What is the recommended treatment for a patient with empyema?

Empyema Treatment

All patients with empyema require immediate broad-spectrum intravenous antibiotics combined with chest tube drainage, and intrapleural fibrinolytics should be administered for complicated parapneumonic effusions or frank empyema to shorten hospital stay and improve outcomes. 1, 2

Initial Antibiotic Therapy

Community-acquired empyema:

• Start IV antibiotics immediately covering Pneumococcus, Staphylococcus aureus, Haemophilus influenzae, and anaerobes 1
• Recommended regimens include:
  • Cefuroxime 1.5 g three times daily IV + metronidazole 400 mg three times daily orally (or 500 mg three times daily IV) 1
  • Alternative: Amoxicillin-clavulanate or clindamycin 300 mg four times daily 1
• Beta-lactams with beta-lactamase inhibitors or metronidazole are essential due to frequent penicillin-resistant aerobes and anaerobes 1

Hospital-acquired empyema:

• Requires broader spectrum coverage with piperacillin-tazobactam 4.5 g four times daily IV, ceftazidime 2 g three times daily IV, or meropenem 1 g three times daily IV 1

Critical antibiotic principles:

• Adjust therapy based on pleural fluid culture results when available 1, 2
• Never use aminoglycosides - they have poor pleural space penetration and are inactive in acidic pleural fluid 1, 2
• Do not administer antibiotics directly into the pleural space - IV administration provides adequate pleural penetration 1, 2
• Continue IV antibiotics for minimum 2-4 weeks, with total duration of 4-6 weeks for complicated cases 2

Pleural Drainage

Chest tube insertion:

• Insert small-bore chest drains under ultrasound or CT guidance within 24 hours of diagnosis 2, 3
• Small-bore catheters are less traumatic and more comfortable than traditional large-bore tubes 1
• Connect to unidirectional flow drainage system kept below chest level at all times 1
• Clamp drain for 1 hour after initially removing 10 ml/kg to prevent re-expansion pulmonary edema 1
• Never clamp a bubbling chest drain 1

Intrapleural fibrinolytics:

• Administer urokinase for any complicated parapneumonic effusion or frank empyema 1, 2
• Dosing: 40,000 units in 40 ml 0.9% saline twice daily for 3 days (6 doses total) for patients ≥10 kg 1, 2
• For patients <10 kg: 10,000 units in 10 ml 0.9% saline 1
• Fibrinolytics shorten hospital stay and improve drainage by breaking down loculations 1, 2

Surgical Intervention Timing

Early surgical consultation:

• Initiate discussion with thoracic surgeon if patient fails to respond to chest tube drainage, antibiotics, and fibrinolytics within 48-72 hours 2, 4
• Specific indications for surgery include:
  • Persisting sepsis after 5-7 days of appropriate drainage and antibiotics 1, 2
  • Organized empyema with thick pleural peel causing restricted lung expansion 4
  • Multiloculated empyema not responding to fibrinolytics 4

Surgical approach selection:

• Video-assisted thoracoscopic surgery (VATS) is preferred for early intervention in fibrinopurulent stage - offers less pain, shorter hospital stay, and better cosmetic results 4, 3, 5
• Open thoracotomy and decortication reserved for late-presenting chronic empyema with thick fibrous peel 4, 6
• Do not operate for persistent radiological abnormality alone in a clinically well, symptom-free patient 4

Transition to Oral Antibiotics

Step-down criteria:

• Switch to oral antibiotics once fever resolves, white blood cell count decreases, and pleural drainage is effective 2
• Assess treatment effectiveness at 5-8 days after starting drainage and antibiotics 2
• Oral regimens must maintain coverage of anaerobes: amoxicillin-clavulanate 1 g three times daily + clavulanic acid 125 mg three times daily, or clindamycin 1, 2
• Never discontinue anti-anaerobic coverage prematurely - inadequate anaerobic treatment increases failure rates 2

Supportive Care

• Provide adequate analgesia, particularly with chest drain in place 1
• Ensure adequate nutritional support from outset - poor nutrition associated with worse outcomes 2
• Do not perform chest physiotherapy - it provides no benefit in empyema 1, 2
• Encourage early mobilization and exercise 1

Follow-Up and Monitoring

• Continue follow-up until complete clinical recovery and chest radiograph returns to near normal 1, 2
• If bacteremia present, obtain blood cultures 2-4 days after initial cultures to document clearance 2
• Consider underlying diagnoses (immunodeficiency, cystic fibrosis) in appropriate cases 1
• Secondary thrombocytosis (platelets >500) is common but benign - no antiplatelet therapy needed 1