Hospital-Acquired Pleural Empyema When Initial Antibiotics and Drainage Have Not Achieved Clinical Improvement
This protocol applies to patients with hospital-acquired (healthcare-acquired) pleural infection who have not responded adequately to an initial course of empirical antibiotics combined with intercostal chest drain insertion.
Hospital-acquired pleural infection
In the hospital-acquired setting, pleural infection usually arises secondary to nosocomial pneumonia, trauma, and surgery. Because of the polymicrobial nature of such infections, empirical antibiotics must provide cover against Gram-positive and Gram-negative aerobes as well as anaerobic organisms.
Previous line did not achieve clinical improvement
The first-line approach — empirical antipseudomonal antibiotics with anaerobic and MRSA coverage, combined with prompt intercostal chest drain insertion — aims to achieve cessation of pyrexia, resolution of inflammatory markers, and radiological improvement. When these goals are not met, the next treatment step is indicated.
Intrapleural fibrinolytic therapy (IPFT)
The next step involves intrapleural fibrinolytic therapy (IPFT), now considered the standard of care for a non-draining infected pleural space in many centres, with an increasing body of evidence demonstrating both safety and efficacy. The full protocol specifies the agents, dosing schedule, clamping regimen, and considerations for specific patient subgroups.
Treatment goal: Improvement in radiographic clearance and effective drainage of the infected pleural space.
References
DOI: 10.1183/20734735.0146-2023
In the hospital-acquired setting, pleural infection usually arises secondary to nosocomial pneumonia, trauma and surgery.
It is therefore recommended that empirical antibiotics provide cover against Gram-positive and Gram-negative aerobes, as well as anaerobic organisms.
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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