Lung abscess medical therapy: Difference between revisions
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==Medical Therapy== | ==Medical Therapy== | ||
*Empiric treatment should be commenced after culture samples are obtained. | *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. | *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 tuberculosis|(multidrug resistant common bacteria]], [[Mycobacterium|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 [[Biopsy|lung biopsy]]).<ref name="pmid20389050">{{cite journal |vauthors=Takayanagi N, Kagiyama N, Ishiguro T, Tokunaga D, Sugita Y |title=Etiology and outcome of community-acquired lung abscess |journal=Respiration |volume=80 |issue=2 |pages=98–105 |year=2010 |pmid=20389050 |doi=10.1159/000312404 |url=}}</ref> | |||
*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. <ref name="pmid20389050">{{cite journal |vauthors=Takayanagi N, Kagiyama N, Ishiguro T, Tokunaga D, Sugita Y |title=Etiology and outcome of community-acquired lung abscess |journal=Respiration |volume=80 |issue=2 |pages=98–105 |year=2010 |pmid=20389050 |doi=10.1159/000312404 |url=}}</ref> | |||
*In that case, the length of [[Antibiotics|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). | |||
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* | ===Empiric=== | ||
*Preferred regimen (1): [[Ampicillin-Sulbactam|Ampicillin + Sulbactum]] 3g IV q6h | |||
*Preferred regimen (2): [[Imipenem-Cilastatin|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): [[Penicillin|Intravenous penicillin G]] (10 to 20 million units daily in divided doses every four to six hours) for 4 to 6 weeks | |||
====[[Nocardia|Nocardia .spp]]==== | |||
*Preferred regimen (1): [[Sulfamethoxazole-Trimethoprim|TMP-SMX]] 15 mg/kg IV of the [[trimethoprim]] component per day in three or four divided doses '''plus'''[[Amikacin]] 7.5 mg/kg IV every 12 hours | |||
====[[Fungi]]==== | |||
*Preferred regimen (1): [[Amphotericin B]] 3-5mg/kg/day/IV | |||
====[[Parasites|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|microaerophilic strains]], [[aerobic streptococci]], and [[Actinomyces]] species.<br> | |||
[[Metronidazole (patient information)|Metronidazole]] in combination with penicillin is given due to the observed failure of penicillin to cure penicillin-resistant [[Prevotella|Prevotella melaninogenica]], [[Porphyromonas|Porphyromonas asaccharolytica]], and [[Bacteroides]] species.<br> | |||
Patients allergic to [[penicillin]] and [[cephalosporins]] may be treated with [[clindamycin]] combined with [[aztreonam]], [[ciprofloxacin]] or [[levofloxacin]] for coverage of [[gram-negative]] pathogens | |||
== Reference == | == Reference == | ||
{{Reflist|2}} | {{Reflist|2}} | ||
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Latest revision as of 22:34, 29 July 2020
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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[1]
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).[2]
- 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. [2]
- 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
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
- ↑ Allewelt M, Schüler P, Bölcskei PL, Mauch H, Lode H (2004). "Ampicillin + sulbactam vs clindamycin +/- cephalosporin for the treatment of aspiration pneumonia and primary lung abscess". Clin. Microbiol. Infect. 10 (2): 163–70. PMID 14759242.
- ↑ 2.0 2.1 Takayanagi N, Kagiyama N, Ishiguro T, Tokunaga D, Sugita Y (2010). "Etiology and outcome of community-acquired lung abscess". Respiration. 80 (2): 98–105. doi:10.1159/000312404. PMID 20389050.