From the Guidelines
The patient with Zenker's diverticulum requires immediate broad-spectrum antibiotic treatment for worsening aspiration pneumonia and a possible anaerobic abscess, with consideration for surgical management of the diverticulum to prevent future aspirations. The CT chest findings indicate a severe infection with increased consolidation, bronchial wall thickening, and multifocal endobronchial debris in the right lower lobe, along with an unchanged cavitary lesion in the left upper lobe, which is most consistent with a cavitary pneumonia or abscess related to anaerobic infection or aspiration 1.
Key Considerations
- The patient's history of Zenker's diverticulum increases the risk of aspiration, which can lead to recurrent lung infections and complications such as bronchiectasis or pulmonary fibrosis.
- The presence of a cavitary lesion in the left upper lobe raises concerns for anaerobic infection, which is common in aspiration pneumonia, but tuberculosis and fungal infections, although less likely, should be ruled out with cultures.
- Treatment should include broad-spectrum antibiotics, such as ampicillin-sulbactam or clindamycin, for a total of 14-21 days, with the possibility of transitioning to oral therapy after clinical improvement.
- Evaluation by ENT for potential surgical management of the Zenker's diverticulum is crucial to prevent recurrent aspirations and reduce the risk of future lung infections.
- Additional measures, such as pulmonary rehabilitation, elevation of the head of bed during sleep, and speech therapy evaluation for swallowing techniques, may help reduce further aspiration events and improve the patient's quality of life.
From the Research
CT Chest Read Impression
The CT chest read impression in a patient with Zenker's diverticulum indicates:
- Increased consolidation in the posterior right lower lobe
- Associated increased right greater than left basilar bronchial wall thickening
- Multifocal endobronchial debris
- Increasing tree in bud nodularity representing sequela of aspiration and associated bronchiolitis/pneumonia
- Unchanged thick-walled cavitary lesion in the left upper lobe along the major fissure, most consistent with cavitary pneumonia/abscess related to anaerobic infection/aspiration given the Zenker diverticulum with tuberculosis and fungal infection possible but less likely
Relevant Studies
Studies have shown that aspiration pneumonia can be effectively treated with broad-spectrum antibiotics, such as ceftriaxone 2. A study comparing ceftriaxone with piperacillin-tazobactam or carbapenems found that ceftriaxone was not inferior to broad-spectrum antibiotic treatment and was more economical 2. Another study examined the pharmacodynamic analysis of various antibiotic agents, including ceftriaxone, and found that it was effective against aerobic bacteria associated with secondary peritonitis 3.
Treatment Options
Treatment options for aspiration pneumonia and associated bronchiolitis/pneumonia may include:
- Broad-spectrum antibiotics, such as ceftriaxone 2
- Combination therapy with metronidazole 4, 5
- Monotherapy with imipenem or piperacillin-tazobactam 3
Considerations
It is essential to consider the patient's specific condition, including the presence of Zenker's diverticulum, and the potential for anaerobic infection or aspiration when selecting a treatment option. The use of proton pump inhibitors, amoxicillin, and metronidazole has been shown to be effective in eradicating Helicobacter pylori 4, 5. However, the patient's condition and medical history should be carefully evaluated to determine the most appropriate treatment plan.