Pediatric Pleural Effusion Medication

Updated: Apr 30, 2018
  • Author: Dagnachew (Dagne) Assefa, MD, FAAP, FCCP; Chief Editor: Girish D Sharma, MD, FCCP, FAAP  more...
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Medication

Medication Summary

The treatment of a transudative, chylous, or hemorrhagic pleural effusion involves treatment of the underlying process. Antibiotics are administered for parapneumonic effusions caused by aerobic and anaerobic organisms. Specific agents should be based on the patient's age and the types of organisms and sensitivities common in the community. Therefore, the list of antibiotics below is only a guide. More than 1 agent may be used for synergy and for polymicrobial infections. Antibiotics may be changed if the organisms and their sensitivities are identified.

Initially, administer antibiotics intravenously while a thoracostomy tube is present until some time after the child is afebrile and improving clinically; then, the IV drugs can be switched to oral medications for 2-4 weeks. Empyema usually requires prolonged antimicrobial therapy.

Antituberculous drugs for tuberculosis-associated effusion should be administered for 6-9 months. Chemotherapeutic agents are used for malignancy. Steroids are indicated for connective-tissue disorders and may be useful for tuberculosis effusion. Fibrinolytic drugs are used to lyse fibrinous strands in loculated empyemas.

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Antibiotics, Other

Class Summary

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

Nafcillin

Nafcillin is a broad-spectrum penicillin. It is used for methicillin-sensitive S aureus and is the initial therapy for suspected penicillin G–resistant streptococcal or staphylococcal infections. In severe infections, start with parenteral therapy, and change to oral therapy as the condition warrants. Because of thrombophlebitis, particularly in elderly persons, administer parenterally for only 1-2 days; change to oral therapy as indicated clinically.

Oxacillin

Oxacillin is a bactericidal antibiotic that inhibits cell-wall synthesis. It is used to treat infections caused by penicillinase-producing staphylococci. Oxacillin may be used to start therapy when a staphylococcal infection is suspected.

Vancomycin (Vancocin)

Vancomycin can be used for methicillin-resistant S aureus and for S pneumoniae. It is a potent antibiotic against gram-positive organisms and is active against Enterococcus species. Vancomycin is indicated for patients who cannot receive or whose conditions fail to respond to penicillins and cephalosporins or those with infections with resistant staphylococci. To avoid toxicity, the current recommendation is to assay vancomycin trough levels 30 minutes before the fourth dose. Use creatinine clearance (CrCl) to adjust the dose in renal impairment.

Penicillin G aqueous (Pfizerpen)

Penicillin G is used to treat S pneumoniae infection and anaerobic bacteria. It interferes with synthesis of cell-wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.

Cefotaxime (Claforan)

Cefotaxime is a third-generation cephalosporin. It can be used for S pneumoniae or H influenzae infection. Cefotaxime arrests bacterial cell-wall synthesis, inhibiting bacterial growth.

Ceftriaxone (Rocephin)

Ceftriaxone is a third-generation cephalosporin; it can be used for S pneumoniae or H influenzae infection. Ceftriaxone arrests bacterial growth by binding to 1 or more penicillin-binding proteins.

Clindamycin (Cleocin, Cleocin Pediatric, ClindaMax Vaginal)

Clindamycin can be used for S pneumoniae infection and anaerobes and as alternative drug for methicillin-resistant S aureus. It is also effective against aerobic and anaerobic streptococci (except enterococci). Clindamycin inhibits bacterial growth, possibly by blocking dissociation of peptidyl transfer ribonucleic acid (tRNA) from ribosomes, causing RNA-dependent protein synthesis to arrest.

Linezolid (Zyvox)

Linezolid prevents the formation of a functional 70S initiation complex, which is essential for the bacterial translation process. It is bacteriostatic against enterococci and staphylococci and bactericidal against most strains of streptococci. Linezolid is used as an alternative in patients who are allergic to vancomycin and for the treatment of vancomycin-resistant enterococci.

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Antitubercular Agents

Class Summary

These agents are used for the treatment of drug-susceptible tuberculosis infection. Recommendations include 6-9 months of therapy. The 6-month regimen includes either 2 months of isoniazid (INH), rifampin, and pyrazinamide once per day, followed by 4 months of INH and rifampin daily, or 2 months of INH, rifampin, and pyrazinamide daily, followed by 4 months of INH and rifampin twice weekly under directly observed therapy (DOT).

For drug-resistant tuberculosis, initial treatment should include 4 drugs until susceptibility is determined. Therapy should last 12-18 months.

Isoniazid

Isoniazid offers the best combination of effectiveness, low cost, and minor adverse effects. It is a first-line drug unless resistance or another contraindication is known. Therapeutic regimens of less than 6 months have an unacceptably high relapse rate. Coadministration of pyridoxine is recommended if peripheral neuropathies secondary to INH therapy develop. Prophylactic doses of 6-50 mg/d are recommended.

Rifampin (Rifadin)

Rifampin is for use in combination with at least 1 other anti-tuberculosis drug. It inhibits RNA synthesis in bacteria by binding to the beta subunit of DNA-dependent RNA polymerase, which in turn blocks RNA transcription. Cross-resistance may occur. Treat the patient for 6-9 months or until 6 months have elapsed from conversion to negative sputum cultures.

Pyrazinamide

This is a pyrazine analog of nicotinamide that may be bacteriostatic or bactericidal against M tuberculosis, depending on the concentration of drug attained at the site of infection. The mechanism of action is unknown. In drug-susceptible patients, administer pyrazinamide for the initial 2 months of a regimen lasting 6 months or longer. Treat drug-resistant cases with individualized regimens.

Streptomycin

Streptomycin is administered for the treatment of susceptible mycobacterial infections. It is used in combination with other anti-tuberculosis drugs (eg, INH, ethambutol, rifampin).

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Thrombolytics

Class Summary

Fibrinolytic drugs may lyse the fibrinous strands in loculated empyemas and thereby clear the lymphatic pores and restore pleural fluid circulation. [104, 105]

Alteplase (Activase, Cathflo Activase, TPA)

Tissue plasminogen activator binds to fibrin in a thrombus and converts the entrapped plasminogen to plasmin, thereby initiating local fibrinolysis. Alteplase's serum half-life is 4-6 minutes, but the half-life is lengthened when alteplase is bound to fibrin in a clot. Circulating plasma levels are not expected to reach pharmacologic concentrations after intrapleural administration.

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