Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

low probability of gram-negative or multidrug resistant organism

1st line – empiric intravenous antibiotics

Back
ACUTE
|
low probability of gram-negative or multidrug resistant organism
|
without penicillin/cephalosporin allergy
1st line – 

empiric intravenous antibiotics

In patients with typical presentations and radiologic findings, start empiric intravenous antibiotics while cultures are pending. Antibiotics should be tailored to culture sensitivities when the results are known. Patients can be converted to oral therapy when clinical response is observed and they can maintain enteral feeding.

Clindamycin is probably superior to penicillin, but its spectrum is restricted to gram-positive microbes, so combination with a second- or third-generation cephalosporin is required.[40][41][42]

Penicillin plus metronidazole should not be given to patients with a high risk of microbial multiresistance.

Treatment is usually continued for at least 6-8 weeks, using serial chest x-rays to monitor therapeutic response.

Primary options

ampicillin/sulbactam: 3 g intravenously every 6 hours

More

OR

cefuroxime sodium: 1.5 g intravenously every 8 hours

or

cefotaxime: 1-2 g intravenously every 4 hours

or

ceftriaxone: 1-2 g intravenously every 24 hours

-- AND --

clindamycin: 600-900 mg intravenously every 8 hours

Secondary options

penicillin G potassium: 2-3 million units intravenously every 4 hours

and

metronidazole: 500 mg intravenously every 6 hours

Plus – chest physical therapy and postural drainage

Back
ACUTE
|
low probability of gram-negative or multidrug resistant organism
|
without penicillin/cephalosporin allergy
Plus – 

chest physical therapy and postural drainage

Treatment recommended for ALL patients in selected patient group

Placing patients with a large lung abscess in the lateral decubitus position with the abscess side down could prevent sudden discharge of abscess content causing asphyxiation or the spread of infection to other lung segments. Chest physical therapy and postural drainage may improve clearance of purulent and necrotic abscess contents.

2nd line – surgical intervention

Back
ACUTE
|
low probability of gram-negative or multidrug resistant organism
|
without penicillin/cephalosporin allergy
2nd line – 

surgical intervention

Interventional drainage is performed for nonresolving abscesses (particularly if associated with empyema), resistance to medical treatment, significant hemorrhage, or large abscesses (>6 cm).[9][44][45][46][47]​ All procedures should be performed by an appropriately trained specialist in a properly equipped facility.

Video-assisted thoracoscopy: a less invasive approach than resection.[48]

Resection of the affected lobe or segment: reserve for patients not responding to antibiotics and other therapies. More likely to be needed for patients with large cavities, massive hemorrhage, concomitant pleural empyema, obstructive neoplasms, or infections caused by multidrug resistant bacteria or fungi.[49] Survival rates after lung resection range from 89% to 95%.

Percutaneous CT scan or ultrasound-guided drainage: superior outcomes but similar complication rates compared with conservative management.[50]​ It is both effective and safe, with failure mainly occurring due to major complications (themselves due to abnormal lung parenchyma).[51]

1st line – empiric intravenous antibiotics

Back
ACUTE
|
low probability of gram-negative or multidrug resistant organism
|
with penicillin/cephalosporin allergy
1st line – 

empiric intravenous antibiotics

In patients with typical presentations and radiologic findings, start empiric intravenous antibiotics while cultures are pending. Antibiotics should be tailored to culture sensitivities when the results are known. Patients can be converted to oral therapy when clinical response is observed and they can maintain enteral feeding.

Patients allergic to penicillin and cephalosporins may be treated with clindamycin combined with aztreonam, ciprofloxacin, or levofloxacin to cover of gram-negative pathogens.

Treatment is usually continued for at least 6-8 weeks, using serial chest x-rays to monitor therapeutic response.

