A46-38 Outpatient Management of Empyema With Serial Thoracentesis and Oral Antibiotics

Abstract Introduction Empyema is an important complication that impacts around 32,000 patients in the United States annually and associated with a mortality rate of up to 15%. The standard of care for empyema and supported by society guidelines includes early intravenous antibiotics and pleural drain placement for source control. Case Patient is a 64 year old man who presented with symptoms of dyspnea and fever and was treated empirically with amoxicillin-clavulanate, azithromycin and methylprednisolone after patient declined imaging studies. At follow-up four months later, pt was endorsing new chest pain, dyspnea and sputum production. Outpatient CTPE study showed a 6x4cm cavitary mass in the right upper lobe and a partially loculated moderate right sided pleural effusion. Within 2 weeks pt underwent bronchoscopy and thoracentesis. Pathology of right upper lobe mass and station 7 lymph node was negative for malignancy but positive for Streptococcus milleri group. Thoracentesis performed and drained 120cc of grey, foul-smelling pleural fluid with pH 6.72, LDH 24,000 U/L, protein 2260 mg/dl, glucose 10mg/dl, WBC 911,000/UL, ADA 695.6 U/L, consistent with empyema. Serum WBC was 20.9k/UL, lactate was normal. Pleural fluid cultures grew Strep milleri group and blood cultures were negative. Results were discussed with patient and he was advised to stay in the hospital for chest tube placement and IV antibiotics but patient refused. Patient had decision making capacity and left with oral antibiotics and strict return precautions. Patient returned weekly for repeat thoracentesis with drainage of 80-100cc of fluid each time with cultures remaining positive. His fourth thoracentesis grew VRE and patient continued to decline hospitalization and IV antibiotics. The following week, fluid was not able to be aspirated. He underwent repeat CT scan that showed decrease in size of cavitary lesion and marked decrease in amount of pleural fluid. Given radiographic improvement and symptom improvement, decision was made to discontinue oral antibiotics after 6 weeks. He underwent repeat CT scan three months later which showed near complete resolution of cavitary lesion and near complete resolution of pleural fluid collection. Discussion Despite the reduction in morbidity and mortality associated with IV antibiotics and chest tube placement for empyema, patients with capacity have the right to refuse recommendations. Here we were able to manage a patient with empyema as an outpatient with serial thoracentesis and antibiotics. While patients should still be recommended the standard of care, outpatient management may be an option for patients refusing inpatient care. This abstract is funded by: None