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Heterogeneity in clinical patterns of adult lung abscess patients: an 8-year retrospective study in a tertiary hospital

BMC Pulmonary Medicine volume 25, Article number: 101 (2025) Cite this article

Abstract

Background

The widespread use of broad-spectrum antibiotics has led to changes in both the microbiological and clinical characteristics of lung abscesses. It is necessary to re-evaluate the bacterial spectrum associated with these infections. As a novel method for pathogen detection, metagenomic next-generation sequencing (mNGS) is increasingly being applied in clinical practice. There is limited research evaluating the use of mNGS in patients with lung abscesses.

Methods

A retrospective analysis was conducted on patients with lung abscess who were hospitalized between July 2015 and July 2023 at a teaching hospital in China. Patients who underwent both computerized tomography (CT) imaging and conventional pathogen testing were included in the study. The efficacy of pathogen detection using conventional methods was compared with that of mNGS. Additionally, the clinical and radiological features were analyzed to provide a comprehensive understanding of the disease patterns.

Results

A total of 782 patients with lung abscess were included in the study and hematogenous abscess accounting for 7.16% (56/782) of cases. The overall hospital mortality rate was 1.53%. The mean age of the patients with lung abscess was 60 years, with a male predominance (80.2%). A significant proportion of patients had comorbid conditions, including diabetes (29.7%) and cardiovascular disease (18.2%). Lung abscesses were predominantly located in the right lung, and pleural effusion was more commonly observed in the deceased group. The detection rate of pathogen via conventional test was lower at 41.8% (327/782). Among patients with positive mNGS results, only 51.9% had pathogens identified through conventional testing methods. Klebsiella pneumoniae was the most frequently detected pathogen by conventional culture, while mNGS identified was Parvimonas micra. Infections caused solely by anaerobic bacteria or facultative anaerobes were associated with shorter hospital stays. Patient infected with Gram-negative bacilli (GNB) had a higher proportion of liver abscesses (11.8%).

Conclusion

Compared to conventional testing methods, mNGS demonstrates superior performance in detecting anaerobic and facultative anaerobic bacteria. The low detection rate of conventional tests may result in an underestimation of the clinical significance of anaerobic bacteria infections. In patients with lung abscess caused by GNB, hematogenous dissemination, liver abscess and diabetes were more commonly observed and these patients tended to have longer hospital stays.

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Introduction

Lung abscess is a purulent infection within the pulmonary parenchyma, characterized by the formation of a cavity containing necrotic debris, inflammatory cells, and infectious material. Recent advancements in understanding the etiology of lung abscess have uncovered a spectrum of contributing factors, including pulmonary structural abnormalities, bronchial obstruction and hematogenous dissemination from distant infected sites [1, 2].

Among these factors, infection plays the central role in the development of lung abscess [1, 3, 4]. Despite significant progress in understanding the underlying mechanisms, lung abscess remains a complex and underexplored condition [5]. Diagnosis typically relies on a combination of imaging studies, clinical evaluation, and laboratory tests. Treatment usually involves targeted antibiotic therapy based on the identified pathogen, and timely intervention is crucial to prevent complications and ensure full recovery. The relationship between different pathogens and clinical outcomes highlights the critical importance of accurately identifying the causative agent.

However, conventional diagnostic methods are often proved time-consuming and less sensitive, leading to delayed diagnosis and inappropriate antibiotic use [6,7,8,9]. Given the multifactorial etiology of lung abscesses, conventional tests fail to meet clinical needs. Metagenomic next-generation sequencing (mNGS) offers a promising solution for pathogen detection, providing an unbiased and highly sensitive method for identifying the causative agents of infection. Despite its potential, limited research has explored the application of mNGS specifically in the context of lung abscesses [10, 11].

This study aims to analyze the clinical and microbiological heterogeneity of lung abscesses in a tertiary hospital setting, using a comprehensive approach that integrates clinical, radiological, and microbiological data. Identifying distinct clinical subtypes of lung abscess will enhance clinical decision-making and management, ultimately improving outcomes for patients.

