Lung abscess in children

doi:10.1016/j.prrv.2006.10.002

Paediatric Respiratory Reviews

Volume 8, Issue 1, March 2007, Pages 77-84

https://doi.org/10.1016/j.prrv.2006.10.002 Get rights and content

Summary

Lung abscess is an uncommon paediatric problem, with a paucity of quality data on the subject in the medical literature. Although the condition has for many years been managed successfully with prolonged courses of intravenous antibiotics, the evolution of interventional radiology has seen the use of percutaneously placed ‘pigtail catheters’ inserted under ultrasound and computed tomography guidance become the mainstay of therapy where such resources are available. This has been suggested to result in a more rapid defervescence of fever and symptoms, shorter periods of intravenous antibiotics and a decreased length of inpatient care. More invasive procedures, aspiration and drainage, together with improved microbiological diagnostic techniques, including polymerase chain reaction testing, has increased the yield of pathogens identified from abscess fluid samples. Culture results will guide treatment, especially for immunocompromised subjects who may develop a lung abscess as a complication of their underlying condition. The predominant pathogens isolated from primary lung abscesses in children include streptococcal species, Staphylococcus aureus and Klebsiella pneumoniae. Children with a lung abscess, both primary and secondary, have a significantly better prognosis than adults with the same condition.

Section snippets

Definition

There are two types of lung abscess, which may be arbitrarily divided into primary and secondary based upon the existence of pre-existing conditions. A primary lung abscess occurs in a previously well child with normal lungs.1, 2, 3 A secondary lung abscess occurs in children with an underlying lung abnormality, which may be congenital (cystic fibrosis, immunodeficiency or structural as in a congenital cyst adenomatoid malformation) or acquired (achalasia or a neurodevelopmental abnormality

Pathophysiology

Pulmonary aspiration may be a central factor in the evolution of a lung abscess. Of course, people of any age probably aspirate to some extent on a daily basis (‘microaspiration’), but it is likely that the number of episodes of aspiration, the volume of aspirated material and any impairment of mucociliary clearance mechanisms contribute to the development of a lung abscess.⁴ Supporting this concept is the fact that lung abscesses occur more commonly in the most dependant parts of the lung for

Factors predisposing to lung abscess

Secondary lung abscesses may be seen in children at increased risk of pulmonary aspiration, immunocompromised hosts and those with underlying localised structural lung abnormalities or generalised suppurative lung disease.7, 8 Broadly speaking, pulmonary aspiration is more likely in children with neurodevelopmental abnormalities, especially those with poorly coordinated swallowing, neuromuscular conditions such as myotonic dystrophy and Duchenne muscular dystrophy, children with oesophageal

Microbiology

Organisms responsible for causing lung abscess are increasingly being sought at or near the time of presentation using techniques of interventional radiology.12, 13 The pathogens may be classified into aerobic, anaerobic and fungal.1, 2, 6, 7, 8 More commonly isolated pathogens are listed in Table 1.1, 6, 8 The increasingly interventional approach has seen the proportion of pathogens responsible for lung abscesses increase from less than 30% to around 60% currently.2, 7 It is worth noting that

Presenting symptoms and signs

The distinction of a lung abscess from pneumonia on history or clinical findings is seldom possible. Consequently, the diagnosis is usually made on the chest radiograph, supported by more definitive imaging initiated as part of interventional therapy. The use of CT scanning may facilitate the distinction between a lung abscess and necrotising pneumonia, as well as being part of the interventional procedure to guide the interventional radiologist as he or she drains the abscess.¹⁴ This has been

Imaging the lung abscess

The basic diagnostic test for a lung abscess is the chest radiograph (Fig. 1). However, in order to distinguish a lung abscess from an empyema, necrotising pneumonia, sequestration, pneumatocoele or underlying congenital abnormality such as a bronchogenic cyst, a contrast-enhanced CT scan is usually considered to be the investigation of choice.12, 13, 14 In many centres, the CT scan will enable the interventional radiologist to undertake diagnostic aspiration of the abscess and often

