Lung Abscess Portugise

8/13/2019 Lung Abscess Portugise

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R e v i s t a P o r t u g u e s a d e P n e u m o l o g i a 165

Vol XV N. 2 Maro/Abr il 2009

Artigo Original

Original Article

Resumo

Abcessos pulmonares (AP) acarretam graves implica-es clnicas e sociais. Os autores analisam retrospec-tivamente a casustica dum hospital tercirio.Identificaram-se 60 internamentos por AP ocorridosentre 2000 e 2005. Quarenta e cinco doentes eramhomens; a idade mdia foi 56,2 (15,1) anos. A dura-o mdia dos sintomas de pr-hospitalizao foi de23,0 (50,2) dias, mas a infeco respiratria agudafoi o modo de apresentao em 36 doentes. Em 40casos, com base em dados clnicos, a suspeita de AP

seria elevada. O diagnstico estabeleceu-se em 8,7(11,4) dias aps a admisso. Identificou-se agentemicrobiano em 26 casos. Em 27 doentes classificou-seo AP como primrio. Mau estado dentrio e imuno-deficincia foram os principais factores de risco. Exis-

Abstract

Lung abscesses (LA) carry with them severe clinicaland social implications. The authors retrospectivelyanalyse case files from a tertiary hospital.Admissions from 2000 to 2005 codified as LA wereidentified. Forty-five patients were males and themean age was 56.2 (15.1) years. The average dura-tion of symptoms pre-hospitalisation was 23.0(50.2) days, with acute respiratory infection the ini-tial syndrome in 36 patients. Clinical data show LAcould have been suspected in 40 patients. Diagnosis

was established 8.7 (11.4) days after admission. Amicrobial pathogen was recovered in 26 cases. Pri-mary LA was diagnosed in 27 patients. Dental diseaseand immunodeficiency were the main risk factors.Other co-morbidities were present in 34 patients. Af-

Abcessos pulmonares: Reviso de 60 casos

Lung abscesses: Review of 60 cases

Recebido para publicao/received for publi cation:07.11.16

Aceite para publ icao/accepted for publication:08.10.13

Lusa Magalhes1

Diana Valadares1

Jlio R Oliveira2

Ernestina Reis2

1Interna Complementar de Medicina Interna / Resident, Internal Medicine2Assistente Hospitalar de Medicina Interna / Internal Medicine Consultant

Hospital Geral de Santo Antnio. Servio de Medicina 1 (Director de Servio: Dr. Nelson Rocha) Unidade D (responsvel de unidade: Dra. Ernestina Reis) / Workcarried out at Hospital Geral de Santo Antnio. Servio de Medicina 1 (Department Head: Dr. Nelson Rocha) Unidade D (Head: Dr. Ernestina Reis)

Correspondncia / Correspondence to:

Dra. Lusa Magalhes

Hospital Geral de Santo Antnio Servio de Medicina 1, Unidade D

Largo do Prof. Abel Salazar, 4099-001, Porto, Portugal.

Nota: Trabalho apresentado como comunicao oral no 13. Congresso Nacional de Medicina Interna 6th European Federation of Internal Medicine Congress, Lisboa,

Maio de 2007 / Note: This work was presented as an oral communication at the 13th National Congress of Internal Medicine 6th European Federation of Internal

Medicine Congress, Lisbon, May 2007

ument downloaded from http://http://www.elsevier.pt, day 25/10/2013. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.


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R e v i s t a P o r t u g u e s a d e P n e u m o l o g i a166


tiam comorbilidades em 34 casos. Aps o diagnstico,todos receberam antibioterapia (AB) intravenosa (IV)em mdia durante 16,5 (10,9) dias. A mdia do tem-po global de AB foi de 39,2 (15,7) dias. Dez opesde AB foram usadas e a AB IV inicial alterada em 23casos. Foi necessria cirurgia em 6 doentes. Conseguiu--se apirexia em mdia aps 6,4 (6,4) dias. Ocorreramcomplicaes em 21 doentes; 7 faleceram. A duraomdia do internamento foi de 27,5 (16,3) dias e 38doentes foram convocados para consulta ps-alta.Estes dados so, em geral, concordantes com a litera-tura. A elevada percentagem de doentes do sexo mas-

culino coincide com maior prevalncia do alcoolismoe do carcinoma pulmonar nos homens. Aspectos per-tinentes no sentido de melhorar o prognstico e tem-po de internamento podero ser a brevidade no diag-nstico e o consenso no tratamento antibitico.

Rev Port Pneumol 2009; XV (2): 165-178

Palavras-chave:Abcesso pulmonar, pneumonia ne-crotizante, infeces pulmonares.

ter LA diagnosis, intravenous (IV) antibiotic (AB)was prescribed for 16.5 (10.9) days with mean totalAB time 39.2 (15.7) days. Ten options of AB wereused and 23 patients had their initial IV AB changedto a second choice. Six patients needed surgery. Apy-rexia was achieved after 6.4 (6.4) days of treatment.21 patients had complications and 7 died. The meanlength of hospital admission was 27.5 (16.3) daysand 38 patients were called for a follow-up visit.These data are generally in accordance with the litera-ture. The high male percentage agrees with the simi-larly high prevalence of alcoholism and lung neo-

plasms in males. Key facts to ameliorate in order toimprove prognosis and length of hospital admissioncould be a swifter diagnosis and consensus on the ABtreatment.

