eMedicine Specialties > Emergency Medicine > Pulmonary
Pneumonia, Empyema and Abscess: Treatment & Medication
Updated: Nov 7, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
- Supplemental oxygen should be given and an intravenous line started.
- Appropriate airway management, including intubation, should be performed depending on the patient's clinical condition.
Emergency Department Care
- All patients should undergo pulse oximetry and evaluation of their respiratory status.
- If respiratory failure is found or likely to occur, intubation and mechanical ventilation is necessary.
- Supplemental oxygen should be started for any patient who is acutely short of breath or who is hypoxic based on pulse oximetric findings.
- Once the diagnosis of a lung abscess is made, parenteral antibiotics should be started. Ideally, sputum and blood culture findings should be obtained prior to the initiation of antibiotics.
- After the diagnosis of empyema is made, prompt drainage by means of tube thoracostomy with use of parenteral antibiotics should be initiated.
Consultations
Treatment of lung abscesses or empyema is performed in-hospital, with consultations involving internists, thoracic surgeons, or both. Many clinicians advocate administering intrapleural fibrinolytics in patients with empyemas to assist in the breakdown of fibrin bands that can cause loculation of the empyema and to allow for better chest tube drainage of the infected material. However, randomized clinical trials have given conflicting results about the benefits of fibrinolytic therapy on outcomes. A recent meta-analysis that included 575 patients showed no benefit for the use of fibrinolytic therapy based on clinical outcomes of death or need for surgery when compared with control groups. If chest tube drainage and fibrinolytic treatment are unsuccessful, many authors recommend video-assisted thoracic surgery (VATS) rather than the more traditional open thoracotomy. VATS is less invasive and well tolerated, and outcomes compare favorably with open thoracotomy.
In the pediatric population, Avansino et al performed a meta-analysis comparing nonoperative (antibiotics and either thoracentesis and/or tube thoracostomy) with operative therapy (antibiotics and either VATS or thoracotomy) in patients with an empyema.1 Their results suggest that, with operative therapy, the in-hospital mortality rate, reintervention rate, length of stay, time with tube thoracostomy, and time of antibiotic therapy are lower compared with nonoperative treatment.
Lung abscesses typically respond well to antibiotic therapy, but when that therapy is unsuccessful, the consulting clinician might consider percutaneous catheter drainage or endoscopic surgical resection of the involved area of the lung.
Medication
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.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
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.
Adult
600 mg IV q6-8h
Pediatric
25-40 mg/kg/d IV divided tid/qid
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
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.
Adult
2 g IV q6-8h
Pediatric
80-160 mg/kg/d IV divided q4-6h
Probenecid may increase effects; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis
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.
Adult
2 million U IV q4h
Pediatric
150,000 U/kg/d IV divided q4h
Probenecid can increase effects; coadministration of tetracyclines can decrease effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function
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.
Adult
3.1 g IV q4-6h
Pediatric
75 mg/kg IV q6h
Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; synergistic effects when administered concurrently with aminoglycosides; probenecid may increase penicillin levels
Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with oral penicillin during acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBC prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT levels during therapy; caution in patients with hepatic insufficiencies; perform urinalysis and BUN and creatinine determinations during therapy, and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions
Piperacillin/tazobactam (Zosyn)
Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.
Adult
3.375 g IV q6h
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Tetracyclines may decrease effects of piperacillin; high concentrations of piperacillin may physically inactivate aminoglycosides if administered in same IV line; synergistic effects when administered concurrently with aminoglycosides; probenecid may increase penicillin levels; high-dose parenteral penicillins may result in increased risk of bleeding
Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with an oral penicillin during the acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBC prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT levels during therapy; caution in patients with hepatic insufficiencies; perform urinalysis and BUN and creatinine determinations during therapy, and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions
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.
Adult
Base initial dose on severity of infection and administer in equally divided doses; dose may range from 250-500 mg IV q6h for a maximum of 3-4 g/d
Alternatively, 500-750 mg IM q12h or intra-abdominally
Pediatric
<12 years: Not established; 15-25 mg/kg/dose IV q6h suggested for >3 mo
Fully susceptible organisms: Not to exceed 2 g/d
Infections with moderately susceptible organisms: Not to exceed 4 g/d
>12 years: Administer as in adults
Coadministration with cyclosporine may increase CNS side effects of both agents; coadministration with ganciclovir may result in generalized seizures
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in renal insufficiency; avoid use in children <12 y
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.
Adult
500 mg to 2 g/d IV divided tid/qid
Pediatric
40 mg/kg/d IV divided tid/qid
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that associated with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure and neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given IV over 2 h or as PO or IP administration; red man syndrome is not an allergic reaction
More on Pneumonia, Empyema and Abscess |
| Overview: Pneumonia, Empyema and Abscess |
| Differential Diagnoses & Workup: Pneumonia, Empyema and Abscess |
 Treatment & Medication: Pneumonia, Empyema and Abscess |
| Follow-up: Pneumonia, Empyema and Abscess |
| References |
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References
Avansino JR, Goldman B, Sawin RS, Flum DR. Primary operative versus nonoperative therapy for pediatric empyema: a meta-analysis. Pediatrics. Jun 2005;115(6):1652-9. [Medline].
Anstadt MP, Guill CK, Ferguson ER, Gordon HS, Soltero ER, Beall AC Jr, et al. Surgical versus nonsurgical treatment of empyema thoracis: an outcomes analysis. Am J Med Sci. Jul 2003;326(1):9-14. [Medline].
Bartlett JG. Anaerobic bacterial infections of the lung and pleural space. Clin Infect Dis. Jun 1993;16 Suppl 4:S248-55. [Medline].
