A 55-year-old man with a history of alcoholism complains of more than a month of malaise, low-grade fever, and a productive cough with greenish sputum tinged with blood. Examination shows periodontal disease with bad breath and clubbing of fingers. On chest x-ray, there is a 2 cm cavity with an air–fluid level in the posterior segment of the right upper lobe. Sputum smear shows many neutrophils and a variety of bacteria. Appropriate treatment includes:
Isolate the patient and initiate a four-drug antituberculosis treatment.
Start intravenous administration of clindamycin.
Refer the patient to a dentist for periodontal care.
Schedule a bronchoscopy for the next day.
Start administration of methicillin and tobramycin.
The predisposing factors of alcoholism and periodontal disease, the duration of illness, the symptoms and signs, and the cavity in a dependent segment of the lung seen on CXR suggest an anaerobic lung abscess caused by aspiration of bacteria from the mouth. Clindamycin is the drug of choice. Tuberculosis is not as likely a diagnosis as anaerobic lung abscess. The patient should be isolated until tuberculosis can be ruled out, but empiric treatment without microscopic or culture evidence is not warranted in this chronically ill patient who is stable. Bronchoscopy prior to antibiotic treatment of a lung abscess carries a risk of dissemination and acute sepsis. Dental work without antibiotic coverage also carries a risk of sepsis. Staphylococcal and gram-negative antibiotics are not indicated.