Rev Port Pneumol 2009; XV (2): 165-178

Key-words: Lung abscess, necrotising pneumonia,lung infections.

IntroduoAbcessos pulmonares (AP) definem-se comonecrose piognica cavitada do parnquima pul-monar, processo que habitualmente traduz aevoluo de uma pneumonia necrotizante1,2.Costumam ser entidades clnicas crnicas e in-

capacitantes, que se manifestam de modo indo-lente ao longo de vrias semanas e muitas vezesse acompanham de um marcado atingimentodo estado geral. As implicaes so graves parao doente, com risco de diversas complicaes,sequelas e morte, e tambm para a sociedade,com elevados custos socioeconmicos.

IntroductionLung abscesses (LA) are defined as a loca-lised suppurative necrotising collection oc-curring within the pulmonary parenchy-ma1,2. They are usually chronic andincapacitating clinical conditions which

manifest slowly over the course of severalweeks and are often accompanied by mar-kedly reduced physical capacity. They haveserious implications for the patient, withrisk of several complications, sequelae anddeath, and also for society, involving as theydo high socio-economic costs.

Abcessos pulmonares: reviso de 60 casosLusa Magalhes, Diana Valadares, Jlio R Oliveira, Ernestina Reis



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Tradicionalmente, os AP classificam-se em pri-mrios ou secundrios3,4,5. Os primeiros so

consequncia da aspirao de patognios co-mensais da flora oral, predominantemente deagentes anaerbios6,7. Esto habitualmente as-sociados a mau estado gengivo-dentrio ou asituaes que predisponham broncoaspirao,como sejam consumo de lcool, drogas ilcitas,frmacos depressores do sistema nervoso cen-tral, anestesia geral e disfagia. Os AP secund-rios implicam a presena de condies favorece-doras de infeco local. Incluem-se aqui as quedeprimem as defesas imunolgicas do organis-mo, como a infeco pelo vrus da imunodefi-cincia humana (VIH), a imunossupresso ia-trognica ou a diabetes, e as que condicionamuma obstruo brnquica estrutural, de que soexemplos as neoplasias, os corpos estranhos as-pirados e a broncoestenose.Os autores apresentam uma reviso de 60 ca-sos, admitidos ao longo de um perodo de cin-co anos num hospital tercirio e universitrio.Foi objectivo a anlise da apresentao clnica,

os tempos decorridos antes e aps a hospitaliza-o, a investigao realizada, a estratgia tera-putica e os resultados desses internamentos.

Material e mtodosIdentificaram-se todos os processos de doentesinternados no Hospital Geral de Santo Antnio Porto entre 1 de Janeiro de 2000 e 31 de De-zembro de 2005, cujo diagnstico fosse AP deacordo com a codificao do ICD-9 (cdigo

513.0). De 74 processos reconhecidos, 14 fo-ram eliminados: sete estavam erradamente co-dificados, cinco no estavam disponveis paraconsulta, um no apresentava dados suficientespor transferncia hospitalar precoce e umreferia-se a uma criana. Efectuou-se a descrioe a anlise estatstica dos restantes 60 processos.

LA are traditionally classified as eitherprimary or secondary3,4,5. Primary LA are

the result of aspiration of oral flora-com-mensal pathogens, principally anaerobicagents6,7. Primary LA are usually associ-ated with dental disease or situationswhich predispose towards bronchoaspira-tion, such as alcohol consumption, drugtaking, central nervous system depressormedication, general anaesthetic and dys-phagia. Secondary LA imply the presenceof conditions conducive to local infec-tion, including immunodeficiency, forexample human immunodeficiency virus(HIV) infection, iatrogenic immunosup-pression or diabetes, and those whichlead to a structural bronchial obstruc-tion, for example neoplasm, aspiratedforeign bodies and bronchostenosis.The authors review 60 cases from over afive-year period in a tertiary and universityhospital. We analysed the clinical presenta-tion, time elapsing pre and post-hospitali-

sation, investigation undertaken, treatmentstrategy and results of these hospital admis-sions.

Material and methodsWe identified the clinical files of patientsadmitted to the Hospital Geral de SantoAntnio in Porto between January 1 2000and December 31 2005 who were diagnosedwith LA in accordance with the ICD-9

(code 513.0) classification. Of the 74 filesstudied, 14 were excluded, 7 for beingwrongly coded, 5 for not being open to re-view, 1 for having insufficient data due toan early hospital transfer and 1 as it per-tained to a child. We described and carriedout statistical analysis of 60 files.


Tradicionalmente, os

AP classificam-se em

primrios ou

secundrios



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Resultados

Caracterizao da amostraSetenta e cinco por cento dos doentes (45casos) eram homens. A idade variou entre26 e 85 anos, sendo a mdia 56,2 (dp 15,1).Abcessos pulmonares primrios foram diag-nosticados em 27 doentes (45,0%). Destes,9 casos no apresentavam qualquer factorde risco para AP (Quadro I); nos restantes,o factor de risco mais prevalente foi o mauestado gengivo-dentrio. Em 33 doentes(55,0%) diagnosticou-se AP secundrio,sendo a imunodeficincia o principal factorde risco neste grupo (Quadro II). Doze(20,0%) apresentavam neoplasias pulmona-res, sendo que em seis casos foram diagnos-ticadas na sequncia da investigao do AP.Destes, trs (25,0%) eram mulheres. Doisdoentes apresentavam neoplasias esofgicascom metastizao pulmonar, condicionan-do num dos casos fistulizao esofagobrn-quica e no outro disfagia. Entre os doentes

com AP secundrio, quinze tinham condi-es clnicas por si s favorecedoras de APprimrio (Quadro III). Em 34 doentes(56,7%) foram ainda identificadas outrascomorbilidades (Quadro IV).

