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The materials are intended exclusively for physicians and specialists with higher medical education. Articles are informational and educational in nature. Self-medication and self-diagnosis are extremely dangerous for health. The author of the articles does not give medical advice: a clinical pharmacologist is a doctor only and exclusively for doctors.

Pathogens

• S.aureus including MRSA
• Anaerobes
• Aerobic and microaerobic streptococci, including S. anginosus
• Gram-negative bacteria, especially Klebsiella
• Legionella
• Nocardia
• Actinomycetes
• Streptococcus group A
• H.influenzae (type B)
• Mycobacteria: M. tuberculosis , MAI, M. kansasii
• Fungi: aspergillus, cryptococcus, coccidia, histoplasma, blastomycosis

Clinical

• Clinical : cough, fever, sputum, often purulent, +/- weight loss. Chronic course often with night sweats, predisposition to aspiration and/or pleurisy.
• Physical examination : fever and signs of pneumonia +/- pleural effusion +/- severe gingivitis
• MRSA – Rare but always serious and becoming more common. A patient suspected of having MRSA has recently had or is ill with the flu, and signs of necrotizing pneumonia and shock in young adults or adolescents.
• Abscess rupture into the chest can lead to empyema.

Diagnosis:

• Chest Rg or CT scan scan will show parenchymal infiltrate with cavity
• CT scan provides the best anatomical definition – recommended when x-ray findings are ambiguous or when there is no response to administered antibiotics
• Bacteriological examination of sputum : not useful for anaerobes; indirectly determined by a putrid odor. S. aureus can be detected by gram stain and easily grown on nutrient media.
• Leukocytosis and anemia are characteristic of chronic abscess; leukopenia is characteristic of MRSA.
• Differential diagnosis based on the presence of air in the cavity with fluid : tuberculosis, MAC, empyema, malignancy, cyst, fungal infection, nocardia.
• Bronchoscopy, previously routine for all patients with lung abscess, is now performed only in cases of atypical course or cases of failure to therapy.

Treatment

Antibacterial therapy

• Principles : Rg/CT of the chest will reveal the presence of a cavity. Main reason = anaerobes. It is necessary to exclude tuberculosis, cancer, etc. Conventional treatment: clindamycin (especially if putrefactive). Bronchoscopy should only be used if there is an atypical course or no response to treatment.
• Treatment of choice : clindamycin 600 mg IV every 8 hours, then clindamycin 300 mg PO 4 times a day for 3 months or until chest Rg shows stabilization of a small lesion or complete disappearance of the lesion itself.
• Ampicillin/sulbactam (Unasyn, Sultasin in RF ) 1.5-3.0 g IV every 6 hours, then amoxicillin/clavulanate (Augmentin) 875 mg RO twice daily or clindamycin 300 mg RO qid as mentioned above.
• Imipenem 0.5–1.0 g IV every 6–8 hours or meropenem or doripenem followed by clindamycin 300 mg PO qid or amoxicillin/clavulanate (Augmentin) 875 mg PO twice daily
• MRSA: linezolid 600 mg IV every 12 hours or vancomycin 15 mg/kg IV every 12 hours
• Most non-specific lung abscesses are treated empirically with clindamycin and respond to treatment, but a course of 3 months or more is required.
• Most patients should receive intravenous antibiotics until clinical improvement, then switch to oral antibiotics for 2–3 months or until there is sustained improvement of little or no damage from regular chest Rg.

Antibacterial therapy in special categories of patients, guidelines yami , P. aeruginosa, Nocardia, Cryptococcus, Aspergillus , Pneumocystis pneumonia , Rhodococcus equi , MAC, M. kansasii , lymphoma

Nosocomial : S. aureus Gram-negative bacteria, especially Klebsiella .

Drainage and surgery

• Most patients already have a self-draining bronchial abscess and require only antimicrobial therapy.
• Drainage for bronchoscopy or physiotherapy – generally not helpful.
• Percutaneous transthoracic drainage – indicated for treatment-refractory abscesses.
• Postural drainage – performed frequently but plays no role in treatment and may be hazardous to the patient.
• Resection surgery – usually lobectomy or pulmonectomy if necessary.
• Indications for resection (rare):

§ no response to antibiotic treatment;

§ Abscess cavity > 6 cm in diameter;

§ severe/serious comorbidities;

§ Gram-negative pathogens.

Conclusion

• The duration of antibiotic therapy should be monitored by chest Rg until complete cure or stabilization of the process at the level of small damage.

More information

• The most common cause is anaerobic aspiration infection.
• Mycobacteria (especially tuberculosis), fungi (endemic, such as histoplasmosis, coccidioidomycosis, blastomycosis, cryptococcosis), cancer, infected cysts, and community-acquired MRSA should be excluded.
• Anaerobes are indicated by putrefactive discharge, chronic course, previous aspiration (impaired consciousness, dysphagia or gingivitis).
• Community-acquired pneumonia + abscess often observed in the post-influenza period – alert for S. aureus should lead to prompt administration of vancomycin or linezolid.
• Epidemic MRSA usually results in a fulminant septic course in patients with influenza, which presents with pulmonary necrosis and shock.

