What is the treatment for an empyema (empyema is a condition characterized by the accumulation of pus in the pleural space)?

From the Guidelines

The treatment for an empyema involves a combination of antibiotics and drainage procedures, with surgical intervention considered if there is failure of medical management, persisting sepsis, or complex empyema. Initially, broad-spectrum antibiotics are started to target the likely pathogens, which may include anaerobes, Streptococcus species, or Staphylococcus aureus. Common antibiotic regimens include a combination of a beta-lactam (such as piperacillin-tazobactam 4.5g IV every 6 hours or ceftriaxone 2g IV daily) plus metronidazole 500mg IV every 8 hours, or clindamycin 600mg IV every 8 hours as a single agent 1. Drainage of the infected pleural fluid is essential and can be accomplished through thoracentesis, chest tube placement, or video-assisted thoracoscopic surgery (VATS) depending on the stage and complexity of the empyema. For loculated or organized empyemas, surgical intervention with VATS or thoracotomy with decortication may be necessary to remove fibrous tissue and fully expand the lung, as suggested by the British Thoracic Society guideline for pleural disease 1. Antibiotic therapy typically continues for 2-6 weeks, with the duration depending on clinical response, causative organism, and resolution of infection markers. Drainage tubes remain in place until fluid output decreases significantly (usually less than 50-100 mL per day) and pleural fluid cultures become negative. Some key points to consider in the management of empyema include:

• Failure of chest tube drainage, antibiotics, and fibrinolytics should prompt early discussion with a thoracic surgeon 1
• Patients should be considered for surgical treatment if they have persisting sepsis in association with a persistent pleural collection, despite chest tube drainage and antibiotics 1
• The decision to involve a surgeon early in the decision making process should be encouraged and referral should not automatically mean surgery is inevitable 1
• Surgical treatment should be considered if they have persisting sepsis in association with a persistent pleural collection, despite antibiotics, chest tube drainage, and fibrinolytics 1
• A persistent radiological abnormality in a symptom-free well child is not an indication for surgery 1

From the Research

Treatment Options for Empyema

• The treatment for empyema may involve medical management, such as antibiotics, or surgical intervention, including video-assisted thoracoscopic surgery (VATS) or open thoracotomy 2, 3, 4, 5.
• Antibiotics alone may be used as a first-line treatment, but fibrinolytics or VATS may be considered for patients who do not respond to conservative treatment 2.
• VATS has been shown to be a safe and effective alternative to open thoracotomy, with shorter hospital stays, fewer complications, and improved outcomes 4, 5.
• The use of medical thoracoscopy (MT) has also been explored as a treatment option for empyema, particularly for patients with multiloculated empyema, and has been found to be safe and successful 4.

Surgical Intervention

• VATS decortication has been compared to open thoracotomy in several studies, with results showing that VATS provides comparable outcomes with fewer complications and shorter hospital stays 5.
• The conversion rate of VATS to open thoracotomy can be high, but VATS is still considered a safe and reliable alternative to open thoracotomy 5.

Antibiotic Duration

• The proper duration of antibiotics after VATS is poorly defined, but a recent study found that short antibiotic durations (less than 14 days) were equally effective as longer durations in preventing empyema recurrence 6.
• Further research is needed to determine the optimal duration of antibiotic therapy post-VATS, with a prospective clinical trial recommended to reduce complications of prolonged antibiotic therapies 6.