|Year : 2018 | Volume
| Issue : 4 | Page : 324-325
How to improve the outcome in empyema thoracis
Vishnu Sharma Moleyar
Department of Respiratory Medicine, A J Institute of Medical Sciences, Mangalore, Karnataka, India
|Date of Web Publication||2-Aug-2018|
Vishnu Sharma Moleyar
Department of Respiratory Medicine, A J Institute of Medical Sciences, Mangalore - 575 004, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Moleyar VS. How to improve the outcome in empyema thoracis. Med J DY Patil Vidyapeeth 2018;11:324-5
Empyema thoracis leads to significant mortality and morbidity. Prompt evaluation of pleural effusion and appropriate therapeutic intervention is the key to reduce morbidity and mortality as well as health-care costs.
Risk factors for empyema include diabetes mellitus, immunosuppression, gastroesophageal reflux, alcohol abuse, and intravenous drug abuse. History of aspiration or poor oral hygiene predisposes to anaerobic infection. Iatrogenic pleural infection following pleural interventions and thoracic or esophageal surgery, trauma or esophageal perforation also can lead to empyema. Many patients may not have any apparent risk factors. Risk factors should be identified and treated promptly in all patients with empyema.
Initial treatment of a patient with empyema is to administer an appropriate antibiotic to cover likely pathogens and proper drainage of pleural fluid.
Pleural fluid characteristics are the most reliable diagnostic test to guide the management of pleural effusion. Diagnostic pleural fluid sampling should be done in all patients with a pleural effusion >10 mm depth in association with a pneumonic illness or recent chest trauma or surgery and who have features of ongoing sepsis. Small effusions (i.e., <10-mm thickness) usually resolve with antibiotics. They should be observed and any increase in the size of the effusion or ongoing sepsis should warrant reevaluation and diagnostic pleural fluid sampling in such cases.
The presence of frank pus on diagnostic aspiration indicates empyema and should be treated with prompt chest tube drainage. Pleural fluid pH, protein concentration, and microbiological culture of the pleural fluid should be done in all nonpurulent aspirates immediately. Pleural fluid pH <7.2, the presence of organisms identified by Gram-stain and/or culture indicates empyema and should be treated by chest tube drainage. Patients with a loculated pleural collection should receive early chest tube drainage.
Antibiotic choice should be guided by bacterial culture results and advice from a microbiologist. When bacterial cultures are negative, antibiotics should cover both common community-acquired bacterial pathogens and anaerobic organisms. Empirical antibiotic treatment for hospital-acquired empyema should include treatment for methicillin-resistant Staphylococcus aureus and anaerobic bacteria. Intrapleural antibiotics are not recommended. There is no indication for the routine use of intrapleural fibrinolytics.
Patients with persistent sepsis and with a residual pleural collection should undergo further radiological imaging and should be discussed with a thoracic surgeon to consider possible surgical options available. Video-assisted thoracic surgery is increasingly used as first-line therapy although open thoracic drainage or thoracotomy and decortication remain alternative techniques.
Loculated fluid, pleural fluid culture positivity for microorganisms, anaerobic infection, delay in intercostal tube drain placement, hypoalbuminemia, and associated comorbid illness have been related to adverse outcome in empyema. Hence, all patients with empyema should be evaluated for these factors and should be managed accordingly. In the article “Assessment of factors associated with drainage duration and hospital stay of non tuberculous empyema in a tertiary care hospital of West Bengal: A prospective study” the authors have found comorbid illnesses, positive culture growth, and Gram-negative organism in pleural fluid were the factors associated with increased drainage duration and hospital stay of non tuberculous empyema. Early identification and prompt management of risk factors associated with a poor outcome may decrease the morbidity and mortality in empyema.
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