Pleural empyema medical therapy

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.

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.

• 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.
  • Fibrinolytic agents
    • Empyema drainage is facilitated by the use of intrapleural use of fibrinolytic agents .^{[7][8][9][10][11][12]}

• • • Surgical thoracotomy with decortication is preferred to thorascopic debridement in patients who have more pleural thickness , larger cavity and adhesions.^[13][14][15]
    • Thrombolytics (mainly Urokinase and Streptokinase) have been used to break up loculations and assist drainage.^[16][17]

• • • 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.

Following are the guidelines to treat Pleural empyema .^[18][19]

▸ Click on the following categories to expand treatment regimens.

• 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

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