Treatment of Empyema Thoracis
Empyema thoracis requires a dual approach of appropriate systemic antibiotics combined with effective pleural space drainage, with the specific treatment strategy determined by whether the infection is community-acquired versus hospital-acquired and the stage of disease at presentation. 1
Antibiotic Therapy
Community-Acquired Empyema
For community-acquired cases, initiate parenteral ceftriaxone (second- or third-generation cephalosporin) with metronidazole OR ampicillin/sulbactam 1. The ampicillin/sulbactam combination provides adequate anaerobic coverage on its own, while ceftriaxone requires the addition of metronidazole for anaerobic activity. Clindamycin serves as an acceptable alternative to metronidazole 1.
Continue empiric anaerobic coverage even when cultures are negative, as anaerobes frequently infect empyemas but are inconsistently cultured 1.
Hospital-Acquired or Postprocedural Empyema
For nosocomial cases, use antibiotics covering MRSA and Pseudomonas aeruginosa: vancomycin plus cefepime plus metronidazole OR vancomycin plus piperacillin/tazobactam (dosed for Pseudomonas activity) 1. Consider vancomycin plus meropenem if extended-spectrum beta-lactamase organisms are suspected 1.
Critical Antibiotic Principles
- Avoid aminoglycosides - they are inactivated in empyema fluid 1
- No intrapleural antibiotic administration - systemic antibiotics alone are sufficient 1
- Tailor therapy based on culture results when available 1
- Duration: minimum 2 weeks from drainage and defervescence, with final duration based on organism sensitivities, drainage adequacy, and clinical response 1
Pleural Space Drainage
Initial Diagnostic Criteria for Drainage
Proceed with tube thoracostomy drainage when any of the following are present 1:
- Frank purulence of pleural fluid
- Positive Gram stain or culture
- Pleural pH < 7.2
- Pleural fluid glucose < 40 mg/dL
- Pleural fluid LDH > 1000 IU/L
Thoracentesis alone without drain placement is not recommended for treatment 1.
Drainage Strategy by Stage
Early-stage, minimally septated empyema: Image-guided pleural drain placement is the initial approach 1.
Septated effusions with failed initial drainage: Consider combination tissue plasminogen activator (TPA) plus DNase - administer 10 mg TPA twice daily plus 5 mg DNase twice daily for 3 days (lower dose 5 mg TPA may be used if bleeding risk is elevated) 2. Single-agent TPA or DNase should not be used, and streptokinase is not recommended 2.
Surgical Management
Video-Assisted Thoracoscopic Surgery (VATS)
VATS should be the first-line surgical approach for stage II and mixed stage II/III empyema 1. VATS is also preferred over thoracotomy for surgical management of pleural infection in adults 2.
Convert to open thoracotomy when:
- Uncontrollable bleeding occurs
- Structural injury not amenable to thoracoscopic repair
- Acute intolerance of single-lung ventilation
- Lack of surgical progression
- Failure to achieve evacuation and lung expansion 1
Chronic Empyema (Stage III)
Decortication is the procedure of choice for medically operable patients with chronic empyema and re-expandable underlying lung 1. This involves removing granulation tissue and fibrous peel from visceral and parietal pleura to allow lung expansion, with debridement of infected tissue 1.
For patients not eligible for decortication, consider open-window thoracostomy 1.
Common Pitfalls to Avoid
- Do not delay drainage when diagnostic criteria are met - simple drainage alone has high failure rates, particularly in elderly patients and advanced disease 3
- Do not use swabs for culture - obtain specimens during aspiration or drainage procedures 1
- Do not measure pleural pH from previously placed catheters - 44% of such cultures are inaccurate 1
- Avoid residual lidocaine, heparin, or air in pH measurement syringes - these affect results 1
Culture Technique
Inoculate BACTEC culture bottles in addition to standard laboratory culture to improve yields 1. Always accompany pleural fluid cultures with cell count and chemistry analysis 1.
Special Considerations
For slowly progressing or chronic empyemas, empiric antibiotics can be held until culture results are available for directed therapy. Infectious disease consultation is recommended for chronic empyema management 1.