Empirical therapy for empyema complicating thoracic trauma or haemothorax in patients with sepsis or septic shock

For patients with empyema complicating thoracic trauma or haemothorax who have sepsis or septic shock, start antibiotic therapy within 1 hour of presentation to medical care or, for ward-based patients, development of sepsis or septic shock. Antibiotics should be administered immediately after blood samples are taken for culture. Collect a pleural fluid sample as soon as possible (during drainage of the pleural space for source control); however, do not delay antibiotic administration to do so. For nonantibiotic management of sepsis, see Resuscitation of patients with sepsis or septic shock.

For empirical antibiotic management of empyema complicating thoracic trauma or haemothorax in adults and children with sepsis or septic shock, useAbdul-Aziz, 2024 Dulhunty, 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

patients without septic shock and not requiring intensive care support: 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) 6-hourly

patients with septic shock or requiring intensive care support: 4+0.5 g (child: 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 16+2 g (child: 400+50 mg/kg up to 16+2 g) administered over 24 hours¹ ²

PLUS if the patient has septic shock or is at increased risk of MRSA

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, replace piperacillin+tazobactam in the above regimen with:

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

For patients who have had a severe immediate³ 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 immediate³ hypersensitivity reaction to a penicillin in whom the cefepime-based regimen is not used, or for patients who have had a severe delayed⁴ hypersensitivity reaction to a penicillin, it may be suitable to replace piperacillin+tazobactam in the above regimen with meropenem⁵; useAbdul-Aziz, 2024 Dulhunty, 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

patients without septic shock and not requiring intensive care support: 1 g (child: 20 mg/kg up to 1 g) 8-hourly⁶

patients with septic shock or requiring intensive care support: 1 g (child: 20 mg/kg up to 1 g) administered as a loading dose over 30 minutes. After 4 hours, administer 1 g (child: 20 mg/kg up to 1 g) 8-hourly, as consecutive 8-hour infusions⁷ ⁶ ⁸.

¹ For patients 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 [child: 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

² The modified dosage of piperacillin+tazobactam for patients 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

³ Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

⁴ 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

⁵ 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

⁶ 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.Return

⁷ For patients 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 (1 g [child: 20 mg/kg up to 1 g] 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

⁸ The modified dosage of meropenem for patients 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