What is the most appropriate management for an 81-year-old man with a complex pleural effusion and suspected empyema, presenting with fever, fatigue, and shortness of breath, after recent hospitalization for pneumonia?

Management of Empyema in an 81-Year-Old Man

The most appropriate management for this patient with empyema is to insert a small-bore pleural drain (<14 Fr) and begin piperacillin-tazobactam. 1, 2

Diagnosis Confirmation

This patient has a clear diagnosis of empyema/complicated parapneumonic effusion based on:

• Recent pneumonia with incomplete resolution
• Persistent symptoms (fever, fatigue, shortness of breath)
• Pleural fluid analysis showing:
  • High leukocyte count (22,000/μL)
  • Low glucose (40 mg/dL)
  • Low pH (7.1)
  • Loculations on ultrasound

These findings meet the British Thoracic Society's criteria for a complicated parapneumonic effusion requiring drainage, specifically:

• pH <7.2
• Loculated collection
• Significant symptoms 1

Management Algorithm

1. Drainage with small-bore catheter

   • Small-bore catheters (10-14 Fr) are recommended as first-line for drainage 1
   • These are less traumatic to insert and more comfortable for the patient
   • Should be inserted under ultrasound guidance given the loculated nature of the effusion

2. Appropriate antibiotic therapy

   • Piperacillin-tazobactam is specifically recommended by the British Thoracic Society for hospital-acquired culture-negative pleural infections 1, 2
   • This provides broad-spectrum coverage for both aerobic and anaerobic organisms
   • Aminoglycosides should be avoided due to poor pleural penetration and inactivation in acidic environments 1, 2

3. Ongoing management

   • Monitor drainage output and clinical response
   • Ensure tube patency (flush with saline if needed)
   • Consider CT scan if drainage is inadequate
   • Consider intrapleural fibrinolytics if loculations persist

Why Not Other Options?

• Option A (ceftriaxone and azithromycin): This regimen is more appropriate for community-acquired pneumonia without empyema. It lacks adequate anaerobic coverage needed for empyema treatment 1

• Option B (large-bore drain with levofloxacin): Large-bore drains are no longer first-line for empyema management. Small-bore drains are equally effective and less traumatic 1. Additionally, levofloxacin as monotherapy provides insufficient anaerobic coverage.

• Option D (repeat chest radiograph in 2 weeks): This represents dangerous undertreatment. The patient has clear evidence of empyema requiring immediate drainage and antibiotics 1, 2

Important Considerations

• Drainage should be performed promptly to prevent further loculations and fibrin deposition
• If clinical improvement is not seen within 5-7 days, consider:
  • CT scan to assess drain position and residual collections
  • Possible surgical consultation for VATS or decortication 2
• Monitor for complications including:
  • Drain blockage (flush with saline if needed)
  • Persistent sepsis
  • Development of bronchopleural fistula

This approach aligns with current guidelines and offers the best chance for clinical improvement while minimizing patient discomfort and potential complications.