What is the treatment for empyema?

From the Guidelines

Empyema treatment should involve a combination of antibiotics and drainage procedures, with the most recent guidelines from 2023 recommending individualized surgical approaches based on patient and empyema stage 1. The initial management includes broad-spectrum antibiotics targeting common pathogens like Streptococcus pneumoniae, Staphylococcus aureus, and anaerobes.

• Antibiotic regimens such as piperacillin-tazobactam or a combination of ceftriaxone plus metronidazole are typically used for 2-6 weeks, later narrowed based on culture results.
• Drainage is essential and can be accomplished through thoracentesis for early, fluid empyema or chest tube placement for more established cases.
• Video-assisted thoracoscopic surgery (VATS) or thoracotomy with decortication may be necessary for advanced cases with loculations or thick pleural peel. The choice between these approaches depends on the empyema stage: simple parapneumonic effusion (Stage I), fibrinopurulent (Stage II), or organizing (Stage III). Supportive care including pain management, respiratory therapy, and nutritional support is also important. Treatment success depends on early intervention, appropriate antibiotic selection, and adequate drainage to prevent complications like chronic pleural thickening, restrictive lung disease, or sepsis, as highlighted in previous guidelines 1.

From the FDA Drug Label

LOWER RESPIRATORY TRACT INFECTIONS, including pneumonia, empyema, and lung abscess, caused by Bacteroides species including the B fragilis group. The treatment for empyema is metronidazole tablets, which are indicated for the treatment of lower respiratory tract infections, including empyema, caused by susceptible anaerobic bacteria, such as Bacteroides species including the B. fragilis group 2.

• The decision to use metronidazole tablets should be based on the presence of susceptible bacteria.
• Intraavenous form of metronidazole is usually administered initially for the treatment of most serious anaerobic infections, which may be followed by oral therapy with metronidazole tablets at the discretion of the physician.

From the Research

Treatment Options for Empyema

The treatment for empyema typically involves a combination of the following:

• Antibiotics to treat the underlying infection 3, 4
• Tube drainage to remove the infected fluid from the pleural space 5, 3, 6
• Intrapleural fibrinolytics, such as streptokinase or urokinase, to break down loculations and facilitate drainage 5, 6, 4
• Video-assisted thoracoscopic surgery (VATS) or open thoracotomy and decortication in cases where conservative treatment fails 7, 3

Conservative Treatment

Conservative treatment with antibiotics, tube drainage, and intrapleural fibrinolytics is often effective in managing empyema 5, 6, 4. This approach can result in complete resolution of symptoms and radiographic findings in a significant proportion of patients 4.

Surgical Intervention

Surgical intervention, such as VATS or open thoracotomy and decortication, may be necessary in cases where conservative treatment fails or in patients with complicated empyema 7, 3. Decortication involves the removal of the thickened pleura and can help to resolve the infection and improve lung function.

Efficacy and Safety of Intrapleural Fibrinolytics

Intrapleural fibrinolytics have been shown to be safe and effective in managing empyema 5, 4. Streptokinase and urokinase are commonly used fibrinolytics, and their use can result in improved drainage and resolution of symptoms 5, 4. However, bleeding is a potential complication of fibrinolytic therapy, although it is rare 4.