Empyema medical therapy: Difference between revisions

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{{Empyema}}
{{Empyema}}


{{CMG}}
{{CMG}} {{AE}} {{PTD}}


==Overview==
==Overview==
The mainstay of therapy for empyema includes 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]].
The mainstay of therapy for empyema includes:<ref name="pmid27815709">{{cite journal| author=Reichert M, Hecker M, Witte B, Bodner J, Padberg W, Weigand MA et al.| title=Stage-directed therapy of pleural empyema. | journal=Langenbecks Arch Surg | year= 2016 | volume=  | issue=  | pages=  | pmid=27815709 | doi=10.1007/s00423-016-1498-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27815709  }} </ref> controlling the infectious focus, drainage of fluid and pus, re-expansion of the lung. This involes the use of antimicrobial agents, thrombolytics,<ref name="pmid27866276">{{cite journal| author=Porcel JM, Valencia H, Bielsa S| title=Manual Intrapleural Saline Flushing Plus Urokinase: A Potentially Useful Therapy for Complicated Parapneumonic Effusions and Empyemas. | journal=Lung | year= 2016 | volume=  | issue=  | pages=  | pmid=27866276 | doi=10.1007/s00408-016-9964-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27866276  }} </ref><ref name="pmid21830966">{{cite journal| author=Rahman NM, Maskell NA, West A, Teoh R, Arnold A, Mackinlay C et al.| title=Intrapleural use of tissue plasminogen activator and DNase in pleural infection. | journal=N Engl J Med | year= 2011 | volume= 365 | issue= 6 | pages= 518-26 | pmid=21830966 | doi=10.1056/NEJMoa1012740 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21830966  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22184710 Review in: Ann Intern Med. 2011 Dec 20;155(12):JC6-9] </ref> and drainage of the pleural space.<ref name="pmid2019172">{{cite journal| author=Ashbaugh DG| title=Empyema thoracis. Factors influencing morbidity and mortality. | journal=Chest | year= 1991 | volume= 99 | issue= 5 | pages= 1162-5 | pmid=2019172 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2019172  }} </ref><ref name="pmid7634854">{{cite journal| author=Light RW| title=A new classification of parapneumonic effusions and empyema. | journal=Chest | year= 1995 | volume= 108 | issue= 2 | pages= 299-301 | pmid=7634854 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7634854  }} </ref><ref name="pmid11035692">{{cite journal| author=Colice GL, Curtis A, Deslauriers J, Heffner J, Light R, Littenberg B et al.| title=Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline. | journal=Chest | year= 2000 | volume= 118 | issue= 4 | pages= 1158-71 | pmid=11035692 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11035692  }} </ref> 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==
==Medical Therapy==
 
Therapy focuses on the following:<ref name="pmid27815709">{{cite journal| author=Reichert M, Hecker M, Witte B, Bodner J, Padberg W, Weigand MA et al.| title=Stage-directed therapy of pleural empyema. | journal=Langenbecks Arch Surg | year= 2016 | volume=  | issue=  | pages=  | pmid=27815709 | doi=10.1007/s00423-016-1498-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27815709  }} </ref>
*Controlling the infectious focus
*Drainage of fluid and pus
*Re-expansion of the lung
===Pharmacotherapy===
===Pharmacotherapy===


