What is the treatment for empyema?

Treatment of Empyema

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

Initial Management

Drainage

• Small-bore catheter (10-14 Fr) insertion under ultrasound guidance is recommended as first-line management 1
• Connect to a unidirectional flow drainage system kept below chest level
• Initial drainage should be limited to 10ml/kg, then clamp for 1 hour
• Never clamp a bubbling chest tube
• If the tube is not draining:
  1. Flush with 20-50ml normal saline (smaller volumes for pediatric patients)
  2. Check for kinking, malposition, or blockage
  3. If permanently blocked, remove and insert a new chest tube 1

Antibiotic Therapy

• When a pathogen is identified in blood or pleural fluid, base antibiotic selection on susceptibility testing 2
• For culture-negative empyema:
  • Community-acquired: cefuroxime + metronidazole or amoxicillin + clavulanic acid 1
  • Hospital-acquired: piperacillin/tazobactam 1
  • For suspected or confirmed MRSA: vancomycin IV or linezolid 600mg PO/IV twice daily 1
• Avoid aminoglycosides due to poor pleural penetration 1
• Duration: 2-4 weeks, depending on drainage adequacy and clinical response 2
  • Some experts recommend continuing until the patient is afebrile or chest drain is removed, followed by oral antibiotics for 1-4 weeks 1

Management of Loculations and Fibrinous Peel

Intrapleural Fibrinolytic Therapy

• Consider for management of loculations 1
• Urokinase is the recommended agent:
  • Children ≥10kg: 40,000 units in 40ml 0.9% saline
  • Children <10kg: 10,000 units in 10ml 0.9% saline
  • Administer twice daily for 3 days (6 doses total) 1
• Note: Meta-analyses suggest insufficient evidence for routine use in all cases 1

Indications for Surgical Intervention

• Failed medical management with persistent sepsis 1
• Organized empyema with significant respiratory compromise 1
• No improvement after 7 days of appropriate antibiotics and drainage 1
• Surgical options include:
  • Video-assisted thoracoscopic surgery (VATS)
  • Thoracotomy with decortication 1

Monitoring and Ongoing Management

• Daily assessment of:
  • Vital signs
  • Pain levels
  • Laboratory markers (WBC, CRP)
  • Drainage output and characteristics 1
• Repeat imaging to assess resolution of fluid collection
• Consider CT scan if drainage is inadequate 1
• Provide adequate analgesia and encourage early mobilization 1

Special Considerations

• Chest tube removal criteria: absence of air leak and <1mL/kg/24h of pleural fluid drainage (usually calculated over the last 12 hours), or 25-60mL total in a 24-hour period 2
• For persistently ill patients without microbiologic diagnosis, consider:
  • BAL for mechanically ventilated patients
  • Percutaneous lung aspirate
  • Open lung biopsy in critically ill, mechanically ventilated patients 2

Common Pitfalls and Caveats

• Antibiotics alone are rarely successful for treating empyema 3
• Tube drainage may be associated with higher rates of complications (pleurocutaneous and bronchopleural fistulas) compared to thoracentesis regimens in some studies 4
• Early intervention and expeditious escalation of treatment when needed leads to better outcomes 3
• Chest physiotherapy is not recommended for empyema management 1
• Culture results often do not reflect the full disease process, so empiric coverage should be broad initially 3