Академический Документы
Профессиональный Документы
Культура Документы
INTRODUCTION
The clinical and microbiological characteristics of patients with lung abscess are well described (1,2). Most
cases are associated with recognized risk factors including alcohol abuse, periodontal disease, seizure disorders,
oesophageal disorders and neurological bulbar dysfunction (3). Historically, lung abscesses are associated with
anaerobic bacteria (1). Recent reports suggest, however,
that the spectrum of aetiological agents may be evolving
(2), and that changes may in part reect an increased
number of immunosuppressed patients (2,4). Although
a number of reports suggest an expanded spectrum of
aetiological agents in immunosuppressed patients (3^7),
the clinical and microbiological characteristics of lung abReceived 8 January 2001, accepted in revised form 22 October 2001and
published online 14 January 2002.
Correspondence should be addressed to: Henry Koziel, MD, Division of
Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical
Center; KBS-23, 330 Brookline Avenue, Boston, MA 02215, U.S.A. Fax:
617 667- 4849; E-mail: hkoziel@caregroup.harvard.edu
scess comparing immunocompetent to immunosuppressed patients has not been fully examined.
Recognizing the altered immune function and spectrum of lung infections in patients with chronic corticosteroid use (8 ^10), haematological or solid malignancies
(11,12), organ transplantation (12,13) and human immunodeciency virus (HIV) infection (14 ^16), the clinical characteristics and microbiology of lung abscess may be
dierent when compared to patients without underlying
immunosuppression. One report suggest fewer anaerobic isolates in immunocompromised patients (2). A
recent report of HIV-infected patients noted that
abscesses occurred in advanced HIV-related disease,
was associated with a broad spectrum of pathogens,
responded poorly to antibiotics and was associated
with a poor prognosis (4). Furthermore, the immune
dysfunction associated with conditions such as
diabetes mellitus (17,18) may predispose to certain pulmonary infections (19), although the impact of diabetes
mellitus on lung abscess has not been fully investigated
(20 ^22).
Identifying dierences in the clinical manifestations and microbiological isolates of lung abscesses
may have signicant implications for guiding clinical diagnostic evaluations and empirical antimicrobial management, especially in the immunocompromised host.
However, the clinical characteristics and aetiology of
lung abscess in immunocompromised hosts is not well
characterized, and studies comparing immunocompromised to non-immunocompromised patients are limited.
The purpose of this study was to examine the clinical
characteristics and microbiology in cases of lung abscess
at a tertiary care urban medical center, comparing
immunocompromised to non-immunocompromised
patients.
METHODS
Setting
The Beth Israel Deaconess Medical Center, West
Campus, is a 375-bed tertiary care referral hospital
with general medical service, including infectious
disease and HIV clinical services, medical oncology and
hematology service, diabetic service, and pulmonary
and critical care services. Surgical services included general surgical, thoracic surgical and solid organ transplant
service.
179
Statistical analysis
Statistical analysis of non-continuous dichotomous data
were compared by the Chi-square test (with Yates correction) or the Fischers exact test as appropriate using
INSTAT2 statistical package (Graphpad Software; San
Diego, CA, U.S.A.) on an IBM PS/2 120 MB computer
(IBM Corp; Armonk, NY, U.S.A.). All P-values were
two-sided and statistical signicance was accepted for
Po005.
RESULTS
Clinical characteristics
A total of 46 cases of lung abscess were identied, and
medical records for all 46 cases were reviewed. Twelve
cases were excluded because the identied abscess represented lung necrosis complicating post-obstructive
pneumonia, cavitating lung neoplasm, or the available
medical records were incomplete. A total of 34 cases
were included in this study, which represented a 02%
incidence of lung abscess for all hospitalized cases of
pneumonia. The clinical characteristics for the 10 individuals in the non-immunocompromised group and 24 individuals in the immunocompromised group are presented
in Table 1. For the immunocompromised group, all HIV+
individuals and the organ transplant reciptient were conrmed HIV sero-negative. Although specic serum HIV
antibody data were not available for the non-immunocompromised subjects, none had recognized HIV risk
factors, all had normal peripheral white blood cell counts
and none had lymphopenia.
