Is Zosyn (piperacillin/tazobactam) effective for treating empyema?

Zosyn (Piperacillin/Tazobactam) for Empyema Treatment

Zosyn (piperacillin/tazobactam) is recommended as an effective treatment option for hospital-acquired empyema and should be included in empiric therapy regimens. 1

Antibiotic Selection for Empyema

The British Thoracic Society guidelines specifically recommend piperacillin/tazobactam as a first-line empiric therapy option for hospital-acquired culture-negative pleural infection at a dosage of 4.5g four times daily intravenously 1. This recommendation is based on its broad-spectrum activity against both aerobic and anaerobic pathogens commonly found in empyema.

Pathogen Coverage

• Piperacillin/tazobactam provides coverage against:
  • Gram-positive cocci (except MRSA)
  • Gram-negative bacilli including Pseudomonas
  • Anaerobic organisms including Bacteroides fragilis 2, 3

Clinical Context

For empyema treatment, antibiotic selection should be guided by:

1. Origin of infection (community vs. hospital-acquired)
2. Culture results when available
3. Local resistance patterns

Treatment Algorithm for Empyema

1. Initial Assessment:

   • Determine if community or hospital-acquired
   • Obtain pleural fluid for culture and sensitivity testing
   • Assess need for drainage based on imaging and fluid characteristics

2. Antibiotic Selection:

   • For hospital-acquired empyema: Zosyn 4.5g IV q6h 1
   • For community-acquired empyema: Consider other regimens like cefuroxime + metronidazole or amoxicillin + clavulanic acid 1, 4

3. Drainage Procedure:

   • Small-bore catheter (10-14 Fr) under ultrasound guidance 4
   • Connect to unidirectional flow drainage system 4

4. Duration of Therapy:

   • Continue until patient is afebrile or chest drain is removed
   • Follow with oral antibiotics for 1-4 weeks 4

Evidence for Efficacy

Piperacillin/tazobactam has demonstrated effectiveness in treating polymicrobial infections, which are common in empyema 5. Clinical trials have shown it to be as effective as other relevant comparator antibiotics for various serious infections, including those involving the respiratory tract 6.

In one case report, piperacillin/tazobactam was used to treat Streptococcus intermedius empyema, although the patient ultimately required surgical intervention 7. This highlights the importance of combining appropriate antibiotic therapy with adequate drainage procedures.

Important Considerations and Caveats

• Avoid aminoglycosides for empyema treatment as they have poor penetration into the pleural space and may be inactive in acidic pleural fluid 1, 4
• Monitor for treatment failure: If no improvement after 7 days of appropriate antibiotics and drainage, consider surgical intervention 4
• Combination therapy: For severe hospital-acquired infections, combination therapy may be appropriate initially but should be de-escalated based on culture results 1
• Drainage is crucial: Antibiotics alone are insufficient; adequate drainage of the infected pleural space is essential for successful treatment 4

Dosing Considerations

For adults with normal renal function, the recommended dose of piperacillin/tazobactam for serious infections is 4.5g IV every 6 hours 1, 2. Dose adjustment is required in patients with renal impairment.

Piperacillin/tazobactam should be administered as a 20-30 minute infusion to maximize time above MIC, which is important for beta-lactam antibiotics 1, 2.