What is the treatment for empyema?

Treatment of Empyema

The treatment of empyema requires immediate initiation of antibiotic therapy covering both aerobic and anaerobic pathogens, followed by appropriate drainage procedures, with surgical intervention reserved for cases that fail to respond to initial management. 1, 2, 3

Initial Antibiotic Management

• Start antibiotic therapy immediately in all patients with empyema, with empiric coverage for both aerobic and anaerobic pathogens 1, 3
• Recommended antibiotic regimens include:
  • Piperacillin-tazobactam (4.5g IV every 6 hours) - optimal first-line choice due to excellent pleural penetration 3
  • Second-generation cephalosporin (e.g., cefuroxime 1.5g IV three times daily) plus metronidazole (500mg IV three times daily) 1, 2
  • Benzyl penicillin (1.2g IV four times daily) plus ciprofloxacin (400mg IV twice daily) 1, 3
  • Meropenem (1g IV three times daily) plus metronidazole 1, 2
  • Clindamycin alone (especially in penicillin-allergic patients) 1, 3
• Avoid aminoglycosides due to poor penetration into the pleural space 1, 2, 3
• Adjust antibiotics based on culture and sensitivity results when available 3

Drainage Procedures

• Small-bore chest drains or pigtail catheters should be used whenever possible to minimize patient discomfort 1, 2
• Connect chest tubes to a unidirectional flow drainage system kept below the level of the patient's chest 1, 2
• Perform a chest radiograph after insertion to confirm proper placement 1, 2
• Check for tube obstruction by flushing if drainage suddenly stops 2
• Therapeutic drainage with small-bore tube thoracostomy is effective for early stage empyema 4

Intrapleural Fibrinolytics

• Intrapleural fibrinolytics are recommended for complicated parapneumonic effusions or empyema to shorten hospital stay 1, 2
• Urokinase is the recommended fibrinolytic agent, administered twice daily for 3 days 1, 2
• Dosing depends on patient weight: 40,000 units in 40 ml 0.9% saline for patients ≥10 kg and 10,000 units in 10 ml 0.9% saline for patients <10 kg 2
• Fibrinolytics facilitate catheter drainage by degrading loculations and decreasing fluid viscosity 4

Surgical Management

• Consider surgical consultation if there is no response to drainage and antibiotics after approximately 7 days 1, 2, 3
• Indications for surgical intervention include:
  • Failure of chest tube drainage, antibiotics, and fibrinolytics 1, 2
  • Persistent sepsis 1, 2
  • Organized empyema in a symptomatic patient 1, 2
• Video-assisted thoracoscopic surgery (VATS) is preferred for early-stage empyema, offering less postoperative pain, shorter hospital stay, and better cosmetic results 1, 5, 6
• VATS has been shown to reduce length of hospital stay compared to thoracostomy drainage alone 5
• In children, a primary operative approach may be an effective management strategy, associated with lower mortality and reduced hospital stay 5, 6

Monitoring and Follow-up

• Confirm resolution of pleural infection by a decrease in pleural fluid neutrophil count and sterile cultures 1, 2, 3
• A second paracentesis 48 hours after starting treatment can help assess the effectiveness of antibiotic therapy 1, 3
• Follow patients until complete recovery with near-normal chest radiograph 1, 2
• Consider underlying diagnoses such as immunodeficiency or cystic fibrosis in recurrent cases 2

Special Considerations

• A lung abscess coexisting with empyema should be managed with antibiotics rather than surgical drainage 1
• In children, Streptococcus pneumoniae is the most common pathogen, and third-generation cephalosporins are recommended 2, 3
• Provide adequate analgesia, particularly for patients with chest drains 1, 2
• Early mobilization and exercise are recommended during recovery 2

Common Pitfalls to Avoid

• Delayed diagnosis, inappropriate antibiotic selection, and inadequate chest tube placement contribute to progression of pleural infection 1, 3
• Never clamp a bubbling chest drain; if a patient with a clamped drain complains of breathlessness or chest pain, immediately unclamp it 1, 2
• Manage patients with chest drains on specialist wards by staff trained in chest drain management 2
• Failure to adjust antibiotics based on culture results when available can lead to treatment failure 3