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]

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

Definitive treatment for empyema entails drainage of the infected pleural fluid. A chest tube may be inserted, often using ultrasound guidance. Intravenous antibiotics are given. If this is insufficient, surgical debridement of the pleural space may be required.

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

Surgical management

• Antibiotic treatment should be continued for atleast 4 to 6 weeks. Sometimes it may be needed for a longer time. A CT and chest tube output should be used to confirm a complete fluid drainage with no residual locules present.
• Other modes of draining pleural fluid are tube thoracostomy, video-assisted thoracoscopic surgery (VATS), open decortication, and open thoracostomy.

Tube thoracostomy

• Least invasive
• Preferred for unilocuated effusions and free-flowing fluid.
• For solitary lesions a CT scan or ultrasound is used to guide the tube.
• For lesions more than one multiple small catheters are used to drain.
• When draining empyema fluid, thoracostomy tubes are typically placed using either an ultrasound or CT-guided approach. When multiple loculations are present, we typically place small-bore catheters, as multiple tubes may be needed to drain the multiloculated pleural space.
• A trial showed no difference between different sizes of thoracostomy tube. Smaller tubes were preferred due to decreased pain.
• British thoracic society recommends flushing the tube every 6 hrs to remain patent.. Smaller tubes are more prone to failure due to blockage.. Chest tubes are placed atleast till the cavity closes or drainage falls below 50 ml/day.
• Confirm correct placement of the tube using CT scans and checking drainage .

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.

Post surgical complications

An empyema forming in a space created by surgery with or without a fistula between bronchus and pleura should be treated carefully.Available treatment options are :

1. Irrigation with antibiotic
2. Filling up the space with pedicles of muscles
3. Closing the fistula surgically

Open Thoracostomy

An incision is made through the chest wall to aid drainage at the inferior border of the cavity . A chest tube is inserted and left to drain the remaining cavity . This process is time consuming and requires at least 2-3 months. However a few side effects of anesthesia and chest tube infection still remain.