Literary sources

• Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44 Suppl 2:S27-72. An influential new consensus statement from two major societies. – http://cid.oxfordjournals.org/content/44/Supplement_2/S27.full.pdf
• Bartlett JG. Anaerobic bacterial infections of the lung and pleural space. Clin Infect Dis. 1993 Jun;16 Suppl 4:S248-55. – Available with a paid subscription.

J01CR01 – Ampicillin and beta-lactamase inhibitor

J01CR02 – Amoxicillin and beta-lactamase inhibitor

J01DH02 – Meropenem

J01DH04 – Doripenem

J01DH51 – Imipenem and cilastatin

J01FF01 – Clindamycin

J01XA01 – Vancomycin

J01XX08 – Linezolid

J85 Lung and mediastinal abscess

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The materials are intended exclusively for physicians and specialists with higher medical education. Articles are informational and educational in nature. Self-medication and self-diagnosis are extremely dangerous for health. The author of the articles does not give medical advice: a clinical pharmacologist is a doctor only and exclusively for doctors.

Pathogens

• In 80-90% of cases, brain abscesses are caused by mixed microflora
• Streptococcus can be detected in 30-50% of cases, but it can also be anaerobic and gram-negative flora
• Mainly gram-negative flora occurs in infants
• Foci of fungal infection most often include Candida spp., Aspergillus, Zygomycetes
• Most cases of purulent abscesses have no identified source

​ Primary sources (predisposing diseases) and probable pathogens ) and anaerobic streptococci, Haemo philus spp ., Dacteroides spp., Fusobacterium spp., Prevotella spp .

Odontogenic infection: S. viridans , anaerobic streptococci, Bacteroides spp., Fusbacterium, Prevotella spp., Actinomyces spp .

Clinic

• Massive symptoms: headache, nausea and vomiting, epileptic seizures, mental status changes, fever (usually only in 50% of patients). Focal neurological symptoms
• CT and MRI: Diffuse or annular echo-negative mass +/- edema of surrounding tissues
• Differential diagnosis: exclude tumor, less often – hemorrhage. Although any patient can have an abscess of bacterial etiology, in AIDS patients, immunosuppressed patients, and migrants, consideration should also be given to pathologies such as tuberculosis, fungal infection, and the possibility of parasitic infestation
• Complications of brain abscess may include rupture (ventriculitis/meningitis), coma, neurological sequelae (25-45%), death

Diagnosis

• The gold standard for diagnosis is aspiration or surgical removal of contents for Gram stain and microbiological examination. It is considered ideal to take the material before the start of antibiotic therapy or no later than the third day from its start
• Material samples must be sent for: 1) Gram staining and determination of anaerobic and aerobic cultures; 2) for verification of acid-resistant and mycobacteria; 3) fungi verification; 4) smear for toxoplasma and 5) histological examination
• Diagnosis suggestive on clinical/imaging findings +/- positive blood culture and presence of known source
• Only patients with small abscesses (12 and when the exact etiology of the disease is known are candidates for conservative treatment. Also candidates for conservative treatment are cases of multiple abscesses, abscesses that occur after surgery or when surgical treatment is a mortal danger
• Lumbar puncture is contraindicated and has very little specificity
• An HIV diagnosis must be performed, as a positive result may change the approach to the differential diagnosis.

Treatment

Empiric antibiotic therapy

• May be based on therapy for predisposing disease. Treatment is both surgical and conservative. Efforts should also be made to obtain aspirate/drainage, which can be a further guide to antibiotic therapy (performed before antibiotic therapy or no later than 72 hours from its initiation). Exception for surgical treatment: multiple abscesses, small abscesses (
• If primary source unknown : cefotaxime 2 g IV every 6 hours or ceftriaxone 2 g IV every 12 hours + metronidazole 500 mg IV every 8 hours OR ampicillin/sulbactam 100/50 mg/day kg IV every 6 hours
• Odontogenic infection : penicillin G 4 million units IV every 4 hours + metronidazole 500 mg IV every 6 hours
• Sinusitis : cefotaxime 2 g IV every 6 hours or ceftriaxone 2 g IV every 12 hours + metronidazole 500 mg IV every 8 hours
• Otitis media, mastoiditis : cefotaxime 2 g IV every 4-6 hours or ceftriaxone 2 g IV every 12 hours or cefipime 2 g every 8 hours + metronidazole 500 mg every 8 hours OR piperacillin/tazobactam 4 . 5 g IV every 6 hours
• Endocarditis: vancomycin (loading dose 25-30 mg/kg IV, then 22.5 mg/kg IV every 12 hours) or nafcillin/ofloxacin 2 g IV every 4 hours
• Lung abscess/empyema: penicillin G 4 million units every 4 hours + metronidazole 500 mg IV every 6 hours
• Post-traumatic abscess: cefotaxime 2 g IV every 6 hours or ceftriaxone 2 g IV every 12 hours + metronidazole 500 mg every 8 hours +/- rifampicin 100 mg/kg every 24 hours
• Postoperative abscesses: vancomycin (loading dose 25-30 mg/kg IV, then 22.5 mg/kg IV every 12 hours) or linezolid 600 mg every 12 hours + ceftazidime 2 g IV every 8 hours or cefipime 2 g IV every 8 hours or meropenem 2 g IV every 8 hours or piperacillin/tazobactam 4.5 g IV every 6 hours +/- rifampicin 10 mg/kg every 24 hours
• Nocardia spp : add trimethoprim/sulfamethoxazole 5-6 mg/kg IV every 6-8 hours
• The duration of therapy in each case should be individual. The general course should be at least 4-6 weeks for a surgically treated abscess, 6-8 weeks for non-drained or multiple abscesses.