====Acute Pharmacotherapies====  
====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.
* 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.
** Indications for chest tube drainage include:<ref name="pmid2019172">{{cite journal| author=Ashbaugh DG| title=Empyema thoracis. Factors influencing morbidity and mortality. | journal=Chest | year= 1991 | volume= 99 | issue= 5 | pages= 1162-5 | pmid=2019172 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2019172  }} </ref><ref name="pmid7634854">{{cite journal| author=Light RW| title=A new classification of parapneumonic effusions and empyema. | journal=Chest | year= 1995 | volume= 108 | issue= 2 | pages= 299-301 | pmid=7634854 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7634854  }} </ref><ref name="pmid11035692">{{cite journal| author=Colice GL, Curtis A, Deslauriers J, Heffner J, Light R, Littenberg B et al.| title=Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline. | journal=Chest | year= 2000 | volume= 118 | issue= 4 | pages= 1158-71 | pmid=11035692 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11035692  }} </ref> 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.
*** 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.
*** 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.
*** 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.<ref name="pmid27866276">{{cite journal| author=Porcel JM, Valencia H, Bielsa S| title=Manual Intrapleural Saline Flushing Plus Urokinase: A Potentially Useful Therapy for Complicated Parapneumonic Effusions and Empyemas. | journal=Lung | year= 2016 | volume=  | issue=  | pages=  | pmid=27866276 | doi=10.1007/s00408-016-9964-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27866276  }} </ref>
** [[Thrombolytics]] (mainly [[Urokinase]] and [[Streptokinase]]) have been used to break up loculations and assist drainage.<ref name="pmid27866276">{{cite journal| author=Porcel JM, Valencia H, Bielsa S| title=Manual Intrapleural Saline Flushing Plus Urokinase: A Potentially Useful Therapy for Complicated Parapneumonic Effusions and Empyemas. | journal=Lung | year= 2016 | volume=  | issue=  | pages=  | pmid=27866276 | doi=10.1007/s00408-016-9964-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27866276  }} </ref><ref name="pmid21830966">{{cite journal| author=Rahman NM, Maskell NA, West A, Teoh R, Arnold A, Mackinlay C et al.| title=Intrapleural use of tissue plasminogen activator and DNase in pleural infection. | journal=N Engl J Med | year= 2011 | volume= 365 | issue= 6 | pages= 518-26 | pmid=21830966 | doi=10.1056/NEJMoa1012740 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21830966  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22184710 Review in: Ann Intern Med. 2011 Dec 20;155(12):JC6-9] </ref>
*** 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.
*** 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.
**** 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.
** 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.<ref name="pmid27815709">{{cite journal| author=Reichert M, Hecker M, Witte B, Bodner J, Padberg W, Weigand MA et al.| title=Stage-directed therapy of pleural empyema. | journal=Langenbecks Arch Surg | year= 2016 | volume=  | issue=  | pages=  | pmid=27815709 | doi=10.1007/s00423-016-1498-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27815709  }} </ref>
*** 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.
*** 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.
**** They felt that SK-CT only delayed, and did not prevent definitive treatment with VATS.
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[[Category:Pulmonology]]
[[Category:Pulmonology]]
[[Category:Infectious disease]]

Latest revision as of 17:39, 18 September 2017

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:[1] controlling the infectious focus, drainage of fluid and pus, re-expansion of the lung. This involes the use of antimicrobial agents, thrombolytics,[2][3] and drainage of the pleural space.[4][5][6] 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:[1]

  • 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:[4][5][6] 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.[2][3]
      • 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.[1]
      • 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

  • 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.
  • 2. Pathogen-based therapy
  • 2.1 Acute empyema
  • 2.1.1 Streptococcus pneumoniae, Group A streptrococcus
  • 2.1.2 Staphylococcus aureus
  • 2.1.2.1 MSSA
  • 2.1.2.2 MRSA
  • 2.1.3 Hemophilus influenzae
  • 2.2 Subacute/chronic empyema
  • 2.2.1 Anaerobic streptococcus, Streptococcus milleri, Bacteroides species, Enterobacteriaceae, Mycobacterium tuberculosis

References

  1. 1.0 1.1 1.2 Reichert M, Hecker M, Witte B, Bodner J, Padberg W, Weigand MA; et al. (2016). "Stage-directed therapy of pleural empyema". Langenbecks Arch Surg. doi:10.1007/s00423-016-1498-9. PMID 27815709.
  2. 2.0 2.1 Porcel JM, Valencia H, Bielsa S (2016). "Manual Intrapleural Saline Flushing Plus Urokinase: A Potentially Useful Therapy for Complicated Parapneumonic Effusions and Empyemas". Lung. doi:10.1007/s00408-016-9964-2. PMID 27866276.
  3. 3.0 3.1 Rahman NM, Maskell NA, West A, Teoh R, Arnold A, Mackinlay C; et al. (2011). "Intrapleural use of tissue plasminogen activator and DNase in pleural infection". N Engl J Med. 365 (6): 518–26. doi:10.1056/NEJMoa1012740. PMID 21830966. Review in: Ann Intern Med. 2011 Dec 20;155(12):JC6-9
  4. 4.0 4.1 Ashbaugh DG (1991). "Empyema thoracis. Factors influencing morbidity and mortality". Chest. 99 (5): 1162–5. PMID 2019172.
  5. 5.0 5.1 Light RW (1995). "A new classification of parapneumonic effusions and empyema". Chest. 108 (2): 299–301. PMID 7634854.
  6. 6.0 6.1 Colice GL, Curtis A, Deslauriers J, Heffner J, Light R, Littenberg B; et al. (2000). "Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline". Chest. 118 (4): 1158–71. PMID 11035692.
  7. LastName, FirstName (2007). Sanford guide to antimicrobial therapy. Place of publication not identified: Antimicrobial Therapy. ISBN 9781930808386.