What is the treatment for empyema with a collection of a moderate amount of pus (200-300 milliliters)?

From the Guidelines

The treatment for empyema with a collection of 200-300 ml of pus requires prompt drainage combined with appropriate antibiotic therapy, with the primary intervention being drainage of the pleural space, typically through chest tube insertion or video-assisted thoracoscopic surgery (VATS) depending on the stage and complexity of the empyema.

Key Considerations

• The choice of drainage procedure depends on local expertise, with both chest thoracostomy tube drainage with the addition of fibrinolytic agents and VATS demonstrated to be effective methods of treatment 1.
• For initial empiric antibiotic coverage, a combination of a beta-lactam plus an anti-anaerobic agent is recommended while awaiting culture results, as suggested by guidelines for the management of pleural infection 1.
• The typical duration of antibiotic therapy is 2-6 weeks, depending on clinical response and resolution of infection.
• Small-bore catheters (10-14 French) are often sufficient for drainage, though larger tubes may be needed if the fluid is very thick.
• For loculated empyemas, intrapleural fibrinolytic therapy with agents like tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) may be considered to break down septations and improve drainage.

Adjunctive Measures

• Adequate pain control, respiratory therapy, and nutritional support are essential adjunctive measures during treatment.
• The chest tube should remain in place until drainage is minimal (less than 50-100 ml/day) and the patient shows clinical improvement with resolution of fever and normalization of inflammatory markers.
• Surgical intervention becomes necessary if tube drainage fails or if the empyema is in an organized phase with thick pleural peel formation.

From the Research

Treatment Options for Empyema

The treatment for empyema with a collection of a moderate amount of pus (200-300 milliliters) can vary depending on several factors, including the stage of the empyema and the severity of the condition.

• Treatment options range from intravenous antibiotics alone to open thoracotomy and debridement 2.
• Early drainage with or without intrapleural fibrinolytics is usually required, and this is successful in most patients 3.
• Surgical decortication may be needed in some cases, and clear benefit and low physiologic impact are more likely with early intervention, expeditious escalation of interventions, and care at a center experienced with video-assisted thoracoscopic surgery (VATS) 3.

Comparison of Treatment Options

Several studies have compared the effectiveness of different treatment options for empyema, including:

• Video-assisted thoracoscopic surgery (VATS) versus chest tube drainage with streptokinase: VATS had a significantly higher primary treatment success and patients spent less time in hospital 2, 4.
• Intrapleural fibrinolytic therapy versus conservative management: fibrinolytics reduced the risk of treatment failure, as gauged by the requirement for additional intervention including surgery or death 5.
• VATS versus thoracocentesis or chest tube drainage: VATS is superior to chest tube drainage in terms of duration of chest tubes in situ and length of hospital stay, but there are questions about validity and the study has too few participants to draw conclusions 2, 4.

Considerations for Treatment

When deciding on a treatment option for empyema, several factors should be considered, including:

• The stage of the empyema and the severity of the condition 2.
• The presence of loculation or septation, which may require more aggressive treatment 5.
• The patient's overall health and ability to tolerate surgery or other interventions 3.
• The availability of experienced centers and specialists in VATS and other treatment options 3.