Management of Empyema
Publication Date: February 4, 2017
Last Updated: March 14, 2022
Recommendations
CLINICAL PRESENTATION
1. Class I: The presence of a pleural effusion should be investigated in all patients presenting with signs and symptoms of pneumonia or unexplained sepsis (LOE B).
2. Class I: Failure of a community- or healthcare-associated pneumonia to respond clinically to appropriate antibiotic therapy should prompt investigations to identify the presence of a pleural effusion (LOE B). (, )
2. Class I: Failure of a community- or healthcare-associated pneumonia to respond clinically to appropriate antibiotic therapy should prompt investigations to identify the presence of a pleural effusion (LOE B). (, )
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IMAGING STUDIES
1. Class I: Pleural ultrasound (US) should be performed routinely in addition to conventional chest x-ray (CXR) in the evaluation of pleural space infection, both for diagnostic purposes and image-guidance for pleural interventions (LOE B).
2. Class IIa: Computed tomography (CT) of the chest should be obtained when pleural space infection is suspected (LOE B). ()
2. Class IIa: Computed tomography (CT) of the chest should be obtained when pleural space infection is suspected (LOE B). ()
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LABORATORY AND PLEURAL FLUID ANALYSIS
1. Class I: The presence of pus, positive Gram’s stain, or culture in the pleural fluid establishes the diagnosis of empyema, which should be treated with tube thoracostomy followed by surgical intervention when appropriate (LOE B).
2. Class I: A pleural pH <7.2 in a patient with suspected pleural space infection predicts a complicated clinical course, and tube thoracostomy should be performed followed by surgical intervention when appropriate (LOE B).
3. Class IIa: A pleural fluid LDH >1000 IU/L, glucose <40 mg/dL, or a loculated pleural effusion suggests that the pleural effusion is unlikely to resolve with antibiotics alone, and we recommend tube thoracostomy (LOE B).
4. Class I: Obtain pleural fluid culture specimens during aspiration or drainage procedures, not from previously inserted tubes or drains (LOE B). Inoculate freshly drained pleural fluid into aerobic and anaerobic blood culture vials in addition to sterile containers for gram stain and culture (LOE B). ()
2. Class I: A pleural pH <7.2 in a patient with suspected pleural space infection predicts a complicated clinical course, and tube thoracostomy should be performed followed by surgical intervention when appropriate (LOE B).
3. Class IIa: A pleural fluid LDH >1000 IU/L, glucose <40 mg/dL, or a loculated pleural effusion suggests that the pleural effusion is unlikely to resolve with antibiotics alone, and we recommend tube thoracostomy (LOE B).
4. Class I: Obtain pleural fluid culture specimens during aspiration or drainage procedures, not from previously inserted tubes or drains (LOE B). Inoculate freshly drained pleural fluid into aerobic and anaerobic blood culture vials in addition to sterile containers for gram stain and culture (LOE B). ()
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ACUTE PLEURAL EMPYEMA: ANTIBIOTIC TREATMENT
1. Appropriate empiric antibiotic therapy for acute pleural empyema incorporates an understanding of (1) the patient’s clinical history, (2) local antimicrobial resistance patterns, (3) institutional antibiotic stewardship, and (4) pharmacologic characteristics of the antibiotics. Recommendations include:
a. Class IIa: For community-acquired empyema: a parenteral second- or third-generation cephalosporin (eg, ceftriaxone) with metronidazole or parenteral aminopenicillin with b-lactamase inhibitor (eg, ampicillin/sulbactam) (LOE C).
b. Class IIa: For hospital-acquired or postprocedural empyema: include antibiotics active against methicillinresistant Staphylococcus aureus and Pseudomonas aeruginosa (eg, vancomycin, cefepime, and metronidazole or vancomycin and piperacillin/tazobactam [dosed for activity against P. aeruginosa]) (LOE C).
c. Class I: Avoid aminoglycosides in the management of empyema (LOE B).
d. Class IIa: There is no role for intrapleural administration of antibiotics (LOE C).
2. Class I: If possible, choose antibiotic therapy based on culture results (LOE C).
b. Class IIa: For hospital-acquired or postprocedural empyema: include antibiotics active against methicillinresistant Staphylococcus aureus and Pseudomonas aeruginosa (eg, vancomycin, cefepime, and metronidazole or vancomycin and piperacillin/tazobactam [dosed for activity against P. aeruginosa]) (LOE C).
c. Class I: Avoid aminoglycosides in the management of empyema (LOE B).
d. Class IIa: There is no role for intrapleural administration of antibiotics (LOE C).
a. Class IIa: Consider continuing anaerobic coverage empirically when the anaerobic cultures are negative (LOE C).
