Management of patient with Fusobacterim nucletum related pleural empyema: intrapleural antibiotic therapy can be considered for salvage therapy – BMC Infectious Diseases

Pleural infection is a serious disease that commonly occurs as a secondary infection of severe pneumonia. There is a growing recognition of primary pleural infection without parenchymal involvement. Standard measures against pleural infection include appropriate antimicrobial therapy and chest-tube drainage. New interventions such as thoracoscopy to clear the infected space, intrapleural fibrinolytic therapy, high-volume pleural irrigation with saline/antiseptic solution, and repeated thoracentesis have been introduced [1]. Despite these advancements, pleural infection remains life-threatening, with approximately 15% of patients requiring emergent treatment [8, 9]. The disease poses a significant medical burden, often necessitating prolonged hospitalization. Sometimes surgery can’t be performed because of comorbidities. Therefore, there is a need for new minimally invasive treatment methods. This article presents a case of multiple intrapleural antibiotic therapy under CT guidance in a patient with primary pleural infection.

Accurate etiology and timely anti-infection therapy are essential for improving the prognosis of patients with pleural infections. The most common organisms found in pleural fluid samples are gram-positive cocci, specifically S. pneumoniae, followed by aerobic gram-negative bacilli and anaerobic bacteria [1]. The use of next- generation sequencing has revealed that up to 70% of pleural fluid samples contain anaerobic bacteria [10]. In this particular case, pleural effusion was identified using CT imaging due to regional and multilocular effusion. Fusobacterium, an anaerobic bacteria, is responsible for 0.6–3.5 cases per 1 million population [11] and is often associated with microaspiration of oral secretions and gastric content. These infections are commonly seen in individuals with neurological conditions affecting swallowing, immunocompromised patients, or those at high risk of aspiration [1]. The patient in this case had normal white blood cell count and CD₄⁺/CD₈⁺ T cell ratio (CD4⁺/CD8⁺ 2.07), indicating normal immune function, and did not have any neurological comorbidities. Risk factors for anaerobic empyema development include bacterial pneumonia, surgery or chest trauma, esophageal perforation, thoracentesis, subdiaphragmatic infection, spontaneous pneumothorax, bacteremia, and tobacco or alcohol use [10, 12]. In this case, the patient’s only risk factor was alcohol abuse.

Appropriate antimicrobial therapy and chest-tube drainage are essential components of treating pleural infections. The patient in this case received immediate chest-tube drainage and was prescribed piperacillin/tazobactam with moxifloxacin as empirical antibiotic therapy. Both β-lactam and moxifloxacin are believed to penetrate the pleura effectively, as indicated by animal studies demonstrating higher concentrations in pleural fluid [13]. However, the translation of these findings to human patients remains uncertain [14]. The therapeutic response in this case was suboptimal, possibly due to the fibropurulent stage, which may reduce the effectiveness of antibiotic treatment. Furthermore, inadequate drug concentrations and limited systemic antibiotic efficacy in infected tissues can contribute to the development of antibiotic resistance. Thus, intravenous antibiotics alone may not be effective in this case. Intrathoracic local administration increases local tissue drug concentrations. As an adjunct to intravenous anti-infective therapy, intrathoracic antibiotic injection improves bacterial clearance and promotes absorption in the abscessed chest.