Excavating bronchogenic carcinomas differ from a lung abscess in that a patient with the latter is typically, but not always, febrile and has purulent sputum. On imaging, a bronchogenic carcinoma has a thicker and more irregular wall than a lung abscess.10
Treatment
When antibiotics first became available, penicillin was used to treat lung abscess.11 Then IV clindamycin became the drug of choice after 2 trials demonstrated its superiority to IV penicillin.12,13 More recently, clindamycin alone has fallen out of favor due to growing anaerobic resistance.14
Current therapy includes beta-lactam with beta-lactamase inhibitors.14 Lung abscesses are typically polymicrobial and thus carry different degrees of antibiotic resistance.15,16 If culture data are available, targeted therapy is preferred, especially for secondary abscesses.7 Antibiotic therapy is usually continued until a CXR reveals a small lesion or is clear, which may require several months of outpatient oral antibiotic therapy.4
Our patient was treated with IV clindamycin for 3 days in the hospital. Clindamycin was chosen due to his penicillin allergy and started empirically without any culture data. He was transitioned to oral clindamycin and completed a total 3-week course as his CXR continued to show improvement (FIGURE 3). He did not undergo bronchoscopy. A follow-up CXR showed resolution of lung abscess at 9 months. (FIGURE 4).
THE TAKEAWAY
All patients with lung abscesses should have sputum culture with gram stain done—ideally prior to starting antibiotics.3,4 Bronchoscopy should be considered for patients with atypical presentations or those who fail standard therapy, but may be used in other cases, as well.3
CORRESPONDENCE
Morteza Khodaee, MD, MPH, AFW Clinic, 3055 Roslyn Street, Denver, CO 80238; morteza.khodaee@cuanschutz.edu