3. Class IIb: The duration of antibiotic therapy for acute bacterial empyema is influenced by the organism, adequacy of source control, and clinical response (LOE C). ()701
ACUTE PLEURAL EMPYEMA: PLEURAL DRAINAGE
Thoracentesis
Class III no benefit: Thoracentesis without pleural drain placement is not recommended for the treatment of parapenumonic effusion or empyema (LOE C).
Thoracentesis is a useful tool in the management of uncomplicated pleural effusion and a recommended step in the diagnosis of complicated effusion. In the setting of known pleural infection, however, ongoing pleural drainage is regarded as a requirement for adequate treatment and thoracentesis alone, without pleural drain placement, is not recommended.
Image-Guided Drain Placement
Class III no benefit: Thoracentesis without pleural drain placement is not recommended for the treatment of parapenumonic effusion or empyema (LOE C).
Thoracentesis is a useful tool in the management of uncomplicated pleural effusion and a recommended step in the diagnosis of complicated effusion. In the setting of known pleural infection, however, ongoing pleural drainage is regarded as a requirement for adequate treatment and thoracentesis alone, without pleural drain placement, is not recommended.
Image-Guided Drain Placement
1. Class I: Image-guided pleural drain placement is useful in the treatment of early-stage, minimally septated empyema (LOE B).
2. Class IIa: In septated effusions, placement of small bore catheters are recommended in patients that are not surgical candidates (LOE C).
3. Class I: Routine drain flushing is recommended to prevent occlusion (LOE B).
4. Class I: Tube thoracostomy should be combined with close CT follow-up to confirm adequacy of drainage. Persistence of any undrained fluid should prompt additional drains or more aggressive management (LOE C).
()2. Class IIa: In septated effusions, placement of small bore catheters are recommended in patients that are not surgical candidates (LOE C).
3. Class I: Routine drain flushing is recommended to prevent occlusion (LOE B).
4. Class I: Tube thoracostomy should be combined with close CT follow-up to confirm adequacy of drainage. Persistence of any undrained fluid should prompt additional drains or more aggressive management (LOE C).
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ACUTE PLEURAL EMPYEMA: INTRAPLEURAL FIBRINOLYTIC THERAPY
Class IIa: Intrapleural fibrinolytics should not be used routinely for complicated pleural effusions and early empyemas (LOE A). ()
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ACUTE PLEURAL EMPYEMA: SURGICAL MANAGEMENT
Class IIa: Video-assisted thoracoscopic surgery (VATS) should be the first-line approach in all patients with stage II acute empyema (LOE B). (undefinedundefined)
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CHRONIC EMPYEMA: DECORTICATION
1. Class IIa: Decortication is reasonable in patients with chronic empyemas who are medically operable to tolerate major thoracic surgery (LOE B).
2. Class IIb: There is no compelling evidence that epidural catheters cannot be used safely in patients with chronic empyema if they are otherwise low risk for epidural abscess (LOE C). ()
2. Class IIb: There is no compelling evidence that epidural catheters cannot be used safely in patients with chronic empyema if they are otherwise low risk for epidural abscess (LOE C). ()
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CHRONIC EMPYEMA: SPACE FILLING OF CHRONIC EMPYEMA CAVITIES
Tissue flaps. Class IIa: Tissue flaps consisting of pedicled muscle flaps or omentum can be useful to fill empyema cavities in which there is space created by incomplete lung expansion or close a BPF (LOE C).
Thoracoplasty. Class IIb: Thoracoplasty with resection of ribs may be considered in select cases to obliterate the infected pleural space where previous measures (muscle flaps, open window) have failed (LOE C). ()
Thoracoplasty. Class IIb: Thoracoplasty with resection of ribs may be considered in select cases to obliterate the infected pleural space where previous measures (muscle flaps, open window) have failed (LOE C). ()
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CHRONIC EMPYEMA: PROLONGED TREATMENT MEASURES
Open Thoracic Window
Class IIa: Open thoracic window with marsupialization of the infected thoracic cavity with resection of several ribs and dressing changes is reasonable to be performed in patients with chronic empyema who are medically unfit to tolerate decortication and tissue flap placement or those patients with chronic empyema with a BPF (LOE C).
Wound Vacuum-Assisted Closure (VAC) Device
Class IIb: Wound VACs may be a reasonable alternative to daily dressing changes to debride chronic pleural cavities that are being treated with an open thoracic window. Caution should be exercised in placing VACs when there is a BPF or visceral pleural rents leading to large air leaks (LOE C).
Empyema Tube
Class IIb: An empyema tube draining a chronic empyema cavity may be considered in draining chronic infections in which there is a small persistently infected space or small BPF, especially in those patients who are medically unfit to tolerate decortication and tissue flap placement (LOE C). ()
Class IIa: Open thoracic window with marsupialization of the infected thoracic cavity with resection of several ribs and dressing changes is reasonable to be performed in patients with chronic empyema who are medically unfit to tolerate decortication and tissue flap placement or those patients with chronic empyema with a BPF (LOE C).
