What is the appropriate treatment for enterococcal empyema?

Treatment of Enterococcal Empyema

For enterococcal empyema, the recommended treatment is ampicillin plus gentamicin, with drainage of the empyema fluid through chest tube thoracostomy. This combination provides synergistic bactericidal activity against enterococci while addressing the need for source control 1.

Antimicrobial Regimens

First-line therapy:

• Ampicillin 2g IV every 4 hours plus gentamicin 15 mg/kg/day IV in 2-3 divided doses 1
  • Gentamicin should be administered in multiple divided doses rather than once daily 2
  • Target gentamicin levels: 1-hour concentration of ~3 μg/mL and trough <1 μg/mL 2
  • Duration: 2-4 weeks depending on clinical response

Alternative regimens (based on susceptibility):

1. For aminoglycoside-resistant enterococci:

   • Ampicillin 2g IV every 4 hours plus ceftriaxone 2g IV every 12 hours 2, 1
   • This double β-lactam regimen provides synergistic activity without aminoglycoside toxicity

2. For penicillin-allergic patients:

   • Vancomycin 30 mg/kg/day IV in 2 divided doses plus gentamicin 15 mg/kg/day IV in 2-3 divided doses 1

3. For vancomycin-resistant enterococci:

   • Linezolid 600 mg IV/PO every 12 hours 2, 3
   • Daptomycin 8-12 mg/kg IV daily 2, 1

Drainage and Source Control

Drainage of empyema is essential for successful treatment:

• Chest tube thoracostomy is the primary drainage method 4, 5, 6
• Surgical intervention (decortication) may be necessary if:
  • The empyema occupies >40% of the hemithorax 6
  • Loculations are present
  • Tube drainage fails to resolve the infection

Monitoring and Duration

• Weekly monitoring of renal function when using aminoglycosides 1
• Regular monitoring of creatine kinase (CK) levels if using daptomycin 1
• Total duration of therapy typically 2-4 weeks, depending on:
  • Clinical response
  • Resolution of fever
  • Improvement in radiographic findings
  • Cessation of pleural fluid drainage

Special Considerations

• Enterococcal empyema is uncommon but increasingly recognized, especially in hospitalized or immunocompromised patients 4, 7
• Consider removal of any intravascular catheters if present, as they may be the source of hematogenous spread 2
• If the catheter must be retained, antibiotic lock therapy should be used in addition to systemic therapy 2
• For persistent bacteremia (>72 hours after appropriate antibiotic therapy), evaluate for endocarditis, especially if the patient has prosthetic valves or other risk factors 2

Pitfalls to Avoid

1. Inadequate drainage: Failure to adequately drain the empyema is a common cause of treatment failure
2. Monotherapy: Enterococci often require combination therapy for bactericidal activity
3. Inappropriate aminoglycoside dosing: Using once-daily dosing instead of multiple daily doses reduces efficacy against enterococci
4. Missing vancomycin resistance: Always obtain susceptibility testing to guide therapy
5. Overlooking endocarditis: Consider transesophageal echocardiography if bacteremia persists despite appropriate therapy

Enterococcal empyema requires prompt recognition, appropriate antimicrobial therapy, and adequate drainage for successful treatment.