Infected Parapneumonic Effusions and Empyema - Guideline for the Management of

Publication: 12/06/2009  --
Last review: 18/09/2017  
Next review: 01/09/2020  
Clinical Guideline
CURRENT 
ID: 1679 
Approved By: Improving Antimicrobial Prescribing Group/DTC 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the Management of Infected Parapneumonic Effusions and Empyema

  • Treatment Algorithm
  • Summary
    Infected Parapneumonic Effusions and Empyema

    History
    A parapneumonic effusion or empyema should be suspected in patients with pneumonia failing to respond to appropriate antibiotic therapy (persistently elevated CRP and/or temperature) or with examination findings suggestive of a pleural effusion.

    Examination
    Reduced breath sounds and tactile vocal fremitus may indicate a pleural effusion.

    Initial Investigations

    • CRP, WCC, Chest X-ray
    • Patients with a pleural effusion and sepsis require a diagnostic pleural aspiration under ultrasound guidance.
    • Fluid pH should be analysed immediately by taking the sample in a blood gas syringe to Clinical Chemistry (not if fluid is very thick or presence of pus). Prior notification is required.
    • Samples should be sent for microscopy/culture and sensitivity, LDH, Glucose, and Protein. AAFB and cytology should be requested if TB or malignancy is suspected. is conducted urgently and phoned back to the sender. Consider placing some of the pleural sample in blood culture bottles in addition to a sample in a sterile universal.

    Non-antimicrobial treatment - see full guideline re chest drain insertion
    Antimicrobial treatment

    Empirical therapy (microbiology negative or awaited)

    Community-acquired infection
    First line:  Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav IV 1.2g 8-hourly
    Penicillin allergy: Levofloxacin electronic Medicines Compendium information on Levofloxacin 500mg IV 12-hourly and Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg 8-hourly

    Prior to commencing Levofloxacin electronic Medicines Compendium information on Levofloxacin the possibility of tuberculosis should be considered and , if appropriate, sputum sent for AAFBs

    Patients identified as ‘High Risk’ for MRSA: Patients identified as ‘High Risk’ for MRSA: 1st line Linezolid Description: electronic Medicines Compendium information on   Linezolid* 600mg 12-hourly PO/IV and Ciprofloxacin Description: electronic Medicines Compendium information on CiprofloxacinIV 400mg 12-hourly (or ORAL: 500mg 12-hourly if absorbing) and Metronidazole Description: electronic Medicines Compendium information on MetronidazoleIV 500mg 8-hourly.
    or 2nd line Teicoplanin Description: electronic Medicines Compendium information on   Teicoplanin* IV (see dosing guideline) and Ciprofloxacin Description: electronic Medicines Compendium information on CiprofloxacinIV 400mg 12-hourly (or ORAL: 500mg 12-hourly if absorbing) and Metronidazole Description: electronic Medicines Compendium information on MetronidazoleIV 500mg 8-hourly.

    *Linezolid electronic Medicines Compendium information on 

Linezolid has a number of drug interactions/contraindications. Please see full guidance to check suitability for the patient. This is an off-label use of Linezolid electronic Medicines Compendium information on 

Linezolid and Teicoplanin electronic Medicines Compendium information on 

Teicoplanin; the patient should be informed of this.

    Hospital-acquired infection
    In hospital-acquired empyema, additional cover against MRSA and Gram negative bacilli may be required until cultures become available. Please discuss with the duty microbiologist. In complex cases the Consultant Respiratory Physician should contact the on-call Microbiology Consultant.

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    Background

    Empyema is defined as pus in the pleural space; it usually occurs as a complication of pneumonia but may also complicate thoracic surgery, penetrating chest trauma, oesophageal rupture or leaks from oesophageal anastamoses. Occasionally another focus of infection cannot be found - so called “primary empyema”. The development of empyema secondary to pneumonia evolves through stages beginning with a simple exudate, which then becomes turbid and subsequently frankly purulent (see classification)
    In the UK over 20% of patients with empyema die and 40% require surgery because of failed catheter drainage (Ferguson, A 1996). Rapid evaluation and treatment appears to reduce mortality and cost1.