Methods

Patients and data collection

This was a retrospective single-center study, which was conducted using the administrative hospital database of China-Japan Friendship Hospital (CJFH), a tertiary teaching hospital. Patients with the diagnosis of lung abscess (ICD-10: J85) between July 2015 and July 2023 were screened. Two independent investigators reviewed all relevant medical records and chest computed tomography (CT) scans.

Patients who underwent both CT imaging and conventional pathogen testing were included in the study. Patients without confirmed abscess, younger than 18 years, or with important data missing were excluded. Meanwhile, we also merged records if the interval between two hospitalizations was less than a week (Fig. S1). Basic information including demographic feature, symptoms, biological results, medical history, radiographic image, microbiologic data were collected.

Patients with confirmed lung abscesses who had suggestive imaging findings and/or positive blood cultures indicative of hematogenous spread were referred as hematogenous lung abscesses. The characteristic imaging features of hematogenous lung abscesses, or septic pulmonary embolism, included multiple small cavities and nodules, often located near the pleura, with or without associated pleural effusion [12, 13].

Microbiological testing

In the study, only patients who underwent conventional pathogen testing were included. The conventional testing methods used at CJFH include culture-based techniques, smear microscopy and GeneXpert test for tuberculosis (details in Table S2, S3). The primary sources of specimens for testing were sputum, bronchoalveolar lavage fluid (BALF), pleural fluid, pus, biopsy tissue and blood. The criteria for microbiological culturing was shown in our previous study [14].

We searched the microbiological laboratory system at CJFH to collect microbiological information about the specimen sources, specimen acquisition methods, and pathogen results. The pathogens were classified based on their characteristics into the following categories: aerobic Gram-negative bacilli (GNB), aerobic Gram-positive cocci (GPC), anaerobe, facultative anaerobe, aerobic Gram-positive bacilli (GPB), aerobic Gram -negative cocci (GPC) and fungi (Fig. S2).

Since mNGS is not covered by insurance and requires out-of-pocket payment, its use was determined by the patient’s personal preference. Considering that mNGS can detect a wide range of pathogens, the pathogens identified through mNGS were ranked based on their read counts, and the top five suspected pathogens were included in the analysis. Yeast detected from BALF or sputum, whether by traditional culture methods or mNGS, was considered as a colonizing pathogen (Fig. S3).

Statistical analysis

Continuous variables were described using either means ± standard deviation (SD) or median (interquartile range [IQR]), as appropriate, while categorical variables were presented as counts with percentages (%). To assess differences in characteristics between patients with different pathogens, t-tests or chi-square tests were performed, as appropriate. All tests were two-sided, and P value of less than 0.05 was considered statistically significant. To correct for multiple comparison of demographic and clinical characteristics between the two groups of study participants with different classes of pathogen, we used a Bonferroni-corrected α threshold of 0·00833. All statistical analyses were performed using SPSS (version 29.0) and R software (version 4.3.1).

Results

Study group and patients’ characteristics

A total of 1153 records coded with the diagnosis of ‘Lung abscess’ (ICD-10: J85) between July 2015 and July 2023 were screened. After excluding the duplicates and re-admissions within one week (n = 216), patients who did not meet the diagnosis criteria (n = 29), those with missing key data (n = 25), patients under 18 years old (n = 12), and hospitalizations where lung abscess was not the main reason (n = 89), 782 patients were ultimately included in the study (Fig. S1).

The median age of the cohort was 60 years (IQR 51.0–67.0), and they were predominantly male (80.2%, 627/782). Current or former smoker comprised 48.7% of the patients and 32.4% (253/782) had a history of alcohol consumption. Diabetes was the most common comorbidity, followed by cardiovascular disease. The most common symptoms on admission were cough (73.9%, 578/782), expectoration (68.0%, 532/782), and fever (59.1%, 462/782) (Table 1).

