From the Guidelines
The initial management of empyema requiring critical care involves prompt administration of antibiotics, such as a second-generation cephalosporin or an aminopenicillin, to cover community-acquired bacterial pathogens and anaerobic organisms, as soon as pleural infection is identified. The choice of antibiotics should be guided by bacterial culture results, if available, and should reflect local hospital policy 1.
Key Considerations
- Antibiotics should be chosen to cover the likely organisms that may cause pleural infection, including Pneumococcus, Staphylococcus aureus, and Haemophilus influenzae 1.
- A beta-lactamase inhibitor or metronidazole should also be given because of the frequent co-existence of penicillin-resistant aerobes and anaerobes 1.
- Clindamycin can combine this spectrum into a single agent, and intravenous benzyl penicillin combined with a quinolone also has an appropriate spectrum 1.
Additional Management
- Surgical debridement may have a probable synergistic role, and the drainage of pus from the pleural cavity can be via the insertion of a large bore chest tube or flexible small bore catheters under ultrasound or CT guidance 1.
- Intrapleural fibrinolytic drugs have been reassessed, and several observational series suggest improved pleural drainage with these agents 1.
Supportive Care
- Supportive care includes oxygen supplementation, fluid resuscitation, and pain management.
- If the empyema is loculated or drainage is inadequate, consideration of intrapleural fibrinolytic therapy or surgical intervention with video-assisted thoracoscopic surgery (VATS) or thoracotomy with decortication may be necessary.
From the Research
Initial Management of Empyema Requiring Critical Care
The initial management of empyema requiring critical care involves a combination of antibiotic therapy, drainage, and in some cases, surgical intervention.
- The choice of initial management depends on the severity of the empyema, the presence of any underlying conditions, and the patient's overall clinical status 2, 3, 4, 5.
- Antibiotic therapy is a crucial component of the initial management of empyema, with the choice of antibiotic depending on the suspected or confirmed causative organism 2, 6.
- Drainage of the empyema, either through thoracentesis or intercostal chest tube drainage, is also an important part of the initial management 2, 4, 5.
- In some cases, surgical intervention, such as decortication, may be necessary to manage the empyema, particularly if the patient has failed to respond to conservative management or has developed complications such as bronchopleural fistula 2, 4, 5.
Factors Influencing Initial Management
Several factors can influence the initial management of empyema requiring critical care, including:
- The severity of the empyema, with more severe cases requiring more aggressive management 3, 4.
- The presence of any underlying conditions, such as pulmonary tuberculosis or chronic obstructive pulmonary disease, which can affect the choice of antibiotic therapy and the need for drainage or surgical intervention 4.
- The patient's overall clinical status, with more critically ill patients requiring more intensive management 5.
Treatment Outcomes
The outcomes of the initial management of empyema requiring critical care can vary depending on the severity of the empyema, the effectiveness of the management strategy, and the presence of any complications.
- In general, patients who receive prompt and effective management, including antibiotic therapy and drainage, tend to have better outcomes than those who do not 2, 3, 5.
- However, some patients may still experience complications, such as bronchopleural fistula, which can require more aggressive management, including surgical intervention 4, 6.