What oral antibiotics can be used empirically for pleural infections?

From the Guidelines

Empiric oral antibiotics for pleural infections should include amoxicillin-clavulanate (1 g tds + 125 mg tds) or clindamycin (300 mg qds) as recommended by the BTS guidelines for the management of pleural infection 1. The choice of oral antibiotic regimen depends on the severity of the infection and the patient's ability to tolerate oral intake.

• For community-acquired culture-negative pleural infection, oral antibiotic treatment options include amoxicillin-clavulanate (1 g tds + 125 mg tds) or amoxicillin (1 g tds) + metronidazole (400 mg tds) 1.
• Clindamycin (300 mg qds) is also a suitable option for oral treatment of pleural infections, as it covers a broad spectrum of organisms, including anaerobes and Staphylococcus aureus 1. It is essential to note that oral therapy is only appropriate for patients with mild-to-moderate infections who have shown clinical improvement after initial intravenous therapy.
• Treatment duration generally ranges from 2-6 weeks depending on clinical response, and regular follow-up is necessary to monitor treatment response, with imaging studies recommended at 1-2 week intervals 1. The BTS guidelines emphasize the importance of choosing antibiotics based on the results of pleural fluid culture and sensitivities, and covering community-acquired bacterial pathogens and anaerobic organisms in the absence of positive culture results 1.
• Aminoglycosides should be avoided due to poor penetration into the pleural space and potential inactivity in the presence of pleural fluid acidosis 1.

From the FDA Drug Label

Clindamycin is indicated in the treatment of serious infections caused by susceptible anaerobic bacteria. Clindamycin is also indicated in the treatment of serious infections due to susceptible strains of streptococci, pneumococci, and staphylococci... Anaerobes: Serious respiratory tract infections such as empyema, anaerobic pneumonitis, and lung abscess; Levofloxacin has in vitro activity against Gram-negative and Gram-positive bacteria... Streptococcus pneumoniae (including multi-drug resistant isolates [MDRSP] )

Oral antibiotics for pleural infections:

• Clindamycin (PO) can be used empirically for pleural infections, specifically for anaerobic infections such as empyema 2.
• Levofloxacin (PO) has in vitro activity against Streptococcus pneumoniae, which can cause pleural infections, and may be considered for empirical use 3. Note that bacteriologic studies should be performed to determine the causative organisms and their susceptibility to the chosen antibiotic.

From the Research

Empirical Oral Antibiotics for Pleural Infections

• The choice of empirical oral antibiotics for pleural infections should provide broad-spectrum coverage, including Gram-positive, Gram-negative, and anaerobic organisms 4.
• Amoxicillin-clavulanate is an example of an oral antibiotic that has been studied for the treatment of community-acquired complicated parapneumonic effusions, with a short course (2 weeks) being as effective as an extended course (3 weeks) in some patients 5.
• However, there is limited data on the penetrance of oral antibiotics into the infected pleural space, and more research is needed to determine the optimal oral antibiotic regimen for pleural infections.

Factors to Consider

• The causative organisms of pleural infections can vary depending on geographical location and healthcare setting, making it important to consider local resistance patterns when selecting empirical antibiotics 4.
• The use of oral antibiotics may be sufficient for patients with stabilized pleural infection who do not require surgery, but further studies are needed to confirm this 5.
• Other treatments, such as intrapleural therapy and surgery, may be necessary for patients with more severe or complicated pleural infections 6, 7.

Available Options

• Amoxicillin-clavulanate is one of the few oral antibiotics that has been specifically studied for the treatment of pleural infections 5.
• Other oral antibiotics, such as fluoroquinolones and cephalosporins, may also be effective, but more research is needed to determine their efficacy and safety in this setting.
• The use of oral antibiotics should be guided by the results of microbiological cultures and susceptibility testing, when available 4.