What is the treatment for empyema (empyema is a condition characterized by the accumulation of pus in the pleural space)?

From the Guidelines

Empyema treatment should involve a combination of antibiotics and drainage procedures, with the choice of surgical approach depending on the individual patient's condition, and VATS being a viable option for loculated empyemas, as suggested by the British Thoracic Society guideline for pleural disease 1. The initial management of empyema includes broad-spectrum antibiotics targeting common pathogens like Streptococcus pneumoniae, Staphylococcus aureus, and anaerobes, typically with a regimen such as ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours, or piperacillin-tazobactam 4.5g IV every 6 hours, as recommended by the BTS guidelines for the management of pleural infection 1. Drainage is essential and can be accomplished through:

• Thoracentesis for small collections
• Chest tube placement for larger volumes
• Video-assisted thoracoscopic surgery (VATS) for loculated empyemas Fibrinolytics like alteplase (10mg in 100mL saline daily for 3 days) may be instilled through chest tubes to break down loculations, as supported by the BTS guidelines for the management of pleural infection in children 1. For chronic empyemas with thick pleural peel, surgical decortication may be necessary. Treatment duration typically ranges from 2-6 weeks depending on clinical response, with transition to oral antibiotics once improvement occurs. Adequate drainage is crucial because antibiotics alone cannot penetrate the thick purulent material. Nutritional support and pain management are important adjunctive measures. Early and aggressive management is key to preventing long-term complications like trapped lung and chronic pleural thickening. The decision to use chest tube drainage should be based on the presence of frankly purulent or turbid/cloudy pleural fluid, positive Gram stain or culture, or a pleural fluid pH < 7.2, as recommended by the BTS guidelines for the management of pleural infection 1.

From the FDA Drug Label

The following adverse reactions are discussed in greater detail in Section PRECAUTIONS of the label: Bleeding Hypersensitivity In the clinical trials, the most serious adverse events reported after treatment were sepsis (see PRECAUTIONS, Infections), gastrointestinal bleeding, and venous thrombosis Four catheter-related sepsis events occurred from 15 minutes to 1 day after treatment with Alteplase, and a fifth sepsis event occurred on Day 3 after Alteplase treatment

The FDA drug label does not answer the question.

From the Research

Treatment Options for Empyema

• The treatment of empyema typically involves a combination of medical and surgical interventions, including antibiotics, chest tube drainage, and surgical decortication 2, 3.
• Antibiotics alone are rarely successful in treating empyema and are usually used in conjunction with other treatments 2, 4.
• Early drainage with or without intrapleural fibrinolytics is often required to manage empyema, and this approach is usually successful in most patients 2, 5.
• Surgical decortication, such as video-assisted thoracoscopic surgery (VATS), may be necessary in some cases, particularly when there is a large collection of infected pleural fluid or when other treatments have failed 2, 3, 6.

Role of Intrapleural Fibrinolytics

• Intrapleural fibrinolytics, such as streptokinase and urokinase, have been shown to enhance drainage of infected pleural fluid and may be used in patients with large collections of infected pleural fluid causing breathlessness or respiratory failure 5.
• The combination of intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) has been shown to be significantly superior to tPA or DNase alone or placebo in improving pleural fluid drainage in patients with pleural space infection 5.
• Intrapleural fibrinolysis has not been shown to reduce mortality in adults or children with empyema, but it has been shown to enhance drainage of the pleural space and is a safe treatment option 5.

Surgical Management

• Surgical options, such as open thoracotomy, are typically reserved for patients who fail conservative management and have complicated or chronic empyema 2, 6.
• VATS is a minimally invasive surgical procedure that has been shown to be effective in managing empyema, particularly in patients with loculated pleural effusions or thick pus 3, 6.
• The use of VATS has been associated with shorter hospital stays and fewer complications compared to traditional open thoracotomy 3.

Antibiotic Use

• The choice of antibiotics depends on whether the empyema is community-acquired or nosocomial, and clinicians must recognize that culture results often do not reflect the full disease process 2, 4.
• The use of anti-anaerobic antibiotics has been associated with lower readmission rates for empyema and all-cause hospital readmission 4.
• The optimal duration of antibiotic therapy for empyema is not well established, but longer total antibiotic duration has been associated with lower readmission rates for empyema 4.