Primary options

aztreonam: 1-2 g intravenously every 6-8 hours

or

ciprofloxacin: 400 mg intravenously every 8-12 hours

or

levofloxacin: 500-750 mg intravenously every 24 hours

-- AND --

clindamycin: 600-900 mg intravenously every 8 hours

Plus – chest physical therapy and postural drainage

Back
ACUTE
|
low probability of gram-negative or multidrug resistant organism
|
with penicillin/cephalosporin allergy
Plus – 

chest physical therapy and postural drainage

Treatment recommended for ALL patients in selected patient group

Placing patients with a large lung abscess in the lateral decubitus position with the abscess side down could prevent sudden discharge of abscess content causing asphyxiation or the spread of infection to other lung segments. Chest physical therapy and postural drainage may improve clearance of purulent and necrotic abscess contents.

2nd line – surgical intervention

Back
ACUTE
|
low probability of gram-negative or multidrug resistant organism
|
with penicillin/cephalosporin allergy
2nd line – 

surgical intervention

Interventional drainage is performed for nonresolving abscesses (particularly if associated with empyema), resistance to medical treatment, significant hemorrhage, or large abscesses (>6 cm).[9][44][45][46][47]​​ All procedures should be performed by an appropriately trained specialist in a properly equipped facility.

Video-assisted thoracoscopy: a less invasive approach than resection.[48]

Resection of the affected lobe or segment: reserve for patients not responding to antibiotics and other therapies. More likely to be needed for patients with large cavities, massive hemorrhage, concomitant pleural empyema, obstructive neoplasms, or infections caused by multidrug resistant bacteria or fungi.[49] Survival rates after lung resection range from 89% to 95%.

Percutaneous CT scan or ultrasound-guided drainage: superior outcomes but similar complication rates compared with conservative management.​​​​​​[50]​ It is both effective and safe, with failure mainly occurring due to major complications (themselves due to abnormal lung parenchyma).[51]

high probability of gram-negative or multi-drug resistant organism

1st line – empiric intravenous antibiotics

Back
ACUTE
|
high probability of gram-negative or multi-drug resistant organism
|
without penicillin/cephalosporin allergy
1st line – 

empiric intravenous antibiotics

In patients with typical presentations and radiologic findings, start empiric intravenous antibiotics while cultures are pending. Antibiotics should be tailored to culture sensitivities when the results are known. Patients can be converted to oral therapy when clinical response is observed and they can maintain enteral feeding.

Clindamycin with aztreonam, ciprofloxacin, or levofloxacin are useful combination regimens when gram-negative organisms, such as Pseudomonas aeruginosa, are expected to be involved.[17]

Piperacillin/tazobactam is highly active against mixed bacterial flora, including P aeruginosa.

Carbapenems should be reserved for cases where microbial multiresistance is expected. They are particularly useful for the treatment of infections due to Acinetobacter species. Ertapenem is not appropriate if P aeruginosa or Acinetobacter species are considered a potential pathogen.

Treatment is usually continued for at least 6-8 weeks, using serial chest x-rays to monitor therapeutic response.

Primary options

piperacillin/tazobactam: 3.375 to 4.5 g intravenously every 6 hours

More

OR

aztreonam: 1-2 g intravenously every 6-8 hours

or

ciprofloxacin: 400 mg intravenously every 8 hours

or

levofloxacin: 750 mg intravenously every 24 hours

-- AND --

clindamycin: 600-900 mg intravenously every 8 hours

OR

imipenem/cilastatin: 500-1000 mg intravenously every 6 hours

More

OR

meropenem: 1-2 g intravenously every 8 hours

OR

ertapenem: 1 g intravenously every 24 hours

Plus – chest physical therapy and postural drainage

Back
ACUTE
|
high probability of gram-negative or multi-drug resistant organism
|
without penicillin/cephalosporin allergy
Plus – 

chest physical therapy and postural drainage

Treatment recommended for ALL patients in selected patient group

Placing patients with a large lung abscess in the lateral decubitus position with the abscess side down could prevent sudden discharge of abscess content causing asphyxiation or the spread of infection to other lung segments. Chest physical therapy and postural drainage may improve clearance of purulent and necrotic abscess contents.

