Analysis of antibiotic use and clinical outcomes in adults with known and suspected pleural empyema

Abstract

Background There is not a prevailing consensus on appropriate antibiotic choice, route, and duration in the treatment of bacterial pleural empyema after appropriate source control. Professional society guidelines note the lack of comparative trials with which to guide recommendations. We assessed clinical outcomes in the treatment of known and suspected empyema based upon three aspects of antibiotic use: (1) total duration, (2) duration of intravenous (IV) antibiotics, and (3) duration of anti-anaerobic antibiotics. Methods We performed a hypothesis-generating retrospective chart review analysis of 355 adult inpatients who had pleural drainage, via either chest tube or surgical intervention, for known or suspected empyema. The primary outcome variable was clinician assessment of resolution or lack thereof. The secondary outcomes were death within 90 days, hospital readmission within 30 days for empyema, and all-cause hospital readmission within 30 days. Mann-Whitney U test was used to compare outcomes with regard to these variables. Results None of the independent variables was significantly associated with a difference in clinical resolution rate despite trends for total antibiotic duration and anti-anaerobic antibiotic duration. None of the independent variables was associated with mortality. Longer total antibiotic duration was associated with lower readmission rate for empyema (median 17 [interquartile range 11–28] antibiotic days in non-readmission group vs. 13 [6-15] days in readmission group), with a non-significant trend for all-cause readmission rate (17 [11–28] days vs. 14 [9–21] days). IV antibiotic duration was not associated with a difference in any of the defined outcomes. Longer duration of anti-anaerobic antibiotics was associated with both lower all-cause readmission (8.5 [0–17] vs. 2 [0–11]) and lower readmission rate for empyema (8 [0–17] vs. 2 [0–3]). Conclusion Our data support the premise that routine use of anti-anaerobic antibiotics is indicated in the treatment of pleural empyema. However, our study casts doubt on the benefits of extended IV rather than oral antibiotics in the treatment of empyema. This represents a target for future investigation that could potentially limit complications associated with the excessive use of IV antibiotics.

Thoracic empyema: aetiology, diagnosis, treatment, and prevention

“…Pathogens vary significantly based on geography and whether there has been healthcare contact as previously described and this must be taken into consideration when choosing treatment. In general, anaerobic cover should be provided due to the frequent coexistence of anaerobes with S. aureus and certain Streptococci [19]. Anaerobes can present a challenge to culture and so negative microbiological samples should not be treated as reassuring for anaerobic polymicrobial empyema.…”

Canine Pyothorax: Comparison of Culture and Susceptibility Results to the BSAVA PROTECT ME Poster and Other Published Recommended Antimicrobial Use Guidelines

“…In people, empirical antimicrobial therapy for community-acquired empyema (pyothorax) includes a second-or third-generation cephalosporin with metronidazole or a parenteral aminopenicillin with beta-lactamase inhibitor, whilst for hospital-acquired or postprocedural empyema, antimicrobials with activity for methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa (e.g., vancomycin and cefepime or vancomycin and piperacillin/tazobactam) are recommended. Anti-anaerobic antibiotics (e.g., metronidazole, potentiated amoxicillin, and clindamycin) are advised in all cases regardless of culture results, and their use has been associated with better outcomes in human patients [11][12][13].…”

Intra-Empyema Antibiotic Administration: A Case Report

“…Because of extensive muscular atrophy including chest wall and intercostal musculature, general anesthesia and/or any surgical approach involving the chest even with local anesthesia would cause consequent deterioration in chest muscular strength and cough. Subsequently, intra-empyemic administration of metronidazole together with intravenous antibiotics showed favorable outcomes, no side effects without any recurrence [16][17][18][19][20].…”