scott@vtx-cpd.com

Replying to Francesca Lamb 22/05/2023 - 19:07

Hi Fran,

Great to hear from you. Brilliant questions! I hope you are enjoying the course.

1. Medical and surgical options are available for treating feline pyothorax, although in the available literature there is no agreement as to the optimal treatment. Prospective studies evaluating and comparing the efficacy of the two options are lacking; furthermore, the literature often reports and compares only limited number of cases, making it even more difficult to draw any meaningful conclusion. Despite this, the general consensus is that medical treatment should be considered, at least initially, as the mainstay of therapy. In a recent retrospective study, 85% of cats (47 animals) with pyothorax in the review were treated medically, with only 5 cats not responding and requiring surgical intervention. In the case that I discussed we suggically interviened after 7 days.

Surgery should be considered if there is an inadequate response to medical therapy after 2-7 days – i.e., insufficient clinical improvement, continued fever, continued presence of pleural fluid or if fluid remains turbid or flocculent, and/or detection of an underlying cause on diagnostic imaging (e.g., abscess, suspicion of a foreign body, loculated (compartmentalized) effusions, thickened pleura).

2. I would indeed use IV antibiotic initially and move to oral once the patient is eating. I have popped the full treatment recomendations from the consensus staement below:

“The Working Group recommends that treatment of pyothorax include IV fluid administration and critically, drainage of pus after placement of chest tubes with intermittent or preferably continuous suction with or without lavage. Surgical debridement might be required in some cases. Sixteen reviewers (94%) agreed, and 1 (6%) disagreed with this Working Group recommendation. The primary comment was that evidence supporting the definitive need for thoracic lavage was lacking. However, based on lack of data supporting its use, the Working Group does not recommend administration of antimicrobial drugs into the pleural space.

The Working Group recommends the combination of parenteral administration of enrofloxacin or marbofloxacin (when available in parenteral form) with a penicillin or clindamycin combined with therapeutic drainage of the pleural space with or without lavage for the initial treatment or canine and feline pyothorax pending the results of culture and antimicrobial susceptibility testing. Sixteen reviewers (94%) agreed and 1 (6%) disagreed with this Working Group recommendation. The primary comment was that pradofloxacin administered PO as a single drug could be effective if available.

Treatment with an antimicrobial drug with activity against anaerobes should be continued regardless of culture results because fastidious anaerobic bacteria could be present. If combination treatment was initiated and the bacterial isolates are susceptible to both drugs in the initial treatment regime, then either of the treatment drugs could be discontinued. If organisms are grown that are resistant to one of the drugs and clinical improvement is not noted, that antimicrobial agent should be discontinued. A second drug to which the isolate is susceptible should be substituted if the animal has not responded sufficiently. If organisms are grown that are resistant to both antimicrobials or clinical evidence of improvement is not evident, antimicrobial treatment should be changed to a drug to which the organisms are susceptible in vitro. Fifteen reviewers (88%) agreed, 1 was neutral (6%), and 1 (6%) disagreed with this Working Group recommendation. The dissenting reviewer stated that mixed culture results can be difficult to interpret and so if the animal’s clinical condition improves on the first therapeutic regimen, changes should not be made.

It has been recommended that cats with pyothorax be treated for a minimum of 3 weeks and ideally 4–6 weeks. Additional research is required to determine whether shorter periods of antimicrobial drug treatment might be adequate. Serial thoracic radiography might be useful to determine whether antimicrobial treatment needs to be continued, although further study is also required to determine whether persistent radiographic abnormalities correlate with the need for additional antimicrobial drug treatment. At a minimum, follow-up radiography should be performed for 10–14 days after starting treatment and at completion of treatment. If the pyothorax persists or reoccurs after cessation of antimicrobials, repeated thoracocentesis should be performed for cytological assessment and for culture and antimicrobial susceptibility testing.”

3. The alternative is just normal saline. To lavage the thoracic cavity, you should first remove as much pleural effusion as possible. Then, slowly instill 5-10 mL/kg warm sterile saline, gently roll the cat around, then suction back until negative pressure (I would use 20 ml/kg slowly). Note that all the instillate will not be obtained. This process can be continued several times a day initially, then tapered and used as needed. Chest tubes can be removed depending on clinical improvement, but can generally be considered when fluid production is less than 2 ml/kg/day, cytologic evidence of infection has resolved, and radiographs are improving.

4. BAL is not safe for every patient. I must admit that I would normally carry out BAL in more chronic patients. I would sometimes carry out this procedure in moreunstable patients with careful considerations of the risks/benefits.

I hope that helps.

Scott 🙂

Replying to Rosanna Vaughan 17/05/2023 - 12:04

Hey.

It is a game changer for some cats… and for you managing them!

Yes, I would get an off licenc form signed if possible.

Scott 🙂

Replying to Emma S. 17/05/2023 - 17:13

Hey Emma!

Really glad you enjoyed it!

Scott 🙂

Replying to Okba Takieddine C. 16/05/2023 - 10:46

Hello!

You are welcome to ask questions on the discussion forum at any time.

I will start a new post to deal with any questions from the first lesson.

Scott 🙂

Replying to Okba Takieddine C. 15/05/2023 - 15:45

Hello Okba,

Lovely to see you here. Thank you so much for joining us!

I hope you enjoy the course. Let me know if you have any questions at any time.

Are you working in a small animal clinic in Dubai?

Scott 🙂