What are the key teaching points for managing empyema?

Key Teaching Points for Managing Empyema

The management of empyema requires prompt antibiotic therapy, appropriate drainage, and consideration of fibrinolytics or surgical intervention when indicated to reduce morbidity and mortality. 1, 2

Pathophysiology and Diagnosis

• Empyema is an infection of the pleural space, typically progressing through three phases: exudative, fibrinopurulent, and organizational stages 3
• Diagnosis is best confirmed through thoracentesis with culture and Gram stain, while contrast-enhanced CT showing a "split pleura" sign is highly suggestive 4
• In children, pleural effusions are usually secondary to acute bacterial pneumonia, with Streptococcus pneumoniae being the most common pathogen 3, 2

Antibiotic Management

• Antibiotic therapy should be started immediately in all patients with empyema, with initial coverage for both aerobic and anaerobic pathogens 1, 2
• Recommended regimens include:
  • Second-generation cephalosporin plus metronidazole
  • Benzyl penicillin plus ciprofloxacin
  • Meropenem plus metronidazole
  • Clindamycin alone (especially in penicillin-allergic patients) 1, 2
• Aminoglycosides should be avoided due to poor penetration into the pleural space 1
• Antibiotic selection should be adjusted based on pleural fluid culture results whenever possible 2

Drainage Procedures

• Small-bore chest drains or pigtail catheters are preferred to minimize patient discomfort 1
• Chest tubes should be connected to a unidirectional flow drainage system kept below the patient's chest level 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 3, 1
• Important safety considerations for chest drain management:
  • A bubbling chest drain should never be clamped 3
  • A clamped drain should be immediately unclamped if a patient complains of breathlessness or chest pain 3
  • Patients with chest drains should be managed on specialist wards by staff trained in chest drain management 3
  • The drain should be removed once clinical resolution is achieved 3, 1

Intrapleural Fibrinolytics

• Intrapleural fibrinolytics shorten hospital stay and are recommended for complicated parapneumonic effusions (thick fluid with loculations) or empyema (overt pus) 3, 1
• Urokinase is the recommended fibrinolytic agent based on randomized controlled trials in children 3, 1
• Dosing regimen for urokinase: twice daily for 3 days (6 doses total)
  • 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 3, 1
• Fibrinolytics work by degrading loculations and decreasing fluid viscosity 4

Surgical Management

• Failure of chest tube drainage, antibiotics, and fibrinolytics should prompt early discussion with a thoracic surgeon 3, 1
• Indications for surgical intervention include:
  • Persisting sepsis with a persistent pleural collection despite chest tube drainage and antibiotics 3
  • No response to drainage and antibiotics after approximately 7 days 1, 2
  • Organized empyema in a symptomatic patient 3, 1
• Video-assisted thoracoscopic surgery (VATS) is most appropriate in early stages, with a lower conversion rate to open thoracotomy 5, 6
• Organized empyema in a symptomatic child may require formal thoracotomy and decortication 3
• A lung abscess coexisting with an empyema should not normally be surgically drained 3

Supportive Care and Follow-Up

• Analgesia is essential, particularly for patients with chest drains 3
• Antipyretics should be given for comfort, though fever is an important indicator of clinical progress 3
• Early mobilization and exercise are recommended during recovery 3, 1
• Chest physiotherapy is not beneficial and should not be performed in children with empyema 3
• Secondary thrombocytosis (platelet count >500) is common but benign; antiplatelet therapy is not necessary 3
• Secondary scoliosis noted on chest radiograph is common but transient; resolution must be confirmed 3, 1

Follow-Up Considerations

• Patients should be followed until complete recovery with near-normal chest radiograph 3, 1
• Consider underlying diagnoses such as immunodeficiency or cystic fibrosis 3, 1
• Resolution of pleural infection should be confirmed by a decrease in pleural fluid neutrophil count and sterile cultures 1, 2

Common Pitfalls to Avoid

• Delayed diagnosis and initiation of antibiotics can increase morbidity and mortality 2, 5
• Inadequate anaerobic coverage may lead to treatment failure 2
• Inappropriate chest tube placement or drainage can compromise antibiotic effectiveness 2
• Failure to adjust antibiotics based on culture results when available 2
• Relying on antibiotics alone, which are rarely successful without drainage 5