Treatment of Chest Wall Empyema

Initial Management

The American Thoracic Society recommends starting antibiotic therapy immediately in all patients with empyema, with initial empiric antibiotics covering both aerobic and anaerobic pathogens commonly associated with empyema 2
Recommended antibiotic regimens include second-generation cephalosporin plus metronidazole, benzyl penicillin plus ciprofloxacin, meropenem plus metronidazole, and clindamycin alone, especially in penicillin-allergic patients 2
Aminoglycosides should be avoided due to poor penetration into the pleural space 2

Small-bore chest drains or pigtail catheters should be used whenever possible to minimize patient discomfort, and chest tubes should be connected to a unidirectional flow drainage system kept below the level of the patient's chest 1, 3
A chest radiograph should be performed after insertion of a chest drain, and when drainage suddenly stops, the drain must be checked for obstruction by flushing 1, 3
The drain should be removed once clinical resolution is achieved 3

Intrapleural fibrinolytics are recommended for complicated parapneumonic effusions or empyema to shorten hospital stay, with urokinase as the recommended fibrinolytic agent based on randomized controlled trials in children 4
Dosing regimen for urokinase includes twice daily for 3 days, with 40,000 units in 40 ml 0.9% saline for patients ≥10 kg and 10,000 units in 10 ml 0.9% saline for patients <10 kg 4, 5

Surgical consultation should be considered if there is no response to drainage and antibiotics after approximately 7 days, with indications for surgical intervention including failure of chest tube drainage, antibiotics, and fibrinolytics, persistent sepsis, and organized empyema in a symptomatic patient 2, 6

Resolution of pleural infection should be confirmed by a decrease in pleural fluid neutrophil count and sterile cultures 2

In children, Streptococcus pneumoniae is the most common pathogen, and third-generation cephalosporins are recommended 2
Early mobilization and exercise are recommended during recovery, and analgesia is important, particularly in patients with chest drains 5

A bubbling chest drain should never be clamped, and if a patient with a clamped drain complains of breathlessness or chest pain, the drain should be immediately unclamped 3
Patients with chest drains should be managed on specialist wards by staff trained in chest drain management 3

Patients should be followed until complete recovery with near-normal chest radiograph, and consider underlying diagnoses such as immunodeficiency or cystic fibrosis 5
Secondary scoliosis on chest radiograph is common but transient and should be monitored until resolution 5