Table 1 Baseline characteristics of lung abscess patients
Full size table

Approximately half of the patients underwent bronchoscopy. In addition, 9.21% (72/782) of them underwent ultrasonography-guided transthoracic fine needle aspiration, while 13.9% (109/782) experienced CT-guided transthoracic needle aspiration. Thoracic drainage was performed in 21.0% (164/782) of patients, and 3.84% (30/782) received surgical treatment (Table 1). The median duration of hospital stay was 13 days (IQR 9.0–20.0). A total of 12 patients (1.53%) died during hospitalization.

Radiological features

All patients underwent chest CT scans for diagnostic purposes, enabling the analysis of radiographic characteristics associated with lung abscess. Among the total cohort of 782 patients, 340 (43.5%) presented with pleural effusion, which was more commonly observed in the deceased. However, it is important to note that the number of deaths in this study was relatively small (n = 12), which may have influenced the statistical proportions. Since pleural fluid tests data were not available, we were unable to differentiate the underlying causes of the pleural effusion.

Of the 56 patients with hematogenous abscess, all had multi-lobar involved. In contrast, among the non-hematogenous abscess patients, lung abscesses were mainly located on the right side, with a high prevalence of right lower lobe (28.8%, 209/726) and right upper lobe (28.1%, 204/726) (Table 2).

Table 2 The imaging features of patients with lung abscess according to the clinical outcome
Full size table

Characteristics of microbiological distribution

All patients underwent conventional microbiological testing, yielding a positive detection rate of 41.8% (327/782). mNGS was performed on 102 patients, with 53 patients showing positive results in both conventional testing and mNGS (Fig. 1A). Specimens from various sources were analyzed, including BALF (n = 428), sputum (n = 243), biopsy tissue (n = 238), pleural fluid (n = 142), blood (n = 36), and others (n = 15). In total, 1102 positive entries were identified from 376 patients, with culture-based methods accounting for 65% and mNGS identifying 35% of the pathogens (Fig. 1B, table S1).

Fig. 1
figure 1

The heterogeneous pathogens of patients with lung abscess (A) The Venn diagram illustration of positive microbiological test results in patients; (B) The distribution of detected pathogens in all samples based on different microbial tests; (C) the most common pathogens in different microbiological tests; (D) Comparison of the diagnostic performance of mNGS with conventional tests. GNB: gram-negative bacilli, GPB: gram-positive bacilli, GPC: gram-positive cocci, GNC: gram-negative cocci

Full size image

The predominant bacteria detected via conventional culture were aerobic GNBs (50%), aerobic GPCs (16.15%) and facultative anaerobes (12.08%). In contrast, mNGS primarily identified anaerobes (54.99%), facultative anaerobes (12.53%), and aerobic GNB (12.53%) as the main bacterial species (Fig. 1C). The detection rate of anaerobic and facultative anaerobic bacteria by traditional culture was significantly lower that by mNGS (Fig. 1D).

Among non-survivor patients, aerobic GNB accounted for 66.7% of the primary types of pathogens, with anaerobes accounted for 11.1%. The most commonly detected pathogens in this group were K. pneumoniae, A. baumannii and P. aeruginosa (Fig. 2A and B). In patients with hematogenous dissemination, a similar pattern was observed, with aerobic GNB being the most prevalent (69.2%). However, there was a significant increase in the proportion of aerobic GPC (18.3%). The most frequently detected pathogens in this subgroup were K. pneumoniae, S. aureus and A. baumannii (Fig. 2A and C).

Fig. 2
figure 2

(A) Features of pathogen distribution across various outcome; (B) Characterizing pathogen distribution based on clinical outcomes; (C) Characterizing pathogen distribution based on hematogenous abscess. GNB: gram-negative bacilli, GPB: gram-positive bacilli, GPC: gram-positive cocci, GNC: gram-negative cocci

Full size image

Among all patients with a potential pathogen detected, K. pneumoniae was the most prevalent bacterium, followed by P. aeruginosa, A. baumannii, S. constellatus and Parvimonas micra (Fig. 2).

Comparison of clinical and radiological patterns among patients with lung abscess, based on the identified category of potential pathogens

Among the 376 lung abscess patients with a potential pathogen identified, mixed infections accounted for 41.5% (156/376), followed by aerobic GNB (29.3%, 110/376), anaerobe or facultative anaerobe (15.2%, 57/376), and aerobic GPC (7.4%, 28/376) (Fig. S4).

