The Etiology and Antimicrobial Susceptibility Patterns of Microorganisms in Acute Community-Acquired Lung Abscess

doi:10.1378/chest.108.4.937

Chest

Volume 108, Issue 4, October 1995, Pages 937-941

https://doi.org/10.1378/chest.108.4.937 Get rights and content

Objective

To determine the spectrum and antibiotic susceptibility patterns of microorganisms causing acute community-acquired lung abscess.

Design

A prospective survey.

Setting

Medical emergency department and wards of a tertiary teaching hospital.

Patients

Thirty-four adult patients with both clinical and radiologic features compatible with a diagnosis of acute community-acquired lung abscess who had received less than 48 h of antibiotic therapy.

Interventions

Microbiologic specimens obtained by percutaneous lung aspiration and with a protected specimen brush via fiberoptic bronchoscopy were submitted for aerobic and anaerobic culture.

Main outcome measures

Identification of all microorganisms, including anaerobes, and determination of antibiotic susceptibility.

Results

A mean of 2.3 bacterial species per patient was isolated, anaerobes alone being isolated in 44% of cases, aerobes alone in 19%, and mixed aerobic and anaerobic isolates in 22%. Aerobic Gram-negative pathogens were uncommon. In seven patients, Mycobacterium tuberculosis was identified; in two it was associated with other bacteria. In four patients, no organisms were isolated. All the nonmycobacterial isolates were susceptible to amoxicillin-clavulanate and in addition the anaerobes were all susceptible to chloramphenicol and almost all to a combination of penicillin and metronidazole. Among the anaerobes, the level of resistance to penicillin, metronidazole, and clindamycin individually was 21%, 12%, and 5%, respectively.

Conclusions

Community-acquired acute lung abscess is usually caused by multiple anaerobic and less frequently aerobic Gram-positive microorganisms, which should respond to empirical therapy with amoxicillin-clavulanate, chloramphenicol, or a combination of penicillin and metronidazole. Tuberculosis, which may be indistinguishable from an acute lung abscess, occurred in 21% of patients in our study. Most bacterial pathogens are sensitive to conventional antimicrobial therapy and further investigation with percutaneous lung aspiration or bronchoscopy is indicated only when there is lack of early response to therapy or there is the presence of atypical clinical features.

Section snippets

Methods

All adult patients with clinical and radiologic features compatible with a diagnosis of acute lung abscess and who required admission to the emergency unit or medical wards of our 1,200-bed teaching hospital from January 1992 until December 1993 were included following informed consent. Patients who had been hospitalized within the past month or who had received antimicrobial therapy for more than 48 h before the special investigations could be performed were excluded. Patients who had sputum

Results

There were 27 male and 7 female patients with a median age of 37 years (range, 20 to 73 years) enrolled into this study over a 24-month period. All patients had received antibiotics prior to microbiologic sampling of the abscess, with 30 patients having received antibiotics for less than 24 h and 4 for less than 48 h. During the study period, 52 patients had been referred for inclusion, of whom 18 were excluded (6 patients had already been receiving antibiotics for more than 48 h, 6 patients

Discussion

The pathogenesis of acute lung abscess has changed over the past decade and in a recent description of this disease,¹ pneumonia (40% of cases), severely immunocompromising disease, including pulmonary metastases (27%), and primary bronchial carcinoma (17%) were the underlying causes. In our study, however, the patient population was similar to earlier descriptions of community-acquired lung abscesses. Most patients were men who had a significant history of alcohol abuse, severe dental caries,

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Empirical antimicrobial therapy is recommended for severe pneumonia. However, the pathogenic organisms of aspiration pneumonia are diverse, including Streptococcus pneumoniae (S. pneumoniae), Haemophilus influenzae, Staphylococcus aureus, Streptococcus milleri group, Pseudomonas aeruginosa, microaerophiles, and anaerobic bacteria [6,11,12]. Cefepime is a fourth-generation cephalosporin with an extended-spectrum.
Treatment of aspiration pneumonia is an important problem due to aging of populations worldwide. However, the effectiveness of cefepime in aspiration pneumonia has not yet been evaluated.
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Lung abscesses are necrotic cavitary lesions of the lung parenchyma. They are usually caused by anaerobic bacteria or mixed flora and typically occur after aspiration. Primary lung abscesses occur in previously healthy patients with no underlying medical disorders and are usually solitary. Secondary lung abscesses occur in patients with underlying or predisposing conditions and may be multiple. The initial diagnosis is usually made by chest radiography showing a lung cavity with an air-fluid level. Typically, the cavity wall is thick and irregular, and a surrounding pulmonary infiltrate is often present. The differential diagnosis of pulmonary cavitation is wide, including different types of possible infections, neoplasia and malformations of the bronchial tree. Management is usually based on prolonged antibiotic treatment. Failure of conservative management, manifested by the persistence of sepsis and/or other abscess complications, may necessitate drainage with invasive techniques (percutaneous, endoscopic or surgical) or open surgical removal of the lung lesion in patients with good performance status and sufficient respiratory reserve.
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Choice of empiric antimicrobials should be guided by clinical history, local antimicrobial resistance patterns, antimicrobial stewardship policies, and pharmacologic properties of antibiotics. For patients with community-acquired pleural empyema in whom the risk for methicillin-resistant S aureus and highly resistant gram-negative infection is low, a second-generation or a nonpseudomonal, third-generation cephalosporin (eg, ceftriaxone) or an aminopenicillin with β-lactamase inhibitor (eg, ampicillin/sulbactam) will provide activity against the most commonly identified organisms.54-58 Anaerobic organisms should be treated empirically and, whereas ampicillin/sulbactam is active against a range of anaerobes, ceftriaxone requires the addition of an agent such as metronidazole.
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Aspiration (Box 3) is the most common cause of lung abscess and tends to primarily affect the dependent portions of the lung, including the posterior segment of the right upper lobe and superior segment of the right lower lobe. Community-acquired lung abscesses tend to be polymicrobial24 and dominated by anaerobic oral flora, including Peptostreptococcus species, Bacteroides species, Fusobacterium species, and Prevotella species, in addition to microaerophilic streptococci such as Streptococcus milleri and Streptococcus anginosus. Hospital-acquired abscesses tend to be more commonly associated with aerobic organisms such as Pseudomonas aeruginosa, Staphylococcus aureus, and Klebsiella pneumoniae.3
Tazobactam/piperacillin for moderate-to-severe pneumonia in patients with risk for aspiration: Comparison with imipenem/cilastatin
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To compare clinical efficacy between TAZ/PIPC (1:4 compound) and imipenem/cilastatin (IPM/CS) in patients with moderate-to-severe aspiration pneumonia.
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Supported by the South African Medical Research Council.

revision accepted May 18.

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Chest

Clinical Investigations: Infection: ArticlesThe Etiology and Antimicrobial Susceptibility Patterns of Microorganisms in Acute Community-Acquired Lung Abscess

Objective

Design

Setting

Patients

Interventions

Main outcome measures

Results

Conclusions

Section snippets

Methods

Results

Discussion

Am J Surg

Am J Med

Chest

Chest

Chest

Chest

Yield of percutaneous needle lung aspiration in lung abscess

Chest

Lung abscess in children in Harare, Zimbabwe

East Afr Med J

Lung abscess and empyema

Q J Med

Clinical Investigations: Infection: Articles
The Etiology and Antimicrobial Susceptibility Patterns of Microorganisms in Acute Community-Acquired Lung Abscess