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, or if bacteria are detected, or if pus is aspirated.
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 a complication of pneumonia, antimicrobial therapy as in section 16.6: Pneumonia, community acquired (but 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.
Treatment duration is until drainage is complete.
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.
Treatment duration is until drainage is complete.
REFERRAL
- Loculated empyema or inadequate drainage.
- Chronic empyema with pleural thickening and restrictive lung disease, for consideration for surgical decortication.