The proportion of patients with a history of alcoholism was significantly higher in the anaerobe or facultative anaerobe infection group compared to other groups. Chronic obstructive pulmonary disease (COPD) was observed in 25% of patients with simple aerobic GPC infections, 10% of patients with simple aerobic GNB infection, 14.7% of patients with mixed infection, and none of patients with simple anaerobe or facultative anaerobe infection. Among the 18 lung abscess patients with concomitant liver abscess, the majority were infected by GNB pathogens (Table 3).

Table 3 Comparison of clinical features among patients with lung abscesses, according to bacteriological class of the pathogen(s) isolated
Full size table

Regarding radiological features, statistically significant differences were observed in all four datasets for abscesses located in the right lower lobe and those exhibiting hematogenous dissemination. Specifically, a statistical difference was found between simple aerobic GNB infection and anaerobe infection when the abscess was situated in the right lower lobe. Similarly, a statistical difference was observed between simple aerobic GNB infection and mixed infection when hematogenous dissemination occurred.

Clinical presentations were comparable across the different pathogen groups. However, patients with exclusive anaerobe or facultative anaerobe infections exhibited less tissue damage compared to the other groups (Table 3). The length of hospital stays for patients infected with anerobic GNB and mixed pathogens infections were 17.0 days (12.0–22.0) and 16.0 days (11.0–28.0), respectively, which was longer than those infected with anaerobe or aerobic GPC.

Discussion

In the pre-antibiotic era, untreated lung abscesses had a mortality rate of 75% approximately, which significantly dropped to less than 10% after the introduction of antibiotic therapy [1, 15]. Our study reported an in-hospital morbidity rate of 1.53%. The mean age of patients with lung abscess was 60 years, with a male predominance, and a significant proportion had comorbidities such as diabetes and cardiovascular disease, consistent with findings from previous studies [4, 16].

Common presenting symptoms on admission included cough, expectoration, and fever; but not all patients exhibited these typical symptoms. Therefore, it is crucial to consider both clinical presentations and imaging features for accurate diagnosis [17, 18]. The most frequently affected location was the right upper lobe followed by the right lower lobe, which aligns with findings from other studies [16, 19, 20]. Additionally noted was a higher incidence of pleural effusion among deceased individuals. Hematogenous dissemination was characterized by multiple peripheral nodules and its occurrence was closely related to the patient’s immune status. Diabetes mellitus and liver abscesses were significantly more prevalent in the hematogenous dissemination group, and the pathogens detected were predominantly aerobic GPC and aerobic GNB, which is consistent with previous research [21].

The treatment of lung abscess typically involves targeted antibiotic therapy against the specific pathogen responsible for the infection, making accurate identification of the potential causative agent crucial. However, conventional culture methods exhibit a detection rate lower than 41.8%. Among patients with positive mNGS results, only 52.0% (53/102) were also identified as positive by traditional culture techniques. This discrepancy is likely due to the limited ability of conventional methods to detect anaerobic and facultative anaerobic bacteria. Previous studies have shown that antibiotic usage significantly reduces the detection of anaerobes via traditional culture techniques [22]. While mNGS is less affected by the antibiotics use [9]. Several studies have highlighted the advantage of mNGS in diagnosing anaerobes and mixed anaerobic infections [10, 23].

Previously, anaerobic bacteria, mainly related to aspiration and poor oral hygiene, were considered as the main causative organisms of lung abscess [24, 25]. However, recent researches have shown that aerobic GNB are now more commonly identified in patients with lung abscesses [3, 15, 19, 26]. Our study, which included the largest cohort of patients with lung abscess undergoing mNGS testing, found that conventional culture methods predominantly identified GNB, especially K. pneumoniae. In contrast, mNGS primarily detected anaerobe followed by facultative anaerobe and GNB. This suggests that the low detection rate of traditional culture methods may underestimate the harm caused by anaerobic bacteria.

