This document provides information on empyema, including its definition, etiology, stages, symptoms, investigations, and management. Empyema is defined as infection of the pleural space resulting in pus accumulation. It is usually caused by bacteria spreading from a pneumonia or other infection. It progresses through exudative, fibrinopurulent, and organizing stages. Symptoms include fever, cough, chest pain, and shortness of breath. Diagnosis involves imaging like chest X-ray or CT scan and thoracentesis. Management includes antibiotics, chest tube drainage, fibrinolytics, VATS, and sometimes open drainage or decortication surgery. The goal is to treat infection, drain pus, and re-expand

1. EMPYEMA
Mohammad Tailakh

2. Contents

Definition

Etiology

Stages

Symptoms & signs

Complications

Investigations

Management

3. Definition
Invading of the pleural space
with bacteria which result in
accumulation of pus .

4. Pleural Empyema / Pyothorax / Purulent
Pleuritis / Empyema Thoracis

5. Etiology (Introduction of infection)
EMPYEMA
THORACIC
SEPSIS
EXTRATHORACIC
SEPSIS IATROGENIC
NON-
IATROGENIC
SUBPHRENIC
ABSCESS,
HEPATIC
ABSCESS
MEDIASTINITIS
PULMONARY
DISEASE
OSTEOMYELI
TIS
LUNG
RESECTION,
OESOPHAGEAL
TEARS,
PARACETESIS
THORACIS,
LIVER BIOPSY
STABBINGS,G
UNSHOT
WOUNDS,ETC
PNEUMONIA, TB,
BRONCHIECTASIS
,LUNG ABCESS
STERNUM,
VERTEBRAE,
RIBS

6. etiology
 PARAPNEUMONIC( secondary to a
pneumonia)the most common
 Post trauma.
 Post surgery(esophageal or pulmonary(
 Subphrenic Abscess

7. Bacteriological data.
 Streptococcus pneumoniae: most common
Increased resistance
 Staphylococcus:15-30%
 Streptococcus spp
 Gram Negative: 20-50%
Klebsiella, Enterobacter,
Pseudomonas, Hemophilus, E.Coli
 Anaerobes:
Fusobacterium, Bacteroides fragilis

8. Influence of predisposing factors
 In adults – empyema arises as a complication of
CAP,often pneumococcal.
 Most common empyema in children post-pneumonia
parcent 80% ,adult 20%.
 Aerobic gram negative bacilli infection likely to affect
pleura – from below diaphragm or as a result of
oesophageal instrumentation.
 Mycobacteria and fungi more common in
immunocompromised.

9. Uncommon microbial causes
 Tuberculous
 Fungal – Aspergillous,Cryptococcus,Blastomyces,
Histoplasmosis.
 Actinomyces – aerobic gram negative filamentous
bacteria.
 Clostridia – anaerobic organism.
 Hydatid disease – Echinococcus.
 Lung fluke – Paragonimus westermani.
 Protozoa – Trichomonas,Entamoeba histolytica.

10. Pathology-Stages

11. Stages cont,

12. Stages cont,
 Stage of vascularization:
 Fibrinous layers starts to organize as collagen.
 Becomes vascularized by ingrowth of capillaries.

13. Stages cont,
 Organizing (chronic) Stage: after 21 days.
 Usually 4-6 weeks.
 Empyema cavity becomes surrounded by a cortex.
 Contains pus.
 Inner layers shows inflammatory cells.
 Outer layers gets fibrous – exerts restrictive effect.
 Compressing the underlying lung (trapped lung
effect).
 Draws the ribs together producing chest deformity.
 Later on gets calcified – fibrothorax.

14. RISK FACTORS
 alcoholism.
drug use.
 HIV infection.
 neoplasm .
pre-existent pulmonary disease
.

15. Symptoms & signs
 Depends on nature of infecting organism
 competence of patients immune system.
 Ranges from complete absence of symptoms to a severe
illness with all usual manifestations of systemic toxicity.
 Fever
 Cough & Expectoration.
 Pleuretic chest pain.
 Dyspnoea
 Easy fatiguability.
 Loss of weight.
 Night sweating.

16. Signs of pleural effusion.
Finger clubbing.

17. Complications
 Rupture into the lung; BronchoPleural
fistula.
 Spread to the subcutaneous tissue;
Empyema necessitans.
 Septicaemia & septic shock.