2nd line – surgical intervention

Back
ACUTE
|
high probability of gram-negative or multi-drug resistant organism
|
without penicillin/cephalosporin allergy
2nd line – 

surgical intervention

Interventional drainage is performed for nonresolving abscesses (particularly if associated with empyema), resistance to medical treatment, significant hemorrhage, or large abscesses (>6 cm).[9][44][45][46][47]​ All procedures should be performed by an appropriately trained specialist in a properly equipped facility.

Video-assisted thoracoscopy: a less invasive approach than resection.[48]

Resection of the affected lobe or segment: reserve for patients not responding to antibiotics and other therapies. More likely to be needed for patients with large cavities, massive hemorrhage, concomitant pleural empyema, obstructive neoplasms, or infections caused by multidrug resistant bacteria or fungi.[49] Survival rates after lung resection range from 89% to 95%.

Percutaneous CT scan or ultrasound-guided drainage: superior outcomes but similar complication rates compared with conservative management.[50]​ It is both effective and safe, with failure mainly occurring due to major complications (themselves due to abnormal lung parenchyma).[51]

1st line – empiric intravenous antibiotics

Back
ACUTE
|
high probability of gram-negative or multi-drug resistant organism
|
with penicillin/cephalosporin allergy
1st line – 

empiric intravenous antibiotics

In patients with typical presentations and radiologic findings, start empiric intravenous antibiotics while cultures are pending. Antibiotics should be tailored to culture sensitivities when the results are known. Patients can be converted to oral therapy when clinical response is observed and they can maintain enteral feeding.

Patients allergic to penicillin and cephalosporins may be treated with clindamycin combined with aztreonam, ciprofloxacin, or levofloxacin for coverage of gram-negative pathogens.

Treatment is usually continued for at least 6-8 weeks. Serial chest x-rays are used to monitor therapeutic response.

Primary options

aztreonam: 2 g intravenously every 6 hours

or

ciprofloxacin: 400 mg intravenously every 8 hours

or

levofloxacin: 750 mg intravenously every 24 hours

-- AND --

clindamycin: 600-900 mg intravenously every 8 hours

Plus – chest physical therapy and postural drainage

Back
ACUTE
|
high probability of gram-negative or multi-drug resistant organism
|
with penicillin/cephalosporin allergy
Plus – 

chest physical therapy and postural drainage

Treatment recommended for ALL patients in selected patient group

Placing patients with a large lung abscess in the lateral decubitus position with the abscess side down could prevent sudden discharge of abscess content causing asphyxiation or the spread of infection to other lung segments. Chest physical therapy and postural drainage may improve clearance of purulent and necrotic abscess contents.

2nd line – surgical intervention

Back
ACUTE
|
high probability of gram-negative or multi-drug resistant organism
|
with penicillin/cephalosporin allergy
2nd line – 

surgical intervention

Interventional drainage is performed for nonresolving abscesses (particularly if associated with empyema), resistance to medical treatment, significant hemorrhage, or large abscesses (>6 cm).[9][44][45][46][47]​ All procedures should be performed by an appropriately trained specialist in a properly equipped facility.

Video-assisted thoracoscopy: a less invasive approach than resection.[48]

Resection of the affected lobe or segment: reserve for patients not responding to antibiotics and other therapies. More likely to be needed for patients with large cavities, massive hemorrhage, concomitant pleural empyema, obstructive neoplasms, or infections caused by multidrug resistant bacteria or fungi.[49] Survival rates after lung resection range from 89% to 95%.

Percutaneous CT scan or ultrasound-guided drainage: superior outcomes but similar complication rates compared with conservative management.[50]​ It is both effective and safe, with failure mainly occurring due to major complications (themselves due to abnormal lung parenchyma).[51]

ONGOING

low probability of gram-negative or multidrug resistant organism

1st line – empiric oral antibiotics

Back
ONGOING
|
low probability of gram-negative or multidrug resistant organism
|
without penicillin/cephalosporin allergy
1st line – 

empiric oral antibiotics

Antibiotics should be tailored to culture sensitivities when the results are known. Patients can be converted to oral therapy when clinical response is observed and they can maintain enteral feeding.