Bartlett JG. Anaerobic bacterial infections of the lung. Chest. Jun 1987;91(6):901-9. [Medline].
Benjamin GC. Aspiration pneumonia, lung abscess and empyema. Emerg Med. 1992;276-8.
Cameron R, Davies HR. Intra-pleural fibrinolytic therapy versus conservative management in the treatment of parapneumonic effusions and empyema. Cochrane Database Syst Rev. 2004;(2):CD002312. [Medline].
Chapman SJ, Davies RJ. Recent advances in parapneumonic effusion and empyema. Curr Opin Pulm Med. Jul 2004;10(4):299-304. [Medline].
Chin NK, Lim TK. Controlled trial of intrapleural streptokinase in the treatment of pleural empyema and complicated parapneumonic effusions. Chest. Feb 1997;111(2):275-9. [Medline].
Colice GL, Curtis A, Deslauriers J, Heffner J, Light R, Littenberg B, et al. Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline. Chest. Oct 2000;118(4):1158-71. [Medline].
Coote N. Surgical versus non-surgical management of pleural empyema. Cochrane Database Syst Rev. 2002;(2):CD001956. [Medline].
Cowen ME, Johnston MR. Thoracic empyema: causes, diagnosis, and treatment. Compr Ther. Oct 1990;16(10):40-5. [Medline].
Davies CW, Gleeson FV, Davies RJ,. BTS guidelines for the management of pleural infection. Thorax. May 2003;58 Suppl 2:ii18-28. [Medline].
Herth F, Ernst A, Becker HD. Endoscopic drainage of lung abscesses: technique and outcome. Chest. Apr 2005;127(4):1378-81. [Medline].
Houston MC. Pleural fluid pH: diagnostic, therapeutic, and prognostic value. Am J Surg. Sep 1987;154(3):333-7. [Medline].
Huang HC, Chang HY, Chen CW, Lee CH, Hsiue TR. Predicting factors for outcome of tube thoracostomy in complicated parapneumonic effusion for empyema. Chest. Mar 1999;115(3):751-6. [Medline].
Hughes CE, Van Scoy RE. Antibiotic therapy of pleural empyema. Semin Respir Infect. Jun 1991;6(2):94-102. [Medline].
Kohan JM, Poe RH, Israel RH, Kennedy JD, Benazzi RB, Kallay MC, et al. Value of chest ultrasonography versus decubitus roentgenography for thoracentesis. Am Rev Respir Dis. Jun 1986;133(6):1124-6. [Medline].
Light RW. Pleural diseases. Dis Mon. May 1992;38(5):261-331. [Medline].
Miller KS, Sahn SA. Chest tubes. Indications, technique, management and complications. Chest. Feb 1987;91(2):258-64. [Medline].
Pennza PT. Aspiration pneumonia, necrotizing pneumonia, and lung abscess. Emerg Med Clin North Am. May 1989;7(2):279-307. [Medline].
Petrakis IE, Kogerakis NE, Drositis IE, Lasithiotakis KG, Bouros D, Chalkiadakis GE, et al. Video-assisted thoracoscopic surgery for thoracic empyema: primarily, or after fibrinolytic therapy failure?. Am J Surg. Apr 2004;187(4):471-4. [Medline].
Porcel JM, Vives M, Esquerda A. Tumor necrosis factor-alpha in pleural fluid: a marker of complicated parapneumonic effusions. Chest. Jan 2004;125(1):160-4. [Medline].
Richardson JD, Carrillo E. Thoracic infection after trauma. Chest Surg Clin N Am. May 1997;7(2):401-27. [Medline].
Sanford JP, Gilbert DN, Moellering RC. Guide to Antimicrobial Therapy. 2006:28-9.
Schiza S, Siafakas NM. Clinical presentation and management of empyema, lung abscess and pleural effusion. Curr Opin Pulm Med. May 2006;12(3):205-11. [Medline].
Schultz KD, Fan LL, Pinsky J, Ochoa L, Smith EO, Kaplan SL, et al. The changing face of pleural empyemas in children: epidemiology and management. Pediatrics. Jun 2004;113(6):1735-40. [Medline].
Thomson AH, Hull J, Kumar MR, Wallis C, Balfour Lynn IM. Randomised trial of intrapleural urokinase in the treatment of childhood empyema. Thorax. Apr 2002;57(4):343-7. [Medline].
[Best Evidence] Tokuda Y, Matsushima D, Stein GH, Miyagi S. Intrapleural fibrinolytic agents for empyema and complicated parapneumonic effusions: a meta-analysis. Chest. Mar 2006;129(3):783-90. [Medline].
Wiedemann HP, Rice TW. Lung abscess and empyema. Semin Thorac Cardiovasc Surg. Apr 1995;7(2):119-28. [Medline].
Wurnig PN, Wittmer V, Pridun NS, Hollaus PH. Video-assisted thoracic surgery for pleural empyema. Ann Thorac Surg. Jan 2006;81(1):309-13. [Medline].
Further Reading
Keywords
aspiration, lung abscess, pleural pus, penetrating chest trauma, esophageal rupture, inoculation of the pleural cavity, thoracentesis, chest tube placement, subdiaphragmatic abscess, paravertebral abscess, poor dentition, absent gag reflex, septic emboli, vasculitic disorders, cavitating lung malignancies, pulmonary cystic disease, needle compression, polymicrobial oral flora, Bacteroides species, Fusobacterium species, Peptostreptococcus species, Staphylococcus aureus, S aureus, MRSA, Mycobacterium tuberculosis, M tuberculosis, skin flora, Staphylococcus epidermis, S epidermis, pleural effusion
