What is the treatment for empyema?

Treatment of Empyema

The treatment of empyema requires a stepwise approach including antibiotics, drainage procedures, and possibly surgical intervention, with the specific approach determined by the stage of empyema and patient response to initial therapy. 1, 2

Initial Management

• Antibiotic therapy should be started immediately in all patients with empyema, with initial empiric coverage for both aerobic and anaerobic pathogens 1, 2
• Recommended antibiotic regimens include:
  • Piperacillin-tazobactam 4.5g IV every 6 hours (first-line choice) 2
  • Second-generation cephalosporin plus metronidazole 1, 2
  • Benzyl penicillin plus ciprofloxacin 1, 2
  • Meropenem plus metronidazole 1, 2
  • Clindamycin alone (especially in penicillin-allergic patients) 1
• Aminoglycosides should be avoided due to poor penetration into the pleural space 1, 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
• If drainage is inadequate, the position of the chest tube should be checked and a new tube inserted if necessary 2

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 for urokinase includes twice daily for 3 days:
  • 40,000 units in 40 ml 0.9% saline for patients ≥10 kg 1
  • 10,000 units in 10 ml 0.9% saline for patients <10 kg 1

Surgical Management

• Surgical consultation should be considered if there is no response to drainage and antibiotics after approximately 7 days 1, 2
• Indications for surgical intervention include:
  • Failure of chest tube drainage, antibiotics, and fibrinolytics 1
  • Persistent sepsis 1
  • Organized empyema in a symptomatic patient 3

Surgical Options

• Video-assisted thoracoscopic surgery (VATS) is preferred for early-stage empyema, offering less postoperative pain, shorter hospital stay, and better cosmetic results 3, 4
• Mini-thoracotomy and debridement is safe and curative for intermediate cases 3
• Formal thoracotomy with decortication is reserved for organized empyema with thick fibrous peel restricting lung expansion 3, 5
• CT scanning with intravenous contrast is useful before surgery to define the thickness of the pleural peel 3

Special Considerations

Empyema with Lung Abscess

• A lung abscess coexisting with an empyema should not normally be surgically drained 3
• The empyema should be managed in the usual way 3
• The antibiotics being given for the empyema should also treat the lung abscess 3

Supportive Care

• Adequate analgesia is essential to keep the patient comfortable, particularly with chest drains 3, 6
• Antipyretics should be given for fever 3
• Chest physiotherapy is not beneficial and should not be performed in children with empyema 3
• Early mobilization and exercise are recommended during recovery 3, 1

Monitoring and Follow-up

• Resolution of pleural infection should be confirmed by a decrease in pleural fluid neutrophil count and sterile cultures 1, 2
• A second paracentesis 48 hours after starting treatment can help assess the effectiveness of antibiotic therapy 2
• Patients should be followed until complete recovery with near-normal chest radiograph 1

Common Pitfalls to Avoid

• Delayed diagnosis, inappropriate antibiotic selection, and inadequate chest tube placement contribute to progression of pleural infection 2
• 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
• Patients with chest drains should be managed on specialist wards by staff trained in chest drain management 1