What is the recommended treatment for a patient with empyema?

Empyema Treatment

Empyema requires immediate broad-spectrum intravenous antibiotics combined with small-bore chest tube drainage, followed by intrapleural urokinase for 3 days, with surgical consultation if no response within 48-72 hours. 1, 2

Immediate Initial Management

• Start broad-spectrum IV antibiotics immediately targeting both aerobic and anaerobic pathogens, before culture results are available 1, 2
• Recommended antibiotic regimens include piperacillin-tazobactam, second-generation cephalosporin plus metronidazole, benzyl penicillin plus ciprofloxacin, meropenem plus metronidazole, or clindamycin alone 1
• Avoid aminoglycosides as they have poor penetration into the pleural space 1
• Adjust antibiotics based on culture results once available, continuing for 2-4 weeks minimum depending on clinical response 2

Drainage Procedures

• Insert a small-bore chest drain or pigtail catheter under ultrasound guidance to minimize patient discomfort 1, 2
• Connect the chest drain to a unidirectional flow drainage system kept below the patient's chest level at all times 1, 2
• Obtain a chest radiograph immediately after drain insertion to confirm proper placement 1
• Never clamp a bubbling chest drain—if a patient with a clamped drain develops breathlessness or chest pain, unclamp immediately 1

Intrapleural Fibrinolytic Therapy

• Administer intrapleural urokinase twice daily for 3 days for all complicated parapneumonic effusions or empyema to shorten hospital stay 1, 2
• Dosing: For adults and children ≥10 kg, use 40,000 units in 40 ml 0.9% saline; for children <10 kg, use 10,000 units in 10 ml 0.9% saline 3
• This intervention should be started early rather than waiting for treatment failure 1

Surgical Escalation Algorithm

• Initiate early discussion with a thoracic surgeon if no response to drainage, antibiotics, and fibrinolytics within 48-72 hours 2, 3
• Specific indications for surgical intervention include: 1, 2, 3
  • Persistent sepsis despite medical management
  • Organized empyema with thick pleural peel causing restricted lung expansion
  • Multiloculated empyema not responding to medical management
  • Bronchopleural fistula with pyopneumothorax

Surgical Approach Selection

• Video-assisted thoracoscopic surgery (VATS) is preferred for early-stage empyema (fibrinopurulent stage), offering less postoperative pain, shorter hospital stay, and better cosmetic results 1, 3, 4
• Open thoracotomy with decortication is reserved for late-presenting, chronic, or organized empyema with thick fibrous peel 2, 3, 5

Critical Pitfalls to Avoid

• Do not surgically drain a coexisting lung abscess—manage it with antibiotics that cover both the empyema and lung abscess, as surgical drainage increases morbidity without improving outcomes 2, 3
• Delayed diagnosis, inappropriate antibiotic selection, and inadequate chest tube placement contribute to progression of pleural infection 1
• A persistent radiological abnormality in a symptom-free, clinically well patient is NOT an indication for surgery 3
• Do not perform chest physiotherapy, as it provides no benefit in empyema 2, 3

Supportive Care

• Provide adequate analgesia to keep the patient comfortable, particularly with chest drains in place 1, 2, 3
• Administer antipyretics for fever control 1, 2, 3
• Encourage early mobilization and exercise once clinically stable 2, 3
• Monitor for secondary thrombocytosis, which is common and benign, requiring no specific treatment 2, 3

Monitoring Response to Treatment

• Assess effectiveness of therapy by measuring pleural fluid neutrophil count decrease and obtaining sterile cultures 1
• Consider a second paracentesis 48 hours after starting treatment to evaluate antibiotic effectiveness 1
• Follow patients until complete clinical recovery and chest radiograph returns to near normal, which may take weeks to months 1, 2, 3