What is the treatment for empyema?

Treatment of Empyema

The treatment of empyema requires a combination of appropriate antibiotics, drainage procedures, and consideration of surgical intervention when medical management fails, with piperacillin/tazobactam (4.5g IV every 6 hours) recommended as first-line empiric therapy for hospital-acquired empyema. 1

Initial Management

Antibiotic Therapy

• Hospital-acquired empyema: Piperacillin/tazobactam 4.5g IV q6h 1
• Community-acquired empyema: Cefuroxime + metronidazole or amoxicillin + clavulanic acid 1
• For MRSA coverage: Vancomycin IV or linezolid 600mg PO/IV twice daily 1
• Avoid aminoglycosides as they have poor penetration into the pleural space 1
• Continue antibiotics until the patient is afebrile or chest drain is removed, followed by oral antibiotics for 1-4 weeks 1

Drainage Procedures

1. Small-bore catheter (10-14 Fr) inserted under ultrasound guidance is recommended as first-line 1
2. Proper drain management:
   • Connect to unidirectional flow drainage system kept below chest level
   • Initial drainage limited to 10ml/kg, then clamp for 1 hour 2
   • Never clamp a bubbling chest drain 2
   • Check for obstruction by flushing if drainage suddenly stops 2

Intrapleural Fibrinolytics

Intrapleural fibrinolytics are recommended for complicated parapneumonic effusions or empyema 2

• Urokinase is the agent of choice 2:
  • For children ≥10 kg: 40,000 units in 40 ml 0.9% saline
  • For children <10 kg: 10,000 units in 10 ml 0.9% saline
  • Administered twice daily for 3 days (6 doses total) 2

While fibrinolytics are recommended in the guidelines, meta-analyses suggest insufficient evidence for routine use in all cases 1. They work by promoting pleural drainage and circulation, breaking down loculations 3.

Surgical Intervention

Consider surgical intervention in the following scenarios:

• Failure of chest tube drainage, antibiotics, and fibrinolytics 2
• Persistent sepsis with persistent pleural collection despite drainage and antibiotics 2
• No improvement after 7 days of appropriate medical management 1

Surgical Options:

1. Video-Assisted Thoracoscopic Surgery (VATS):

   • Preferred for early intervention
   • Associated with less postoperative pain, shorter hospital stay 1, 3
   • May be contraindicated with thick pyogenic material or fibrotic pleural rinds 1

2. Thoracotomy and Decortication:

   • For organized empyema in symptomatic patients 2
   • Procedure of choice when underlying lung is reexpandable 4

3. Open-Window Thoracostomy:

   • For patients not eligible for radical treatment 4
   • Can be both definitive treatment or preparatory for radical procedures 4

Ongoing Management

• 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
• Provide adequate analgesia and antipyretics 2
• Encourage early mobilization and exercise 2
• Chest physiotherapy is not beneficial and should not be performed 2

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
• Attempting to surgically drain a lung abscess coexisting with empyema 2

Follow-Up

• Follow patients until complete recovery and chest radiograph has returned to near normal 2
• Consider underlying diagnoses such as immunodeficiency or cystic fibrosis 2
• Monitor for complications like secondary scoliosis, which is common but transient 2

The management of empyema has evolved from traditional conservative treatment to more aggressive approaches including early drainage with fibrinolytics and surgical intervention when appropriate, resulting in shorter hospital stays and fewer complications 3.