Surgery and complementary therapies:

• Surgical tactics: aspiration of the contents of the abscess through a burr hole OR surgical drainage by craniotomy
• Dexamethasone (10 mg IV loading dose, then 4 mg every 6 hours) may be needed if the disease is extensive and/or there is significant neurological impairment
• The problem of lowering intracranial pressure may require additional neurosurgical procedures, such as ventriculostomy or shunt placement
• Abscess smaller than 2.5-3.0 cm can be treated with conservative methods only
• There is no reliable data indicating which method of surgical treatment of brain abscess is the best – aspiration or excision.

Pathogenetic therapy

• Streptococci (penicillin-susceptible): penicillin G 4 million units every 4 hours or ampicillin 2 g IV every 4 hours
• S. aureus (MSSA): nafcillin or oxacillin 2 g IV every 4 hours
• MRSA: vancomycin (loading dose 25-30 mg/kg IV, then 22.5 mg/kg IV every 12 hours) or linezolid 600 mg every 12 hours
• Streptococci, gram-negative rods, H. influenzae : cefotaxime 2 g IV every 4-6 hours or ceftriaxone 2 g IV every 12 hours or cefepime 2 g IV every 8 hours
• Anaerobes: metronidazole 500 mg IV every 6 hours or clindamycin 600–1200 mg IV every 6–8 hours
• Gram-negative rods, anaerobes: meropenem 2 g IV every 8 hours
• H. influenzae , gram-negative rods, streptococcus: ciprofloxacin 400 mg IV every 8 hours or levofloxacin 750 mg IV every 24 hours
• Gram-negative rods: aztreonam 2 g IV every 6-8 hours
• Nocardia : trimethoprim/sulfamethoxazole 10-20 mg/kg IV divided every 6-8 hours (highest dose for nocardia)
• Cysticercosis: albendazole 400 mg PO twice a day for 8-30 days or praziquantel 15 mg/kg 3 times a day orally x 15 days

Conclusion

• Patients who do not respond to ongoing therapy within 1-2 weeks should be operated on, especially in the case of only conservative therapy
• The duration of therapy should be strictly individual. The usual course should be at least 4-8 weeks and longer if necessary
• Oral therapy can also be used, but there is still no good quality evidence to justify recommending it
• The recurrence rate of brain abscesses is about 8%
• Patients with multiple abscesses or abscesses less than 2.5 cm are often treated empirically only
• Indications for surgical treatment are: the presence of an abscess, an abscess refractory to empirical therapy, an immunocompromised patient

Optional:

Arlotti M, Grossi P, Pea F, Tomei G, Vullo V, De Rosa FG, Di Perri G, Nicastri E, Lauria FN, Carosi G, Moroni M, Ippolito G; GISIG (Gruppo Italiano di Studio sulle Infezioni Gravi) Working Group on Brain Abscesses. Consensus document on controversial issues for the treatment of infections of the central nervous system: bacterial brain abscesses . Int J Infect Dis. 2010 Oct – http://www.ijidonline.com/article/S1201-9712(10)02368-4/pdf

J01CA01 – Ampicillin

J01CE09 – Benzylpenicillin procaine

J01CF04 – Oxacillin

J01CR01 – Ampicillin and beta-lactamase inhibitor

J01CR05 – Piperacillin and beta-lactamase inhibitor

J01DD01 – Cefotaxime

J01DD02 – Ceftazidime

J01DD04 – Ceftriaxone

J01DF01 – Aztreonam

J01DH02 – Meropenem

J01FF01 – Clindamycin

J01MA02 – Ciprofloxacin

J01MA12 – Levofloxacin

J01XA01 – Vancomycin

J01XD01 – Metronidazole

J01XX08 – Linezolid

J04AB02 – Rifampicin

P02BA01 – Praziquantel

P02CA03 – Albendazole

G06.