Community-Acquired Pleural Empyema in Penicillin-Allergic Patients When Initial Antibiotic Therapy Has Not Achieved Clinical Improvement

Clinical scenario

This protocol addresses adults with community-acquired pleural infection who have a history of penicillin allergy. In this population, antibiotic selection targets both Gram-positive aerobes and anaerobes; penicillin-allergic patients are treated with alternative regimens such as clindamycin (alone or in combination) alongside prompt chest drainage.

When first-line therapy falls short

If clindamycin-based antibiotic therapy — clindamycin alone, or in combination with ciprofloxacin or a cephalosporin — together with intercostal chest drain insertion, fails to achieve clinical improvement (cessation of pyrexia, resolution of inflammatory markers, and radiological improvement), the next treatment step is required.

Next-line approach

The next step involves intrapleural fibrinolytic therapy (IPFT) — a procedure in which agents are instilled directly into the pleural space to promote drainage and radiographic clearance of the infected collection. The specific agents, dosing approach, scheduling, and adjustments for high-risk patient subgroups are set out in the full structured protocol.

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References

DOI: 10.1183/20734735.0146-2023

In the community-acquired infection setting, treatment should target both Gram-positive aerobes and anaerobes until results of cultures become available.

For patients that are penicillin-allergic, clindamycin alone, or in combination with ciprofloxacin or a cephalosporin, is likely to provide a good alternative.

Currently, IPFT is the standard of care for non-draining infected pleural space in many centres, with an increasing body of evidence demonstrating both safety and efficacy.

The effect of IPFT on clinical outcomes was studied in the MIST-2 trial, which demonstrated that a combination of tPA and DNase led to improvements in radiographic clearance.

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