suprative lung infection

1. Mulugeta A.(MD,INTERNIST)

2. BRONCHIECTASIS

3. Outline
• Introduction
• Etiology
• Clinical manifestations
• Diagnosis
• Management

4. Introduction
• Bronchiectasis refers to an irreversible airway dilation that
involves the lung in either a focal or a diffuse manner
• Shares many clinical features with COPD including
• Inflamed and collapsible airways
• Obstruction to airflow, and
• Frequent office visits and hospitalizations
• Commonly affects proximal and medium-sized bronchi
(>2mm in diameter)
• Caused by weakening or destruction of the muscular and
elastic components of the bronchial walls

7. Epidemiology
• The prevalence of bronchiectasis is unknown
• The emergence of vaccines and antibiotics in the 20th century
resulted in a decline in the rate of bronchiectasis in developed
countries
• Still a major cause of morbidity in developing countries due to
limited access to medical care and antibiotic therapy
• The prevalence increases with age
• Persons aged 60-80 years have the highest frequency
• More common in women than men

8. Etiology
• Can arise from infectious or noninfectious causes
• Pattern of lung involvement often gives a clue to the underlying
etiology
• Focal bronchiectasis
• Bronchiectatic changes in a localized area of the lung
• Can be due to obstruction to the airway
• Diffuse bronchiectasis
• Widespread bronchiectatic changes throughout the lung
• Often arises from an underlying systemic or infectious disease
process
• 25-50% of patients with bronchiectasis have idiopathic disease

11. Clinical findings
• The classic features are cough and the daily production of
mucopurulent and tenacious sputum lasting months to years
• Dyspnea
• Wheezing
• Pleuritic chest pain
• Patients often report frequent bouts of “bronchitis” requiring therapy
with repeated courses of antibiotics
• Crackles and wheezing on auscultation
• Clubbing of digits

12. Diagnosis
• Based on
• Persistent chronic cough and sputum production and
• Consistent radiographic features
• chest X-ray
• Less sensitive
• “tram tracks” indicating dilated airways is consistent with
bronchiectasis
• Chest CT
• More specific and the imaging modality of choice for confirming the
diagnosis
• Airway dilation, lack of bronchial tapering, bronchial wall thickening in
dilated airways, inspissated secretions, or cysts emanating from the
bronchial wall are signs of bronchiectasis

13. Types of bronchiectasis

18. Treatment
• Goals
• Improve symptoms
• Reduce complications
• Control exacerbations
• Reduce morbidity and mortality
• Antibiotics and chest physiotherapy are the mainstay
modalities
• Treatment of underlying conditions

19. QUESTIONS???

20. LUNG ABSCESS

21. INTRODUCTION
• Lung abscess is defined as pulmonary parenchymal necrosis
and cavitation resulting from infection
• The development of a lung abscess implies a high
microorganism burden as well as inadequate microbial
clearance
• Aspiration is the most common cause
• Other predisposing conditions for lung abscess include
periodontal disease and alcoholism

22. CLASSIFICATION
• Lung abscesses are classified by clinical & pathologic
features including the tempo of progression, the presence or
absence of an associated underlying lesion, & microbial
pathogen responsible
• Duration defines the infection as acute versus chronic, with
the dividing line usually at 4–6 weeks.
• Abscesses occurring in the presence of underlying pulmonary
lesions are referred to as secondary; those that occur in the
absence of underlying pulmonary lesions are considered
primary

23. CLASSIFICATION … contd
• Lung abscess can also be defined by the responsible
microbial pathogen (eg, Pseudomonas lung abscess,
anaerobic bacterial lung abscess, or Aspergillus lung abscess
• The term nonspecific lung abscess refers to cases in which
no likely pathogen is recovered from expectorated sputum;
most such cases are presumed to be due to anaerobic
bacteria
• Putrid lung abscess is a term applied to anaerobic bacterial
lung abscesses, which are characterized by distinctive foul-
smelling breath, sputum, or empyema fluid

24. MICROBIOLOGY
• Anaerobic bacteria are the most common causative organisms
• Aerobic or facultative bacteria such as S. aureus, Klebsiella
pneumoniae, Nocardia spp., and gram-negative organisms, as
well as nonbacterial pathogens such as fungi and parasites, may
also cause abscess formation
• In an immunocompromised host, aerobic bacteria and
opportunistic pathogens may predominate
• Mycobacteria, especially M. tb, are a very important cause of
pulmonary infections and abscess formation
• Multiple isolates are more commonly seen in all patients when
anaerobic and aerobic cultures are done

25. MICROBIOLOGY … contd

26. CLINICAL MANIFESTATIONS
• The symptoms of lung abscess are typical of pulmonary
infection in general and may include cough, purulent sputum
production, pleuritic chest pain, fever, and hemoptysis.
• In anaerobic infection, the clinical course may evolve over an
extended period of time, and some patients may be
asymptomatic
• More acute presentations are typical of infection with aerobic
bacteria

