From the Guidelines
The best approach to prevent empyema in a patient with residual hemothorax and a chest tube in place is intravenous third-generation cephalosporins (option a). When a patient has a residual hemothorax despite having a chest tube, the risk of developing empyema is significant, with S. aureus being responsible for 35–75% of subsequent infections 1. Presumptive antibiotic use in thoracostomy has a clear role in preventing infectious complications in chest trauma patients, particularly in penetrating injuries 1. The administration of an antibiotic prophylaxis, such as third-generation cephalosporins, has been associated with a reduced risk for post-traumatic empyema and pneumonia in patients with blunt or penetrating thoracic trauma requiring the insertion of a chest drain 1. Some key points to consider:
- The use of antibiotics, such as third-generation cephalosporins, can help prevent empyema in patients with residual hemothorax and a chest tube in place 1.
- Placement of a second chest tube (option b) may be considered in some cases, but it does not address the issue of infection prevention directly.
- Needle thoracentesis (option c) provides only temporary drainage and is insufficient for continuous evacuation of the pleural space.
- Intravenous vancomycin (option d) may be considered in cases where methicillin-resistant S. aureus (MRSA) is suspected, but third-generation cephalosporins are generally recommended as the first-line treatment 1.
From the Research
Prevention of Empyema
To prevent empyema in a patient with residual hemothorax and a chest tube in place, several options can be considered:
- Intravenous antibiotics: The use of intravenous antibiotics, such as third-generation cephalosporins 2 or vancomycin, may help prevent empyema by reducing the risk of infection.
- Placement of a second chest tube: However, there is no evidence to suggest that placing a second chest tube is effective in preventing empyema 3.
- Needle thoracentesis: Needle thoracentesis may not be sufficient to prevent empyema, as it may not effectively drain the residual hemothorax 4.
- Surgical intervention: Surgical intervention, such as video-assisted thoracoscopic surgery (VATS) or open decortication and drainage, may be effective in preventing empyema by allowing for complete drainage of the residual hemothorax 5, 6.
Key Findings
Some key findings from the studies include:
- Residual hemothorax is a significant risk factor for empyema 2, 4, 5.
- The use of intravenous antibiotics may help reduce the risk of empyema 5.
- Surgical intervention, such as VATS or open decortication and drainage, may be effective in preventing empyema 5, 6.
- The timing of surgical intervention is not well established, but earlier intervention may be beneficial in preventing empyema 6.