Assessment and management

The assessment and management of lung abscesses in children varies with the degree of experience of the clinician and the access to interventional radiologists and surgeons. For a primary lung abscess, the prognosis following a variety of treatment strategies is usually favourable. The mortality in paediatric lung abscess almost always relates to the conditions predisposing to a secondary lung abscess.1, 2, 4 From the more conservative approaches of lengthy courses of intravenous antibiotics to

Complications

Complications of lung abscess may arise by progression of the condition or occur as a result of treatment. The lung abscess may spontaneously rupture into adjacent compartments, rupture into the pleural space leading to empyema, pyothorax or pneumothorax.9, 18 The connection between the abscess cavity and the pleural space may persist, leading to the formation of a bronchopleural fistula.²⁷ Alternatively, if the lung abscess has occurred as a result of haematogenous spread, multiple abscesses

Long-term outcome

The prognosis for children with primary lung abscess is overwhelmingly favourable. In adults, the morbidity with lung abscess is reported as being 15–20%,²⁸ whereas in children the mortality is significantly lower, probably of the order of less than 5%, and occurs predominantly in those with a secondary lung abscess.8, 9 In adults with a lung abscess, factors such as the presence of pneumonia, cancer, a reduced level of consciousness, anaemia and the isolation of Pseudomonas aeruginosa, Staph.

Further evidence needed to improve management

Once again, there is a clear need for a collaborative database to monitor the prevalence and progress of children with a lung abscess. In particular, with the increasing use of antibiotics both in the community and in the hospital setting for complex cases, monitoring pathogens and antibiotic resistance patterns will be important. Clinical guidelines based upon pooled experience, encompassing interventional radiology and a less invasive approach, will assist clinicians to care better for

Key points

•
Pulmonary aspiration may be a central factor in the development of lung abscess.
•
The evolution of a lung abscess may be surprisingly indolent, occurring over several weeks. The predominant symptoms are cough and fever.
•
The early use of interventional radiology for the placement of drainage catheters is increasingly being recognised as a way of hastening recovery, decreasing the length of hospitalisation and improving the yield of cultures.
•
For primary lung abscesses, antibiotic choices should

Educational aims

•
To appreciate the presenting features of lung abscess in children.
•
To distinguish between a primary and a secondary lung abscess in terms of management and outcome.
•
To consider antibiotic therapy choices for children with a lung abscess.
•
To appreciate the role of interventional radiology in the management of lung abscess.

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References (30)

A.M. Kosloske et al.
Drainage of pediatric lung abscess by cough, catheter or complete resection
J Pediatr Surg
(1986)
E.J. Sims et al.
Neonatal screening for cystic fibrosis is beneficial even in the context of modern treatment
J Pediatr
(2005)
F.C. Lin et al.
Differentiating pyopneumothorax and peripheral lung abscess: chest ultrasonography
Am J Med Sci
(2004)
H.J. Corbett et al.
Pulmonary sequestration
Pediatr Respir Rev
(2004)
C.C. Chidi et al.
Lung abscess. A study of the results of treatment based on 90 consecutive cases
J Thorac Cardiovasc Surg
(1974)
I. Brook et al.
Bacteriology and therapy of lung abscess in children
J Pediatr
(1979)
V. Monaldi
Endocavitary aspiration in the treatment of lung abscess
Chest
(1956)
D. Weissberg
Percutaneous drainage of lung abscess
J Thorac Cardiovasc Surg
(1984)
A. Nonoyama et al.
Surgical treatment of pulmonary abscess in children under ten years of age
Chest
(1984)
I. Brook
Lung abscess and pleural empyema in children
Adv Pediatr Infect Dis
(1993)

P.C. Chan et al.

Clinical management and outcome of childhood lung abscess: a 16 year experience

J Microbiol Immunol Infect

(2005)

M.I. Asher et al.

Primary lung abscess in childhood

Am J Dis Child

(1982)

I. Brook

Anaerobic pulmonary infections in children

Pediatr Emerg Care

(2004)

J.G. Bartlett et al.

Anaerobic infections of the lung and pleural space

Am Rev Respir Dis

(1974)

T.Q. Tan et al.

Pediatric lung abscess: clinical management and outcome

Pediatr Infect Dis J

(1995)

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CME articleLung abscess in children