18. Diagnosis
 LRTI)lower respiratory tract infection) – possibility of
complicating empyema.
 History and physical findings may be suggestive.
 CXR,USG(ultrasonogrophy),CT.
 Thoracentesis- PH < 7.4
Glucose <40 mg/dl
LDH> 1000 iu/dl
Protein > 2.5 gm/dl
Sp.gravity >1.018
 Other findings (non specific):neutrophil leucocytosis

19. Chest x ray
 In early stages same as
uncomplicated pleural
effusion.
 As time passes, fibrosis
develops around empyema
cavity.
 Fluid contained in one
location.
 Air fluid level
 Homogenous shadow
extending upwards.

20. Empyema Ct scan

21. empyema
ultrasonography

22. Thoracentesis:PH < 7.4
Glucose <40 mg/dl
LDH> 1000 iu/dl
Protein > 2.5 gm/dl
Sp.gravity >1.018

23. Lateral cxr
 opacity convex anteriorly.
Tapering at its upper and
lower ends
Extending into the thorax.
D – shaped shadow.

26. Pleural Empyema
Management

27. Goals of the treatment
 Treat the infection.
 Drain the purulent effusion adequately and
completely.
 Re-expand the lung to fill the pleural space.
 Eliminate complications and avoid chronicity.

28. Antimicrobial Therapy
 Choice of antibiotic – microbiological C/S testing.
 Anaerobes- may be treated with Benzylpenicillin.
 If resistant – add metronidazole.
 Better response – Clindamycin + Penicillin ( active
against Bacteroids fragilis and other penicillin-
resistant anaerobes

29.  Pneumococcus
 Responds to high dose benzylpenicillin
initially,continuing with oral phenoxy methyl
penicillin(penicillin V) or amoxycillin.
 Alternatives for penicillin allergic individuals- Cefradin or
Clarithromycin.

30.  Staphylococcus aureus
 Dicloxacillin,oxacillin for parenteral use.
 First generation cephalosporins – cefradine.
 MRSA- vancomycin,Linezolid.
 Gram negative aerobes
 Serious aerobic infections may be treated with the
combination of a third generation cephalosporin –
Ceftazidime and an amynoglycoside such as gentamycin.
 Mixed infection,including anaerobes – piperacillin.

31.  Adults with empyema who are admitted from the
community, and in whom infecting organism have not
yet been identified may be treated initially with a
combination that includes co-amoxyclav,metronidazole
and flucloxacillin.
 This regimen is modified in the light of cultures and the
patients clinical response.
 Duration of therapy is likely to be several weeks.
 It can be continued for at least 3 weeks after all
drainage has ceased.

32. BTS guidelines for the management of empyemaOrigin of infection Intravenous antibiotic
treatment
Oral antibiotic treatment
Community acquired culture
negative pleural infection
Cefuroxime 1.5 g tds iv +
metronidazole 400 mg tds
orally or 500 mg tds iv
Amoxycillin 1 g tds +
clavulanic acid 125 mg tds
Benzyl penicillin 1.2 g qds iv
+ ciprofloxacin 400 mg bd iv
Amoxycillin 1 g tds +
metronidazole 400 mg tds
Meropenem 1 g tds iv +
metronidazole 400 mg tds
orally or 500 mg tds iv
Clindamycin 300 mg qds
Hospital acquired culture
negative pleural infection
Piperacillin + tazobactam 4.5
g qds iv
Not applicable
Ceftazidime 2 g tds iv,
Meropenem 1 g tds iv ±
metronidazole 400 mg tds
orally or 500 mg tds iv

33. Tuberculous Empyema
 Rare entity.
 Purulent fluid loaded with tuberculous organisms.
 Usually develops in fibrous scar tissue resulting from
pleurisy, artificial pneumothorax or thoracoplasty.
 Underlying pleura is heavily calcified.
 Sub acute or chronic illness
 Fatigue, low grade fever and weight loss.
 Radigraphically – obvious pleural effusion, pleural
thickening.
 CT scan – thick calcified pleural rind and rib thickening
surrounded by loculated pleural fluid.

34. Tuberculous Empyema
 Diagnosis – thoracentesis, AFB smear and
culture.
 Treatment – intensive chemotherapy coupled
with serial thoracentesis can be curative at
times.
 Multiple drug regimen at their maximal tolerated
dosages.
 Strong tendency to develop resistant organisms.
 ATT frequently do not reach there normal levels
in the pleural space owing to the thick, fibrous
and often calcified pleura.
 VATS/Decortication.