Modo de apresentaoA durao mdia dos sintomas (em dias) at admisso hospitalar foi de 23,0 (dp 50,2;max 365; min 1; moda 7; mediana 8). Trin-ta e seis doentes (60,0%) referiram obser-vao mdica inicial sintomas compatveiscom infeco respiratria aguda (tosse pro-dutiva e febre com menos de 15 dias de evo-luo), 14 (23,3%) queixaram-se de sinto-mas com durao superior, 8 (13,3%)indicaram apenas sintomas aqui descritos

Results

Sample characterisation:Seventy five percent of patients (45 cases)were male. Ages ranged from 26-85 yearsold, with mean age 56.2 (15.1) yearsold. Primary LA was diagnosed in 27 pa-tients (45.0%). Of these, 9 cases present-ed no risk factor for LA (Table I), withdental decay the most prevalent risk fac-tor in the rest. Secondary LA was diag-nosed in 33 patients (55.0%), with im-munodeficiency the main risk factor inthis group (Table II). Twelve patients(20.0%) presented pulmonary neoplasms,which in 6 cases were diagnosed duringthe LA investigation. Three of these latter(25.0%) were female. Two presented oe-sophageal neoplasm with pulmonarymetastization, leading to oesophageal-bronchialfistula in one and dysphagia inthe other.Fifteen of the secondary LA patients had

clinical conditions which in themselves wereconducive to primary LA (Table III). Otherco-morbidities were identified in 34 pa-tients (56.7%) (Table IV).

PresentationMean duration of symptoms before hos-pital admission was 23.0 days (sd 50.2;max 365; min 1; mode 7; median 8).Thirty six patients (60.0%) cited in theinitial medical examination symptomscompatible with acute respiratory infec-tion (wet cough and fever under 15days); 14 (23.3%) complained of lon-ger-lasting symptoms, 8 (13.3%) indi-cated those symptoms described here asconstitutional syndrome (weight loss,




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Quadro I Factores de risco para AP primrio

Factores de risco

N.

de doentes

(%)

Nenhum 9 (15,0)

Mau estado dentrio 11 (18,3)

Alcoolismo 9 (15,0)

Uso de depressores do SNC 4 (6,7)

Disfagia 2 (3,3)

Nota:Entre parntesis, indica -se a percentagem relativamente ao

total de doentes da amostra

Quadro II Factores de risco para AP secundrio

Factores de riscoN.

de doentes

(%)

Imunodeficincia 32 (53,3)

diabetes mellitus

corticoterapia

quimioterapia

imunossupresso

infeco por VIH

pancitopenia iatrognica

17 (28,3)

6 (10,0)

5 (8,3)

2 (3,3)

1 (1,7)

1 (1,7)

Neoplasia 14 (23,3)

j conhecida

descoberta aps o AP

8 (13,3)

6 (10,0)Broncoestenose 1 (1,7)

Fstula broncoesofgica 1 (1,7)

Aspirao de corpo estranho 1 (1,7)



Quadro III AP secundrios com factores de risco

adicionais para AP primrio

Factores de risco

N.

de doentes

(%)Mau estado dentrio 7 (11,7)

Alcoolismo 6 (10,0)

Disfagia 4 (6,7)

Uso de depressores do SNC 2 (3,3)



Table I Risk factors for primary LA

Risk factors

No.

of patients

(%)

None 9 (15.0)

Dental decay 11 (18.3)

Alcoholism 9 (15.0)

CNS depressor use 4 (6.7)

Dysphagia 2 (3.3)

Note:The percentage relative to the total number of patients in the

sample is given between brackets

Table II Risk factors for secondary LA

Risk factorsNo.

of patients

(%)

Immunodeficiency 32 (53.3)

diabetes mellitus

cortico-steroid treatment

chemotherapy

immunosuppression

HIV infection

iatrogenic pancytopaenia

17 (28.3)

6 (10.0)

5 (8.3)

2 (3.3)

1 (1.7)

1 (1.7)

Neoplasm 14 (23.3)

already known

discovered after the LA

8 (13.3)

6 (10.0)Bronchostenosis 1 (1.7)

Bronchial-oesophageal fistula 1 (1.7)

Foreign body aspiration 1 (1.7)



Table III Secondary LA with additional risk factors for

primary LA

Risk factors

No.

of patients

(%)Dental decay 7 (11.7)

Alcoholism 6 (10.0)

Dysphagia 4 (6.7)

CNS depressor use 2 (3.3)






