4.

4 Recommendation:

Initial antibiotics should be high dose and intravenous to ensure adequate pleural penetration. All

patients should receive antibiotics targeted to treat the bacterial profile of modern pleural

infection and based on local antibiotic policies and resistance patterns.

Empirical antibiotic treatment must ensure Streptococcus pneumoniae and Staphylococcus

aureus cover.

Thoracic empyema documented by the presence of pleural pus, we recommend prompt drainage

of any remaining pleural fluid rather than observation.

Chest drainage alone is not recommended and the intervention of choice is either percutaneous

small bore drainage with urokinase or video-assisted thoracoscopic surgery.

Continued failure of adequate pleural drainage should prompt thoracoscopy or thoracotomy to

lyse adhesions, fully drain the pleural space, and optimize chest tube placement.

The choice between thoracoscopic debridement and decortication depends on several factors;

those favoring decortication include more adhesions, greater visceral pleural thickness, and

larger empyema cavity size.

A large scale study of different areas should be conducted to make a definite conclusion for the

treatment protocol and management of empyema thoracis.