Infection of the pleural space; make the diagnosis on the basis of the parameters of the tap of the pleural fluid. Lots of PMN's, bacteria on gram stain, pH < 7.2 (if in the 6 range think esophageal rupture), glucose level < 40 mg/dl, and lactic dehydrogenase > 1000 IU/liter. From 2007 review: PubMed.
|Glucose ratio pleural/serum||>0.5||<0.5||na|
|Culture||negative||occ positive||usually positive|
These often occur on a spectrum, and the closer it is to pus, the more loculation, the more you should push to drainage.
Pneumonia, esophageal rupture, trauma.
Viral is due to Bornholm disease aka epidemic pleurodynia aka epidemic myalgia aka the devils grippe,due to Coxsackie B virus and other viruses
Mortality: hospital-acquired infection 47% vrs community 17% and gram-negative 45%, S. aureus 44%, or mixed aerobic infections 46%, vrs streptococcal infection 17% and anaerobes bacteria 20%.
If you find Candida, think esophageal perforation.
Depends on what you suspect and the gram stain.
Duration of therapy is longer rather than shorter; it is until the patient is cured. What a concept.
"The duration of treatment for pleural infection has not been assessed in detailed clinical trials, however antibiotics are often continued for at least 3 weeks, again based on clinical, biochemical (eg, CRP) and radiological response (PubMed)."
There are no good recommendations for how long to treat and when to change to po. It depends in the organism, adequacy of source control, and the clinical response and is why you get to put MD/DO after you name.
Drain it. Sooner rather than later. Never let the sun set on an empyema unless, of course, you live at the poles. Video Assisted Thoracic Surgery (VATS) has a better outcome than regular chest tubes for large complex empyemas.
Culture positive empyema's do worse clinically by most parameters (PubMed).
In the middle ages they did not take prisoners on the battlefield. There was someone whose job it was to slit the throats of the enemy wounded (barbers became surgeons, these folks became agents). That is the role of antibiotics in empyema: You win or lose based on the drainage.
Relevant links to my Medscape blog
Last Update: 06/25/18.