Clindamycin is probably superior to penicillin, but, as its spectrum is restricted to gram-positive microbes, combination with a second- or third-generation cephalosporin is required.[40][41][42]

Penicillin plus metronidazole should not be given to patients with a high risk of microbial multiresistance.

Treatment is usually continued for at least 6-8 weeks. Serial chest x-rays used to monitor therapeutic response.

Primary options

amoxicillin/clavulanate: 500 mg orally three times daily, or 875 mg orally twice daily

More

OR

cefuroxime axetil: 500 mg orally two to three times daily

and

clindamycin: 300-600 mg orally three times daily

Secondary options

penicillin V potassium: 500 mg orally three to four times daily

and

metronidazole: 500 mg orally three times daily

Plus – chest physical therapy and postural drainage

Back
ONGOING
|
low probability of gram-negative or multidrug resistant organism
|
without penicillin/cephalosporin allergy
Plus – 

chest physical therapy and postural drainage

Treatment recommended for ALL patients in selected patient group

Placing patients with a large lung abscess in the lateral decubitus position with the abscess side down could prevent sudden discharge of abscess content causing asphyxiation or the spread of infection to other lung segments. Chest physical therapy and postural drainage may improve clearance of purulent and necrotic abscess contents.

1st line – empiric oral antibiotics

Back
ONGOING
|
low probability of gram-negative or multidrug resistant organism
|
with penicillin/cephalosporin allergy
1st line – 

empiric oral antibiotics

Antibiotics should be tailored to culture sensitivities when the results are known. Patients can be converted to oral therapy when clinical response is observed and they can maintain enteral feeding.

Patients allergic to penicillin and cephalosporins may be treated with clindamycin combined with ciprofloxacin, or levofloxacin for coverage of gram-negative pathogens.

Treatment is usually continued for at least 6-8 weeks. Serial chest x-rays are used to monitor therapeutic response.

Primary options

ciprofloxacin: 500-750 mg orally twice daily

or

levofloxacin: 500-750 mg orally once daily

-- AND --

clindamycin: 300-600 mg orally three times daily

Plus – chest physical therapy and postural drainage

Back
ONGOING
|
low probability of gram-negative or multidrug resistant organism
|
with penicillin/cephalosporin allergy
Plus – 

chest physical therapy and postural drainage

Treatment recommended for ALL patients in selected patient group

Placing patients with a large lung abscess in the lateral decubitus position with the abscess side down could prevent sudden discharge of abscess content causing asphyxiation or the spread of infection to other lung segments. Chest physical therapy and postural drainage may improve clearance of purulent and necrotic abscess contents.

high probability of gram-negative or multidrug resistant organism: with or without penicillin/cephalosporin allergy

1st line – empiric oral antibiotics

Back
ONGOING
|
high probability of gram-negative or multidrug resistant organism: with or without penicillin/cephalosporin allergy
1st line – 

empiric oral antibiotics

Antibiotics should be tailored to culture sensitivities when the results are known. Patients can be converted to oral therapy when clinical response is observed and they can maintain enteral feeding.

Clindamycin with ciprofloxacin, or levofloxacin is a useful combination regimen when gram-negative organisms, such as Pseudomonas aeruginosa, are expected to be involved.[17]

Treatment is usually continued for at least 6-8 weeks. Serial chest x-rays are used to monitor therapeutic response.

Primary options

ciprofloxacin: 750 mg orally twice daily

or

levofloxacin: 750 mg orally once daily

-- AND --

clindamycin: 300-600 mg orally three times daily

Plus – chest physical therapy and postural drainage

Back
ONGOING
|
high probability of gram-negative or multidrug resistant organism: with or without penicillin/cephalosporin allergy
Plus – 

chest physical therapy and postural drainage

Treatment recommended for ALL patients in selected patient group

Placing patients with a large lung abscess in the lateral decubitus position with the abscess side down could prevent sudden discharge of abscess content causing asphyxiation or the spread of infection to other lung segments. Chest physical therapy and postural drainage may improve clearance of purulent and necrotic abscess contents.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer