Critical Alerts

• Empyema is a surgical infection - drainage is essential, not just antibiotics
• Delay in drainage worsens outcomes - early intervention improves survival
• Complicated parapneumonic effusion progresses to empyema without intervention
• Loculated effusions require specialty intervention (VATS, fibrinolytics)
• Consider empyema in any patient with pneumonia not responding to antibiotics

Key Diagnostics

• CT chest with contrast (best for loculations, staging)
• Diagnostic thoracentesis with pleural fluid analysis
• Pleural fluid criteria: pH <7.2, glucose <40 mg/dL, LDH >1000 IU/L, positive Gram stain/culture
• Blood cultures (often negative)
• Inflammatory markers (CRP, procalcitonin)

Emergency Treatments

• IV antibiotics: Empiric broad-spectrum coverage including anaerobes
• Chest tube drainage: Large bore (24-28 Fr) or image-guided small bore
• Cardiothoracic surgery consultation: For loculated disease, treatment failure
• Intrapleural fibrinolytics: TPA/DNase for loculated empyema
• Supportive care: Oxygen, fluids, nutrition

Empyema thoracis is defined as the presence of pus in the pleural space. It represents the end stage of a spectrum of pleural space infections that begins with simple parapneumonic effusion and progresses through complicated parapneumonic effusion to frank empyema. Early recognition and aggressive management are crucial for optimal outcomes.

Stages of Pleural Infection

Classification

Simple Parapneumonic Effusion

• Sterile
• pH >7.2
• Glucose >60 mg/dL
• LDH <1000 IU/L
• Resolves with antibiotics alone

Complicated Parapneumonic Effusion

• pH <7.2 or
• Glucose <40 mg/dL or
• LDH >1000 IU/L or
• Positive Gram stain/culture
• Requires drainage

Empyema

• Frank pus in pleural space or
• Positive culture with biochemical markers

Epidemiology

• Incidence: 1-5% of patients hospitalized with pneumonia
• Mortality: 5-15% with treatment; higher in elderly, immunocompromised
• Risk factors: Diabetes, alcohol use, aspiration, poor dentition, immunosuppression
• Trends: Increasing incidence of methicillin-resistant Staph aureus (MRSA)

Critical Findings

Indicators of Poor Prognosis

• Age >65 years
• Nosocomial acquisition
• Poor nutritional status
• Delayed drainage (>7 days from diagnosis)
• Loculated disease
• Positive blood cultures
• Renal impairment
• Low serum albumin

Causes of Exudative Pleural Effusion

Distinguishing Empyema from Other Effusions

Light's Criteria (Exudate if ANY met)

1. Pleural protein / Serum protein >0.5
2. Pleural LDH / Serum LDH >0.6
3. Pleural LDH > 2/3 upper limit of serum normal

Empyema-Specific Criteria

• pH <7.2
• Glucose <40 mg/dL
• LDH >1000 IU/L
• Positive Gram stain or culture
• Frank pus

Clinical Assessment

Key History

• Duration and progression of symptoms
• Prior pneumonia and antibiotic treatment
• Risk factors for aspiration
• Prior chest procedures or thoracic surgery
• Dental health (anaerobic source)

Imaging

Chest X-ray

• May show pleural effusion (blunted costophrenic angle)
• Loculated effusions may appear as D-shaped densities
• May see consolidation suggesting underlying pneumonia
• Air-fluid level suggests bronchopleural fistula

CT Chest with Contrast (Gold Standard)

Ultrasound

• Excellent for guiding thoracentesis
• Can detect loculations and septations
• "Complex" appearance suggests complicated effusion
• Useful for small effusions

Thoracentesis

Indications

• Any new pleural effusion in setting of pneumonia
• Effusion >10mm on lateral decubitus or >25mm on CT

Fluid Analysis

Laboratory Studies

ICU Admission Criteria

• Sepsis or septic shock
• Respiratory failure requiring high-flow O2 or ventilation
• Need for emergent drainage
• Hemodynamic instability
• Significant comorbidities requiring monitoring

Hospital Ward Admission

• All patients with empyema require admission
• Hemodynamically stable patients
• Post-chest tube placement observation
• IV antibiotic therapy

Transfer Considerations

• Transfer to facility with cardiothoracic surgery if unavailable
• Complex/refractory cases may need specialized center

Discharge Criteria

• Afebrile for 48+ hours
• Chest tube removed, lung expanded on CXR
• Tolerating oral antibiotics
• Stable or improving inflammatory markers
• Follow-up arranged

Outpatient Follow-up

Understanding Empyema

• Empyema is an infection in the space around the lung
• It usually develops from pneumonia
• Treatment requires both antibiotics and drainage
• Recovery takes several weeks

Chest Tube Care

• The tube drains infected fluid from your chest
• It will be attached to a collection device
• Report pain, difficulty breathing, or tube dislodgement
• Keep insertion site clean and dry

Recovery Expectations

• Hospital stay typically 1-2 weeks or longer
• Fatigue may persist for weeks to months
• Gradual return to normal activity
• Complete antibiotic course is essential

Warning Signs After Discharge

• Fever returning
• Worsening shortness of breath
• Increasing chest pain
• Drainage from chest tube site
• Feeling unwell/deteriorating

Immunocompromised Patients

• Higher risk for atypical organisms (fungi, mycobacteria, Nocardia)
• May present with minimal symptoms
• Broader empiric coverage needed
• Consider early surgical consultation

Elderly Patients

• Higher mortality rates
• Often delayed presentation
• More comorbidities complicating management
• May require extended hospitalization

Post-Surgical/Traumatic Empyema

• Often S. aureus or Gram-negatives
• May have resistant organisms
• Early surgical involvement
• Consider possibility of esophageal injury

Tuberculous Empyema

• Chronic presentation (weeks to months)
• Lymphocytic predominant fluid
• Elevated adenosine deaminase (ADA)
• Requires anti-tuberculous therapy
• May need surgical decortication

Pediatric Considerations

• S. pneumoniae and S. aureus most common
• More likely to develop empyema from CAP than adults
• Often respond well to fibrinolytics
• Generally better outcomes than adults

Performance Indicators

Documentation Requirements

• Pleural fluid analysis results
• Imaging findings (loculations, size)
• Drainage method and output
• Antibiotic regimen and duration plan
• Response to treatment
• Disposition rationale

Diagnostic Pearls

1. Suspect empyema in any pneumonia not improving on antibiotics
2. CT is gold standard for assessing loculations and guiding intervention
3. pH <7.2 requires drainage - don't wait for culture
4. Split pleura sign on contrast CT indicates active pleural infection
5. Think of anaerobes in aspiration-related cases

Treatment Pearls

1. Antibiotics alone are insufficient - drainage is essential
2. Earlier drainage = better outcomes
3. Small bore catheters work if free-flowing
4. TPA/DNase combination reduces surgery need in loculated disease
5. Don't delay surgery if drainage fails after 5-7 days

Disposition Pearls

1. All empyema requires admission - no outpatient management
2. CT before discharge is not always needed if clinically resolved
3. Oral step-down after at least 1 week IV and clinical improvement
4. Follow-up CXR at 4-6 weeks to confirm resolution
5. Smoking cessation counseling for all