Comparison of age, gender, tobacco use, pre-existing
pulmonary disease or recognized aspiration risk factors
180
RESPIRATORY MEDICINE
Immunocompromised
P-value
10
591717
24
501718
NS
7
3
20
4
NS
NS
8
F
F
F
2
18
2
3
1
F
F
F
F
F
F
7 (70%)
3 (30%)
5 (50%)
10 (100%)
7
7
5
4
1
16 (67%)
6 (25%)
11 (46%)
24 (100%)
NS
NS
NS
NS
181
TABLE 2. Symptoms and signs attime of presentation for patients with lung abscess
Fever
Cough
Gastrointestinal symptoms*
Dyspnoea
Weight loss
Pleuritic chest pain
Haemoptysis
Asymptomatic
Total WBC 105 (cells mm3)
Non-immunocompromised
(%)
Immunocompromised
(%)
P-value
20
20
0
20
10
40
10
30
12074
46
42
29
21
21
12
8
4
12778
NS
NS
007
NS
NS
NS
NS
NS
NS
RUL, n (%)
LUL, n (%)
LLL, n (%)
RLL, n (%)
Multiple lobes, n (%)
RML, n (%)
Total
Non-immunocompromised
Immunocompromised
P-value
5 (50%)
2 (20)
1 (10)
0
0
2 (20)
10 (100%)
8 (33%)
5 (21)
3 (12)
3 (12)
3 (12)
2 (8%)
24 (100%)
NS
NS
NS
NS
NS
NS
RUL: right upper lobe; LUL: left upper lobe; LLL: left lower lobe;RLL: right lower lobe;RML: right middle lobe.
immunocompromised group to the immunocompromised group. Collectively, the upper lobes accounted for
the majority of cases, with 70% of non-immunocompromised patients and 54% of immunocompromised patients (P4005). For both groups, the right upper lobe
(RUL) was more often involved than the left upper lobe
(LUL), although this dierence was not statistically significant. Multiple lung abscesses (Xtwo sites) were observed only in the immunocompromised group,
occurring in 12% of cases.
tures were not performed on BAL specimens. For individuals with positive blood cultures, the same microbe was
isolated from the blood and respiratory tract specimens.
Only two patients (59%), both immunocompromised,
allowed only examination of sputum specimens and refused more invasive investigation. For six individuals, no
potential pathogen was isolated despite sputum and
blood cultures, bronchoscopy, CT-guided needle biopsy
or surgical biopsy. All specimens were submitted for routine gram stain, routine bacterial culture, Legionella spp.
culture, fungal culture, acid fast bacillus (AFB) stain and
culture, and P. carinii stain. Anaerobic culture were performed on 490% of the submitted specimens.
182
RESPIRATORY MEDICINE
TABLE 4. Diagnostic method* which identied a potential pathogen in patients with lung abscess
Non-immunocompromised
Immunocompromised
Total
4
1
1w
0
1
1z
0
3
8
5
4
1
4
2z
2}
3
12 (35)
6 (18)
5 (15)
3 (88)
2 (59)
6 (18)
Immunocompromised
2 (20)
1
F
F
0
F
1
F
F
3 (30)
1
1
1
0 (0)
F
F
F
2 (20)
2
F
3 (30)
15 (63)w
5
3
2
1
1
1
1
1
2 (8)
2
F
F
2 (8)
2
1 (4)
1
5 (21)
4
1
3 (8)
group (20% vs. 63%; P=0057), whereas no signicant differences were observed for the isolation of anaerobic,
Legionella spp., mycobacteria or fungi.For the non-immunocompromised group, anaerobes were most frequently
isolated, followed equally by aerobic bacteria and fungi.
For the immunocompromised patients, aerobic bacteria
were most commonly isolated, representing a broad
spectrum with P. aerugenosa, Hemophilis spp. (non-inuenza), X. maltophilia, H. inuenza, Enterobacter spp. and
K. oxytoca exclusively isolated in the immunocompro-
183
Immunocompromised
5 (50)
5 (50)
10 (100)
0 (0)
15 (63)
9 (37)
22 (92)
2 (8)
DISCUSSION
This retrospective review of consecutive cases of lung
abscess in adults at tertiary care medical center suggests
that certain important clinical similarities as well as important clinical dierences exist comparing immunocompromised patients to patients without recognized
immunocompromised states. For both non-immunocompromised and immunocompromised patients, the
identied cases were predominantly male patients
(70 ^ 83%), with a mean age of 50 ^59 years, with a history of tobacco use (67^70%) and with underlying pulmonary disease (25^30%). Recognized aspiration risks
were identied equally in both groups, present in 46 ^
50% of cases.
Several important clinical dierences were suggested
in this study.The observation that twice as many cases of
lung abscess were identied in the immunocompromised
group compared to the non-immunocompromised
group suggests that primary lung abscess may be more
184
RESPIRATORY MEDICINE
isolates which would not respond to most empirical antimicrobial regimens (27).These observations suggest the
importance of identifying a potential causative agent,
and support a strategy to aggressively identify aetiological agents from abscess material.
