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

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.

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