What is the recommended management for empyema thoracis?

Management of Empyema Thoracis

Immediate Initial Management

All patients with empyema thoracis require immediate broad-spectrum intravenous antibiotics combined with chest tube drainage, and early surgical consultation should occur by day 7 if there is persistent sepsis despite medical management. 1, 2

Antibiotic Therapy

• Start IV antibiotics immediately upon diagnosis, before culture results are available 1
• For community-acquired empyema, use a second-generation cephalosporin (cefuroxime 1.5g TDS IV) plus metronidazole (400mg TDS orally or 500mg TDS IV), or alternatively meropenem 1g TDS IV plus metronidazole 1, 2
• For hospital-acquired empyema, use broader spectrum coverage with piperacillin-tazobactam 4.5g QDS IV, ceftazidime 2g TDS IV, or meropenem 1g TDS IV 1
• Avoid aminoglycosides as they penetrate poorly into pleural space and are inactive in acidic pleural fluid 1
• Adjust antibiotics based on culture results when available; Staphylococcus aureus (especially MRSA) is the most common pathogen and frequent cause of treatment failure 3, 4
• Continue antibiotics until clinical resolution with sterile cultures 2

Chest Tube Drainage

• Place a chest tube as soon as empyema is identified, as delay increases morbidity, hospital stay, and potentially mortality 1
• Use small-bore chest tubes with ultrasound guidance rather than large-bore tubes, as there is no advantage to larger drains 2, 5
• Connect to a unidirectional flow drainage system kept below chest level at all times 2, 5
• Misdiagnosis, inappropriate antibiotics, and inappropriate chest tube placement are major factors contributing to progression of pleural infection 1, 4

Intrapleural Fibrinolytic Therapy

• Administer intrapleural urokinase for complicated parapneumonic effusions and empyema to shorten hospital stay 2, 5
• Dosing: 40,000 units in 40ml 0.9% saline twice daily for 3 days (for adults and children ≥10kg) 5

Critical Decision Point: Day 5-7 Assessment

Assess response to medical management (antibiotics, drainage, fibrinolytics) at 5-7 days and document this assessment in clinical notes. 1, 2

Criteria for Surgical Referral

Refer to thoracic surgery if any of the following are present:

• Persistent sepsis with ongoing pleural collection despite 7 days of chest tube drainage, antibiotics, and fibrinolytics 1, 2, 6
• Bronchopleural fistula with pyopneumothorax 2, 5
• Multiloculated empyema not responding to medical management 2
• Organized empyema with thick fibrous peel causing chronic sepsis and restricted lung expansion 2

Common pitfall: Delaying surgical referral beyond 7 days of failed medical management significantly increases morbidity, hospital stay, and need for more extensive procedures like decortication 1, 4. Early referral (within 7 days) results in lower morbidity and shorter hospital stays 4.

Surgical Management Algorithm

Video-Assisted Thoracoscopic Surgery (VATS)

• VATS is the preferred first-line surgical approach for persistent multiloculated empyema in the fibrinopurulent stage 2, 5, 7
• VATS offers shorter operative time (76 minutes vs 125 minutes), less blood loss (132ml vs 314ml), and shorter chest tube duration (4.7 days vs 8.3 days) compared to open thoracotomy 7
• Success rate of 91-92% for multiloculated empyema 2

Open Thoracotomy with Decortication

• Reserved for organized empyema with thick fibrous peel causing chronic sepsis and trapped lung 2, 6, 5
• Required in approximately one-third of empyema cases that fail conservative management 8
• Requires preoperative CT scanning with IV contrast to define pleural peel thickness versus consolidated lung 2, 6

Critical pitfall: Do not attempt VATS in organized empyema with thick fibrotic peel, as this leads to conversion to open thoracotomy 2. Conversely, do not operate on radiological abnormalities alone in asymptomatic, clinically well patients 2, 5.

Alternative for High-Risk Patients

• For patients unfit for general anesthesia with persistent sepsis, consider re-imaging and placement of additional image-guided catheters, or rib resection with open drainage under local anesthesia 1

Essential Supportive Care

Nutritional Support

• Provide aggressive nutritional support immediately upon diagnosis, as poor nutrition is a critical determinant of outcome 1, 6
• Hypoalbuminemia is associated with poor outcomes; measure BMI, obtain formal dietitian assessment, and provide dietary supplementation 1, 6
• Malnutrition must be optimized before surgery 6

Bronchoscopy

• Perform bronchoscopy only if high suspicion of bronchial obstruction exists, as tumor is found in less than 4% of cases 1, 6

Pain Management

• Ensure adequate analgesia, as pleuritic pain affects respiratory mechanics and recovery 6, 5

Specialist Care Coordination

• Empyema management should be concentrated in specialist hands (respiratory physician with established liaison to thoracic surgeon) due to complexity and need for prompt treatment 1
• In centers with immediately available thoracic surgery, surgical opinion is appropriate after approximately 7 days in any patient not improving with drainage and antibiotics 1

Follow-Up

• Continue follow-up until complete recovery with near-normal chest radiograph 2, 5
• Monitor for secondary thrombocytosis and scoliosis, which are common but benign and resolve spontaneously 5