What is the recommended antibiotic regimen for coverage of empyema?

From the Guidelines

The recommended antibiotic regimen for empyema should cover community-acquired bacterial pathogens and anaerobic organisms, with a second-generation cephalosporin (e.g., cefuroxime) or an aminopenicillin (e.g., amoxycillin) being suitable choices, and a beta-lactamase inhibitor or metronidazole should also be given due to the frequent co-existence of penicillin-resistant aerobes and anaerobes. When considering the management of empyema, it is crucial to prioritize antibiotics that can effectively penetrate the pleural space, as indicated by the BTS guidelines for the management of pleural infection 1.

Key Considerations

• Antibiotics should be guided by bacterial culture results whenever possible, but in the absence of positive culture results, empirical treatment should cover the likely organisms that may cause pleural infection 1.
• Aminoglycosides should be avoided due to their poor penetration into the pleural space and potential inactivity in the presence of pleural fluid acidosis 1.
• The choice of antibiotic regimen should reflect whether the infection was contracted in the community or in the hospital, with community-acquired infections typically requiring coverage for organisms such as Pneumococcus, Staphylococcus aureus, and Haemophilus influenzae 1.
• Hospital-acquired empyema requires broader spectrum antibiotic cover, taking into account the potential for resistant organisms 1.

Treatment Approach

• Initial empiric therapy should include coverage for both aerobic and anaerobic organisms, with the specific choice of antibiotics depending on local hospital policy and the suspected source of the infection 1.
• Clindamycin can be considered as a single agent that combines coverage for both aerobic and anaerobic organisms, or intravenous benzyl penicillin combined with a quinolone may be used, potentially reducing the incidence of Clostridium difficile diarrhea 1.
• The duration of antibiotic therapy typically ranges from 2-6 weeks, depending on clinical response, with transition to oral antibiotics once clinical improvement occurs, and pleural fluid culture results guiding targeted therapy 1.

From the Research

Antibiotic Regimen for Empyema Coverage

The recommended antibiotic regimen for coverage of empyema, particularly for methicillin-resistant Staphylococcus aureus (MRSA) infections, includes:

• Vancomycin and linezolid as primary treatments 2, 3
• Daptomycin as an effective alternative for MRSA empyema refractory to vancomycin and linezolid 2, 3
• Combination therapy with vancomycin and ceftaroline for refractory MRSA bacteremia 4

Specific Considerations

• Daptomycin can penetrate the pleural space and may be better at treating MRSA empyema than vancomycin and linezolid 2
• Empyema necessitans caused by MRSA is rare but associated with high mortality, and treatment requires careful examination and appropriate antibiotics and drainage 5
• Chest tube-related MRSA empyema might be prevented by coating the chest tube with antiseptic agents 6

Treatment Outcomes

• Daptomycin has been shown to successfully treat MRSA empyema refractory to vancomycin and linezolid 2, 3
• Combination therapy with vancomycin and ceftaroline may be effective for refractory MRSA bacteremia 4
• Patients with MRSA-associated empyema necessitans frequently develop disseminated lesions and require careful examination and treatment 5