What is the treatment for empyema?

Treatment of Empyema

The treatment of empyema requires a combination of drainage procedures, appropriate antibiotics, and consideration of surgical intervention when medical management fails. 1

Initial Management

Drainage Options

• First-line approach: Small-bore percutaneous drains inserted under ultrasound guidance 1
  • Connect to unidirectional flow drainage system kept below chest level
  • Initial drainage limited to 10ml/kg, then clamp for 1 hour
  • Never clamp a bubbling chest drain

Intrapleural Fibrinolytics

• Recommended for: Complicated parapneumonic effusions (thick fluid with loculations) or empyema (overt pus) 2
• Agent of choice: Urokinase (most evidence in children) 2, 1
• Dosing regimen:
  • Children ≥10 kg: 40,000 units in 40 ml 0.9% saline
  • Children <10 kg: 10,000 units in 10 ml 0.9% saline
  • Administration: Twice daily for 3 days (6 doses total) 2
• Note: Meta-analyses suggest insufficient evidence for routine use in all cases 2, 1

Antibiotic Therapy

• Immediate initiation with coverage for both aerobic and anaerobic organisms 1
• Community-acquired empyema:
  • First-line options: Cefuroxime + metronidazole, amoxicillin + clavulanic acid, benzyl penicillin + ciprofloxacin, or clindamycin as a single agent 1
• Hospital-acquired empyema:
  • Broader spectrum: Piperacillin-tazobactam, ceftazidime, or meropenem 1
• MRSA empyema: Vancomycin or linezolid 1, 3
• Important: Avoid aminoglycosides due to poor pleural penetration and inactivation in acidic pleural fluid 1
• Duration: Continue until patient is afebrile or chest drain is removed, followed by oral antibiotics for 1-4 weeks 1
• Anti-anaerobic coverage: Associated with lower readmission rates for empyema 4

Surgical Management

Indications for Surgical Consultation

• Failure of chest tube drainage, antibiotics, and fibrinolytics 2, 1
• Persistent sepsis with persistent pleural collection 2, 1
• Complex empyema with multiple loculations 1
• Organized empyema with thick fibrous peel 2
• No improvement after 7 days of medical management 1

Surgical Options

1. Video-Assisted Thoracoscopic Surgery (VATS):

   • Preferred for early intervention 1
   • Associated with less postoperative pain, shorter hospital stay, and better cosmetic results 2
   • Contraindications: Inability to develop pleural window, presence of thick pyogenic material, fibrotic pleural rinds 2

2. Thoracotomy and Decortication:

   • For organized empyema with thick fibrous peel 2, 5
   • Requires excision of both visceral and parietal pleural rinds 2
   • Procedure of choice when underlying lung is reexpandable 5

3. Open-Window Thoracostomy:

   • For patients not eligible for radical treatment 1, 5
   • Can be both definitive treatment or preparatory for radical procedures 5

Special Considerations

Empyema with Lung Abscess

• Manage empyema as usual; do not surgically drain lung abscess 2
• Antibiotics being given for empyema should also treat the lung abscess 2

Patient Care

• Provide adequate analgesia and antipyretics 2, 1
• Encourage early mobilization and exercise 1
• Chest physiotherapy is NOT recommended 2, 1

Monitoring Response

• Daily assessment of vital signs, pain levels, and laboratory markers (WBC, CRP) 1
• Monitor drainage output and characteristics 1
• Repeat imaging to assess resolution of fluid collection 1

Common Pitfalls to Avoid

• Delaying drainage when indicated 1
• Inappropriate clamping of chest drains 1
• Failure to recognize when medical therapy is failing and surgical intervention is needed 1
• Overlooking potential underlying conditions predisposing to empyema 1
• Using aminoglycosides which have poor pleural penetration 1