What is the medical management of empyema thoracis?

Medical Management of Empyema Thoracis

Initiate broad-spectrum intravenous antibiotics immediately targeting both aerobic and anaerobic organisms, combined with small-bore chest tube drainage and intrapleural fibrinolytic therapy, with early surgical consultation if no clinical response occurs within 7 days. 1, 2

Initial Antibiotic Therapy

Start empiric antibiotics immediately upon diagnosis, before culture results are available. 2 The recommended regimens include:

• Second-generation cephalosporin plus metronidazole 2
• Benzyl penicillin plus ciprofloxacin 2
• Meropenem plus metronidazole 2
• Clindamycin alone (particularly effective in penicillin-allergic patients, with 82% success rate) 2, 3

Avoid aminoglycosides due to poor pleural space penetration. 2 For pediatric cases, third-generation cephalosporins are preferred as Streptococcus pneumoniae is the most common pathogen. 2 The most frequently isolated organisms in adults are Staphylococcus aureus (21-35%), Streptococcus species (31%), and anaerobes including Bacteroides (15%). 4, 5, 3

Pleural Space Drainage

Use small-bore chest drains or pigtail catheters rather than large-bore drains to minimize patient discomfort, as there is no evidence that large-bore drains provide any advantage. 1, 2

Key drainage principles include:

• Utilize ultrasound guidance to determine the optimal site for drain insertion 1
• Connect the drain to a unidirectional flow drainage system kept below the patient's chest level at all times 1, 2
• Clamp the drain for 1 hour once 10 ml/kg are initially removed to prevent re-expansion pulmonary edema 1
• Never clamp a bubbling chest drain 1, 2
• If a clamped drain causes breathlessness or chest pain, immediately unclamp and seek medical advice 2

Closed tube thoracostomy alone achieves cure rates of 62-63% in adults. 3, 6

Intrapleural Fibrinolytic Therapy

Administer intrapleural urokinase for any complicated parapneumonic effusion or empyema, as this shortens hospital stay. 1, 2 The dosing protocol is:

• Children ≥10 kg: 40,000 units in 40 ml 0.9% saline 1
• Children <10 kg: 10,000 units in 10 ml 0.9% saline 1
• Frequency: Twice daily for 3 days (6 doses total) 1, 2

While a meta-analysis suggests insufficient evidence to support routine fibrinolytic use, randomized controlled trials demonstrate benefit in shortening hospital stay. 7, 2

Timing of Surgical Consultation

Initiate early discussion with a thoracic surgeon if the patient fails to respond to chest tube drainage, antibiotics, and fibrinolytics within 7 days. 7, 1, 2 Specific indications for surgical intervention include:

• Persisting sepsis with persistent pleural collection despite antibiotics, chest tube drainage, and fibrinolytics 7, 1, 2
• Complex empyema with significant lung pathology (delayed presentation with significant peel and trapped lung) 7, 1
• Bronchopleural fistula with pyopneumothorax 7, 1
• Organized empyema with thick fibrous peel causing chronic sepsis and restricted lung expansion 1, 2

Critical pitfall to avoid: A persistent radiological abnormality in a symptom-free, clinically well patient is NOT an indication for surgery. 7, 1

Surgical Approach Selection

When surgery is indicated, the choice between video-assisted thoracoscopic surgery (VATS) and open thoracotomy depends on disease stage:

VATS is most appropriate for early surgery in the fibrinopurulent stage, offering less postoperative pain (operative time 76 minutes vs 125 minutes), shorter chest tube duration (4.7 days vs 8.3 days), less blood loss (132 ml vs 314 ml), and better cosmetic results. 7, 1, 2, 6 However, VATS has higher failure rates in advanced organized empyema, with conversion to thoracotomy required in 6.7-10% of cases. 7, 6

Open thoracotomy and decortication is reserved for late presenting empyema, chronic empyema, and organized empyema with thick fibrous peel. 1, 2 Decortication is ultimately necessary in 42-55% of patients with primary empyema, particularly with anaerobic (55%), tuberculous, staphylococcal, and pneumococcal infections. 3

Supportive Care

• Provide adequate analgesia, particularly with chest drains in place 1, 2
• Give antipyretics for fever control 1, 2
• Do NOT perform chest physiotherapy—it is not beneficial in empyema 1, 2
• Encourage early mobilization and exercise once clinically stable 1, 2

Follow-Up and Monitoring

Follow patients until complete clinical recovery with near-normal chest radiograph, which may take weeks to months. 2 Monitor for:

• Resolution confirmed by decreased pleural fluid neutrophil count and sterile cultures 2
• Secondary thrombocytosis (common but benign, requires no treatment) 1, 2
• Secondary scoliosis (common but benign) 1
• Consider underlying diagnoses such as immunodeficiency, cystic fibrosis, or tuberculosis (especially if bilateral effusions) in appropriate cases 1, 2

Special Considerations

Prophylactic antibiotics for trauma patients with tube thoracostomy: Evidence shows protective effect against empyema and pneumonia in penetrating thoracic injuries, but no protective effect in blunt trauma. 7 Given the low incidence of post-traumatic empyema (1.6-2%), routine antibiotic prophylaxis is not recommended for all trauma patients undergoing tube thoracostomy. 4