27. CLINICAL MANIFESTATIONS … contd
• Physical examination is often unrevealing
• Rales or evidence of consolidation may be present
• Fetid breath and poor dentition may be diagnostic clues
… the foul odor is presumably due to the organisms'
production of short-chain fatty acids, such as butyric or
succinic acid
• Clubbing or hypertrophic pulmonary osteoarthropathy may
occur in chronic cases

28. Radiology
• Sequential CXR / CT scans show the evolution of lesion from
pneumonitis to cavitation, that generally requires 7–14 days
• CXR classically reveals one or two thick-walled cavities in
dependent areas of the lung & air-fluid level is often present
• Chest CT is helpful in defining the size & location of the
abscess, as well as to evaluate for additional cavities and the
presence of pleural disease
• Cavitary lesions in nondependent regions such as the RML or
anterior segments of the upper lobes should raise the
possibility of other causes, including malignancy

29. • LAP is not associated with bacterial lung abscess … alternative dx
• Laboratory studies may reveal leukocytosis, anemia, and an ↑ESR

30. DIAGNOSIS
• Is based on clinical symptoms, identification of predisposing
conditions, and chest radiographic findings
• The ddx includes mycobacterial infection, pulmonary
sequestration, malignancy, pulmonary infarction, & infected
bulla
• Identification of a causative organism is an ideal but
challenging goal
• Blood, sputum cultures, and (when appropriate) pleural fluid
cultures should be obtained

31. DIAGNOSIS … contd
• The role of fiberoptic bronchoscopy with bronchoalveolar
lavage or protected- specimen brush for dx is controversial
… Low yield Vs the risk of spillage into the airways.
• Bronchoscopy is perhaps most useful to rule out airway
obstruction, mycobacterial infection, or malignancy
• Other less commonly used methods for microbiologic
sampling are transtracheal or transthoracic aspiration

32. TREATMENT
• For many years, penicillin was the mainstay of empiric
antibiotic therapy for lung abscess
• Because of the emergence of β-lactamase–producing
organisms, clindamycin (150–300 mg q6 h) is now standard
therapy
… clindamycin proved superior to penicillin G in a randomized clinical trial
• Other agents, such as carbapenems and β-lactam/β-
lactamase inhibitor combinations, may be useful
• Metronidazole alone is asso with a high treatment failure rate
… highly active against virtually all anaerobes but not against aerobic
microaerophilic streptococci, which play an important role in mixed
infections

33. TREATMENT … contd
• When possible, the choice of antibiotics should be guided by
microbiologic results
• The duration of treatment for lung abscess is controversial
• Four to 6 weeks of antibiotic therapy is typically used
… Many experts recommend continuation of oral Rx until imaging shows
that chest lesions have cleared or have left a small, stable scar
• Parenteral treatment may be followed by orally administered
amoxicillin/clavulanate

34. TREATMENT … contd
• Persistence of fever beyond 5–7 days or progression of the
infiltrate suggests failure of therapy
… need to exclude factors such as obstruction, complicating
empyema, and involvement of antibiotic-resistant bacteria
• Postural drainage was previously popular for pts with lung
abscess
… but this strategy may result in spillage to other pulmonary
segments, leading to airway obstruction and clinical
deterioration
• Lung abscess due to S. aureus is usually treated with
vancomycin

35. TREATMENT … Surgery
• Surgery has a limited role … reserved for ~10–12% of pts
• Indications include: refractory hemoptysis, inadequate
response to medical Rx, or suspected neoplasm
• Failure to respond to antibiotics is usually due to an
obstructed bronchus & an extremely large abscess (>6 cm ɸ )
or to infection involving relatively resistant bacteria, such as P.
aeruginosa
• The usual procedure is lobectomy or pneumonectomy
• An alternative intervention is percutaneous drainage under
CT guidance

36. Response to Therapy
• Pts usually show clinical improvement, with ↓ed fever, within
3–5 days of initiation of antibiotic Rx
• Defervescence can be expected within 5–10 days
• Pts with fevers persisting for 7–14 days should undergo
bronchoscopy or other diagnostic tests to better define
anatomic changes and microbiologic findings
• The response to therapy apparent on serial chest radiographs
is delayed in comparison with the clinical course.
• In fact, infiltrates usually progress during the first 3 days of
treatment in approximately one-half of patients

37. Prognosis
• In general, outcomes for patients with classic anaerobic lung
abscess are favorable, with a 90%–95% cure rate
• Higher MR in immunocompromised pts; those with significant
comorbidities; and those with infection with P. aeruginosa, S.
aureus, and K.pneumoniae

38. THANK YOU