Wound Vacuum-Assisted Closure (VAC) Device
Class IIb: Wound VACs may be a reasonable alternative to daily dressing changes to debride chronic pleural cavities that are being treated with an open thoracic window. Caution should be exercised in placing VACs when there is a BPF or visceral pleural rents leading to large air leaks (LOE C).
Empyema Tube
Class IIb: An empyema tube draining a chronic empyema cavity may be considered in draining chronic infections in which there is a small persistently infected space or small BPF, especially in those patients who are medically unfit to tolerate decortication and tissue flap placement (LOE C). ()
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POSTRESECTIONAL EMPYEMA
Postpneumonectomy Empyema
Class I: Prompt intervention to identify or rule out the presence of a BPF and provide drainage of sepsis is recommended in patients suspected of having postpneumonectomy empyema (LOE C).
Class IIa: An aggressive surgical approach that includes antibiotics, serial debridement, closure of the BPF when present, and obliteration of the residual pleural space using vascularized tissue transposition is a reasonable strategy to manage postpneumonectomy empyema (LOE C). (, )
Class I: Prompt intervention to identify or rule out the presence of a BPF and provide drainage of sepsis is recommended in patients suspected of having postpneumonectomy empyema (LOE C).
Class IIa: An aggressive surgical approach that includes antibiotics, serial debridement, closure of the BPF when present, and obliteration of the residual pleural space using vascularized tissue transposition is a reasonable strategy to manage postpneumonectomy empyema (LOE C). (, )
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EMPYEMA ASSOCIATED WITH BPF
1. Class IIa: Closure of BPFs should be attempted with a combination of primary closure and buttressing with a wellvascularized transposed soft-tissue pedicle (LOE C).
2. Class IIb: Transposition of the omentum is preferred over skeletal muscle flaps or mediastinal soft tissue, and this should be attempted after the purulent fluid has been drained completely and the pleural cavity has a surface of granulation tissue (LOE C).
Management of the residual thoracic space
1. Class IIb: Primary chest closure should be attempted with the chest cavity filled with antibiotic solution after granulation tissue has formed in the chest cavity and if the patient is medically fit to undergo another operation (LOE B).
2. Class IIa: The creation of a permanent open thoracostomy window is an acceptable treatment strategy for patients treated for an empyema with a recurrent or persistent BPF who are medically unfit for another operation or for those with recurrent cancer (LOE C). ()
2. Class IIb: Transposition of the omentum is preferred over skeletal muscle flaps or mediastinal soft tissue, and this should be attempted after the purulent fluid has been drained completely and the pleural cavity has a surface of granulation tissue (LOE C).
Management of the residual thoracic space
1. Class IIb: Primary chest closure should be attempted with the chest cavity filled with antibiotic solution after granulation tissue has formed in the chest cavity and if the patient is medically fit to undergo another operation (LOE B).
2. Class IIa: The creation of a permanent open thoracostomy window is an acceptable treatment strategy for patients treated for an empyema with a recurrent or persistent BPF who are medically unfit for another operation or for those with recurrent cancer (LOE C). ()
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PEDIATRICS
1. Class I: Tube thoracostomy with or without the subsequent instillation of fibrinolytic agents should be attempted as the initial treatment for pediatric patients with an empyema (LOE A).
2. Class IIa: Thoracoscopic debridement and drainage is recommended in pediatric patients not responding adequately to tube thoracostomy and fibrinolytic instillation (LOE B).
3. Class IIa: VATS debridement is preferred rather than open thoracotomy for the surgical management of empyema in the pediatric population (LOE C). ()
2. Class IIa: Thoracoscopic debridement and drainage is recommended in pediatric patients not responding adequately to tube thoracostomy and fibrinolytic instillation (LOE B).
3. Class IIa: VATS debridement is preferred rather than open thoracotomy for the surgical management of empyema in the pediatric population (LOE C). ()
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Recommendation Grading
Overview
Title
Management of Empyema
Authoring Organization
American Association for Thoracic Surgery
Publication Month/Year
February 4, 2017
Last Updated Month/Year
January 17, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
To establish The American Association for Thoracic Surgery (AATS) evidence-based guidelines for the management of empyema.
Inclusion Criteria
Female, Male, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Management, Treatment
Diseases/Conditions (MeSH)
D004653 - Empyema, D016724 - Empyema, Pleural, D013354 - Empyema, Subdural
Keywords
empyema, thoracic surgery, lung disease, bronchopleural fistula, video-assisted thoracoscopic surgery