A previously healthy four-year old girl was admitted to the hospital 3 days ago with a diagnosis of pneumonia. She was started on appropriate broad spectrum antibiotics based on organisms from her sputum culture. She continues to have fevers and a productive cough. Although the initial chest radiograph was consistent with pneumonia, the most recent radiograph revealed an air fluid level. A computerized tomography scan is shown with no evidence of foreign body. The best next step in the management of this patient with a lung abscess is:

 

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[size=20px]A change intravenous antibiotics.

 

B continue current antibiotic regimen.

 

C image guided transpleural drain placement.

 

D bronchoscopy with lavage.

 

E lobectomy.[/size]

Edited April 14, 20242 yr by Admin

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Correct answer

B continue current antibiotic regimen.

 

Lung abscess is uncommon in children. The most common etiology is the progression of pneumonia to necrosis and cavitation. Other related causes include a congenital anomaly (e.g. cystic malformation or sequestration) or an indwelling foreign body in the bronchial space.

 

Treatment for lung abscesses may include intravenous antibiotics for two to three weeks, postural drainage and respiratory support. Sputum should be sent to identify the causative organism and tailor antimicrobial therapy. In this case, the child is on the correct antibiotic regime based upon sputum culture. Streptococcus, Staphylococcus and oral anaerobes are the most common pathogens.

 

Although the majority of lung abscesses are treated successfully with antibiotics, medical treatment fails in about 10% of cases. Percutaneous drainage is considered when a patient does not get better with intravenous antibiotics for seven to 10 days. The complication rate is 10% and the complications include hemothorax, pneumothorax, empyema, incomplete drainage and bronchopleural fistula. Chan performed a retrospective review of 27 children with lung abscess. They recommended early percutaneous aspiration for diagnosis and treatment following an appropriate course of antibiotics. As this patient has only been treated for 3 days with appropriate medical management, the recommended course of action is to continue with her current antibiotic regimen.

 

Endobronchial drainage has been described in the literature, but its use in pediatric patients has not been widespread.

 

Surgical drainage or resection are typically reserved for those who do not respond to antibiotic therapy and percutaneous drainage, persistent abscess, bronchiectasis, hemoptysis or bronchopleural fistulas.