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asthenia, anorexia, fatigue, etc.) and 2(3.3%) presented for other reasons. Theclinical files, in conjunction with timeprogress, presence of risk factors andinitial radiography evaluation could in-

como sndroma constitucional (emagreci-mento, astenia, anorexia, fadiga, etc.) e 2(3,3%) apresentaram-se por outros motivos.O conjunto da anamnese, evoluo tempo-ral, presena de factores de risco e avaliao

Quadro IV Comorbilidades presentes nos doentes com AP

Patologias

N.

de doentes

(%)

Patologia respiratria 11 (18,3)

DPOC 6 (10,0)

Pneumoconiose 1 (1,7)

Bronquiectasias 1 (1,7)

Asma 1 (1,7)

Deformidade da parede torcica 1 (1,7)

Infeces recorrentes 1 (1,7)

Patologia neurolgica 7 (11,7)

Demncia senil 2 (3,3)

Paramiloidose familiar 1 (1,7)

Miastenia gravis 1 (1,7)

Epilepsia ps-traumtica 1 (1,7)

Oligofrenia 1 (1,7)

Hidrocefalia 1 (1,7)

Patologia heptica 7 (11,7)

Cirrose 5 (8,3)

Infeco por VHC 2 (3,3)

Patologia cardaca 6 (10,0)

Cardiopatia isqumica 5 (8,3)

Cor pulmonale 1 (1,7)

Patologia neoplsica prvia 4 (6,7)

Hematolgica 2 (3,3)

Carcinoma pavimentoso oral 1 (1,7)

Carcinoma vesical 1 (1,7)

Patologia autoimune (LES) 1 (1,7)

Patologia renal (IRC) 1 (1,7)

Patologia oftalmolgica (glaucoma) 1 (1,7)

Caquexia (etiologia indeterminada) 1 (1,7)

Tabagismo 6 (10,0)

SNC, sistema nervoso central; VIH, vrus da imunode ficincia hu-

mana; DPOC, doena pulmonar obstrutiva crnica; VHC, vrus da

hepatite C; LES, lpus eritematoso sistmico; IRC, insu ficincia

renal crnica.



Table IV Co-morbidities present in LA patients

Pathologies

No.

of patients

(%)

Respiratory pathology 11 (18.3)

COPD 6 (10.0)

Pneumoconiosis 1 (1.7)

Bronchiectasias 1 (1.7)

Asthma 1 (1.7)

Thoracic wall deformity 1 (1.7)

Recurrent infections 1 (1.7)

Neurological pathology 7 (11.7)

Senile dementia 2 (3.3)

Familial paramyloidosis 1 (1.7)

Miastenia gravis 1 (1.7)

Post traumatic epilepsy 1 (1.7)

Oligophrenia 1 (1.7)

Hydrocephalus 1 (1.7)

Hepatic pathology 7 (11.7)

Cirrhosis 5 (8.3)

HCV infection 2 (3.3)

Cardiac pathology 6 (10.0)

Ischaemic cardiopathy 5 (8.3)

Cor pulmonale 1 (1.7)

Underlying neoplastic pathology 4 (6.7)

Haematological 2 (3.3)

Floor of mouth carcinoma 1 (1.7)

Vesical carcinoma 1 (1.7)

Au to-immune patho logy (SLE) 1 (1.7)

Renal pathology (CRF) 1 (1.7)

Ophthalmological pathology (Glaucoma) 1 (1.7)

Cachexia (aetiology unknown) 1 (1.7)

Smoking 6 (10.0)

CNS, Central nervous system; HIV , Human immunode ficiency vi-

rus; COPD, chronic obstructive pulmonary disease; HCV, Hepatitis

C virus; SLE, systemic lupus erythematosus; CRF , chronic renal

failure






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radiogrfica inicial poderia indicar elevadasuspeita clnica para AP em 40 doentes

(66,7%).

DiagnsticoO tempo decorrido desde a admisso at aodiagnstico variou entre 1 e 60 dias, tendo amdia sido de 8,7 (dp 11,4; moda 1; mediana3,5). Vinte e oito casos (46,7%) foram diag-nosticados nos dois primeiros dias de interna-mento. Foi possvel identificar um agente mi-crobiano em 26 doentes (43,3% QuadroV), sendo que as bactrias Gram negativas fo-ram isoladas em 10 casos (16,7% do total daamostra). Em 9 doentes (15,0%) foram isola-das bactrias Gram positivas; microrganismosanaerbios identificados apenas em trs casos(5,0%) e em dois (3,3%) houve somente iso-lamento de fungos. Cinco doentes (8,3%) ti-veram isolamento de mais do que um agente eem nove (15,0%) foram isolados agentes no-socomiais (com destaque para a Pseudomonas

aeruginosa, oS. aureusmeticilino-resistente e oAcinetobacter baumannii). Os produtos biol-gicos que tiveram resultados culturais positivosforam: a expectorao em 15 doentes, o aspi-rado broncoalveolar em 5, o sangue em 3 e olquido pleural em 1; h ainda um caso emque o agente patognico foi isolado no sangue,no aspirado broncoalveolar e no lquido pleu-ral, mas no nas secrees brnquicas, e umcaso em que o nico agente identificado foi aLegionella pneumophilapor intermdio da de-

teco do seu antignio urinrio e serologias.Cinquenta e nove doentes (98,3%) realizaramTAC torcica e 32 (53,3%) foram submetidosa broncofibroscopia ptica (BFO).

dicate a heavy suspicion of LA in 40 pa-tients (66.7%).

