Empirical therapy for complicated parapneumonic effusion or empyema complicating high-severity CAP in adults

When treating adults with complicated parapneumonic effusion or empyema complicating high-severity CAP, consider both the recommendations in this topic and management advice in Community-acquired pneumonia in adults. Additional treatment may be needed for:

• influenza
• Staphylococcus aureus
• Pseudomonas aeruginosa.

Infection with Streptococcus pyogenes (group A streptococcus) is associated with severe disease and a high mortality, but is an uncommon cause of pneumonia, parapneumonic effusion and empyema. For suspected or confirmed parapneumonic effusion or empyema due to S. pyogenes, consider the addition of clindamycin to the regimens below, as for Streptococcus pyogenes (group A streptococcus) bloodstream infections, including toxic shock syndrome.

Atypical pathogens¹ (eg Legionella species, Chlamydophila [Chlamydia] pneumoniae, Mycoplasma pneumoniae) are unlikely to cause parapneumonic effusion or empyema so the addition of azithromycin is not required.

The regimens below are not suitable for adults in tropical regions of Australia² unless Burkholderia pseudomallei and Acinetobacter baumannii have been excluded. Until these pathogens are excluded, manage the patient as for Empirical therapy for high-severity CAP in adults in tropical regions of Australia.

For antibiotic management of complicated parapneumonic effusion or empyema complicating high-severity CAP in adults, use:

Pharmacokinetics may be altered in patients who are critically ill (eg because of enhanced kidney clearance or changes in volume of distribution). To ensure adequate drug exposure in adults with complicated parapneumonic effusion or empyema who have septic shock or require intensive care support, a modified dosage of ceftriaxone is recommended. Once the critical illness has resolved, consider switching to the standard dosage.

For adults who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use ceftriaxone plus metronidazole (at the dosages above).

For adults who have had a severe immediate³ hypersensitivity reaction to a penicillin, ceftriaxone plus metronidazole (at the dosages above) can be considered if a beta-lactam antibiotic is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).

For adults who have had a severe immediate³ hypersensitivity reaction to a penicillin in whom ceftriaxone is not used, or for adults who have had a severe delayed⁴ hypersensitivity reaction to a penicillin, use: