What are the current guidelines for managing empyema?

Management of Empyema: Current Guidelines

Early chest tube drainage combined with appropriate antibiotics is the cornerstone of empyema management, with consideration for surgical intervention if no improvement occurs within 7 days. 1

Diagnostic Approach

• Imaging:

  • Posteroanterior/anteroposterior chest radiographs (lateral views not routinely needed) 2
  • Ultrasound to confirm pleural fluid collection and guide drainage procedures 2
  • CT scan with contrast for complex cases or when drainage fails (not routine) 1

• Microbiology:

  • Blood cultures in all patients 2
  • Pleural fluid for Gram stain, culture, and cell count 2
  • Sputum cultures when available 2

Treatment Algorithm

1. Antibiotic Therapy

• Immediate initiation upon identification of pleural infection 2, 1

• Community-acquired empyema:

  • Cefuroxime 1.5g TDS IV + metronidazole 400mg TDS oral/500mg TDS IV
  • Benzyl penicillin 1.2g QDS IV + ciprofloxacin 400mg BD IV
  • Amoxicillin + clavulanic acid or metronidazole
  • Clindamycin 300mg QDS as single agent option 2

• Hospital-acquired empyema:

  • Piperacillin + tazobactam 4.5g QDS IV
  • Ceftazidime 2g TDS IV
  • Meropenem 1g TDS IV ± metronidazole 2

• Duration:

  • Continue IV antibiotics until patient is afebrile or chest drain removed
  • Follow with oral antibiotics for 1-4 weeks (longer if residual disease) 2

Caution: Avoid aminoglycosides due to poor pleural penetration and inactivation in acidic pleural fluid 2, 1

2. Pleural Drainage

• Indications: Enlarging effusions or those compromising respiratory function 2

• Technique:

  • Small-bore percutaneous drains inserted at site suggested by ultrasound 2, 1
  • Connect to unidirectional flow drainage system kept below chest level 2
  • Initial drainage should be limited to 10ml/kg, then clamp for 1 hour 2

• Drain Management:

  • Flush with saline if blockage occurs 2
  • Check drain position with imaging if poor drainage persists 2
  • Remove once clinical resolution achieved 2

3. Intrapleural Fibrinolytics

• Indications: Complicated parapneumonic effusion (thick fluid with loculations) or empyema 2
• Recommended Agent: Urokinase (most evidence in children) 2
• Dosing:
  • Children ≥10kg: 40,000 units in 40ml 0.9% saline
  • Children <10kg: 10,000 units in 10ml 0.9% saline
  • Administer twice daily for 3 days (6 doses total) 2

Note: Alteplase (tPA) may be used as an alternative fibrinolytic agent, but caution is needed in patients with bleeding risks 3

4. Surgical Intervention

• Timing: Consider if no improvement after 7 days of medical management 2, 1
• Indications:
  • Persistent sepsis with pleural collection despite drainage and antibiotics
  • Complex empyema with significant lung pathology
  • Bronchopleural fistula with pyopneumothorax 2
• Options:
  • Video-assisted thoracoscopic surgery (VATS) - preferred for early intervention
  • Formal thoracotomy and decortication for organized empyema 2

Special Considerations

• Children: Management principles similar to adults but require age-appropriate antibiotic dosing 2
• Complications to monitor:
  • Secondary thrombocytosis (common but benign)
  • Secondary scoliosis (usually transient)
  • Residual pleural thickening (may resolve over time) 2

Follow-up

• Continue follow-up until complete recovery and near-normal chest radiograph 2
• Consider underlying diagnoses (immunodeficiency, cystic fibrosis) in recurrent cases 2

Common pitfall: Delay in drainage is associated with increased morbidity, hospital stay, and potentially mortality. Early intervention with appropriate antibiotics and drainage is crucial for optimal outcomes 2, 1.