A 68-yeаr-оld mаn аrrives at the emergency rооm complaining of fever and shortness of breath. He reports that his symptoms began 1 week ago, but he was too busy to go to the doctor, so he took antibiotics he had “left over.” A physical examination is notable for left basilar crackles and dullness to percussion. A chest radiograph shows a left lower lobe pneumonia and pleural effusion. Labs are drawn and thoracentesis is performed, with results as follows: • Ratio of pleural fluid protein to serum protein of 0.76• Ratio of pleural fluid LDH to serum LDH of 0.88• Gross appearance of pleural fluid: cloudy, yellow• Pleural fluid WBC count: 50,000/mm3 (95% neutrophils) The patient refuses to be admitted because he “can’t take off from work” and leaves against medical advice. Four days later, the patient comes to the emergency room with worsening fever, dyspnea, and chest pain. He also reports a harsh cough that brings up putrid-smelling phlegm that is occasionally blood-streaked. The patient’s temperature is 102°F (38.9°C), blood pressure is 124/78 mmHg, pulse is 88/min, and respirations are 18/min with an oxygen saturation of 95% on room air. Another CXR is obtained, as shown below (see Figure A). What is the most appropriate management of this patient’s condition?
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