The duration of therapy depends on the clinical course, but prolonged treatment for four to eight weeks is usually required. Although B. fragilis is usually penicillin resistant, patients with mixed anaerobic infections that include small numbers of B. fragilis organisms generally respond well to penicillin. In addition to antibiotics, adequate drainage is essential and can usually be achieved with intensive pulmonary physiotherapy and postural drainage. Bronchoscopy can be very useful for promoting drainage and for excluding the diagnosis of cancer. Although surgery was once the mainstay of treatment, antibiotics are now almost always capable of controlling the infection, and surgery is needed only for complications.
Massive hemoptysis is an indication for lung resection.
Uncontrolled sepsis may occasionally require lobectomy. CT-guided percutanous tube drainage may be very helpful in patients who are too ill to tolerate thoracotomy and may be the treatment of choice for lung abscesses that are refractory to medical management. Empyema, another complication of lung abscess, requires external drainage by thoracentesis, chest tube, or rib resection. The persistence of a thin-walled cavity after otherwise successful medical treatment, however, does not constitute an indication for surgery. Recurrent or persistent infection, recurrent hemoptysis, or the suspicion of tumor may mandate operative intervention.