pediatric lung urokinase and video-assisted thoracoscopic surgery for treat-
abscess: clinical management and outcome, Pediatr Infect Dis ment of childhood empyema, Am J Respir Crit Care Med 174
J 14 (1995), 51–55. (2006), 221–227.
[19] J.F. Johnson, W.E. Shiels, C.B. White and B.D. Williams, Con- [23] S. Sonnappa and A. Jaffe, Treatment approaches for empyema
cealed pulmonary abscess: diagnosis by computed tomogra- in children, Paediatr Respir Rev 8 (2007), 164–170.
phy, Pediatrics 78 (1986), 283–286. [24] P.C. Chan, L.M. Huang, P.S. Wu et al., Clinical management
[20] E. Bouza and E. Cercenado, Klebsiella and enterobacter: an- and outcome of childhood lung abscess: a 16-year experience,
tibiotic resistance and treatment implications, Semin Respir J Microbiol Immunol Infect 38 (2005), 183–188.
Infect 17 (2002), 215–230. [25] C.C. Yen, R.B. Tang, S.J. Chen and T.W. Chin, Pediatric
[21] B. Hirshberg, M. Sklair-Levi, R. Nir-Paz, L. Ben-Sira, V. lung abscess: a retrospective review of 23 cases, J Microbiol
Krivoruk and M.R. Kramer, Factors predicting mortality of Immunol Infect 37 (2004), 45–49.
patients with lung abscess, Chest 115 (1999), 746–750. [26] D. Isaacs and H. Kilham, The Children’s Hospital at Westmead
[22] S. Sonnappa, G. Cohen, C.M. Owens et al., Comparison of Handbook, Sydney: McGraw Hill, North Ryde, 2004.