DiagnosisTime from admission to diagnosis rangedfrom 1 60 days, mean 8.7 (sd 11.4;mode 1; median 3.5). Twenty eight cases(46.7%) were diagnosed within the firsttwo days of hospital admission. A micro-bial pathogen was recovered in 26 cases(43.3% Table V), with Gram negativebacteria isolated in 10 cases (16.7% oftotal sample). Gram positive bacteriawere isolated in 9 patients (15.0%);anaerobic microorganisms were identi-fied in only 3 cases (5.0%) and fungi onlyin 2 (3.3%). In five patients (8.3%) morethan one agent was isolated and hospital-acquired agents in 9 (15.0%) (particu-larly Pseudomonas aeruginosa, methicillin-resistant S. aureus and Acinetobacterbaumannii). The biological products with

positive culture results were sputum in15 patients, broncho-alveolar aspirate in5, blood in 3 and pleural liquid in 1.There was a further case in which the mi-crobial pathogen was isolated in blood,broncho-alveolar aspirate and pleural li-quid, but not the bronchial secretions. In1 case the sole agent identified was Legio-nella pneumophilavia detection of its uri-nary and serology antigen. Fifty nine pa-tients (98.3%) underwent chest CT scan

and 32 (53.3%) underwent fibre-opticbronchofibroscopy (BFO).




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TratamentoAps o diagnstico, todos os doentes recebe-ram AB IV por um perodo mdio de 16,5dias (dp 10,9; max 56; min 1; moda 14; me-

TreatmentAfter LA diagnosis, intravenous (IV) antibi-otic (AB) was prescribed for a mean periodof 16.5 days (sd 10.9; max 56; min 1; mode

Quadro V Agentes microbianos isolados nos doentes com AP

Doente Microrganismo isolado

Momento

do isolamento Produto b io lgico Es tado imuno lgico

1 Staphylococcus aureus Admisso ABA + SB Ctx + DM + Is

2 Streptococcus pneumoniae Admisso ABA Neoplasia

3 Staphylococcus aureus 7. dia LP Imunocompetente

4 Streptococcus pneumoniae Admisso SB Imunocompetente

5 Porphyromonas 4. dia ABA DM

6 Haemophilus inuenzae Admisso SB DM

7 Zygomicetes 6. dia LBA Is + DM

8 Legionella pneumophila Admisso AgU Competente

9 Serratia marcescens Admisso SB Ctx

10Enterobacter cloacae

S. aureus MR

20. dia

24. dia

SB

SB

Neoplasia

11

Pseudomonas aeruginosa

S. aureus MR

Acinetobacter baumannii

13. dia

30. dia

30. dia

SB

SB

SB

Imunocompetente

12 Pseudomonas aeruginosa 10. dia HC + SB Neoplasia

13 Klebsiella pneumoniae Admisso SB DM + neoplasia

14 Streptococcus pneumoniae Admisso HC Imunocompetente

15Streptococcus pneumoniae

Moraxella catarrhalis

Admisso

Admisso

HC

SB

Imunocompetente

16

Candida albicans

Candida cruzei

Corynebacterium jeikeium


Admisso

Admisso

7. dia

23. dia

SB

LP

HC

LP + SB

Imunocompetente

17 Staphylococcus chromogenes Admisso HC Neoplasia + Qtx

18 Anaerbios Admisso ABA Imunocompetente

19 Pseudomonas aeruginosa Admisso HC Qtx + Ctx

20Klebsiella pneumoniae

Klebsiella pneumoniae

15. dia

20. dia

SB

ABADM + Ctx

21 Escherichia coli Admisso SB DM

22Staphylococcus cohnii


Admisso

7. dia

HC + Ps

ABA

Imunocompetente

23 Moraxella catarrhalis Admisso SB Imunocompetente

24 Pseudomonas aeruginosa 10. dia SB Imunocompetente

25 Escherichia coli Admissso SB Imunocompetente

26 Anaerbios 4. dia ABA DM

ABA, aspirado broncoalveolar; SB, secrees brnquicas; Ctx, corticoterapia sistmica; DM, diabetesmellitus; Is, imunossupresso iatrog-

nica; LP, lquido pleural; LBA, lavado broncoalveolar; AgU, antignio urinrio; HC, par de hemoculturas; Qtx, quimioterapia sistmica




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diana 14). A durao total de AB foi 39,2dias (dp 15,7; max 90; min 2; moda 42; me-diana 40). Foram vrios os antibiticos pres-critos para tratamento inicial, mas os mais

14; median 14). The total AB time was 39.2days (sd 15.7; max 90; min 2; mode 42; me-dian 40). A range of AB was prescribed forinitial treatment, with the most used (in de-

Table V Microbial pathogens isolated in LA patients

Patient Microorganism isolated When isolated

Biological

product Immunological state

1 Staphylococcus aureus Admission BAA + BS Ctx + DM + Is

2 Streptococcus pneumoniae Admission BAA Neoplasm

3 Staphylococcus aureus 7thday PL Immunocompetent

4 Streptococcus pneumoniae Admission BS Immunocompetent

5 Porphyromonas 4thday BAA DM

6 Haemophilus inuenzae Admission BS DM

7 Zygomicetes 6thday BAL Is + DM

8 Legionella pneumophila Admission UAg Competent

9 Serratia marcescens Admission BS Ctx

10Enterobacter cloacae

S. aureus MR

20thday

24thday

BS

BS

Neoplasm

11


S. aureus MR

Acinetobacter baumannii

13thday

30thday

30thday

BS

BS

BS

Immunocompetent

12 Pseudomonas aeruginosa 10thday HC + BS Neoplasm

13 Klebsiella pneumoniae Admission BS DM + Neoplasm

14 Streptococcus pneumoniae Admission HC Immunocompetent

15Streptococcus pneumoniae

Moraxella catarrhalis

Admission

Admission

HC

BS

Immunocompetent

16

Candida albicans

Candida cruzei

Corynebacterium jeikeium


Admission

Admission

7thday

23rdday

BS

PL

HC

PL + BS

Immunocompetent

17 Staphylococcus chromogenes Admission HC Neoplasm + Qtx

18 Anaerobic Admission BAA Immunocompetent

19 Pseudomonas aeruginosa Admission HC Qtx + Ctx

20Klebsiella pneumoniae


15thday

20thday

BS

BAA

DM + Ctx

21 Escherichia coli Admission BS DM

22Staphylococcus cohnii


Admission

7thday

HC + Pus

BAA

Immunocompetent

23 Moraxella catarrhalis Admission BS Immunocompetent

24 Pseudomonas aeruginosa 10thday BS Immunocompetent

25 Escherichia coli Admission BS Immunocompetent

26 Anaerobic 4thday BAA DM

BAA, broncho-alveolar aspirate; BS, bronchial secretion; Ctx, systemic corticotherapy; DM, diabetes mellitus; Is, iatrogenic im munosup-

pression; PL, pleural liquid; BAL, broncho-alveolar lavage; UAg, urinary antigen; HC, haemoculture pair; Qtx, systemic chemotherapy




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utilizados foram, por ordem decrescente: as-sociao de piperacilina + tazobactam (em

19 casos), amoxicilina + cido clavulnico(em 16) e carbapenmicos (em 11). A clin-damicina foi o primeiro antibitico prescritoem trs doentes. Em 23 casos (38,3%), a ABIV inicial foi alterada por razes que inclu-ram falncia teraputica, ajuste conformeresultados de antibiograma ou passagempara esquema posolgico oral. Seis doentes(10,0%) necessitaram de tratamento cirrgi-co, por falncia da teraputica mdica oupor desenvolvimento de complicaes.

Resultados clnicosConseguiu-se apirexia aps 6,4 dias de trata-mento, em mdia (dp 6,4; max 28; min 1;moda 2; mediana 5). Dezassete doentes(28,3%) ficaram apirticos em menos de 72horas. Desenvolveram-se complicaes em21 doentes (35,0%), que consistiram em:derrame pleural (5 casos), spsis (5), falncia

da teraputica mdica (3), reinternamento(3), fstula broncopleural (2), hemoptises se-veras (1), necessidade de ventilao invasiva(1) e reaco alrgica (1). Sete (11,7%) fale-ceram, maioritariamente por spsis (em umcaso, a causa clnica da morte foi neoplasiapulmonar em fase terminal). Nenhum doen-te foi autopsiado. A durao do internamen-to variou entre 2 e 90 dias, tendo a mdiasido 27,5 dias (dp 16,3; moda 32; mediana26). Aps a alta hospitalar, 38 doentes

(63,3%) foram convocados para consultamdica hospitalar.

DiscussoOs resultados apresentados esto de acordocom a literatura no que respeita caracteri-

scending order) association of piperacillin +tazobactam (19 cases), amoxicilina + clavu-

lanic acid (16) and carbapenemic com-pounds (11). Clindamycin was the first an-tibiotic prescribed in 3 patients. Patientsinitial IV AB was changed in 23 cases(38.3%) and reasons for this alteration in-cluded treatment failure, adjustment in linewith antibiogram results or change to anoral dosing schedule. Six patients (10.0%)needed surgery due to treatment failure orcomplications.

Clinical resultsApyrexia was achieved after a mean of 6.4days of treatment, (sd 6.4; max 28; min 1;mode 2; median 5). Apyrexia was achievedin sixteen patients (28.3%) in less than 72hours. 21 patients (35.0%) had complica-tions. These were pleural infusion (5 cases),sepsis (5), treatment failure (3), re-admis-sion (3), bronco-pleural fistula (2), severe

haemoptysis (1), need for mechanical venti-lation (1) and allergic reaction (1). Sevenpatients (11.7%) died, mainly due to sepsis(in 1 case, clinical cause of death was endstage pulmonary neoplasm). No patient un-derwent autopsy. Hospital stay ranged from2 90 days, mean 27.5 days (sd 16.3; mode32; median 26). After discharge form hospi-tal, thirty eight patients (63.3%) were calledfor a follow-up visit.

DiscussionOur results are in agreement with the litera-ture in terms of LA patients general charac-terisation: more males than females, typicalpresentation in 5th decade of life and riskfactors present in the majority of cases5,8,9.