    Classification
    Parapneumonic effusions may be simple, complicated or an empyema.

    • A simple parapneumonic effusion is clear with pH >7.2 and will usually resolve with antibiotics alone, although a chest tube may be required for symptom relief. Other fluid characteristics are LDH <1000 IU/L, glucose >2.2 mmol/L and the absence of organisms on Gram-stain or culture.
    • A complicated parapneumonic effusion is clear or turbid usually with a pH <7.2, and requires chest tube drainage. Other fluid characteristics are LDH >1000 IU/L and glucose <2.2 mmol/L. The Gram stain or culture may or may not be positive
    • Frank pus is diagnostic of empyema and pH measurement is not required

    Microbiology
    Streptococci and Staphylococcus aureus are the most common causes of empyema. S. aureus is more commonly seen following surgery, trauma, healthcare associated infection and in immunocompromised patients1. Among the streptococci, Streptococcus pneumoniae and Streptococcus anginosus group (often called “Streptococcus milleri”) are the most important.

    Gram negatives such as Escherichia coli, Klebsiella species, Haemophilus influenzae and Pseudomonas aeruginosa are not uncommon but may be present as part of mixed infections, often with anaerobes. Yeasts are often involved if the empyema is secondary to oesophageal rupture or anastamotic leaks.

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    Clinical Diagnosis

    History

    • A parapneumonic effusion or empyema should be suspected in patients with pneumonia failing to respond to appropriate antibiotic therapy (persistently elevated CRP and/or temperature) or with examination findings suggestive of a pleural effusion. 

    Examination
    A reduction in breath sounds, tactile vocal fremitus can be useful in determining the presence of an effusion.

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    Investigation
    • Blood tests - CRP and WCC are useful for monitoring progress of the infection but have no diagnostic value.
    • Radiology

    Step 1:Chest radiograph
    The size and appearance of parapneumonic effusion on the chest x-ray is a poor guide as to how well patients will respond to antibiotics.

    N.B. In the presence of consolidation it can be very difficult to tell from the chest radiograph that there is fluid present.

    A CXR should be performed after chest tube insertion (see non-antimicrobial treatment section) or when there is a poor response to antibiotics. A parapneumonic effusion /empyema is not always seen on chest radiograph.

    Step 2: Ultrasound
    Ultrasound is more sensitive in detecting small effusions and in demonstrating loculations.  Small or localized effusions are best drained under ultrasound guidance.   Please discuss with the chest radiologists.  [Evidence level C]

    Step 3: CT scan
    A CT scan should be considered following ultrasound if the patient is not improving despite drainage and appropriate antibiotic therapy.  CT can demonstrate the full extent of the parapneumonic effusion, pleural enhancement and thickening, and distinguish empyema from a pulmonary abscess. Please discuss with the chest radiologists.
    [Evidence level C]

    • Diagnostic Aspiration
      • All patients with a pleural effusion associated with sepsis require a diagnostic pleural aspiration under ultrasound guidance. [Evidence level C]
      • Fluid pH should be analysed immediately using a blood gas machine (not if fluid is very thick or presence of pus). [Evidence level B]
      • Samples should be sent for microscopy/culture and sensitivity, LDH, Glucose, and Protein.  AAFB and cytology should be requested if TB or malignancy is suspected. Out-of-hours it may be advisable to contact the lab in advance to make sure that the Gram film is conducted urgently and phoned back to the sender.  [Evidence level C]

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    Treatment
    Non-Antimicrobial Treatment

    A chest tube should be inserted in the following situations:

    • For symptomatic relief in large simple parapneumonic effusions [Evidence level C]
    • Persistent pyrexia and/or elevated CRP [Evidence level B]
    • Frank pus or cloudy/turbid fluid on diagnostic aspiration  [Evidence level B]
    • Pleural pH <7.2 (caution – other conditions can cause low pH and as disease progresses pH falls.  A higher pH does not exclude complicated parapneumonic effusion)  [Evidence level B]
    • Organisms identified in pleural fluid on Gram-stain or culture (Microbiology may be negative if patient is on antibiotics).  [Evidence level B]

