What is the management of empyema thorax with empyema necessitans?

Management of Empyema Thorax with Empyema Necessitans

Empyema necessitans requires immediate broad-spectrum antibiotics covering aerobic and anaerobic pathogens, combined with drainage procedures (chest tube or surgical intervention), and early surgical consultation is critical when medical management fails. 1, 2

Initial Antibiotic Therapy

Start empiric antibiotics immediately covering both aerobic and anaerobic organisms commonly associated with empyema. 1

Recommended antibiotic regimens include:

• Second-generation cephalosporin plus metronidazole 1
• Benzyl penicillin plus ciprofloxacin 1
• Meropenem plus metronidazole 1
• Clindamycin alone (particularly in penicillin-allergic patients) 1

Avoid aminoglycosides due to poor pleural space penetration. 1

For pediatric cases, third-generation cephalosporins are recommended as Streptococcus pneumoniae is the most common pathogen. 1 In adults, Staphylococcus aureus (especially methicillin-resistant strains) is frequently isolated and represents the most common cause of antibiotic failure. 3

Drainage Procedures

Chest Tube Drainage

Small-bore chest drains or pigtail catheters should be used to minimize patient discomfort, connected to a unidirectional flow drainage system kept below the patient's chest level. 1

Critical management principles:

• Perform chest radiograph after drain insertion 1
• Check for obstruction by flushing when drainage suddenly stops 1
• Never clamp a bubbling chest drain 4
• If a clamped drain causes breathlessness or chest pain, immediately unclamp and seek medical advice 1
• Remove drain once clinical resolution is achieved 1

Surgical Drainage Options

Empyema necessitans specifically requires more aggressive intervention than simple empyema. Surgery plays a critical role in selected patients, with three main approaches: 2

1. Tube thoracostomy drainage - for early, less organized collections 2, 5
2. Open drainage - for chronic or complex cases 2
3. Decortication - for organized empyema with thick fibrous peel restricting lung expansion 4, 2

Distinguish empyema necessitans from superficial abscess using point-of-care ultrasound to identify the tract extending from the skin nodule to the pleural space, as this determines whether local drainage versus chest tube/surgical intervention is required. 5

Intrapleural Fibrinolytics

Intrapleural fibrinolytics are recommended for complicated parapneumonic effusions or empyema to shorten hospital stay. 1

Urokinase is the recommended agent based on randomized controlled trials:

• Patients ≥10 kg: 40,000 units in 40 ml 0.9% saline 1
• Patients <10 kg: 10,000 units in 10 ml 0.9% saline 1
• Administer twice daily for 3 days (6 doses total) 4, 1

However, meta-analyses show insufficient evidence to support routine fibrinolytic use for all empyemas. 4

Surgical Consultation and Intervention

Early surgical consultation is essential when medical management fails. 1

Indications for Surgery:

• Failure of chest tube drainage, antibiotics, and fibrinolytics after approximately 7 days 1
• Persistent sepsis with persistent pleural collection despite drainage and antibiotics 4
• Organized empyema with thick fibrous peel in symptomatic patients requiring formal thoracotomy and decortication 4, 1

Surgical Approach Selection:

Video-assisted thoracoscopic surgery (VATS) is preferred when feasible, showing reduced postoperative pain, shorter hospital stay, and better cosmetic results compared to open thoracotomy. 4

Formal thoracotomy with decortication is reserved for:

• Late-presenting or chronic empyema 4
• Thick fibrous peel restricting lung expansion causing chronic sepsis 4
• Contraindications to VATS (inability to develop pleural window, thick pyogenic material, fibrotic pleural rinds) 4

Important caveat: A coexisting lung abscess with empyema should not be surgically drained; manage the empyema in the usual way as antibiotics will treat both. 4

Supportive Care

• Provide adequate analgesia, particularly with chest drains in place 4, 1
• Give antipyretics for comfort 4, 1
• Avoid chest physiotherapy - it is not beneficial in empyema 4, 1
• Encourage early mobilization and exercise 4, 1

Follow-Up and Monitoring

Follow patients until complete recovery with near-normal chest radiograph. 1

Monitor for:

• Resolution confirmed by decreased pleural fluid neutrophil count and sterile cultures 1
• Secondary scoliosis (common but transient, requires monitoring until resolution) 1
• Consider underlying diagnoses such as immunodeficiency, cystic fibrosis, or tuberculosis (especially if bilateral effusions) 1

Special Considerations for Empyema Necessitans

Tuberculosis is a common cause of empyema necessitans and should be considered, particularly in endemic areas. 2, 6 Five of nine patients in one surgical series had tuberculous empyema. 2

Gram-negative organisms (including Proteus species) can cause empyema necessitans, though less commonly than tuberculosis or Actinomyces. 6

Success rates are high with appropriate management: 91% cure rate without conversion to open thoracostomy in one large trauma series, though decortication was frequently required. 3