Empyema
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2019 Edition
J86.0/J86.9
DESCRIPTION
- Pus in the pleural cavity and/or bacteria present in a pleural effusion.
- An empyema is always secondary to another process, e.g. pneumonia (especially aspiration pneumonia), lung abscess, tuberculosis, bacteraemia, or a penetrating chest wall or oesophageal injury.
GENERAL MEASURES
- Aspirate and analyse all pleural effusions.
- A parapneumonic effusion should be distinguished from an empyema by biochemical analysis, fluid microscopy and culture – tube drainage is indicated if the pH is <7.2, shows bacteria on MCS, or is purulent.
- The primary management of empyema is early and complete drainage by insertion of an intercostal drain to prevent long-term complications.
MEDICINE TREATMENT
Antimicrobial therapy
If an empyema occurs due to a complication of pneumonia, antimicrobial therapy should be prescribed as guided in Pneumonia, community acquired (the duration of therapy should be prolonged until drainage is complete).
If not a complication of pneumonia:
- Amoxicillin/clavulanic acid, IV, 1.2 g 8 hourly, until patient is apyrexial for 24 hours.
Follow with:
- Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly.
Continue treatment until drainage is complete.
LoE:III
Severe penicillin allergy (and not a complication of pneumonia): (Z88.0)
- Moxifloxacin, IV, 400 mg daily, until patient is apyrexial for 24 hours.
Follow with:
- Moxifloxacin, oral, 400 mg daily.
Continue treatment until drainage is complete.
LoE:III
REFERRAL
- Loculated empyema or inadequate drainage.
- Chronic empyema with pleural thickening and restrictive lung disease, for consideration for surgical decortication.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.1_16 September 2024
Chapter 16: Respiratory Disorders _16.8 Empyema