What is the treatment for empyema?

Empyema Treatment

Empyema requires immediate IV antibiotics combined with pleural space drainage, and if there is no clinical improvement within 5-7 days, early surgical consultation is mandatory. 1, 2

Immediate Antibiotic Therapy

First-Line Antibiotic Regimens

Start IV antibiotics immediately upon diagnosis—delayed treatment significantly increases morbidity and mortality. 1, 2

Piperacillin-tazobactam 4.5g IV every 6 hours is the optimal first-line choice due to excellent pleural space penetration and broad-spectrum coverage including anaerobes. 1, 2

Alternative regimens for community-acquired empyema include: 1, 2

• Cefuroxime 1.5g IV three times daily PLUS metronidazole 500mg IV three times daily
• Meropenem 1g IV three times daily PLUS metronidazole 400mg three times daily
• Benzyl penicillin 1.2g IV four times daily PLUS ciprofloxacin 400mg IV twice daily
• Clindamycin alone (excellent for penicillin-allergic patients, provides both aerobic and anaerobic coverage as a single agent) 1

MRSA Coverage

Add vancomycin 15-20 mg/kg IV every 8-12 hours (targeting trough levels 15-20 mg/mL) or linezolid 600mg IV every 12 hours if MRSA is suspected or confirmed. 1, 2

Critical Antibiotic Considerations

• Never use aminoglycosides—they have poor pleural space penetration and are inactivated by acidic pleural fluid 1, 2, 3
• Anaerobic coverage is essential—anaerobes are frequently present and inadequate coverage leads to treatment failure 1, 2
• Adjust therapy based on pleural fluid culture and sensitivity results whenever possible 1, 2

Pleural Space Drainage

All empyemas require drainage in addition to antibiotics—antibiotics alone are insufficient. 2

Drainage Technique

• Insert small-bore chest drains or pigtail catheters under ultrasound or CT guidance within 24 hours of diagnosis 2, 3
• Connect chest tubes to a unidirectional flow drainage system kept below the level of the patient's chest 3
• Perform chest radiograph after drain insertion 3
• Check drain patency if there is sudden cessation of fluid drainage by flushing 4, 3
• Replace blocked drains that cannot be unblocked if significant pleural fluid remains 4, 2

Intrapleural Fibrinolytics

Administer urokinase for complicated parapneumonic effusions or empyema with thick fluid and loculations—this shortens hospital stay. 4, 2, 3

Dosing regimen: 4, 2, 3

• Urokinase 40,000 units in 40 mL 0.9% saline twice daily for 3 days (6 doses total) for patients ≥10 kg
• Urokinase 10,000 units in 10 mL 0.9% saline twice daily for 3 days for patients <10 kg

Surgical Intervention

Obtain early discussion with a thoracic surgeon if the patient fails to respond to chest tube drainage, antibiotics, and fibrinolytics within 48-72 hours. 2

Patients should be considered for surgery if they have persisting sepsis in association with a persistent pleural collection after 5-7 days of appropriate drainage and antibiotics. 4, 2, 3

Surgical options include: 2, 3

• Video-assisted thoracoscopic surgery (VATS) as the preferred minimally invasive approach
• Open thoracotomy with decortication for organized empyema
• Local anesthetic rib resection for patients unsuitable for general anesthesia

Duration and Transition of Antibiotic Therapy

Continue IV antibiotics for a minimum of 2-4 weeks, with total duration of 4-6 weeks for complicated cases. 2

Transition to Oral Antibiotics

Switch to oral antibiotics only after clinical improvement is demonstrated: resolution of fever, decreasing white blood cell count, and effective pleural drainage. 1, 2

Give oral antibiotics at discharge for 1-4 weeks, longer if residual disease persists. 1, 2, 3

Preferred oral regimens: 1

• Amoxicillin-clavulanate 1g/125mg three times daily
• Clindamycin 300mg four times daily (excellent for penicillin-allergic patients)

Supportive Care

• Provide adequate analgesia to keep patients comfortable, particularly with chest drains in place 4, 2, 3
• Encourage early mobilization and exercise 4, 2, 3
• Do not perform chest physiotherapy—it provides no benefit in empyema 4, 2
• Ensure adequate nutritional support from the outset—poor nutrition is associated with worse outcomes 2
• Give antipyretics as needed 4

Monitoring Treatment Response

Assess treatment effectiveness 5-8 days after starting chest tube drainage and antibiotics. 2

Resolution of pleural infection is confirmed by: 2, 3

• Pleural fluid neutrophil count <250/mm³
• Sterile cultures
• Clinical improvement (fever resolution, improved respiratory status, decreased white blood cell count)

Remove drain once there is clinical resolution. 4, 2, 3

Critical Pitfalls to Avoid

• A bubbling chest drain should never be clamped 4, 3
• If a patient with a clamped drain complains of breathlessness or chest pain, immediately unclamp the drain 4, 3
• Patients with chest drains should be managed on specialist wards by staff trained in chest drain management 4, 3
• Delayed diagnosis and inappropriate antibiotic selection contribute to progression of pleural infection 1

Follow-Up

Continue follow-up until complete clinical recovery and chest radiograph returns to near normal, which may take weeks to months. 2, 3

Consider underlying diagnoses such as immunodeficiency, cystic fibrosis, or bronchial obstruction in appropriate cases. 4, 2, 3