From the Guidelines
Empyema typically requires hospital-level care, often in an inpatient setting, with immediate initiation of broad-spectrum antibiotic therapy and drainage of the infected pleural fluid. The management of empyema should prioritize the patient's morbidity, mortality, and quality of life, and thus, hospital admission is crucial for initial management.
Key Considerations
- Antibiotic therapy should be guided by bacterial culture results when possible, but in the absence of positive culture results, antibiotics should cover community-acquired bacterial pathogens and anaerobic organisms, as suggested by the BTS guidelines for the management of pleural infection 1.
- The choice of antibiotics should reflect local hospital policy and the severity of the infection, with options including second-generation cephalosporins, aminopenicillins, or combinations that cover a broad spectrum of organisms, including penicillin-resistant aerobes and anaerobes.
- Drainage of the pleural fluid can be accomplished through chest tube placement or video-assisted thoracoscopic surgery (VATS), depending on the stage and complexity of the empyema, with flexible small bore catheters inserted under ultrasound or CT guidance being a less traumatic option for patients.
Treatment Approach
- Broad-spectrum antibiotic therapy should be initiated as soon as pleural infection is identified, with the regimen adjusted based on culture results and clinical response, as recommended by the BTS guidelines 1.
- The duration of antibiotic therapy typically ranges from 2-6 weeks, depending on the clinical response, and some patients may be transitioned to oral antibiotics and outpatient care after demonstrating clinical improvement.
- Severe cases or those with complications may require intensive care unit admission to manage potential complications such as sepsis, respiratory failure, and death.
Clinical Decision-Making
- The decision to admit a patient with empyema to the hospital should be based on the severity of the infection, the patient's overall health status, and the potential for complications, with a focus on minimizing morbidity, mortality, and improving quality of life.
- Clinicians should be aware of the potential for antibiotic resistance and adjust their treatment regimens accordingly, as well as consider the use of intrapleural fibrinolytic drugs in certain cases, as suggested by observational series and small controlled trials 1.
From the FDA Drug Label
Serious infections due to susceptible strains of streptococci (including S. pneumoniae) -septicemia, empyema, pneumonia, pericarditis, endocarditis and meningitis 12 to 24 million units/day depending on the infection and its severity administered in equally divided doses every 4 to 6 hours Serious infections due to susceptible strains of staphylococci-septicemia, empyema, pneumonia, pericarditis, endocarditis and meningitis 5 to 24 million units/day depending on the infection and its severity administered in equally divided doses every 4 to 6 hours.
The level of care for empyema involves administering 12 to 24 million units/day of penicillin G for streptococci infections and 5 to 24 million units/day for staphylococci infections, divided into equal doses every 4 to 6 hours 2.
- Key considerations:
- The dosage depends on the infection severity and the causative organism.
- The treatment should be administered in a hospital setting with close monitoring due to the severity of empyema.
- Surgical intervention may be necessary in addition to antibiotic therapy.
From the Research
Empyema Level of Care
The level of care for empyema, a serious condition characterized by the accumulation of pus in the pleural space, can vary depending on several factors, including the severity of the infection, the patient's overall health, and the presence of any underlying conditions.
- The initial choice of antibiotics depends on whether the empyema is community-acquired or nosocomial, and clinicians must recognize that culture results often do not reflect the full disease process 3.
- Antibiotics alone are rarely successful and can be justified only in specific circumstances, with early drainage with or without intrapleural fibrinolytics usually required 3.
- The management of empyema requires a multidisciplinary approach, with collaboration between clinicians from various disciplines, and active management is needed as the clinical course over a few days determines subsequent refinement 3.
Treatment Options
Several treatment options are available for empyema, including:
- Thoracentesis and chest tube drainage, with or without intrapleural fibrinolytic therapies 3, 4
- Video-assisted thoracic surgery (VATS) or thoracotomy 3, 4
- Medical management, including antibiotic therapy and supportive care 5
- Surgical intervention, which may be required if medical management is unsuccessful 5, 6
Nursing Role
The nursing role in the management of empyema involves:
- Providing support and education to patients and their families 5
- Monitoring patients for signs of complications and reporting any concerns to the healthcare team 5
- Assisting with medical and surgical interventions, as needed 5
- Providing long-term management and follow-up care to patients with empyema 5
Optimal Care
The optimal care for patients with empyema is not yet fully established, and more research is needed to determine the best treatment approaches 6, 7.
- A comprehensive review of the current evidence on the diagnosis and management of empyema in children found that the optimal imaging modality, first treatment option, and optimal timing in the management of empyema are still unclear 7.
- The use of fibrinolytic agents in the management of pleural infections is not recommended as a routine practice, and more research is needed to determine their efficacy and safety 6.