Modification of therapy for complicated parapneumonic effusion or empyema complicating CAP in adults

For complicated parapneumonic effusion or empyema complicating CAP in adults, modify antibiotic therapy based on the results of microbiological investigations, noting that these infections are typically polymicrobial.

Once the patient has improved and, if drainage is feasible, the pleural space is adequately drained, switch to oral therapy. For guidance on when to switch to oral therapy, see Guidance for intravenous to oral switch. For oral continuation therapy for parapneumonic effusion or empyema complicating CAP in adults, use:

amoxicillin+clavulanate 875+125 mg orally, 12-hourly¹. For dosage adjustment in adults with kidney impairment, see amoxicillin+clavulanate oral dosage adjustment. See advice on duration of therapy. amoxicillin + clavulanate amoxicillin+clavulanate amoxicillin+clavulanate

For adults with nonsevere (immediate or delayed) penicillin hypersensitivity, or severe immediate² penicillin hypersensitivity who tolerated a ceftriaxone-based regimen³, use:

cefuroxime 500 mg orally, 12-hourly⁴. For dosage adjustment in adults with kidney impairment, see cefuroxime dosage adjustment. See advice on duration of therapy cefuroxime cefuroxime cefuroxime

PLUS

metronidazole 400 mg orally, 12-hourly. See advice on duration of therapy. metronidazole metronidazole metronidazole

For adults with severe immediate² penicillin hypersensitivity in whom ceftriaxone was not used nor tolerated, or for patients with severe delayed⁵ penicillin hypersensitivity, use:

moxifloxacin 400 mg orally, daily. For dosage adjustment in adults with kidney impairment, see moxifloxacin dosage adjustment. See advice on duration of therapy. moxifloxacin moxifloxacin moxifloxacin

¹ For adults who have significant residual pleural fluid remaining after drainage, or who have an effusion or empyema that is unable to be drained, consider giving amoxicillin+clavulanate 8-hourly, or adding an additional amoxicillin dose (eg 1 g orally, at midday) to the 12-hourly amoxicillin+clavulanate regimen.Return

² Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

³ For patients with severe immediate penicillin hypersensitivity who tolerated initial intravenous therapy with ceftriaxone, it is safe to use cefuroxime.Return

⁴ Cefuroxime is preferred to cefalexin or cefaclor because of its superior antipneumococcal activity; see Practical information on using beta lactams: cephalosporins for further information.Return

⁵ Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return