This topic covers infections that complicate or extend beyond ordinary pneumonia: lung abscess, infected pleural effusions (parapneumonic effusion and empyema), pleurisy, fungal lung infections, and sepsis arising from the lungs. Pneumonia itself is covered in Topic 16 and tuberculosis in Topic 17.

Lung abscess

• A localized area of necrosis with a pus-filled cavity in the lung
• Most often follows aspiration of oropharyngeal material in clients with reduced consciousness (alcohol use, sedation, seizures, stroke), dysphagia, or poor dental hygiene/periodontal disease; mixed oral anaerobes are typical
• Aspirated material goes to dependent segments — commonly the posterior segments of the upper lobes and the superior segments of the lower lobes, more often on the right
• Other causes: necrotizing pneumonia (e.g., Staphylococcus aureus, Klebsiella), obstruction by a tumor or foreign body, septic emboli

Pleural infection

• The pleural space normally contains a few milliliters of fluid. Pneumonia can trigger a parapneumonic effusion:
  1. Uncomplicated — sterile exudate that resolves with antibiotics
  2. Complicated — bacteria invade; fluid becomes acidic, glucose falls, fibrin septations (loculations) form
  3. Empyema — frank pus in the pleural space; a thick peel can trap the lung
• Pleurisy (pleuritis) — inflamed pleural surfaces rub together, causing sharp pain with breathing

Fungal lung infections

• Histoplasmosis (soil contaminated with bird or bat droppings), coccidioidomycosis (dry soil in desert regions), aspergillosis (immunocompromised clients, lung cavities), and Pneumocystis pneumonia (HIV with low CD4 count, other immunosuppression)
• Generally not spread from person to person

Sepsis from a lung source. Pneumonia is the most common source of sepsis. Early (warm) septic shock is distributive: vasodilation causes a low systemic vascular resistance (SVR) with a compensatory high cardiac output; low central venous pressure reflects relative hypovolemia. Later, cardiac output can fall.

Lung abscess

• Fever, night sweats, weight loss over weeks
• Cough with large amounts of foul-smelling, purulent sputum (may occur suddenly when the abscess drains into a bronchus)
• Hemoptysis, pleuritic chest pain
• Poor dentition, history of alcohol use or aspiration

Parapneumonic effusion / empyema

• Pneumonia that is not improving: persistent or recurrent fever after 2–3 days of antibiotics
• Pleuritic chest pain, dyspnea
• Dullness to percussion, diminished or absent breath sounds, decreased tactile fremitus over the effusion; tracheal shift away from a large effusion

Pleurisy

• Sharp, stabbing pain on inspiration or coughing, often one-sided; shallow breathing
• Pleural friction rub (grating sound in both inspiration and expiration)

Sepsis

• Fever or hypothermia, tachycardia, tachypnea, hypotension, warm flushed skin early (cool and mottled later), altered mental status, oliguria

Transudate vs. exudate: transudates come from pressure or protein imbalance (heart failure, cirrhosis, nephrotic syndrome); exudates come from inflammation, infection, or cancer.

Lung abscess

• Prolonged antibiotics covering oral anaerobes (e.g., ampicillin-sulbactam IV, then oral amoxicillin-clavulanate; clindamycin as an alternative), commonly for several weeks until imaging shows resolution
• Postural drainage and airway clearance to help the cavity empty
• Treat dental disease; evaluate swallowing
• Percutaneous drainage or surgical resection if not responding

Parapneumonic effusion and empyema

• Antibiotics that cover likely organisms, including anaerobes for empyema, often for several weeks
• Drainage of complicated effusions and empyema: chest tube (tube thoracostomy), often small-bore and ultrasound-guided
• Intrapleural fibrinolytic plus DNase (tissue plasminogen activator with dornase alfa) given into the pleural space through the chest tube to break up loculations when drainage is poor — a different use from inhaled dornase
• Video-assisted thoracoscopic surgery (VATS) or decortication for persistent collections or a trapped lung

Pleurisy — treat the cause; NSAIDs for pain when not contraindicated.

Fungal infections — azoles (itraconazole, voriconazole, fluconazole) or amphotericin B for severe disease; trimethoprim-sulfamethoxazole for Pneumocystis.

Septic shock (bundle principles)

• Blood cultures, then broad-spectrum antibiotics as soon as possible (within 1 hour when shock is likely)
• Measure lactate; 30 mL/kg IV crystalloid for hypotension or lactate ≥ 4 mmol/L (36 mg/dL)
• Norepinephrine as first-line vasopressor to keep mean arterial pressure ≥ 65 mmHg
• Source control (e.g., drain empyema)

Drug safety

Listed in priority order.

1. Airway, breathing, and oxygenation
   • Monitor respiratory rate, SpO₂, breath sounds; give oxygen as ordered
   • Upright positioning; for pleurisy, having the client splint the painful side with a pillow or lie on the affected side reduces chest wall movement and pain
   • Watch for sudden large-volume sputum or hemoptysis when an abscess ruptures into a bronchus — aspiration risk to the healthy lung
2. Circulation (sepsis) — monitor BP, MAP, heart rate, urine output (≥ 0.5 mL/kg/h), lactate, mental status; give fluids and vasopressors as ordered
3. Obtain cultures before antibiotics, then give antibiotics without delay
4. Airway clearance
   • Postural drainage for lung abscess: position the affected segment uppermost (e.g., a right-sided abscess → lie on the left side with the right side up), then cough and expectorate; provide an emesis basin and tissues
   • Deep breathing, incentive spirometry, fluids unless restricted
5. Thoracentesis care
   • Before: confirm consent, check coagulation status and anticoagulant use, obtain baseline vital signs and SpO₂; position sitting upright, leaning forward over an overbed table (or lying on the unaffected side with the affected side up if unable to sit)
   • During: instruct the client not to cough, talk, or move while the needle is inserted; monitor for dizziness, pallor, hypotension, dyspnea, and coughing. Large volumes are usually limited (commonly about 1–1.5 L) to reduce the risk of re-expansion pulmonary edema
   • After: monitor for pneumothorax (the most common complication) — sudden dyspnea, chest pain, tachycardia, falling SpO₂, reduced breath sounds; check the puncture site for bleeding or leakage; post-procedure chest X-ray as ordered; label and send specimens promptly
6. Chest tube care
   • Keep the drainage system below chest level, tubing free of dependent loops and kinks
   • Tidaling in the water-seal chamber is expected; continuous bubbling in the water-seal chamber = air leak — check connections and report. Gentle continuous bubbling in a wet suction-control chamber is expected; do not strip or milk tubing unless ordered
   • Record drainage amount and character; report a sudden large increase (e.g., more than 100 mL/h, or per facility protocol) or bright red drainage
   • Do not clamp routinely. If the tube disconnects, place the end in sterile water; if it is pulled out, cover the site with a sterile occlusive dressing taped on three sides and notify the provider
7. Oral hygiene and aspiration prevention — tooth brushing, dental referral, swallow screen, upright positioning for meals
8. Nutrition and comfort — high-calorie, high-protein diet; analgesia to allow effective coughing

• Complete the full, often long, antibiotic course; follow-up imaging confirms healing
• Report fever that returns, increased or foul sputum, blood in sputum, worsening shortness of breath, or chest pain
• Maintain good oral hygiene and see a dentist; limit alcohol; avoid sedatives with alcohol
• Continue postural drainage and breathing exercises at home as taught
• After a chest tube or thoracentesis: report shortness of breath, chest pain, or drainage from the site; keep the dressing dry
• Fungal infection prevention: wear a mask and avoid disturbing soil with bird or bat droppings or dusty soil in endemic areas if immunocompromised
• On clindamycin: report frequent watery diarrhea
• Vaccination (pneumococcal, influenza, COVID-19, RSV as recommended) reduces pneumonia and its complications

• Lung abscess follows aspiration (alcohol, sedation, dysphagia, poor dentition): foul sputum, cavity with air–fluid level
• Postural drainage: affected area uppermost
• Parapneumonic effusion is suspected when pneumonia fails to improve; findings: dullness, decreased breath sounds and fremitus
• pH < 7.20, low glucose, positive culture, or pus = drain with a chest tube
• Light's criteria separate exudate from transudate
• Thoracentesis position: sitting, leaning over a table; no coughing or moving during insertion
• Most common thoracentesis complication: pneumothorax
• Continuous bubbling in the water-seal chamber = air leak; tidaling is normal
• Pleurisy: sharp inspiratory pain, friction rub; splint the chest
• Early septic shock: ↑cardiac output, ↓SVR, low CVP
• Sepsis: cultures, antibiotics within 1 hour, 30 mL/kg crystalloid, norepinephrine for MAP ≥ 65 mmHg
• Amphotericin B: nephrotoxicity, hypokalemia, infusion reactions