Empyema medical therapy: Difference between revisions

Jump to navigation Jump to search
No edit summary
Line 8: Line 8:


==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===



Revision as of 17:16, 4 January 2017

Empyema Microchapters

Patient Information

Overview

Classification

Subdural empyema
Pleural empyema

Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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, Nafcillinor 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: 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.
      • 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. 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. 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. 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. LastName, FirstName (2007). Sanford guide to antimicrobial therapy. Place of publication not identified: Antimicrobial Therapy. ISBN 9781930808386.