Guidelines Summary
The American Association of Thoracic Surgery (AATS) has released consensus guidelines for the management of empyema. The guidelines were developed by a multidisciplinary group of experts and were based on a comprehensive review of the literature, as well as on expert opinion when high-quality evidence was not available. Key recommendations include the following [35] :
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Patients with pneumonia that fail to respond to established antibiotic therapy or unexplained sepsis should always be evaluated for a possible pleural effusion. If either a parapneumonic effusion or empyema is found, patients should undergo immediate treatment.
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Pleural ultrasound should be done routinely in addition to conventional chest X-ray to evaluate pleural space infection, both for diagnostic purposes and image guidance for pleural interventions.
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To establish a diagnosis of empyema, clinicians should consider the presence of pus, positive Gram's stain, or culture.
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A pleural pH below 7.2 in a patient with suspected pleural space infection predicts a complicated clinical course, and tube thoracostomy should be done followed by surgical intervention when appropriate.
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In patients with community-acquired empyema, a parenteral second- or third-generation cephalosporin plus metronidazole or parenteral aminopenicillin with beta-lactamase inhibitor.
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For those with hospital-acquired or postprocedural empyema, antibiotics should include those active against methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa.
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Aminoglycosides should be avoided, and antibiotic therapy should be chosen based on culture results when possible
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In stage II acute empyema, video assisted thoracoscopic surgery (VATS) should be the first-line treatment.
The American Pediatric Surgical Association Outcomes and Clinical Trials Committee published guidelines for the diagnosis and management of empyema in children. Recommendations include the following [36] :
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Once an effusion is diagnosed as empyema, definitive management should be initiated with mechanical (VATS) or chemical debridement (fibrinolysis)
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Operative management should be reserved for patients who fail to respond to chemical debridement if healthcare resources allow for such management.
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Consideration for VATS after chemical debridement should occur when the patient is persistently ill after the chest tube drainage is diminished and imaging proves substantial pleural space disease.
The AATS guidelines noted that there is disagreement about the best treatment protocols for children with empyema. After a comprehensive analysis of current literature, the guidelines recommendation was that pediatric patients should initially be treated with a tube thoracostomy with or without the subsequent instillation of fibrinolytic agents. [35]
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Empyema and Abscess Pneumonia. Histology of a lung abscess shows dense inflammatory reaction (low power).
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Empyema and Abscess Pneumonia. A thick-walled lung abscess.
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Empyema and Abscess Pneumonia. Pneumococcal pneumonia complicated by lung necrosis and abscess formation.
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Empyema and Abscess Pneumonia. A lateral chest radiograph shows air-fluid level characteristic of lung abscess.
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Empyema and Abscess Pneumonia. A 54-year-old patient developed cough with foul-smelling sputum production. A chest radiograph shows lung abscess in the left lower lobe, superior segment.
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Empyema and Abscess Pneumonia. A 42-year-old man developed fever and production of foul-smelling sputum. He had a history of heavy alcohol use, and poor dentition was obvious on physical examination. Chest radiograph shows lung abscess in the posterior segment of the right upper lobe.
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Empyema and Abscess Pneumonia. A 42-year-old man developed fever and production of foul-smelling sputum. He had a history of heavy alcohol use, and poor dentition was obvious on physical examination. Lung abscess in the posterior segment of the right upper lobe was demonstrated on chest radiograph. CT scan shows a thin-walled cavity with surrounding consolidation.
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Empyema and Abscess Pneumonia. Chest radiograph of a patient who had foul-smelling and bad-tasting sputum, an almost diagnostic feature of anaerobic lung abscess.
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Empyema and Abscess Pneumonia. Histology of a lung abscess shows dense inflammatory reaction (high power).
