Management of Multiloculated Empyema When Percutaneous Drainage Fails
When percutaneous drainage of a multiloculated empyema yields only minimal fluid, proceed immediately to intrapleural fibrinolytic therapy through the existing catheter, and if no clinical improvement occurs within 3–7 days, refer urgently for video-assisted thoracoscopic surgery (VATS) or open surgical drainage. 1, 2
Immediate Next Steps After Failed Percutaneous Drainage
Optimize the Existing Drainage System
Verify catheter position and patency using ultrasound or CT imaging to ensure the catheter tip is within the largest fluid collection and not kinked or obstructed. 1
Flush the catheter daily with 20–50 mL normal saline if drainage suddenly stops or becomes minimal, as fibrinous debris commonly occludes small-bore catheters in empyema. 2
Consider placing additional catheters under imaging guidance into separate loculated compartments, as multiloculated empyemas often require two or more drainage catheters to achieve adequate source control. 3, 4
Initiate Intrapleural Fibrinolytic Therapy
Administer intrapleural fibrinolytics immediately for any multiloculated empyema that fails to drain adequately with catheter placement alone. 1, 2, 5
Use urokinase 40,000 units in 40 mL saline (for adults ≥10 kg) instilled through the chest tube twice daily for three days (total of 6 doses), as this regimen has demonstrated efficacy in breaking down loculations and improving fluid evacuation. 2
Clamp the catheter for 1–2 hours after instilling the fibrinolytic to allow dwell time, then resume drainage. 2, 6
Expect clinical improvement within 48–72 hours if fibrinolytic therapy is effective, including increased drainage volume, fever resolution, and improved respiratory status. 2, 6
Ensure Appropriate Antibiotic Coverage
Verify that the patient is receiving broad-spectrum IV antibiotics with mandatory anaerobic coverage, as anaerobes are present in approximately 76% of empyema cases and their omission markedly increases mortality. 2, 7
Preferred empiric regimen is piperacillin-tazobactam 4.5 g IV every 6 hours, which provides excellent pleural space penetration and covers the expected pathogens in pancreatitis-associated empyema. 2, 7
Alternative regimens include cefuroxime 1.5 g IV three times daily plus metronidazole 500 mg IV three times daily, or meropenem 1 g IV three times daily plus metronidazole. 2, 7
Never use aminoglycosides (gentamicin, tobramycin, amikacin) even for gram-negative coverage, as they have poor pleural space penetration and are inactivated by the acidic pleural fluid. 2, 7
Timing of Surgical Referral
Indications for Urgent Surgical Consultation
Refer to thoracic surgery if no clinical improvement occurs after 7 days of adequate chest-tube drainage, appropriate antibiotics, and fibrinolytic therapy. 1, 2
Earlier surgical referral (within 3–5 days) is warranted when:
Immediate respiratory medicine or thoracic surgery consultation reduces mortality and improves outcomes in empyema patients, so involve specialists early rather than waiting for treatment failure. 2
Surgical Options
Video-assisted thoracoscopic surgery (VATS) is the preferred surgical approach for early-stage multiloculated empyema, offering less postoperative pain, shorter hospitalization, and better cosmetic outcomes compared to open thoracotomy. 2, 5, 9
Medical thoracoscopy (MT) is an alternative that is lower in cost, better tolerated in frail patients, and does not require tracheal intubation, while still being safe and successful in multiloculated empyema treatment. 9
Open thoracotomy with decortication is reserved for late-presenting, chronic, or organized empyema with a thick fibrous peel that cannot be managed with VATS. 2
Common Pitfalls to Avoid
Do not delay surgical referral beyond 7 days of failed medical management, as delays increase morbidity, prolong hospital stay, and worsen mortality. 1, 2
Do not assume a single catheter is sufficient for multiloculated empyema; most cases require two or more catheters placed into separate compartments under imaging guidance. 3, 4
Do not omit fibrinolytic therapy when loculations are present on ultrasound or CT, as this intervention significantly improves drainage success rates and may avoid the need for surgery. 2, 5, 6
Do not use blind chest tube placement for loculated collections; ultrasound or CT guidance improves success rates and safety. 1, 2, 4
Do not wait for culture results to initiate or adjust antibiotics if the patient remains septic; empiric broad-spectrum coverage with anaerobic activity must be maintained throughout. 2, 7
Monitoring Response to Therapy
Assess clinical response within 5–8 days of initiating chest-tube drainage and antibiotics, documenting fever resolution, improved respiratory status, decreased white blood cell count, and effective pleural drainage. 1, 2
Obtain repeat imaging (ultrasound or CT) if clinical improvement does not occur, to identify residual loculations, inadequate catheter position, or the need for additional drainage procedures. 1, 8
Persistent radiologic abnormality in an asymptomatic, well-appearing patient does not constitute an indication for surgical intervention, as residual pleural thickening commonly persists after successful treatment. 2