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zao geral dos doentes com AP: maior pre-valncia nos homens, apresentao mdia na

quinta dcada de vida e presena de factoresde risco na maioria dos casos5,8,9. A elevadapercentagem de doentes do sexo masculinocoincide com maior prevalncia de alcoolis-mo e de neoplasias pulmonares neste grupo.J o modo de apresentao inicial pareceinesperado5,9, pois 60% dos doentes nestaamostra referiram admisso sintomas comdurao inferior a 15 dias. Talvez o contextodo servio de urgncia, onde o diagnsticode AP foi estabelecido na maioria dos casos,tenha induzido os clnicos e os doentes a so-brevalorizar manifestaes agudas da doen-a em detrimento da sua evoluo subagudaou crnica. Esta contingncia poder ter in-fluenciado o atraso no diagnstico em inter-namento. Assim, apesar de 66,7% dos doen-tes reunirem condies sugestivas de altasuspeita clnica (com base na anamnese,presena de factores de risco, evoluo tem-poral e avaliao radiolgica inicial), o diag-

nstico estabeleceu-se em mdia apenas aofim de 8,7 dias. No entanto, importa realarque 46,7% dos doentes foram diagnostica-dos no dia da admisso ou no dia imediato.Para estes valores aparentemente contradi-trios poder talvez contribuir a inclusonesta amostra de doentes internados por ou-tros motivos que no o AP. Nestes casos, al-guns AP podero ser nosocomiais. Em ou-tros, o alerta para um eventual AP s surgiumais tarde, durante o internamento.

Um nmero elevado de doentes foi submeti-do a BFO (53,3%), apesar de actualmente serecomendar a realizao desta tcnica invasi-va apenas nos casos atpicos e/ou com fortesuspeita de obstruo mecnica10. Contudo,a rentabilidade foi alta, j que em catorzedoentes (cerca de metade dos que realizaram

The high male percentage agrees with thesimilarly high prevalence of alcoholism and

lung neoplasms in males.Initial form of presentation seems unex-pected5,9: 60% of patients in our samplecited on admission symptoms of less than15 days duration. Maybe the fact that themajority of LA diagnoses were made in theEmergency Room induced physicians andpatients to over-emphasise acute manifesta-tions of the disease at the expense of its sub-acute or chronic presentations.This couldhave influenced the delayed diagnosis dur-ing hospital stay. Thus, only 66.7% of pa-tients presented conditions suggestive of ahigh degree of clinical suspicion (based onclinical file, presence of risk factors, timeprogress and initial radiological evaluation),with diagnosis established on average onlyafter 8.7 days. It is important, however, toemphasise that 46.7% of patients were diag-nosed on the day of admission or the dayafter. Perhaps the inclusion of patients ad-

mitted to hospital for reasons other than LAin the sample may have added to these ap-parently contradictory values. In these cases,some LA may have been hospital-acquired.In others, being alert to a possible LA onlycame later, during hospital stay.A high number of patients underwent BFO(53.3%), despite current recommendationsthat this invasive technique should only beused in atypical cases and/or those with a highdegree of suspicion of mechanical obstruc-

tion10. The success rate was high, however, andin 14 patients (around half of those who un-derwent the exam) BFO was the only methodwhich allowed hitherto unknown structuralalterations to be detected (9 cases, including 6de novoneoplasms) and/or the identificationof the microbial pathogen (5 cases).




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este exame) a BFO foi o nico mtodo quepermitiu a deteco de alteraes estruturais

at ento desconhecidas (9 casos, incluindo6 neoplasias de novo) e/ou a identificao doagente microbiano (5 casos).A taxa de identificao de agente microbiano(43,3%) bastante satisfatria, embora na li-teratura se mencionem por vezes valores mui-to superiores, que todavia se referem a sries dedoentes nos quais a pesquisa de microrganis-mos (nomeadamente anaerbios) foi feita demodo exaustivo (incluindo atravs de aspira-o transtraqueal), o que no corresponde nossa realidade quotidiana6,7. Por outro lado,as comorbilidades e internamentos prolonga-dos podero ter favorecido a identificao deagentes cujo papel na etiologia do AP no serde afirmao definitiva. Em quatro doentesque apresentavam como comorbilidade doen-a respiratria crnica, apenas foram isoladosagentes habituais colonizantes destas patolo-gias (como aM. catarrhalis, a K. pneumoniae,a S. marcescense o H. influenza) e apenas na

cultura de secrees brnquicas, no sendopor isso claro o papel etiolgico destes micror-ganismos na patogenia do AP. O elevado n-mero de isolamentos de agentes nosocomiais(9) tambm merece destaque, sendo possvelque a maioria destes casos correspondam adoentes sem identificao inicial de agente enos quais, mais tarde, se tenha manifestado asobreinfeco pelo agente nosocomial. Refira--se ainda a situao pouco comum, embora jmencionada na literatura11, de AP por Legio-

nella pneumophila, acrescentando-se para me-lhor esclarecimento que este doente tinha esta-do internado por pneumonia por estemicrorganismo, no mesmo local anatmico,cerca de um ms antes do diagnstico de AP.Em relao s taxas de necessidade de inter-veno cirrgica, desenvolvimento de com-

