From the Guidelines
Antibiotics for empyema should be started empirically with broad-spectrum coverage, such as a combination of an anti-pseudomonal beta-lactam (e.g., piperacillin-tazobactam 4.5g IV every 6 hours) and a fluoroquinolone (e.g., levofloxacin 750mg IV daily), and later tailored based on culture results 1.
Key Considerations
- The choice of antibiotics should target common causative organisms, including Streptococcus species, Staphylococcus aureus, gram-negative bacteria, and anaerobes, while considering local resistance patterns and patient risk factors for resistant organisms.
- If MRSA is suspected, vancomycin 15-20mg/kg IV every 8-12 hours or linezolid 600mg IV twice daily should be added to the treatment regimen 1.
- For anaerobic coverage, metronidazole 500mg IV every 8 hours can be included if not using piperacillin-tazobactam.
- Treatment duration is typically 2-6 weeks depending on clinical response, with transition to oral antibiotics once improvement occurs.
- Drainage procedures, such as thoracentesis, chest tube placement, or surgical intervention, are essential components of empyema management and should be performed in conjunction with antibiotic therapy.
Empiric Treatment Options
- For community-acquired empyema, empirical treatment with a second-generation cephalosporin (e.g., cefuroxime) or an aminopenicillin (e.g., amoxicillin) may be sufficient, with the addition of a beta-lactamase inhibitor or metronidazole for anaerobic coverage 1.
- For hospital-acquired empyema, broader-spectrum antibiotic coverage, such as piperacillin-tazobactam or cefepime, may be necessary, with consideration of MRSA coverage and local resistance patterns 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Antibiotics for Empyema
The choice of antibiotics for empyema depends on the underlying cause and the suspected or confirmed pathogens involved.
- Empyemas that occur in association with lung infections are often polymicrobial and mixed, containing multiple species of both aerobic and anaerobic bacteria 2.
- In contrast, empyema following thoracic surgery is more likely to be monomicrobial and caused by common nosocomial pathogens such as Staphylococcus aureus and aerobic gram-negative bacilli 2.
- Single antibiotic agents that are likely to be active against the wide spectrum of potential pathogens include imipenem-cilastatin and ticarcillin-clavulanic acid 2.
- Combinations of antibiotics should include an effective agent against anaerobic bacteria (clindamycin, metronidazole) coupled with an agent active against aerobic gram-positive cocci and gram-negative bacilli 2.
Duration of Antibiotic Treatment
The optimal duration of antibiotic treatment for empyema is not well established, and there is a lack of comparative trials to guide recommendations 3.
- A retrospective chart review analysis found that longer total antibiotic duration was associated with lower readmission rate for empyema, but IV antibiotic duration was not associated with a difference in any of the defined outcomes 3.
- The use of anti-anaerobic antibiotics is indicated in the treatment of pleural empyema, and longer duration of anti-anaerobic antibiotics was associated with both lower all-cause readmission and lower readmission rate for empyema 3.
Current Guidelines and Research
Current guidelines for the treatment of empyema are limited, and there is a need for further research to standardize treatment and improve outcomes 4, 5.
- The Japanese Association for Chest Surgery has established guidelines for the treatment of empyema, which include recommendations for surgical treatment and antibiotic therapy 4.
- Novel biomarkers are being investigated to aid in the diagnosis of empyema, and there is a need for further research on the aetiology, diagnosis, treatment, and prevention of empyema 5.
- A study on the antistaphylococcal efficacy of cefepime, meropenem, and piperacillin-tazobactam in patients with polymicrobial infection with MSSA bacteremia or pneumonia found no difference in treatment success between the three antibiotics 6.