The low rate of recovery of anaerobes for both groups
in the current study contrasts the ndings of prior reports (1,28,29) where anaerobes were isolated in up to
93% of cases (exclusively in 56% of cases). As 490% of
specimens in the current study were submitted for anaerobic culture, the low incidence of anaerobic isolation in
the current study does not reect omission of anaerobic
cultures, but may reect sampling methods (no transtracheal aspirations were performed in the current
study), lapses in appropriate handling of respiratory tract
specimens, or changes in the microbiological spectrum in
our study populations, perhaps reecting the state of
immunocompetence. Alternatively, the spectrum of microbes may be altered due to the high rate of premorbid
antibiotic prescriptions for both groups. Importantly, a
recent report of lung abscess in HIV-infected individuals
failed to identify anaerobes (4), which taken together
with the ndings in the current study suggests that the
microbial aetiology for immunocompromised patients
maybe distinct from non-immunocompromisedpatients.
The observed mortality associated with lung abscess
was low for both groups, and lower than the reported
mortality rates of 15^28% (2,30 ^32). The favourable
outcomes in the current study may in part reect the
patient population, the aggressive management (employing surgical resection in many cases), and the use of antimicrobial agents directed against all isolated microbial
agents.The only observed deaths occurred in the immunocompromised patients, and both cases involved fungal
abscess. Although denitive conclusions are not possible,
other investigators have reported high mortality rates
associated with fungal lung abscess (25,33).
Other limitations of this study include the retrospective nature and the relatively small number of cases identied in each group. The limited number of cases
identied despite a comprehensive review of medical records over a 13-year period suggests that the development of lung abscess may be infrequent, and may reect
a change in the evolution of lung abscess, or may reect
antimicrobial use patterns, clinical practices or patient
populations specic to our institution. The absence of
statistical dierences comparing the two groups may reect the fact that dierences do not exist, or perhaps
the small number the non-immunocompromised patients likely limited the statistical analysis comparing
these groups. The relatively limited number of each of
the immunocompromised patients did not allow for subgroup analysis, such as determining the inuence of diabetes mellitus. The inclusion of only cases requiring
hospitalization may under-estimate the total number of
actual cases of lung abscess at our institution, as ambula-
tory patients were not included. In the absence of a standardized approach to the diagnostic and therapeutic
management of patients included in this retrospective
study, conclusions or recommendations regarding the
appropriate management practice is not possible.
Although a broad spectrum of immunocompromised
states were represented, including HIV disease, malignancy, diabetes mellitus, chronic corticosteroid use, and
organ transplantion, the ndings may not apply to other
immunocomromised patients. Finally, the experience at
our institution may not reect the experience of other
medical centers, although a broad spectrum of medical
conditions were represented in this study.
In summary, this retrospective review of lung abscesses comparing non-immunocompromised patients
to immunocompromised patients notes that the clinical
characteristics of lung abscess are remarkably similar
comparing the two groups, with a favourable short-term
prognosis. However, several observations suggest that
important dierences may exist, as immunocompromised patients with lung abscess may present more often
with gastrointestinal symptoms, more often have multiple abscesses, more often have aerobic bacteria isolated
from abscess material, and may have exclusive isolation of
certain microbes or multiple microbes, although additional larger studies are needed to further assess for
these dierences. The observed broad spectrum of microbial isolates associated with lung abscesses for each
group has important implications for the clinical and empirical management of these patients, and supports a
strategy to aggressively identify causative agents
Acknowledgements
These data were presented in part at the1998 American
Thoracic Society/American Lung Association International Conference in Chicago, IL, U.S.A.
REFERENCES
1. Bartlett J, Finegold S. Anaerobic infections of the lung and pleural
space. Am Rev Respir Dis 1974; 110: 56^77.
2. Pohlson EC, McNamara JJ, Char, C et al. Lung abscess: a changing
pattern of the disease. Am J Surg 1985; 150: 97^101.
3. Wiedemann HP, RiceTW. Lung abscess and empyema. SeminThoracic Cardiovasc Surg 1995; 7: 119^128.
4. Furman AC, Jacobs J, Sepkowitz KA. Lung abscess in patients with
AIDS.Clin Infect Dis 1996; 22: 81^ 85.
5. Ernst A,Gordon FD, Hayek J, et al. Lung abcess complicating Legionella micdadei pneumonia in an adult liver transplant recipient.
Transplantation 1998; 65: 130 ^134.
6. Ruutu P,ValtonenV, Elonen E, et al. Invasive pulmonary aspergillosis:
a diagnostic and herapeutic problem.Clinical experience with eight
haematologic patients. Scand J Infect Dis 1987; 19: 569^575.
7. Bauling PC, Weil R, Schroter GP. Legionella lung abscess after renal
transplantation.J Infect 1985; 11: 51^55.
8. Slade JD, Hepburn B. Prednisone-induced alterations of circulating
human lymphocyte subsets.J Lab Clin Med 1983; 101: 479^ 487.
