From the Guidelines
Empyema necessitans requires aggressive management with both antimicrobial therapy and surgical intervention to prevent further complications such as sepsis, chronic bronchopleural fistula, or persistent infection. The condition is a serious complication of empyema where the infection extends beyond the pleural cavity into the chest wall, creating a fistulous tract that may drain spontaneously through the skin. Patients should receive broad-spectrum antibiotics initially, typically a combination of a beta-lactam (such as piperacillin-tazobactam 4.5g IV every 6 hours) plus coverage for methicillin-resistant Staphylococcus aureus (vancomycin 15-20 mg/kg IV every 8-12 hours) for 2-6 weeks, later narrowed based on culture results 1.
Diagnosis and Treatment
The diagnosis of empyema necessitans involves the identification of a fistulous tract extending from the pleural cavity to the chest wall, often with spontaneous drainage of pus through the skin. Treatment requires a multidisciplinary approach, including:
- Broad-spectrum antibiotics to cover common bacterial pathogens, including Streptococcus pneumoniae and Staphylococcus aureus 1
- Surgical management, including drainage of the empyema, debridement of necrotic tissue, and closure of the fistulous tract, typically requiring video-assisted thoracoscopic surgery (VATS) or thoracotomy with decortication 1
- Specific anti-tuberculous therapy if tuberculosis is identified as the cause, particularly in endemic areas
Key Considerations
- Prompt recognition and aggressive management are crucial to prevent further complications and improve outcomes 1
- The optimal duration of antibiotic treatment may vary depending on the adequacy of drainage and the pathogen involved, but treatment for 2-6 weeks is commonly recommended 1
- Surgical intervention should be considered early in the management of empyema necessitans, particularly if there is evidence of complicated parapneumonic effusion or empyema, such as loculations or thickening of the pleural peel 1
From the Research
Diagnosis of Empyema Necessitans
- Empyema necessitans is a rare complication of empyema, characterized by the dissection of pus through the soft tissues of the chest wall and eventually through the skin 2
- Diagnosis can be challenging, but it is crucial for early recognition and treatment of this condition 3
- Clinical presentation may include fever, chills, productive cough, and chest pain with purulent secretions from the chest wall 4
Treatment of Empyema Necessitans
- Treatment options include broad-spectrum antibiotics, video-assisted thoracic surgery (VATS), and chest tube drainage for complete drainage 4
- Surgery plays a critical role in the management of empyema necessitans in selected patients, with options including tube drainage, open drainage, and decortication 2
- Decortication of the thoracic cavity may be used in some patients to obliterating the cavity and regenerating pulmonary function 2, 5
- Anti-tuberculosis therapy may be necessary in cases where empyema necessitans is caused by mycobacterium tuberculosis 3
- Fibrinolytics may also be used to promote pleural drainage and circulation, although this is not directly mentioned in the context of empyema necessitans, it is a treatment option for empyema 6