Treatment of Empyema Necessitans
Empyema necessitans requires immediate broad-spectrum intravenous antibiotics combined with surgical drainage, with the specific surgical approach ranging from chest tube drainage with fibrinolytics for early cases to open drainage or formal decortication for advanced organized disease. 1, 2
Understanding the Condition
Empyema necessitans represents a rare but serious complication where infected pleural fluid dissects through the parietal pleura into the chest wall soft tissues and potentially through the skin. 3, 4 This occurs from inadequate treatment of the underlying empyema and typically involves indolent organisms like Mycobacterium tuberculosis and Actinomyces israelii, though Gram-negative bacteria can also be causative. 3, 2, 5
Initial Medical Management
Antimicrobial Therapy
- Start broad-spectrum intravenous antibiotics immediately targeting common pathogens, then adjust based on culture results. 1
- Consider antituberculosis therapy if tuberculous empyema is suspected based on clinical presentation and epidemiology. 2
- Continue antibiotic therapy for extended duration (typically 2-4 weeks minimum) depending on clinical response. 6
Diagnostic Workup
- Obtain chest imaging (radiography and CT with IV contrast) to define the extent of pleural disease, chest wall involvement, and thickness of any pleural peel. 7, 4
- Point-of-care ultrasound can rapidly identify the tract extending from the chest wall lesion to the pleural space, distinguishing this from a simple superficial abscess. 4
- Aggressively pursue cultures from pleural fluid and any accessible collections to guide antimicrobial therapy. 6
Surgical Management Algorithm
For Early/Uncomplicated Cases
- Insert a small-bore chest drain under ultrasound guidance connected to a unidirectional drainage system. 1
- Clamp the drain for 1 hour after initially removing 10 ml/kg to prevent re-expansion pulmonary edema. 1
- Administer intrapleural urokinase (40,000 units in 40 ml 0.9% saline for children ≥10 kg; 10,000 units in 10 ml for <10 kg) twice daily for 3 days to facilitate drainage. 1
- Simple tube drainage combined with antibiotics may suffice in select cases without significant organization. 2
For Advanced/Organized Cases
- Open drainage is indicated when there is significant chest wall involvement or when less invasive approaches have failed. 2
- Formal thoracotomy with decortication is required for organized empyema with thick fibrous peel causing chronic sepsis, fever, and restricted lung expansion. 7, 2
- Video-assisted thoracoscopic surgery (VATS) may be considered for early intervention but has higher failure rates in advanced organized disease. 7
Critical Surgical Timing
- Initiate early discussion with a thoracic surgeon if the patient fails to respond to chest tube drainage, antibiotics, and fibrinolytics within 48-72 hours. 1
- Specific indications for surgical intervention include persisting sepsis, organized empyema with thick pleural peel, and multiloculated empyema not responding to medical management. 7, 1
Important Caveats
Do not surgically drain any coexisting lung abscess. The empyema management and antibiotics will treat the lung abscess, and surgical drainage increases morbidity without improving outcomes. 7, 6
Distinguish empyema necessitans from a simple superficial abscess. The former requires pleural space drainage (chest tube, open drainage, or decortication), while the latter only needs local incision and drainage. 4 Misdiagnosis leads to inadequate treatment and continued morbidity.
Supportive Care
- Provide antipyretics for fever control and adequate analgesia, particularly with chest drains in place. 7, 1
- Do not perform chest physiotherapy as it provides no benefit in empyema. 7, 1
- Encourage early mobilization and exercise once clinically stable. 7, 1
- Monitor for secondary thrombocytosis, which is common but benign and requires no specific treatment. 7, 1