Empirical therapy for empyema complicating thoracic trauma or haemothorax in patients without sepsis or septic shock

For empirical antibiotic management of empyema complicating thoracic trauma or haemothorax in adults and children without sepsis or septic shock, use:

1amoxicillin+clavulanate intravenously; see advice on modification and duration of therapy amoxicillin + clavulanate amoxicillin+clavulanate amoxicillin+clavulanate

2+0.2 g formulation

adult, or child 40 kg or more: 2+0.2 g 8-hourly. For dosage adjustment in adults with kidney impairment, see amoxicillin+clavulanate intravenous dosage adjustment

OR

1+0.2 g formulation

adult, or child 40 kg or more: 1+0.2 g 6-hourly. For dosage adjustment in adults with kidney impairment, see amoxicillin+clavulanate intravenous dosage adjustment

child 3 months or older and less than 40 kg: 25+5 mg/kg up to 1+0.2 g 6-hourly

OR (as a 2-drug regimen)

1cefazolin 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see cefazolin dosage adjustment. See advice on modification and duration of therapy cefazolin cefazolin cefazolin

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

For patients at increased risk of infection with MRSA, add to either of the above regimens:

vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for noncritically ill adults or Intermittent vancomycin dosing for young infants and children. 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 the cefazolin-based regimen above.

For patients who have had a severe immediate¹ hypersensitivity reaction to a penicillin, the cefazolin-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 immediate¹ hypersensitivity reaction to a penicillin in whom cefazolin is not used, or for patients who have had a severe delayed² hypersensitivity reaction to a penicillin, use:

clindamycin 15 mg/kg up to 600 mg intravenously, 8-hourly³. See advice on modification and duration of therapy clindamycin clindamycin clindamycin

PLUS if the patient is at increased risk of infection with MRSA

vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for noncritically ill adults or Intermittent vancomycin dosing for young infants and children. See advice on modification and duration of therapy. vancomycin vancomycin vancomycin

For patients using a clindamycin-based regimen, if prompt source control (drainage) is unlikely to be achieved (eg within 24 hours), consider adding metronidazole because of increasing resistance to clindamycin in gram-negative anaerobes (especially Bacteroides); add to the clindamycin-based regimen:

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

¹ Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

² 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

³ There are more clinical and microbiological data to support the use of clindamycin than lincomycin. Intravenous lincomycin can be used at the same dosage if clindamycin is unavailable or if a local protocol recommends its use.Return