From the Guidelines
Empyema should be treated with broad-spectrum antibiotics and drainage of the infected fluid as soon as possible to prevent complications and improve outcomes. The choice of antibiotic therapy should be guided by bacterial culture results, but in the absence of positive culture results, empirical treatment with a second-generation cephalosporin (e.g., cefuroxime) or an aminopenicillin (e.g., amoxycillin) should be used to cover expected organisms such as Pneumococcus, Staphylococcus aureus, and Haemophilus influenzae 1. Additionally, a beta-lactamase inhibitor or metronidazole should be given to cover penicillin-resistant aerobes and anaerobes.
Diagnosis and Staging
The diagnosis of empyema is typically made based on the presence of frank pus in the pleural space, and the staging of the disease can be determined by the characteristics of the pleural fluid, including pH, lactate dehydrogenase (LDH) levels, and glucose levels 1. The frequency of anaerobic isolates is rising, and anaerobes may be present in up to 76% of cases, making it essential to cover these organisms in the empirical antibiotic regimen.
Treatment Options
Drainage of the infected fluid is essential and can be accomplished through thoracentesis, chest tube placement, or surgical intervention like video-assisted thoracoscopic surgery (VATS) for loculated empyema. The choice of drainage method depends on the stage and complexity of the empyema. Intrapleural fibrinolytic drugs, such as streptokinase, urokinase, or alteplase, may be used to lyse fibrinous strands in loculated empyemas and improve pleural drainage, especially in children 1.
Key Considerations
Key considerations in the treatment of empyema include:
- Early intervention to prevent complications such as lung restriction, chronic infection, or sepsis
- Broad-spectrum antibiotic coverage to include common pathogens such as Streptococcus pneumoniae, Staphylococcus aureus, and anaerobes
- Drainage of the infected fluid through thoracentesis, chest tube placement, or surgical intervention
- Use of intrapleural fibrinolytic drugs in loculated empyemas to improve pleural drainage.
From the Research
Definition and Causes of Empyema
- Empyema is a condition where pus accumulates in the pleural space, often as a complication of pneumonia 2, 3, 4, 5, 6.
- It can be caused by various bacteria, including Staphylococcus aureus, and can lead to serious complications if left untreated or inadequately treated 2.
Symptoms and Diagnosis
- Symptoms of empyema include fever, chills, cough, and chest pain, with yellowish purulent secretions from the chest wall in some cases 2.
- Diagnosis is typically made through imaging studies, such as chest X-rays or CT scans, and laboratory tests to identify the underlying cause of the infection 3, 4, 5, 6.
Treatment Options
- Treatment options for empyema include:
- Antibiotics, which are often ineffective on their own and require additional interventions 3, 4, 5, 6.
- Thoracentesis, or the removal of fluid from the pleural space, which can be performed with or without intrapleural fibrinolytic therapies 3, 4.
- Chest tube drainage, which can be used to remove pus and fluid from the pleural space 3, 4, 5, 6.
- Video-assisted thoracic surgery (VATS) or open thoracotomy, which can be used to remove infected tissue and drain the pleural space 3, 5, 6.
Comparison of Treatment Outcomes
- Studies have compared the outcomes of different treatment options for empyema, including:
- A retrospective study that found patients treated with a lavage regimen had a shorter hospital stay and fewer complications compared to those treated with tube drainage 4.
- A study that found VATS decortication provided comparable results to open thoracotomy, with shorter lengths of stay and fewer postoperative complications 5.
- A study that found patients managed with chest tubes had higher readmission and reintervention rates compared to those who underwent surgical intervention 6.