    Parapneumonic effusions which do not meet the above criteria should be treated with antibiotics alone.  However poor clinical progress or significant effusion should lead to prompt patient review and probably chest tube drainage.  [Evidence level B]

    Fibrinolysis

    The MIST-2 Protocol is followed [Evidence level B]:

    The Treatment Regimen is:

    • Alteplase 10mg in 30mL NaCl 0.9% TWICE a day for 3 days (i.e. 6 doses in total)
    • Dornase 5mg in 30mL Water for Injection TWICE a day (i.e. 6 doses in total)

    Give both intrapleurally via the chest drain.

    • Alteplase is given first and then the chest drain is clamped for 1 hour, then allowed to drain freely for 1 hour. This is then repeated with dornase alfa.

    Currently, funding for this regimen is not approved.  Before prescribing, the treatment regimen must be approved by the Clinical Lead for Respiratory (currently Dr Daniel Peckham) or the Cardio-respiratory CSU General Manager (currently Gina McGawley).

    • Referral for Surgery

    Early consultation with Thoracic surgeons  is important in the event of  failure of chest tube drainage

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    Empirical Antimicrobial Treatment

    Empirical therapy (microbiology negative or awaited)
    Community-acquired infection
    First line: Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav IV 1.2g 8-hourly
    Penicillin allergy: Levofloxacin electronic Medicines Compendium information on Levofloxacin 500mg IV 12-hourly and Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg 8-hourly

    Prior to commencing Levofloxacin electronic Medicines Compendium information on Levofloxacin the possibility of tuberculosis should be considered and, if appropriate, sputum sent for AAFBs

    Patients identified as ‘High Risk’ for MRSA: 1st line Linezolid Description: electronic Medicines Compendium information on   Linezolid* 600mg 12-hourly PO/IV and Ciprofloxacin Description: electronic Medicines Compendium information on CiprofloxacinIV 400mg 12-hourly (or ORAL: 500mg 12-hourly if absorbing) and Metronidazole Description: electronic Medicines Compendium information on MetronidazoleIV 500mg 8-hourly.
    or 2nd line Teicoplanin Description: electronic Medicines Compendium information on   Teicoplanin* IV (see dosing guideline) and Ciprofloxacin Description: electronic Medicines Compendium information on CiprofloxacinIV 400mg 12-hourly (or ORAL: 500mg 12-hourly if absorbing) and Metronidazole Description: electronic Medicines Compendium information on MetronidazoleIV 500mg 8-hourly..
    *Linezolid electronic Medicines Compendium information on 

Linezolid has a number of drug interactions/contraindications. Please see full guidance to check suitability for the patient. This is an off-label use of Linezolid electronic Medicines Compendium information on 

Linezolid and Teicoplanin electronic Medicines Compendium information on 

Teicoplanin; the patient should be informed of this.

    Hospital-acquired infection
    In hospital-acquired empyema, additional cover against MRSA and Gram negative bacilli may be required until cultures become available.  Please discuss with the duty microbiologist.  In complex cases the Consultant Respiratory Physician should contact the on-call Microbiology Consultant.

    Directed Therapy
    Staphylococcus aureus Flucloxacillin electronic Medicines Compendium information on FlucloxacillinIV 2g 6-hourly

    “Streptococcus milleri”, Streptococcus pneumoniae, β haemolytic streptococci:
    Benzyl penicillin electronic Medicines Compendium information on Benzyl penicillin IV 2.4g 6-hourly +/- Metronidazole electronic Medicines Compendium information on Metronidazole IV 500mg 8-hourly (depending on gram stain results)

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    Directed Antimicrobial Treatment (when microbiology results are known)

    If documented penicillin anaphylaxis and no alternative is recommended, please contact Microbiology.  In complex cases the Consultant Respiratory Physician should contact the on-call Microbiology Consultant.

