Empyema medical therapy

Empyema Microchapters
Patient Information
Overview
Classification Subdural empyema Pleural empyema
Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]

Overview

The mainstay of therapy for empyema includes: controlling the infectious focus, drainage of fluid and pus, re-expansion of the lung. This involes the use of antimicrobial agents, thrombolytics, and drainage of the pleural space. Pharmacologic therapies for acute empyema include either Ceftriaxone, Nafcillin or Oxacillin, Vancomycin or Linezolid, or TMP-SMX. The preferred regimen for subacute and chronic empyema is a combination of Clindamycin and Ceftriaxone.

Medical Therapy

Therapy focuses on the following:

• Controlling the infectious focus
• Drainage of fluid and pus
• Re-expansion of the lung

Pharmacotherapy

Acute Pharmacotherapies

• Appropriate antibiotics are indicated in all patients with an underlying infection. Drainage of the pleural space should be considered early, as delay of even a few days is associated with an increase in morbidity and mortality.
  • Indications for chest tube drainage include: a pH < 7.0, glucose < 40-50, gross pus, or organisms on Gram’s stain.
    • In borderline cases, reassessment with a repeat tap should be preformed in 12 – 24 hours. If the LDH is increasing, and the pH and glucose are decreasing, a chest tube should be placed immediately.
    • The chest tube should be at least a 28 F (smaller tubes become obstructed with fibrin clot), and left in place until the drainage is clear and yellow, and its volume is < 50 cc/day.
    • Patients will get better within 24 – 48 hours. If they don’t, suspect inadequate drainage due to loculations or inappropriate antibiotics.
  • Thrombolytics (mainly Urokinase and Streptokinase) have been used to break up loculations and assist drainage.
    • The typical Streptokinase (SK) dose is 250,000 units in 30 – 100 cc normal saline solution (NS), and the typical Urokinase dose in 100,000 units, also in 30 – 60 cc NS. They are instilled via the chest tube, left in place for 1-4 hours (chest tube clamped), and repeated daily as needed.
      • Two randomized studies comparing SK to chest tube drainage alone have shown an increase in the amount of drainage, however a statistical difference in the resolution of white blood cell (WBC) count and fever, the need for surgical drainage, or the duration of hospitalization has not been demonstrated.
  • More recently, however, VATS (video-assisted thoracoscopic surgery) has been compared to treatment by treatment with SK and chest tube drainage (SK-CT) in randomized trials.
    • Wait et.al. studied 20 patients and found that VATS was associated with a significantly higher primary treatment success (91% vs. 44%), lower chest tube duration (6 days vs. 10 days) and a lower number of hospital days (9 vs. 13). VATS was also associated with a non-significant trend towards lower hospital costs.
      • They felt that SK-CT only delayed, and did not prevent definitive treatment with VATS.
      • It should be noted, however, that the patients in Wait’s study had fibrinopurulent empyema, and not simple parapneumonic effusions or chronic empyema.
  • Obviously, the definitive answer is still out on the optimal management of empyema, however, the above data may indicate a more aggressive approach in these patients.

Antibiotics

• Empyema

• 1. Empiric antimicrobial therapy or culture negative therapy

• Causative pathogens:

• Streptococcus milleri
• Streptococcus pneumoniae
• Streptococcus intermedius
• Staphylococcus aureus
• Enterobacteriaceae
• Escherichia coli
• Fusobacterium spp.
• Bacteroides spp.
• Peptostreptococcus spp.

• Preferred regimen (1): Cefuroxime 1.5 g IV q8h AND Metronidazole 500 mg IV q8h
• Preferred regimen (2): Ceftriaxone 1.5 g IV q8h AND Metronidazole 500 mg IV q8h
• Preferred regimen (3): Piperacillin-Tazobactam 3.375 g IV q4h OR Ticarcillin-clavulanate 3.1 g IV q4h OR Ampicillin-Sulbactam 2/1 g IV q6h
• Preferred regimen (4): Meropenem 1 g IV q8h OR Imipenem 500 mg IV q6h
• Note: Consider coverage for MRSA if high suspicion exists.

• 2. Pathogen-based therapy

• 2.1 Acute empyema

• 2.1.1 Streptococcus pneumoniae, Group A streptrococcus

• Preferred regimen: Ceftriaxone 1.5 g IV/IM q24h

• 2.1.2 Staphylococcus aureus

• 2.1.2.1 MSSA

• Preferred regimen: Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h

• 2.1.2.2 MRSA

• Preferred regimen: Vancomycin 1 g IV q12h OR Linezolid 600 mg PO/IV q12h

• 2.1.3 Hemophilus influenzae

• Preferred regimen: Ceftriaxone 1.5 g IV/IM q24h
• Alternative regimen: Trimethoprim-Sulfamethoxazole 8-20 mg TMP/kg/day IV q6-12h or Ampicillin-Sulbactam 2/1 g IV q6h

• 2.2 Subacute/chronic empyema

• 2.2.1 Anaerobic streptococcus, Streptococcus milleri, Bacteroides species, Enterobacteriaceae, Mycobacterium tuberculosis

• Preferred regimen: Clindamycin 450–900 mg IV q8h AND Ceftriaxone 1.5 g IV/IM q24h
• Alternative regimen: Imipenem 500 mg IV q6h OR Piperacillin-Tazobactam 3.375 g IV q4h OR Ticarcillin-clavulanate 3.1 g IV q4h OR Ampicillin-Sulbactam 2/1 g IV q6h