Pleural empyema medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Chetan Lokhande, M.B.B.S [2] Prince Tano Djan, BSc, MBChB [3]

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

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.

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.
  • Fibrinolytic agents
    • Empyema drainage is facilitated by the use of intrapleural use of fibrinolytic agents .

• • • Surgical thoracotomy with decortication is preferred to thorascopic debridement in patients who have more pleural thickness , larger cavity and adhesions.
    • 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.

Antibiotic Therapy

Following are the guidelines to treat Pleural empyema .

▸ Click on the following categories to expand treatment regimens.

Pleural Empyema   ▸   Neonates   ▸   Infants/Children   ▸   Adult

Neonates Preferred Regimen Age 0-7 days and Weight ≤ 2000 gm ▸ If MSSA ▸ Nafcillin 25 mg/kg IV q12h OR Oxacillin 25 mg/kg IV q12h ▸ If MRSA ▸ Vancomycin 12.5 mg/kg IV q12h Age 7-28 days and Weight ≤ 2000 gm ▸ If MSSA ▸ Nafcillin 25 mg/kg q8h OR Oxacillin 25 mg/kg IV q12h ▸ If MRSA ▸ Vancomycin 15 mg/kg IV q12h Age 0-7 days and Weight > 2000 gm ▸ If MSSA ▸ Nafcillin 25 mg/kg q8h OR Oxacillin 25 mg/kg IV q12h ▸ If MRSA ▸ Vancomycin 18 mg/kg IV q12h Age 7-28 days and Weight > 2000 gm ▸ If MSSA ▸ Nafcillin37 mg/kg q6h OR 'Oxacillin 37 mg/kg q6h ▸ If MRSA ▸ Vancomycin 22 mg/kg q12h

Infants/Children Preferred Regimen ▸Cefotaxime 100 mg/kg IV q8h OR Ceftriaxone 100 mg/kg IV q24h 'If MSSA ▸ Vancomycin 40 mg/kg/day IV in 3-4 divided doses With or Without ▸ 'Cefotaxime 100 mg/kg IV q8h OR ▸Ceftriaxone 100 mg/kg IV q24h If H.Influenzae suspected

Adult Preferred Regimen For Strep. pneumoniae or Streptococcus sp (Group A) ▸Cefotaxime 2 gm IV q8h OR ▸Ceftriaxone 2 gm IV q24h or Penicillin 12-18 million units IV divided q4h/day OR ▸Ampicillin 8-12 gm IV divided q4h/day For Staph. aureus ▸MSSA Nafcillin2 gm IV q4h OR ▸ Oxacillin 2 gm IV q4h ▸MRSA Vancomycin 10-15 mg/kg IV q8-12h OR ▸ Linezolid 600 mg IV q12h For H. influenzae ▸Ceftriaxone 2 gm IV q24h Subacute/Chronic ▸Clindamycin 450-900 mg IV q8h PLUS ▸Ceftriaxone 2 gm IV q24h Alternative Regimens For Strep. pneumoniae or Streptococcus sp (Group A) ▸Vancomycin 1 gm IV q12h For H. influenzae ▸TMP-SMX (5-10 mg/kg/day as trimethoprim component) IV/po in 2-3 divided doses OR Ampicillin Sulbactam 3 gm IV q6h (child dose 100-300 mg/kg/day IV divided q6h) Chronic ▸Cefoxitin 2 gm IV q6-8h OR ▸ Imipenem 0.5 gm IV q6h OR ▸ Piperacillin Tazobactam 3.375 gm IV q6h (or 4-hour infusion of 3.375 gm q8h) OR ▸Ampicillin Sulbactam 3 gm IV q6h

• 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