Infectious Diseases

	Answer 5 Chest tube placement and IV vancomycin. This patient had an empyema most likely secondary to methicillin-resistant Staphylococcus aureus (MRSA). He is at risk for MRSA infection since he has been incarcerated in the recent past and had the flu.8,9 In this case, chest tube placement and drainage is indicated along with initiation of appropriate antibiotic treatment. Indications for drainage of an empyema are as follows: pleural fluid pH less than 7.20, glucose level less than 60 mg/dL, lactate dehydrogenase level greater than 600 U/L, and bacteria on Gram stain.10 Empiric treatment with an antibiotic, such as IV vancomycin, with a spectrum that covers MRSA is appropriate.11 Final therapy decisions should be based on results of cultures and antimicrobial susceptibility testing.11 Ampicillin/sulbactam has no activity against MRSA.11 Surgical intervention is indicated for effusions with multiple loculations or those that have not responded to catheter drainage and for empyema at the organizing stage. REFERENCE 8. Hageman JC, Uyeki TM, Francis JS, et al. Severe community-acquired pneumonia due to Staphylococcus aureus, 2003–04 influenza season. Emerg Infect Dis 2006;12:894–9. 9. Naimi TS, LeDell KH, Como-Sabetti K, et al. Comparison of community- and health care–associated methicillin-resistant Staphylococcus aureus infection. JAMA 2003;290:2976–84. 10. Colice GL, Curtis A, Deslauriers J, et al. Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline [published erratum appears in Chest 2001;119:319]. Chest 2000;118:1158–71. 11. Gorwitz RJ, Jernigan DB, Powers JH, Jernigan JA. Strategies for clinical management of MRSA in the community: summary of an experts’ meeting convened by the Centers for Disease Control and Prevention. 2006. Available at www.cdc.gov/ncidod/dhqp/pdf/ar/CAMRSA_ExpMtgStrategies.pdf. Accessed 21 Jan 2009. Click here to return to the questions
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