Empyema Quiz: Ace Your Exams

A 67-year-old woman is brought to the emergency department for fever and disorientation. The patient’s partner states that the patient has had a productive cough and fever for the past five days that was being treated with azithromycin without improvement. Past medical history is significant for hypertension, diabetes, and dermatomyositis. Current medications include amlodipine/hydrochlorothiazide/valsartan, insulin, and prednisolone. Upon examination, the patient appears uncomfortable and disoriented. Temperature is 38.8°C (101.8°F), heart rate is 110 bpm, respirations are 26/min, blood pressure is 105/50 mmHg, oxygen saturation is 96% on room air. She is oriented only to person. Chest auscultation reveals decreased breath sounds at the left base and dullness to percussion. Abdominal examination reveals multiple longitudinal stretch marks. Chest X-ray is shown below. Point of care ultrasound shows a loculated pleural effusion. Diagnostic thoracentesis is performed and shows frank pus. Pleural fluid analysis reveals pH of 7.12 (reference range: 7.6-6.64) and glucose of 39 mg/dL (reference range: 70-110 mg/dL). The patient is admitted to the intensive care unit and intravenous antibiotics are started. Which of the following is the best next step in management?