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Parapneumonic Pleural Effusions and Empyema Thoracis Follow-up

  • Author: Atikun Limsukon, MD; Chief Editor: Ryland P Byrd, Jr, MD  more...
Updated: Mar 12, 2014

Further Outpatient Care

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  • Often, prolonged antibiotic therapy is required, particularly in patients who have anaerobic infections. The length of antibiotic therapy is generally dictated by the response to antibiotics and clinical and radiologic resolution.

Further Inpatient Care

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  • Patients require hospitalization for antibiotic therapy, drainage of pleural space, thrombolytic therapy (possibly), and surgery (in patients in whom medical therapy is unsuccessful).

Inpatient & Outpatient Medications

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  • Extended treatment with antibiotics may be required. See Medication for the antibiotic list.


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  • If specialty services are not available (interventional radiologist and/or thoracic surgeon), some patients may require transfer to a hospital that is able to provide these services.


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  • Early diagnosis and intervention (thoracentesis and/or drainage procedure), may obviate the need for surgical treatment.


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  • Complications are related to adverse events related to incomplete drainage of infected pleural fluid. These include chronic, indolent infections, chest tube site infections, trapped lung, bronchopleural fistulas, and pneumothoraces.
  • Untreated infections may lead to sepsis, septic shock, and death.


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  • Most patients recover, but the mortality rate remains approximately 10%.
  • Appropriate antibiotic therapy and early drainage of pleural fluid are crucial for recovery.
  • Approximately 15-25% of patients require surgical intervention, including decortication and/or an open drainage procedure.

Patient Education

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  • For excellent patient education resources, visit eMedicineHealth's Lung Disease and Respiratory Health Center. Also, see eMedicineHealth's patient education article Bacterial Pneumonia.
Contributor Information and Disclosures

Atikun Limsukon, MD Instructor, Department of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Thailand

Disclosure: Nothing to disclose.


Guy W Soo Hoo, MD, MPH Clinical Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Medical Intensive Care Unit, Pulmonary and Critical Care Section, West Los Angeles Healthcare Center, Veteran Affairs Greater Los Angeles Healthcare System

Guy W Soo Hoo, MD, MPH is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Thoracic Society, Society of Critical Care Medicine, California Thoracic Society, American Association for Respiratory Care

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Ryland P Byrd, Jr, MD Professor of Medicine, Division of Pulmonary Disease and Critical Care Medicine, James H Quillen College of Medicine, East Tennessee State University

Ryland P Byrd, Jr, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

Michael Peterson, MD Chief of Medicine, Vice-Chair of Medicine, University of California, San Francisco, School of Medicine; Endowed Professor of Medicine, University of California, San Francisco-Fresno, School of Medicine

Michael Peterson, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Thoracic Society

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Sat Sharma, MD, FRCPC, to the development and writing of this article.

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Left pleural effusion developed 4 days after antibiotic treatment for pneumococcal pneumonia. Patient developed fever, left-sided chest pain, and increasing dyspnea. During thoracentesis, purulent pleural fluid was removed, and the Gram stain showed gram-positive diplococci. The culture confirmed this to be Streptococcus pneumoniae.
Left lateral chest radiograph shows a large, left pleural effusion.
A right lateral decubitus chest radiograph shows a free-flowing pleural effusion, which should be sampled with thoracentesis for pH determination, Gram stain, and culture.
CT scan of thorax shows loculated pleural effusion on left and contrast enhancement of visceral pleura, indicating the etiology is likely an empyema.
Chest CT scan with intravenous contrast in a patient with mixed Streptococcus milleri and anaerobic empyema following aspiration pneumonia, showing a thickened contrast-enhanced pleural rind, high-density pleural effusion, loculation, and septation. Thoracentesis yielded foul-smelling pus.
Chest CT scan with intravenous contrast in a patient with mixed Streptococcus milleri and anaerobic empyema following aspiration pneumonia, 3 days following thoracostomy and intrapleural fibrinolysis (Reteplase).
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