Empyema and Abscess Pneumonia in Emergency Medicine Medication

  • Author: Mark Zwanger, MD, MBA; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Jan 24, 2011
 

Medication Summary

Lung abscesses are treated with a prolonged course of parenteral antibiotics that target organisms found in aspiration pneumonia. The initial choice of antibiotics frequently is empiric, beginning with clindamycin, cefoxitin, ticarcillin, or piperacillin/tazobactam, although penicillin has been very effective when the organism is sensitive. Some authors advocate adding coverage for Klebsiella as well. Subsequent therapy should be based on sputum or blood culture results.

An empyema is treated with parenteral antibiotics and prompt chest tube drainage. Empiric therapy for an empyema is frequently with imipenem or piperacillin/tazobactam until a definitive organism is identified on pleural fluid cultures and sensitivities are obtained. Antibiotic coverage for anaerobic organisms is also recommended since anaerobes frequently coexist but are more difficult to isolate. For an empyema secondary to aspiration pneumonia or a parapneumonic process, choose antibiotics that are active against mouth flora, S aureus and Streptococcus species. For an empyema secondary to penetrating chest trauma, administer antibiotics that have coverage for skin flora. If MRSA is suspected, include vancomycin in the treatment plan. Pleural fluids or sputum specimens that are obtained should be cultured for M tuberculosis as well.

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Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

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Clindamycin (Cleocin)

 

Lincosamide for the treatment of serious skin and soft-tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest.

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Cefoxitin (Mefoxin)

 

Second-generation cephalosporin indicated for infections with gram-positive cocci and gram-negative rod. Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond.

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Penicillin G (Pfizerpen)

 

Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms; traditional drug for the treatment of lung abscess, but its spectrum of activity is narrow.

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Ticarcillin/clavulanate (Timentin)

 

Inhibits biosynthesis of cell wall mucopeptide and is effective during active growth stage. Antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most gram-positive bacteria, most gram-negative bacteria, and most anaerobes.

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Piperacillin/tazobactam (Zosyn)

 

Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.

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Imipenem and cilastatin (Primaxin)

 

For treatment of multiple organism infections in which other agents do not have wide-spectrum coverage or are contraindicated because of potential for toxicity.

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Vancomycin (Vancoled, Vancocin, Lyphocin)

 

Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who cannot receive or whose conditions are unresponsive to penicillins and cephalosporins or have infections with resistant staphylococci. For abdominal-penetrating injuries, it is combined with an agent active against enteric flora and/or anaerobes. To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use CrCl to adjust dose in patients with renal impairment.

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Contributor Information and Disclosures
Author

Mark Zwanger, MD, MBA  Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mark S Slabinski, MD, FACEP, FAAEM  Vice President, EMP Medical Group

Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Ohio State Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Paul Blackburn, DO, FACOEP, FACEP  Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

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Histology of a lung abscess shows dense inflammatory reaction (low power).
A thick-walled lung abscess.
Pneumococcal pneumonia complicated by lung necrosis and abscess formation.
A lateral chest radiograph shows air-fluid level characteristic of lung abscess.
A 54-year-old patient developed cough with foul-smelling sputum production. A chest radiograph shows lung abscess in the left lower lobe, superior segment.
A 42-year-old man developed fever and production of foul-smelling sputum. He had a history of heavy alcohol use, and poor dentition was obvious on physical examination. Chest radiograph shows lung abscess in the posterior segment of the right upper lobe.
A 42-year-old man developed fever and production of foul-smelling sputum. He had a history of heavy alcohol use, and poor dentition was obvious on physical examination. Lung abscess in the posterior segment of the right upper lobe was demonstrated on chest radiograph. CT scan shows a thin-walled cavity with surrounding consolidation.
Chest radiograph of a patient who had foul-smelling and bad-tasting sputum, an almost diagnostic feature of anaerobic lung abscess.
Histology of a lung abscess shows dense inflammatory reaction (high power).
 
 
 
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