From the Guidelines
Empyema patients should receive empiric antibiotics covering community-acquired bacterial pathogens and anaerobic organisms, such as a second-generation cephalosporin (e.g., cefuroxime) or an aminopenicillin (e.g., amoxycillin), with the addition of a beta-lactamase inhibitor or metronidazole. The choice of antibiotics should be guided by the suspected origin of the infection, whether community-acquired or hospital-acquired, with the latter requiring broader spectrum coverage 1. In the absence of positive culture results, the selected regimen should reflect local hospital policy and cover expected organisms such as Pneumococcus, Staphylococcus aureus, and Haemophilus influenzae. Some key points to consider when selecting empiric antibiotics for empyema include:
- Aminoglycosides should be avoided due to poor penetration into the pleural space and potential inactivity in the presence of pleural fluid acidosis 1.
- Beta-lactams, including penicillins and cephalosporins, show good penetration of the pleural space and are considered the drugs of choice 1.
- Clindamycin can provide coverage for both aerobes and anaerobes, making it a suitable option for empiric treatment 1.
- The treatment regimen should be adjusted based on culture results when available, and the duration of treatment typically ranges from 2-6 weeks, depending on clinical response 1. Key considerations for treatment include:
- Drainage of the empyema through chest tube placement or surgical intervention is essential alongside antibiotic therapy.
- Regular reassessment of clinical response, including fever, white blood cell count, and radiographic findings, should guide treatment duration and potential need for additional interventions.
From the Research
Empyema Empiric Antibiotics
- The bacteriology of empyemas is often polymicrobial and mixed, containing multiple species of both aerobic and anaerobic bacteria 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.
Antibiotic Combinations
- Vancomycin with piperacillin-tazobactam demonstrated enhanced antimicrobial activity against MRSA and VISA compared with vancomycin alone 3, 4, 5.
- The combination of vancomycin and piperacillin-tazobactam achieved a significant reduction in inoculum at 72 hours compared with vancomycin alone 3.
- Vancomycin with piperacillin-tazobactam or oxacillin demonstrated synergistic activity against MRSA and VISA 4.
Clinical Implications
- The clinical implications of using vancomycin in combination with a β-lactam for invasive MRSA infections should be investigated 3, 4.
- Antibiotic overtreatment in children with PPE/PE is a concern, particularly the frequent use of combinations of antibiotics 6.
- The low rate of children with streamlined antibiotic therapy even upon pathogen detection indicates a necessity for antibiotic stewardship measures in PPE/PE 6.