A 62-year-old man comes to the emergency department because of fever, chills, and productive cough for the last 5 days. Three days ago, he began to experience right-sided chest pain and shortness of breath. The chest pain increases with deep breathing. He was discharged from the hospital one week ago after an elective right knee replacement. His other medical problems include hypertension, type 2 diabetes, and hyperlipidemia. He has smoked one pack of cigarettes per day for 40 years and he drinks 1-2 glasses of wine on the weekends. He does not use illicit drugs.
His temperature is 39.4 C (103 F), blood pressure is 120/70 mm Hg, pulse is 98/min, and respirations are 22/min. The patients pulse oximetry is 92% on room air. Breath sounds are decreased at the right lung base with dullness to percussion. Heart sounds are normal. The right knee scar is healing well. The remainder of the examination is unremarkable.
Laboratory results are as follows:

Chest x-ray shows right lower lobe consolidation and pleural effusion. Lateral decubitus film shows free layering pleural effusion.
The patient is started on broad-spectrum antibiotics. Thoracentesis is performed and 250 mL of cloudy pleural fluid is removed. Pleural fluid glucose is 45 mg/dL and pH is 7.18. Gram stain shows many neutrophils and gram-negative rods.
Which of the following is the best next step in management?

Question

A 62-year-old man comes to the emergency department because of fever, chills, and productive cough for the last 5 days.  Three days ago, he began to experience right-sided chest pain and shortness of breath.  The chest pain increases with deep breathing.  He was discharged from the hospital one week ago after an elective right knee replacement.  His other medical problems include hypertension, type 2 diabetes, and hyperlipidemia.  He has smoked one pack of cigarettes per day for 40 years and he drinks 1-2 glasses of wine on the weekends.  He does not use illicit drugs.
His temperature is 39.4 C (103 F), blood pressure is 120/70 mm Hg, pulse is 98/min, and respirations are 22/min.  The patients pulse oximetry is 92% on room air.  Breath sounds are decreased at the right lung base with dullness to percussion.  Heart sounds are normal.  The right knee scar is healing well.  The remainder of the examination is unremarkable.
Laboratory results are as follows:

Chest x-ray shows right lower lobe consolidation and pleural effusion.  Lateral decubitus film shows free layering pleural effusion.
The patient is started on broad-spectrum antibiotics.  Thoracentesis is performed and 250 mL of cloudy pleural fluid is removed.  Pleural fluid glucose is 45 mg/dL and pH is 7.18.  Gram stain shows many neutrophils and gram-negative rods.
Which of the following is the best next step in management?

Quizplus · Accepted Answer

11ec193a_969a_d67e_853d_13bfee2aff93_MD0002_00 This patients presentation is consistent with empyema, defined as a parapneumonic effusion with positive Gram stain, acidic pH, and/or purulent fluid. Most pleural effusions in the setting of pneumonia meet indications for thoracentesis. Parapneumonic effusions range as a spectrum from uncomplicated to empyema. Patients usually present with pneumonia symptoms, pleuritic chest pain, and physical examination findings suggestive of pleural effusion. indications for thoracentesis Uncomplicated parapneumonic effusion refers to movement of fluid from the lung parenchyma to the pleural space due to increased hydrostatic pressure. Although the fluid is usually exudative, it typically resolves with antibiotics as the pneumonia resolves. Complicated parapneumonic effusions involve persistent bacterial invasion into the pleural space, further lowering the pleural fluid glucose (utilized by bacteria) and increasing the LDH (from lysis of neutrophils). Because bacteria can be cleared easily from the pleural space, the culture is usually negative. Some patients do resolve with antibiotics alone, but most patients also require early chest tube drainage for faster clinical recovery and hospital discharge. Empyema develops due to bacterial colonization and presents with acidic pH (< 7.20), positive Gram stain for bacteria, positive bacterial culture from pleural fluid, and purulent malodorous fluid. Fluid with glucose < 60 mg/dL and pH < 7.20 does not usually resolve spontaneously and requires drainage with chest tube, sometimes with ultrasound or CT guidance. Multiple loculated collections of fluid may require multiple tubes. A chest CT should be performed within 24 hours to check tube location and assess drainage. This patient has empyema and requires both chest tube drainage and antibiotics. (Choices A and D) Observation, clinical follow-up, or repeat chest x-ray in 24 hours is reasonable for uncomplicated or complicated parapneumonic effusions treated with antibiotics. However, this patient has empyema that requires prompt drainage. (Choice C) Since anaerobic organisms grow poorly from pleural fluid and are common in empyema, all therapeutic choices should be broad spectrum and include coverage for anaerobic organisms. Most antibiotics except aminoglycosides have adequate pleural penetration for treatment of empyema. (Choice E) Video-assisted thorascopic surgery or open thoracotomy is indicated for individuals who fail to improve with chest tube insertion combined with antibiotic therapy. These individuals often have multiloculated, polymicrobial (typically gram-negative organisms) effusions. Educational objective: Thoracentesis should be performed on suspected parapneumonic pleural effusions in the setting of pneumonia. Parapneumonic effusions range from uncomplicated to empyema based on pleural fluid analysis. Uncomplicated effusions typically resolve with antibiotic therapy for pneumonia, while complicated effusions and empyema require chest tube drainage and antibiotics. Surgery is reserved for individuals who fail to respond to drainage and antibiotics. __________ References: Practical management of pleural empyema. (http://www.ncbi.nlm.nih.gov/pubmed/21214042) Empyema thoracis (http://www.ncbi.nlm.nih.gov/pubmed/21157522) Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline. (http://www.ncbi.nlm.nih.gov/pubmed/11035692)

A 62-Year-Old Man Comes to the Emergency Department Because of Fever