What is the treatment for empyema?

Treatment of Empyema

The treatment of empyema requires a combination of antibiotics, drainage procedures, and possible surgical intervention, with intrapleural fibrinolytics recommended for complicated parapneumonic effusions or empyema to shorten hospital stay. 1

Initial Management

Antibiotic Therapy

• Initiate broad-spectrum antibiotics immediately with coverage for both aerobic and anaerobic organisms 1
  • For community-acquired empyema:
    • Cefuroxime + metronidazole
    • Amoxicillin + clavulanic acid
    • Benzyl penicillin + ciprofloxacin
    • Clindamycin (as single agent)
  • For hospital-acquired empyema:
    • Piperacillin-tazobactam
    • Ceftazidime
    • Meropenem
  • For MRSA empyema:
    • Vancomycin or linezolid
  • Avoid aminoglycosides (poor pleural penetration and inactivation in acidic pleural fluid) 1

Drainage Procedures

• Small-bore percutaneous drains inserted under ultrasound guidance are typically sufficient 1
• Proper drain management is essential:
  • Connect to unidirectional flow drainage system kept below chest level
  • Initial drainage limited to 10ml/kg, then clamp for 1 hour
  • Flush with saline if blockage occurs
  • Never clamp a bubbling chest drain 2
  • Immediately unclamp if patient complains of breathlessness or chest pain 2
  • Remove once clinical resolution achieved 2

Advanced Treatment Options

Intrapleural Fibrinolytics

• Recommended for any complicated parapneumonic effusion (thick fluid with loculations) or empyema (overt pus) 2
• Urokinase is the recommended fibrinolytic agent for children 2
  • Dosing: twice daily for 3 days (6 doses total)
    • 40,000 units in 40 ml 0.9% saline for children ≥10 kg
    • 10,000 units in 10 ml 0.9% saline for children <10 kg

Surgical Intervention

• Indications for surgical consultation: 2, 1
  • Failure of chest tube drainage, antibiotics, and fibrinolytics
  • Persistent sepsis with persistent pleural collection
  • Complex empyema with multiple loculations
  • Organized empyema
• Surgical options:
  • Video-assisted thoracoscopic surgery (VATS) - preferred for early intervention 1, 3
  • Formal thoracotomy and decortication - for organized empyema 2, 4
  • Open-window thoracostomy - for patients not eligible for radical treatment 4

Treatment Algorithm

1. Initial assessment:

   • Confirm diagnosis with imaging (chest X-ray, ultrasound, CT showing "split pleura" sign) 5
   • Perform diagnostic thoracentesis for culture and Gram stain 5

2. First-line treatment:

   • Start appropriate antibiotics based on likely pathogens
   • Insert chest drain under ultrasound guidance
   • Consider intrapleural fibrinolytics for complicated cases

3. Monitoring response:

   • Daily assessment of vital signs, pain levels, and laboratory markers (WBC, CRP)
   • Monitor drainage output and characteristics
   • Repeat imaging to assess resolution of fluid collection

4. If inadequate response after 5-7 days:

   • Consider surgical intervention (VATS or thoracotomy)
   • For patients with poor surgical candidacy, consider open-window thoracostomy

Supportive Care

• Provide adequate analgesia (particularly important with chest drain) 2
• Administer antipyretics 2
• Encourage early mobilization and exercise 2
• Note that chest physiotherapy is not beneficial and should not be performed 2

Follow-up

• Continue follow-up until complete recovery and chest radiograph returns to near normal 2
• Consider evaluation for underlying conditions (immunodeficiency, cystic fibrosis) 2
• Be aware that secondary thrombocytosis and scoliosis are common but transient 2

Common Pitfalls to Avoid

• Delaying drainage when indicated
• Inappropriate clamping of chest drains
• Failure to recognize when medical therapy is failing and surgical intervention is needed
• Overlooking potential underlying conditions predisposing to empyema
• Using aminoglycosides which have poor pleural penetration

The treatment approach should be guided by the stage of empyema, with early intervention being key to successful management and improved outcomes 4.