What is the treatment for empyema?

Treatment of Empyema

Empyema requires immediate triple therapy: empiric IV antibiotics covering aerobic and anaerobic pathogens, urgent pleural drainage with small-bore chest tube under imaging guidance, and early surgical consultation if no improvement within 7 days. 1, 2, 3

Immediate Antibiotic Therapy

Start empiric IV antibiotics immediately without waiting for diagnostic thoracentesis, as delayed treatment increases morbidity and mortality. 3

First-Line Antibiotic Regimens

• Piperacillin-tazobactam 4.5g IV every 6 hours is the optimal choice due to excellent pleural space penetration and broad-spectrum coverage 3
• Alternative regimens include:
  • Cefuroxime 1.5g IV three times daily PLUS metronidazole 500mg IV three times daily 3
  • Meropenem 1g IV three times daily PLUS metronidazole 500mg IV three times daily 1, 2, 3
  • Benzyl penicillin 1.2g IV four times daily PLUS ciprofloxacin 400mg IV twice daily 1, 2, 3
  • Clindamycin 600-900mg IV three times daily (especially for penicillin-allergic patients) 1, 2, 3

Critical Antibiotic Pitfalls

• Anaerobic coverage is mandatory as anaerobes frequently co-exist with aerobes in empyema 3
• Never use aminoglycosides due to poor pleural space penetration and inactivation by pleural fluid acidosis 1, 2, 3
• Adjust antibiotics based on culture results when available and narrow to a single agent once sensitivities are known 3

Urgent Pleural Drainage

Insert a chest tube immediately under ultrasound or CT guidance—this is essential and should not be delayed. 3

Drainage Technique

• Use small-bore chest drains or pigtail catheters (8-14 French) whenever possible to minimize patient discomfort 1, 2, 3
• Ultrasound or CT guidance improves success rates and safety compared to blind insertion 3
• Connect chest tubes to a unidirectional flow drainage system kept below the level of the patient's chest 1, 2
• Perform chest radiograph after insertion to confirm proper placement 1, 2

Drainage Monitoring

• Check chest tube patency daily and flush with 20-50ml normal saline if drainage suddenly stops 1, 3
• Never clamp a bubbling chest drain—if a patient with a clamped drain complains of breathlessness or chest pain, immediately unclamp the drain 1, 2
• Remove the drain once clinical resolution is achieved 1

Intrapleural Fibrinolytics

Consider intrapleural fibrinolytics for complicated parapneumonic effusions or empyema to shorten hospital stay. 1, 2

• Urokinase is the recommended fibrinolytic agent based on randomized controlled trials 1, 2
• Dosing regimen: twice daily for 3 days 1, 2
  • For patients ≥10 kg: 40,000 units in 40 ml 0.9% saline 1
  • For patients <10 kg: 10,000 units in 10 ml 0.9% saline 1

Surgical Management

Obtain immediate respiratory medicine or thoracic surgery consultation, as specialist involvement reduces mortality and improves outcomes. 3

Indications for Surgical Intervention

Consider surgery if no clinical improvement after 7 days of drainage and antibiotics, with specific indications including: 1, 2, 3

• Failure of chest tube drainage, antibiotics, and fibrinolytics 1, 2, 3
• Persistent sepsis despite appropriate treatment 1, 2, 3
• Organized empyema with trapped lung in a symptomatic patient 1, 2, 3
• Multiple loculations not responding to fibrinolytics 3

Surgical Approach by Stage

• For Stage 2 or early-stage empyema: Video-assisted thoracoscopic surgery (VATS) is preferred, offering less postoperative pain, shorter hospital stay, and better cosmetic results 2, 4
• For Stage 3 chronic empyema with pleural peel: Open thoracotomy with decortication is the procedure of choice when the underlying lung can reexpand 4, 5
• For patients unfit for radical surgery: Open-window thoracostomy can be considered as definitive or preparatory treatment 5

Duration and Monitoring

Treatment Duration

• Total antibiotic duration: 2-4 weeks depending on clinical response 3
• Transition to oral antibiotics after clinical improvement and adequate drainage, continuing for 1-4 weeks after discharge if residual disease persists 3

Expected Clinical Response

• Clinical improvement expected within 48-72 hours, including fever resolution, improved respiratory status, and decreased white blood cell count 3
• Confirm resolution of pleural infection by decrease in pleural fluid neutrophil count and sterile cultures 1, 2
• Follow patients until complete recovery with near-normal chest radiograph 1, 2

Special Considerations

Pediatric Empyema

• Streptococcus pneumoniae is the most common pathogen in children—use third-generation cephalosporins 1
• Primary operative approach in children is associated with lower mortality rate and reduced hospital stay 4

Post-Pneumonectomy Empyema

• Uncomplicated cases without bronchopleural fistula can be managed with minimally invasive techniques including fenestration and VATS debridement 4
• Cases with bronchopleural fistula require individualized open surgical techniques including direct repair and myoplastic techniques 4

Coexisting Lung Abscess

• A lung abscess coexisting with empyema should not be surgically drained—manage with antibiotics covering both conditions 2

Supportive Care

• Provide adequate analgesia to keep patients comfortable, particularly those with chest drains 1, 2
• Give antipyretics for fever 2
• Encourage early mobilization and exercise during recovery 1
• Manage patients with chest drains on specialist wards by staff trained in chest drain management 1