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    Duration of Treatment

    The duration of treatment has not been assessed in clinical trials. Antibiotics are often continued for several weeks. If there has been adequate pleural drainage and the patient is clinically improved treatment for approximately 3 weeks is probably appropriate. Please discuss with the duty microbiologist.

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    Switch to oral agent(s)

    Like most complex infections, there are no fixed rules regarding when to switch to oral antibiotics.  A decision should be made, tailored to each patient's need, based ideally on microbiological and clinical findings, close monitoring, and appropriate drainage being carried out. However oral switch should not be made before there has been a significant clearing of the empyema fluid

    Recommended regimens
    Community-acquired infection – empirical therapy (i.e. negative/no microbiology)

    First choice:
    ORAL:  Amoxicillin electronic Medicines Compendium information on Amoxicillin 1g 8-hourly and Metronidazole electronic Medicines Compendium information on Metronidazole 400mg  8-hourly

    Second choice (patient intolerant of Metronidazole electronic Medicines Compendium information on Metronidazole :
    ORAL: Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 625mg  8-hourly and Amoxicillin electronic Medicines Compendium information on Amoxicillin 500mg 8-hourly

    Penicillin allergic patients:
    ORAL:  Levofloxacin electronic Medicines Compendium information on Levofloxacin 500mg once-daily and Metronidazole electronic Medicines Compendium information on Metronidazole 400mg 8-hourly

    Prior to commencing Levofloxacin electronic Medicines Compendium information on Levofloxacin the possibility of tuberculosis should be considered and , if appropriate, sputum sent for AAFBs

    Oral switch therapy may also be guided by culture and sensitivity results e.g. oral Flucloxacillin electronic Medicines Compendium information on Flucloxacillin may be used if the cause is identified as meticillin-susceptible S. aureus. Please seek Microbiology advice on a case-by-case basis.

    Hospital-acquired infection - empirical therapy (i.e. negative/no microbiology)
    In hospital-acquired empyema, additional cover against MRSA and Gram negative bacilli may be required -please discuss with the duty microbiologist.

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    Treatment Algorithm

    The chest drain can be removed if fluid is less than 25 ml/day (excluding flushes). It is sometimes useful to leave a drain in situ when undertaking CT in cases of treatment failure. This allows the drain position to be determined.

     

    Davies HE, Davies RJO, Davies CWH, on behalf of the BTS Pleural Disease Guideline Group. Management of pleural infection in adults: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65(Suppl 2):ii51-ii53

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    Treatment Failure

    Please contact Microbiology if the patient is not responding to the recommended antimicrobial regimens

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    Referral Criteria
    • All patients with a moderate/large simple parapneumonic effusion, complicated parapneumonic effusions or empyema should be managed by a Respiratory physician.
    • Early consultation with Thoracic surgeons  is important in the event of  failure of chest tube drainage

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    Provenance

    Record: 1679
    Objective:
    • To provide evidence-based recommendations for appropriate investigation of infected parapneumonic effusions and empyemas.
    • To provide evidence-based recommendations for appropriate empirical or directed antimicrobial therapy of infected parapneumonic effusions and empyemas.
    • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
    • To advise in the event of antimicrobial allergy.
    • To set-out criteria for referral to specialists.
    Clinical condition:

    Infected Parapneumonic Effusions and Empyema

    Target patient group: All patients with empyema and parapneumonic effusions
    Target professional group(s): Secondary Care Doctors
    Secondary Care Nurses
    Pharmacists
    Adapted from:

    Evidence base

    1. Davies CW, Gleeson FV, Davies RJ. BTS guidelines for the management of pleural infection. Thorax. 2003 May;58 Suppl 2:ii18-28.

    Evidence levels:
    A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
    B. Robust experimental or observational studies
    C. Expert consensus.

    Approved By

    Improving Antimicrobial Prescribing Group/DTC

    Document history

    LHP version 1.0

    Related information

    Not supplied

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