35. Primary treatment options
 Antibiotics alone;
 Recurrent thoracocentesis
 Insertion of chest drain alone or in combination with fibrinolytics
 VATS.
 Open decortication

36. Thoracocenthesis
 Big caliber needle.
 Repeated aspiration is carried out.
 Use of Abrams punch biopsy needle
is useful initially. Wide callibre
allow easy aspiration and also
permits pleural biopsy.
 Mostly diagnosis technique
 Therapeutically used if the liquid
remains fluid
 Helps in pleural lavage also.

37. Chest Tube
 Closed tube thoracostomy.
 As soon as the fluid is thick.
 Localization
 loculated: Chest imaging using
ultrasonography and/or computed
tomography
 Size: 20 - 28 F
 Passed under USG guidance,helps in
breaking fibrinous septa and pus
rapidly gets removed
 Bedside

38. Pleural Lavage
 Isotonic saline
 +/- Noxyflex (noxytioline)
 Modalités
 3 way stopcock
 Directly through the CT: 250 to 500 ml
 Cautiously if suspicion of broncho-pleural
fistula
 Timing:
 Immediately after CT placement+++
 Once a day until the liquid is clear

39. Fibrinolytics
Intrapleural Streptokinase;
 Indications
 Acute or fibrino purulent stage
 Presence of loculations.
 Incomplete drainage after tube insertion
 Contraindications:
 Chronic stage
 Post-operative empyema
 Empyema with BPF.

40. Fibrinolytics
 Was reported in 1949.
 Then was abandoned due to allergic reactions,but taken up
again due to availability of purer forms of
streptokinase,urokinase.
 (Davies RJO,Trail ZC Thorax 1997; 52:416.)
 Urokinase: 100 000 or 300 000 IU .
 Streptokinase: 250000 IU .
 250.000 IU in 10-20 ml isotonic saline.
 Don’t evacuate before 24 to 48 hours.
 Constantly associated with fever (38-39°C).
 Then evacuate.

41.  Local antibiotics
 Intrapleural instillation of antibiotics, especially
metronidazole,Colimycin.
 Still debated.
 Do not replace systemic treatment.

42. Video-assisted thoracic surgery
 VATS.
 If closed drainage does not result in
prompt re-expansion of the lung and
especially if loculi have been identified
by USG.
 Decision to intervene early is made.
 Debridement and drainage.
 Breakage of loculi,evacuating pus,debris
and freeing lung.
 Helps in re expansion of lung.

43. Compare Chest Tube + Streptokinase
(n=9) vs VATS (n=11)
Wait et al, Chest 1997

44. Bronchoscopy
 Recommended following the successful conclusion
of closed drainage.
 In order to exclude any endobronchial causes of
obstruction, such as tumour or foreign body.

45. Open drainage
 If empyema persists both clinically and radiologically.
 In whom closed drainage has proved unsuccessful.
 If VATS unavailable, unsuccessful or considered
inappropriate.
 Rib Resection Drainage.
 Eloesser Flap .

46. Open chest drainage (Eloesser flap).a) Photograph shows a
right Eloesser flap 8 months .b) after creation that was
closed with a muscle flap

47. Decortication
 Elective surgical procedure.
 Unsuitable for patients who are ill and toxic.
 Fibrous wall of the empyema cavity,reffered to as
cortex is exposed at thoracotomy is stripped off and
adjacent visceral and parietal pleura may be left
intact.
 Indications
 Closed drainage/thoracoscopic methods have been
unsuccessful.
 Patients who has entered a chronic phase in which
underlying lung does not expand because of failure
of cortex to become reabsorbed.

48.  There is no optimal time for decortication.
 Some surgeons arguing for early intervention and
others opting for a conservative approach.
 Early surgical intervention in pleural empyema.thorac cardiovascular surg
1985.

49. Decortication

51. Indications
Thoracocentesis
Clear liquid Not clear or purulent effusion
pH>7.20 pH<7.20
No intervention
Not loculated Loculated
Drainage
Pleural lavage
Fibrinolytics 24-48h
Drainage
Fibrinolytics
Pleural lavage
VATS
Drainage
Pleural lavage
Failure
VATS
Surgery
Failure
Surgery
Reccurent
thoracocentesis
Hamm et al, ERJ 1997