What is the treatment for chest wall empyema?

Treatment of Chest Wall Empyema

The treatment of chest wall empyema requires a combination of appropriate antibiotic therapy, drainage procedures, and possible surgical intervention, with small-bore chest tubes being preferred over large-bore tubes to minimize patient discomfort. 1

Initial Management

• Antibiotic therapy should be started immediately in all patients with empyema 2
• Initial empiric antibiotics should cover both aerobic and anaerobic pathogens commonly associated with empyema 2
• Recommended antibiotic regimens include:
  • Second-generation cephalosporin plus metronidazole 2, 3
  • Benzyl penicillin plus ciprofloxacin 2
  • Meropenem plus metronidazole 2
  • Clindamycin alone (especially in penicillin-allergic patients) 2
• Aminoglycosides should be avoided due to poor penetration into the pleural space 2

Drainage Procedures

• Small-bore chest drains or pigtail catheters should be used whenever possible to minimize patient discomfort 1
• Chest tubes should be connected to a unidirectional flow drainage system kept below the level of the patient's chest 1
• A chest radiograph should be performed after insertion of a chest drain 1
• When drainage suddenly stops, the drain must be checked for obstruction by flushing 1
• The drain should be removed once clinical resolution is achieved 1

Intrapleural Fibrinolytics

• Intrapleural fibrinolytics are recommended for complicated parapneumonic effusions or empyema to shorten hospital stay 1
• Urokinase is the recommended fibrinolytic agent based on randomized controlled trials in children 1
• Dosing regimen: twice daily for 3 days (6 doses total) 1
  • 40,000 units in 40 ml 0.9% saline for patients ≥10 kg
  • 10,000 units in 10 ml 0.9% saline for patients <10 kg

Surgical Management

• Surgical consultation should be considered if there is no response to drainage and antibiotics after approximately 7 days 2
• Indications for surgical intervention include:
  • Failure of chest tube drainage, antibiotics, and fibrinolytics 1
  • Persistent sepsis with ongoing pleural collection despite chest tube drainage 1
  • Organized empyema in a symptomatic patient (may require thoracotomy and decortication) 1

Monitoring and Duration of Treatment

• Longer duration of anti-anaerobic antibiotics is associated with lower readmission rates for empyema 4
• Resolution of pleural infection should be confirmed by a decrease in pleural fluid neutrophil count and sterile cultures 2
• Total antibiotic duration is typically 2-4 weeks, with longer courses associated with lower readmission rates 4

Special Considerations and Complications

• Empyema necessitans is a rare complication where infection extends beyond the pleural space into the chest wall 5, 6
• This complication requires aggressive surgical and antimicrobial therapy 5
• In children, Streptococcus pneumoniae is the most common pathogen, and third-generation cephalosporins are recommended 2, 7
• Early mobilization and exercise are recommended during recovery 1
• Analgesia is important, particularly in patients with chest drains 1

Chest Drain Management Pitfalls

• A bubbling chest drain should never be clamped 1
• If a patient with a clamped drain complains of breathlessness or chest pain, the drain should be immediately unclamped 1
• The drain should be clamped for 1 hour once 10 ml/kg are initially removed 1
• Patients with chest drains should be managed on specialist wards by staff trained in chest drain management 1

Follow-Up

• Patients should be followed until complete recovery with near-normal chest radiograph 1
• Consider underlying diagnoses such as immunodeficiency or cystic fibrosis 1
• Secondary scoliosis on chest radiograph is common but transient and should be monitored until resolution 1