Empyema

Background

• Pleural space infections with positive Gram stain or culture OR parapneumonic effusions without pleural fluid sampling
• 3 stages
  • 1. Exudative
    • Free-flowing pleural effusion amenable to chest tube drainage; may only last <48hr
  • 2. Fibrinopurulent
    • Loculations develop making resolution w/ single chest tube drainage unlikely
  • 3. Organizational
    • Takes several weeks to develop; "pleural peel" restricts lung expansion

Causes

1. Pneumonia
2. Complications of chest or abdominal trauma
3. Esophageal perforation
4. Extension from lung abscess
5. Osteomyelitis or other near pleural infections
6. Hemothorax, chylothorax, or hydrothorax that becomes infected

Diagnosis

• Usually preceded by PNA
  • Suspect if symptoms of PNA do not resolve
• Diagnostic criteria
  • Aspiration of purulent material on thoracentesis and at least 1 of the following:
    • 1. Positive Gram stain or culture
    • 2. Pleural fluid glucose <40
    • 3. pH <7.1
    • 4. LDH >1000

Treatment

• Treat underlying disease
• Perform thoracentesis versus chest tube drainage if e/o respiratory distress
• Abx
  • Piperacillin-tazobactam 3.375-4.5gm q6hr IV or imipenem 0.5-1gm q6hr
  • Consider adding vancomycin if pt at risk for MRSA

See Also

• Pleural Effusion

Source

• Tintinalli