What is the recommended duration of antibiotic therapy for the treatment of empyema (empyema is a condition characterized by the accumulation of pus in the pleural space)?

From the Guidelines

Antibiotic treatment for empyema should be given for 2-4 weeks, depending on the adequacy of drainage and the clinical response demonstrated for each patient. The management of empyema requires careful consideration of the patient's clinical response and the causative organism 1. When the blood or pleural fluid bacterial culture identifies a pathogenic isolate, antibiotic susceptibility should be used to determine the antibiotic regimen 1.

Key Considerations

• The duration of antibiotic treatment depends on the adequacy of drainage and on the clinical response demonstrated for each patient 1.
• In most children, antibiotic treatment for 2–4 weeks is adequate 1.
• Antibiotic selection should be based on the treatment recommendations for patients hospitalized with community-acquired pneumonia (CAP) in the case of culture-negative parapneumonic effusions 1.

Treatment Approach

• Treatment should begin with empiric broad-spectrum antibiotics that cover common respiratory pathogens.
• Antibiotics should be continued until clinical improvement occurs, including resolution of fever, normalization of white blood cell count, and radiographic improvement.
• Most patients require drainage of the empyema in addition to antibiotics, either through chest tube placement or surgical intervention, as antibiotics alone are often insufficient.

From the Research

Duration of Antibiotic Therapy for Empyema

• The duration of antibiotic therapy for empyema can vary, but a study published in 2016 found that the median length of antimicrobial therapy from the time of source control was 27 days, with a range of 15-31 days 2.
• The same study found that longer courses of parenteral therapy, but not oral therapy, were associated with fewer cases of clinical failure, suggesting that three weeks of therapy may be generally adequate to prevent clinical failure 2.
• Another study published in 2015 compared the effectiveness of oral versus outpatient parenteral antibiotic therapy for empyema and found that the frequency of complications was similar between the two groups, suggesting that oral antibiotics may be considered safe and effective for children with empyema who will be discharged to complete therapy in the outpatient setting 3.
• The choice of antibiotics depends on whether the empyema is community-acquired or nosocomial, and clinicians must recognize that culture results often do not reflect the full disease process, as noted in a 2019 study 4.
• A 2022 study found that Streptococcus constellatus empyema were mostly seen in old males with comorbid diseases, and the primary treatment was timely pus drainage, intravenous antibiotics, and enough nutrition support, with intrapleural fibrinolytics and surgery recommended as needed 5.

Factors Influencing Antibiotic Therapy Duration

• The severity of the empyema, as well as the presence of comorbidities, can influence the duration of antibiotic therapy, as noted in the 2019 study 4.
• The type of organism causing the empyema can also influence the choice and duration of antibiotic therapy, as seen in the 2022 study on Streptococcus constellatus empyema 5.
• The 2016 study found that the median length of hospitalization was 9 days, and the length of antimicrobial therapy was variable, suggesting that the duration of antibiotic therapy may depend on the individual patient's response to treatment 2.