Management of Empyema Thoracis with Panresistant Klebsiella pneumoniae
Initial Management
- The Infectious Diseases Society of America recommends surgical debridement and drainage of the empyema as the mainstay of therapy and should be performed whenever feasible 3
- Infectious disease consultation is highly recommended for management of infections caused by multidrug-resistant organisms, according to the Journal of Microbiology, Immunology and Infection 2
Antimicrobial Therapy
- The American College of Clinical Pharmacy recommends intravenous polymyxins (colistin or polymyxin B) as the backbone of therapy for carbapenem-resistant pathogens that are sensitive only to polymyxins 1, 4
- Adjunctive inhaled colistin is recommended to improve clinical outcomes by achieving higher drug concentrations at the infection site, as suggested by the Clinical Infectious Diseases journal 1, 4
- Therapeutic drug monitoring (TDM) should be performed whenever possible when using polymyxins to optimize dosing and minimize toxicity, according to the Journal of Microbiology, Immunology and Infection 5
Combination Therapy Options
- For patients in septic shock or at high risk of death, combination therapy with multiple active agents is recommended by the European Society of Clinical Microbiology and Infectious Diseases 6, 7
- Fosfomycin can be considered as an addition to polymyxin therapy based on synergy testing, as recommended by the Journal of Microbiology, Immunology and Infection 5
- Prolonged infusion of β-lactams (if any susceptibility remains) is recommended for pathogens with high MICs, according to the Journal of Microbiology, Immunology and Infection 2
Duration of Therapy
- A minimum of 2-4 weeks of antimicrobial therapy is typically required for empyema thoracis, though duration should be individualized based on clinical response, as recommended by the Clinical Infectious Diseases journal 1, 4
- Therapy should be continued until clinical, radiological, and laboratory parameters show significant improvement, according to the Clinical Infectious Diseases journal 1
Monitoring and Follow-up
- Regular monitoring of renal function is essential when using polymyxins due to nephrotoxicity risk, as recommended by the Journal of Microbiology, Immunology and Infection 5
- Hypokalemia is a common adverse effect of intravenous fosfomycin and polymyxin therapy and requires close monitoring, according to the Journal of Microbiology, Immunology and Infection 5
- Nephrotoxicity is a major concern with polymyxin therapy; dose adjustment is necessary in renal impairment, as recommended by the Journal of Microbiology, Immunology and Infection 5