Antibiotic management of empyema complicating an indwelling pleural catheter

Indwelling pleural catheters are becoming an increasingly common management approach for malignant pleural effusion in adults. However, the risk of infection associated with long-term device placement is 4.8%Lui, 2016. Indwelling pleural catheters are rarely used in children – seek expert advice for management of an associated empyema in children.

Note: Seek expert advice for management of children with empyema complicating an indwelling pleural catheter.

Adults with empyema complicating an indwelling pleural catheter require:

  • admission to hospital
  • pleural fluid sampling and drainage
  • intrapleural enzyme therapy
  • intravenous antibiotics.

For definitions of empyema complicating an indwelling pleural catheter, and a summary of management, see Definitions and management of parapneumonic effusion and thoracic empyema.

Empyema complicating an indwelling pleural catheter typically occurs at least 6 to 8 weeks after catheter insertion, rather than immediately after. While gram-negative bacteria may be involved, the most common pathogens are skin flora: Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus [MRSA]), coagulase-negative staphylococci, streptococci and Propionibacterium acnesFysh, 2013. These infections are typically associated with lower severity and mortality than empyema associated with community-acquired pneumoniaLui, 2016.

Typical features of infection include any of the following:

  • local exit-site features of skin and soft tissue infection
  • increasing purulent output
  • systemic signs of infection
  • rarely, sepsis or septic shock.

If infection is suspected based on clinical signs, obtain pleural fluid samples to analyse for:

  • biochemistry (which may include pH, lactate dehydrogenase [LDH], protein and glucose)
  • cytology
  • culture.

Culturing pleural fluid in blood culture bottles, in addition to standard culture, can increase microbial yieldMenzies, 2011.

Isolation of organisms from pleural fluid culture via the catheter, in the absence of local, systemic or pleural features of infection may represent colonisation rather than active infection, and expert opinion should be considered. Using biochemical analysis alone to distinguish infected malignant loculated effusion, from those that are noninfective, is challenging – both may have reduced pH and glucose, and elevated protein and LDHLui, 2016Psallidas, 2016.

For adults with empyema complicating an indwelling pleural catheter 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; however, do not delay antibiotic administration to do so. For nonantibiotic management of sepsis, see Resuscitation of patients with sepsis or septic shock.