Empirical therapy for complicated parapneumonic effusion or empyema complicating HAP or VAP

When treating patients with complicated parapneumonic effusion or empyema complicating VAP or high-severity HAP, consider both the recommendations in this topic and management advice in Hospital-acquired pneumonia or Ventilator-associated pneumonia.

Additional treatment may be needed for patients with high-severity HAP who have:

Additional treatment may be needed for patients with VAP who have:

For antibiotic management of complicated parapneumonic effusion or empyema complicating HAP or VAP in adults and children, useAbdul-Aziz, 2024Dulhunty, 2024:

piperacillin+tazobactam intravenously. For dosage adjustment in adults with kidney impairment, see piperacillin+tazobactam dosage adjustment. See advice on modification and duration of therapy piperacillin + tazobactam piperacillin+tazobactam piperacillin+tazobactam

adult without septic shock and not requiring intensive care support: 4+0.5 g 6-hourly1

adult with septic shock or requiring intensive care support: 4+0.5 g administered as a loading dose over 30 minutes. After 3 hours, start a continuous infusion of 16+2 g administered over 24 hours23

child without septic shock: 100+12.5 mg/kg up to 4+0.5 g, 6-hourly1

child with septic shock: 100+12.5 mg/kg up to 4+0.5 g, administered as a loading dose over 30 minutes. After 3 hours, start a continuous infusion of 400+50 mg/kg up to 16+2 g, administered over 24 hours45

PLUS if the patient is at increased risk of MRSA infection

vancomycin intravenously; for initial dosing, see Vancomycin dosing in adults or Intermittent vancomycin dosing for young infants and children. Loading doses are recommended for critically ill adults. See advice on modification and duration of therapy. vancomycin vancomycin vancomycin

For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use:

cefepime 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see cefepime dosage adjustment. See advice on modification and duration of therapy cefepime cefepime cefepime

PLUS

metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) intravenously, 12-hourly. See advice on modification and duration of therapy metronidazole metronidazole metronidazole

PLUS if the patient is at increased risk of MRSA infection

vancomycin intravenously; for initial dosing, see Vancomycin dosing in adults or Intermittent vancomycin dosing for young infants and children. Loading doses are recommended for critically ill adults. See advice on modification and duration of therapy. vancomycin vancomycin vancomycin

For patients who have had a severe immediate6 hypersensitivity reaction to a penicillin, the cefepime-based regimen (as 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 patients who have had a severe immediate6 hypersensitivity reaction to a penicillin in whom cefepime is not used, or for patients who have had a severe delayed7 hypersensitivity reaction to a penicillin, meropenem may be suitable8. UseAbdul-Aziz, 2024Dulhunty, 2024:

meropenem intravenously. For dosage adjustment in adults with kidney impairment, see meropenem dosage adjustment. See advice on modification and duration of therapy meropenem meropenem meropenem

adult without septic shock and not requiring intensive care support: 1 g 8-hourly

adult with septic shock or requiring intensive care support: 2 g administered as a loading dose over 30 minutes. After 4 hours, administer 2 g 8-hourly, as consecutive 8-hour infusions910

child without septic shock: 20 mg/kg up to 1 g, 8-hourly11

child with septic shock: 40 mg/kg up to 2 g, administered as a loading dose over 30 minutes. After 4 hours, administer 40 mg/kg up to 2 g, 8-hourly, as consecutive 8-hour infusions1213

PLUS if the patient is at increased risk of MRSA infection

vancomycin intravenously; for initial dosing, see Vancomycin dosing in adults or Intermittent vancomycin dosing for young infants and children. Loading doses are recommended for critically ill adults. See advice on modification and duration of therapy. vancomycin vancomycin vancomycin

1 Administration of piperacillin+tazobactam over 3 hours may be preferred to ensure adequate drug exposure for Pseudomonas aeruginosa. For more information, see Practical information on using beta lactams: penicillins.Return
2 For adults with septic shock or requiring intensive care support, administering the total daily dose of piperacillin+tazobactam over 24 hours is preferred to ensure adequate drug exposure. If this is not possible (eg the patient is receiving other drugs via the same line), administer the standard dose (4+0.5 g intravenously, 6-hourly) as an extended infusion over 3 hours. If a 3-hour infusion is not possible, administer over 30 minutes. For more information, see Practical information on using beta lactams: penicillins.Return
3 The modified dosage of piperacillin+tazobactam for adults with septic shock or those requiring intensive care support is recommended to ensure adequate drug exposure, because pharmacokinetics may be altered in patients with critical illness (eg because of enhanced kidney clearance or changes in volume of distribution). Once the critical illness has resolved, consider switching to the standard dosage.Return
4 For children with septic shock, administering the total daily dose of piperacillin+tazobactam over 24 hours is preferred to ensure adequate drug exposure. If this is not possible (eg the child is receiving other drugs via the same line), administer the standard dose (100+12.5 mg/kg up to 4+0.5 g intravenously, 6-hourly) as an extended infusion over 3 hours. If a 3-hour infusion is not possible, administer over 30 minutes. For more information, see Practical information on using beta lactams: penicillins.Return
5 The modified dosage of piperacillin+tazobactam for children with septic shock is recommended to ensure adequate drug exposure, because pharmacokinetics may be altered in patients with critical illness (eg because of enhanced kidney clearance or changes in volume of distribution). Once the critical illness has resolved, consider switching to the standard dosage.Return
6 Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return
7 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
8 In patients with penicillin hypersensitivity, the rate of immune-mediated cross-reactivity with carbapenems is approximately 1%; therefore, meropenem can be considered in supervised settings. However, in patients with a history of a severe cutaneous adverse reaction (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN]), consider meropenem only in a critical situation when there are limited treatment options.Return
9 For adults with septic shock or requiring intensive care support, administering the total daily dose of meropenem over 24 hours (as 3 consecutive 8-hourly infusions) is preferred to ensure adequate drug exposure. If this is not possible (eg the patient is receiving other drugs via the same line), administer the dose (2 g intravenously, 8-hourly) as an extended infusion over 3 hours. If a 3-hour infusion is not possible, administer over 30 minutes. For more information, see Practical information on using beta lactams: carbapenems.Return
10 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 meropenem is recommended. Once the critical illness has resolved, consider switching to the standard dosage.Return
11 Some centres use a meropenem dosage of 40 mg/kg up to 2 g intravenously, 8-hourly for children who are very unwell; however, no data are available to support the use of this dosage except in children with central nervous system infection or septic shock.Return
12 For children with septic shock, administering the total daily dose of meropenem over 24 hours (as 3 consecutive 8-hourly infusions) is preferred to ensure adequate drug exposure. If this is not possible (eg the child is receiving other drugs via the same line), administer the dose (40 mg/kg up to 2 g intravenously, 8-hourly) as an extended infusion over 3 hours. If a 3-hour infusion is not possible, administer over 30 minutes. For more information, see Practical information on using beta lactams: carbapenems.Return
13 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 children with complicated parapneumonic effusion or empyema who have septic shock, a modified dosage of meropenem is recommended. Once the critical illness has resolved, consider switching to the standard dosage.Return