Infections caused exclusively by anaerobic bacteria or facultative anaerobes tend to be associated with shorter hospital stays and relatively improved laboratory indicators. This may be attributed to the early administration of broad-spectrum antibiotics [27]. In contrast, infections caused solely by aerobic GNB or GNC exhibit a significantly higher proportion of hematogenous dissemination, particularly in cases with K. pneumoniae and S. aureus. Furthermore, infections caused by aerobic GNB exhibit a notable prevalence of liver abscesses. Over the past three decades in China, K. pneumoniae has increasingly replaced Escherichia coli as the predominant pathogen in liver abscess infections, now accounting for more than 80% of reported cases [28,29,30].

This study has several limitations. First, as a retrospective, single-center investigation, it is subject to potential bias in data collection. Second, while mNGS has been shown to have a significantly higher positivity rate compared to conventional microbiological methods, there is currently no standardized approach for interpreting mNGS results. This poses challenges in distinguishing between colonization and infection, particularly with non-sterile specimens like BALF [31]. Morever, further prospective studies are needed to determine whether mNGS can effectively reduce the inappropriate use of broad-spectrum antibiotics. Lastly, as lung abscess patients typically receive broad-spectrum antibiotic treatment upon symptom onset, the obtained pathogen results may not accurately reflect their actual conditions. Future prospective studies are required to validate the findings presented in this study.

In conclusion, the use of antibiotics has significantly reduced the mortality rate of lung abscess compared to previous decades. mNGS demonstrates superior performance in detecting anaerobic or facultative anaerobic bacteria in patients with lung abscess compared to conventional tests, providing crucial evidence for clinical decision-making. The low detection rate of traditional culture may underestimate the harm caused by anaerobic bacteria. Patients with GNB are more likely to experience hematogenous dissemination and have longer hospital stays.

Data availability

This data is not publicly accessible. However, it can be provided upon a reasonable request directed to the corresponding author.

Abbreviations

mNGS:

Metagenomic next-generation sequencing

BALF:

Bronchoalveolar lavage fluid

GNB:

Gram-negative bacilli

GPB:

Gram-positive bacilli

GPC:

Gram-positive cocci

GNC:

Gram-negative cocci

CT:

Computed tomography

SD:

Standard deviation

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Funding

This work was supported by the funds of National Natural Science Foundation of China (NSFC, NO.82030002), Beijing Nova Program of Science and Technology under grant NO.20220484049 and the National High Level Hospital Clinical Research Funding, the Elite Medical Professionals Project of China-Japan Friendship Hospital (No. ZRJY2021-QM09).

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Author notes

  1. Hui Li and Bin Cao contributed equally to this work.

Authors and Affiliations

  1. Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China

    Rongling Zhang, Zeyi Wang & Bin Cao

  2. Department of Pulmonary and Critical Care Medicine, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China

    Rongling Zhang, Jiapei Yu, Hui Li & Bin Cao

  3. Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China

    Rongling Zhang, Jiapei Yu, Hui Li & Bin Cao

  4. Tsinghua University-Peking University, Joint Centre for Life Sciences, Tsinghua University, Beijing, China

    Xiao Shang & Bin Cao

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Contributions

BC and HL conceived and designed the study. RLZ, JPY and HL analyzed and interpreted the data. RLZ, HL, XS and ZYW drafted the manuscript.

Corresponding authors

Correspondence to Hui Li or Bin Cao.

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Ethical approval

The study is approved by the ethics committee of China-Japan Friendship Hospital (2019-122-K84) and the database was anonymized. The requirement for informed consent was waived by the ethics committee of China-Japan Friendship Hospital due to the retrospective nature of the study. All procedures were performed in accordance with the principles of the Declaration of Helsinki.

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The need for informed consent was waived because of the study’s retrospective design.

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Zhang, R., Yu, J., Shang, X. et al. Heterogeneity in clinical patterns of adult lung abscess patients: an 8-year retrospective study in a tertiary hospital. BMC Pulm Med 25, 101 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12890-025-03487-2

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Keywords

BMC Pulmonary Medicine

ISSN: 1471-2466

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