What is the recommended clinical management for a patient diagnosed with empyema thoracis?

Clinical Management of Empyema Thoracis

Empyema thoracis requires immediate broad-spectrum intravenous antibiotics combined with prompt chest tube drainage, as delays in drainage are associated with increased morbidity, prolonged hospitalization, and potentially increased mortality. 1

Immediate Antibiotic Therapy

All patients must receive antibiotics as soon as pleural infection is identified. 1

Culture-Directed Therapy

• Antibiotics should be guided by pleural fluid culture results and sensitivities whenever possible 1
• Beta-lactams (penicillins and cephalosporins) remain the drugs of choice due to excellent pleural space penetration 1
• Avoid aminoglycosides as they have poor pleural space penetration and may be inactive in acidotic pleural fluid 1
• Never administer antibiotics directly into the pleural space 1

Empirical Antibiotic Regimens

For community-acquired empyema (culture-negative): 1

• IV regimens: Cefuroxime 1.5g TDS IV + metronidazole 400mg TDS orally (or 500mg TDS IV), OR benzyl penicillin 1.2g QDS IV + ciprofloxacin 400mg BD IV, OR meropenem 1g TDS IV + metronidazole 1
• Oral regimens: Amoxicillin 1g TDS + clavulanic acid 125mg TDS, OR amoxicillin 1g TDS + metronidazole 400mg TDS, OR clindamycin 300mg QDS 1
• Coverage must include Pneumococcus, Staphylococcus aureus, Haemophilus influenzae, and anaerobic organisms 1

For hospital-acquired empyema: 1

• Requires broader spectrum coverage: Piperacillin-tazobactam 4.5g QDS IV, OR ceftazidime 2g TDS IV, OR meropenem 1g TDS IV ± metronidazole 1

Critical pitfall: Penicillin alone frequently fails—nine of 17 patients (53%) failed penicillin monotherapy in one series, particularly with Bacteroides organisms present. 2

Pleural Space Drainage

Prompt chest tube drainage is essential and should not be delayed. 1

Drainage Technique

• Small-bore chest drains are recommended over large-bore drains, as there is no evidence of superiority for large-bore drains and they cause more patient discomfort 3
• Use ultrasound guidance to determine optimal drain insertion site 3
• Connect to a unidirectional flow drainage system kept below chest level at all times 3
• To prevent re-expansion pulmonary edema: Clamp drain for 1 hour after initially removing 10 mL/kg, but never clamp if bubbling 3

Intrapleural Fibrinolytic Therapy

• Administer intrapleural urokinase for any complicated parapneumonic effusion or empyema to shorten hospital stay 3
• Dosing protocol: 40,000 units in 40 mL 0.9% saline for patients ≥10 kg; 10,000 units in 10 mL 0.9% saline for patients <10 kg, administered twice daily for 3 days 3
• Fibrinolytics facilitate drainage by degrading loculations and decreasing fluid viscosity 4
• Note: A meta-analysis found insufficient evidence to support routine fibrinolytic use, though individual studies show benefit 1

Surgical Intervention

Initiate early discussion with a thoracic surgeon if the patient fails to respond to chest tube drainage, antibiotics, and fibrinolytics within 48-72 hours. 3

Indications for Surgery

• Persisting sepsis with persistent pleural collection despite medical management 3
• Organized empyema with thick pleural peel causing chronic sepsis and restricted lung expansion 3
• Multiloculated empyema not responding to drainage 3
• Bronchopleural fistula with pyopneumothorax 3

Surgical Approach Selection

• Video-Assisted Thoracoscopic Surgery (VATS): Most appropriate for early intervention in the fibrinopurulent stage, offering less postoperative pain, shorter hospital stay (mean 17.6 days vs thoracotomy), shorter operative time (76.2 vs 125 minutes), less blood loss (131.6 vs 313.9 mL), and better cosmetic results 3, 5
• Open thoracotomy and decortication: Reserved for late-presenting empyema, chronic empyema, and organized empyema with thick fibrous peel 3, 5
• Conversion from VATS to open thoracotomy occurs in approximately 6.7% of cases 5

Critical pitfall to avoid: A persistent radiological abnormality in a symptom-free, clinically well patient is NOT an indication for surgery. 3

Specialist Care and Timing

Care should be focused in specialist hands, ideally under a respiratory physician with established liaison to thoracic surgery. 1

• In centers with immediately available thoracic surgery, surgical opinion is appropriate after approximately 7 days in any patient not settling with drainage and antibiotics 1
• Misdiagnosis, inappropriate antibiotics, and inappropriate chest tube placement are important factors contributing to disease progression 1

Conservative Management Success Rates

• Approximately two-thirds of patients with primary bacterial empyema achieve resolution with conservative therapy (thoracentesis, appropriate antibiotics, and tube drainage) 2
• The remaining one-third require decortication 2
• Overall cure rate without conversion to open thoracotomy approaches 91% with appropriate management 6

Supportive Care

• Provide antipyretics for fever control and adequate analgesia, particularly with chest drain in place 3
• Do not perform chest physiotherapy—it is not beneficial in empyema 3
• Encourage early mobilization and exercise once clinically stable 3
• Monitor for secondary thrombocytosis (common but benign, requires no treatment) 3

Follow-Up

• Follow patients until complete clinical recovery and chest radiograph returns to near normal 3
• Consider underlying diagnoses such as immunodeficiency or cystic fibrosis in appropriate cases 3