The microbial pathogen identification rate(43.3%) is highly satisfactory, although in

the literature there are several references tovastly higher values. These, however, referto patient series in which the search for mi-croorganisms (namely anaerobic) was pur-sued exhaustively (including through trans-tracheal aspiration), which is not the case inour daily practice6,7. Equally so, the co-mor-bidities and prolonged hospital admissionscould have favoured the identification ofagents whose role in the aetiology of LA hasnot been definitely confirmed. In 4 patientswith chronic respiratory disease as co-mor-bidity, only the usual colonising agents ofthese pathologies (such asM. catarrhalis, K.pneumoniae, S. marcescensand H. influenza)were identified, and only in the bronchialsecretion cultures. The aetiological rolethese microorganisms play in LA pathoge-nesis is thus not clear. The high number ofisolations of hospital-acquired agents (9)also deserves highlighting. It is possible that

the majority of these cases were patients inwhich initial identification of the agent wasnot made and in which a super-infection byhospital-acquired agent was later identified.We further mention an uncommon situa-tion, although one which appears in the li-terature11, of AP due to Legionella pneumo-

phila, and, to explain further, this patienthad been admitted to hospital for Legionellapneumophila pneumonia at the same sitearound 1 month prior to the LA diagnosis.

The need for surgery, development of com-plications and mortality was the same in ourseries as in the literature5,9,12.In our sample, the long duration of hospitalstay particularly stands out. Diagnosis wasestablished quickly in the majority of cases,making it interesting to assess up to which




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plicaes e mortalidade, os valores encontra-dos nesta srie so similares aos habitualmente

publicados5,9,12

.Nesta amostra, destaca-se sobretudo a longadurao do internamento hospitalar. Aten-dendo brevidade com que o diagnstico foiestabelecido na maioria dos casos, interessaavaliar at que ponto o desvio s orientaesteraputicas internacionais influenciou o tem-po de internamento. Esta presuno podeconsubstanciar-se no grande nmero de anti-biticos utilizado (mais de 10 frmacos dife-rentes), na durao de teraputica IV muitopara alm do atingimento de apirexia (mdiasde, respectivamente, 16,5 e 6,4 dias) e nas fre-quentes mudanas de tratamento (38,3% dosdoentes), por vezes sem motivo explcito.Alis, note-se que apenas a trs doentes foi ini-cialmente prescrita a clindamicina, que actual-mente um dos AB de referncia paratratamento primrio dos AP. Factores como orisco de incumprimento teraputico no domi-clio, a presena de comorbilidades significati-

vas, a descompensao de patologias crnicas eo isolamento de microrganismos de difcil tra-tamento tambm podero ter contribudopara o atraso da alta hospitalar.Os autores admitem que estas dificuldades nodiagnstico e tratamento dos AP se relacionemcom a baixa prevalncia na populao geral des-ta entidade nosolgica, conforme explicitadopelo reduzido nmero de doentes que constituiesta amostra: 60 casos admitidos num hospitaltercirio ao longo de um perodo de 5 anos.

ConclusoOs AP so patologias crnicas, incapacitan-tes e com graves implicaes. So conheci-dos diversos factores de risco, modalidadesde apresentao clnica, estratgias diagns-

point deviations in international treatmentguidelines influenced the length of hospital

stay.This assumption could be borne out bythe high number of antibiotics used (over10 different drugs), prolonged IV treatmenteven after apyrexia was achieved (mean 16.5and 6.4 days in turn) and the frequentchanges in treatment (38.3% of patients),sometimes with no explicable motive. Forexample, clindamycin was the first AB pre-scribed in only 3 patients, when it is cur-rently a gold standard AB in first line LAtreatment. Factors such as the risk of non-compliance with treatment at home, thepresence of significant co-morbidities, thedifficulties attendant on chronic conditionsand the isolating of difficult-to-treat micro-organisms could also add to the delay inhospital discharge.The authors acknowledge that these diffi-culties in diagnosing and treating LA areconnected to the low prevalence of this hos-pital-acquired condition in the general po-

pulation, explained by the reduced numberof patients in our sample: 60 cases admittedto a tertiary hospital over a 5-year period.

ConclusionLAs are chronic, incapacitating conditionswith severe implications. Several risk fac-tors, forms of clinical presentation, diagnos-tic approaches and treatment options areknown, but no clinically valid procedural

protocols exist. The low prevalence of thisentity makes it hard to perform reviews oflarge series of cases.Our work shows that a swift diagnosis basedon the clinical picture is possible and thatswifter diagnosis and consensus on AB treat-ment seem to be fundamental areas for fu-


Os AP so patologias

crnicas,

incapacitantes e com

graves impl icaes



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ticas e opes teraputicas, no existindo noentanto protocolos de actuao clinicamen-

te validados. A baixa prevalncia desta enti-dade dificulta a realizao de revises degrandes sries de casos.Este trabalho mostrou que possvel antecipar odiagnstico com base na clnica e que a celerida-de no diagnstico e o consenso no tratamentoparecem ser pontos fundamentais a desenvolverno futuro, com vista melhoria do prognsticodestes doentes e tambm a uma reduo dos cus-tos socioeconmicos que esta patologia acarreta.A investigao invasiva do agente etiolgico pare-ce ser mais rentvel nos imunodeprimidos, dadaa probabilidade de estarem envolvidos agentesresistentes ao tratamento de primeira linha. Aidentificao de grupos de risco para neoplasiapulmonar e correspondente seleco para BFOpoder aumentar o rendimento deste exame semaumento da taxa de falsos positivos.

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