Case Report: Endobronchial antibiotic instillation for refractory lung abscess due to Streptococcus pyogenes

Lung abscesses can be difficult to treat despite long antibiotic courses, and treatment failure is frequently observed. Percutaneous drainage or surgical resection may be considered in select patients, and intracavitary antimicrobial instillation has been described for treatment failure in highly selected cases. We present a case of an immunosuppressed patient with acute respiratory distress syndrome who required mechanical ventilation and venovenous extracorporeal membrane oxygenation due to Streptococcus pyogenes pneumonia with a large intrapulmonary abscess. The abscess was refractory to appropriate systemic antibiotic therapy, and direct intracavitary instillation was not feasible, so serial endobronchial antimicrobial lavage near the abscess site was used as salvage therapy to treat the abscess. Radiographic and clinical improvement were noted soon thereafter, without any observed adverse effects. Proximate endobronchial antimicrobial therapy was well tolerated and may be useful in additional cases of refractory pulmonary abscess. In this report, we describe the rationale and considerations underlying the choice of antimicrobial therapy.