185
9. Walzer PD, LaBine M, RedingtonTJ, et al. Lymphocyte changes during chronic administration of and withdrawal form corticosteroids:
relation to Pneumocystis carinii pneumonia. J Immunol 1984; 133:
2502^2508.
10. Ten Berge RJM, Sauerwein HP, Young SL, et al. Administration of
prednisolone in vivo aects the ratio of OKT4/OKT8 and the
LDH-isoenzyme pattern of humanT lymphocytes.Clin Immunol Immunopathol 1984; 30: 91^103.
11. Siminski J, Kidd P, Phillips GD, et al. Reversed helper/suppressor Tlymphocyte ratio in bronchoalveolar lavage uid from patients with
breast cancer and Pneumocystis carinii pneumonia. Am Rev Respir Dis
1991; 143: 437^ 440.
12. Collin BA, Ramphal R. Pneumonia in the compromised host including cancer patients and transplant patients. Infect Dis Clin N Am
1998; 12: 781^ 805.
13. Hughes W, Smith B. Provocation of infection due to Pneumocystis
carinii by cyclosporin A.J Infec Dis 1982; 145: 767.
14. Murray J, Mills J. Pulmonary infectious complications of human immunodeciency virus infection. Part I. Am Rev Respir Dis 1990; 141:
1356^1372.
15. Murray J, Mills J. Pulmonary infectious complications of human immunodeciency virus infection. Part II. Am Rev Respir Dis 1990; 141:
1582^1598.
16. Bartlett JG. Pneumonia in the patient with HIV infection. Infect Dis
Clin N Am 1998; 12: 807^ 820.
17. Glass EJ, Stewart J, Matthews DM, et al. Impairment of monocyte
lectin-like receptor activity in Type I (insulin-dependent) diabetic
patients. Diabetologia 1987; 30: 228 ^231.
18. Geisler C, Almdal T, Bennedsen J, et al. Monocyte functions in diabetes mellitus. Acta Pathol Microbiol Immunol Scand1982; 90: 33^37.
19. Koziel H, Koziel MJ. Pulmonary complications of diabetes mellitus:
pneumonia. Infect Dis Clin N Am 1995; 9: 65^96.
20. Cheng DL, Liu YC, Yen MY, et al. Septic metastatic lesions of pyogenic liver abscess.Their association with Klebsiella pneumonia bacteremia in diabetic patients. Arch Intern Med 1991; 151: 1557^1559.
21. Jerng JS, Hsueh PR, Teng LJ, et al. Empyema thoracis and lung abscess caused by viridans streptococci. Am J Respir Crit Care Med
1997; 156: 1508 ^1514.
22. LimTK, ChanTB. Sudden death from primary lung abscess in middle-aged diabetic menFtwo case reports. Singapore Med J 1989;
30: 102^104.
23. Bartlett JG, Gorbach SL, Tally FP, et al. Bacteriology and treatment
of primary lung abscess. Am Rev Respir Dis 1974; 109: 510 ^518.
24. Stark DD, Federle MP, Goodman PC, et al. Dierentiating lung abscess and empyema: radiography and computed tomography. Am J
Roentgenol 1983; 141: 163^167.
25. Mori T, EbeT,Takahashi M, et al. Lung abscessFanalysis of 66 cases
from 1979 to1991. Intern Med 1993; 32: 278 ^284.
26. Stover DE, Zaman MB, Hajdu SI, et al. Bronchoalveolar lavage in the
diagnosis of diuse pulmonary inltrates in the immunosuppressed
host. Ann Intern Med 1984; 101: 1^7.
27. Bartlett JG. Antibiotics in lung abscess. Semin Respir Infect 1991; 6:
103^111.
28. Bartlett JG. Anaerobic bacterial infections of the lung and pleural
space.Clin Infect Dis 1993; 16: S248 ^S255.
29. Hammond JMJ, Potgieter PD, Hanslo D, et al.The etiology and antimicrobial susceptability patterns of microorganisms in acute community acquired lung abcess.Chest 1995; 108: 937^941.
30. Hirshberg B, Sklair-Levi M, Nir-Paz R, et al.Factors predicting mortality of patients with lung abscess. Chest 1999; 115: 746 ^750.
31. Harber P, Terry PB. Fatal lung abscesses: review of 11 years experience. South Med J 1981; 74: 281^283.
32. Hagan JL, Hardy JD. Lung abscess revisted: a survey of 184 cases.
Ann Surg 1983; 197: 755^762.
33. Grinan NP, Lucena FM, Romero JV, et al.Yield of percutaneous needle lung aspiration in lung abscess.Chest 1990; 97: 69^74.