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Management and prognosis of parapneumonic

pleural effusion and empyema in adults
Author:
Charlie Strange, MD
Section Editors:
V Courtney Broaddus, MD
Julio A Ramirez, MD, FACP
Deputy Editors:
Geraldine Finlay, MD
Sheila Bond, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2020. | This topic last updated: Jan 14, 2020.

INTRODUCTION A parapneumonic effusion is a pleural effusion that

forms in the pleural space adjacent to a pneumonia. When micro-organisms infect

the pleural space, a complicated parapneumonic effusion or empyema may result.
Prompt therapy of these entities can be lifesaving.

The treatment and prognosis of parapneumonic effusion and empyema are reviewed
here. The clinical diagnosis of parapneumonic effusion and empyema in adults and
management in children are discussed separately. (See "Epidemiology, clinical
presentation, and diagnostic evaluation of parapneumonic effusion and empyema in
adults" and "Epidemiology, clinical presentation, and evaluation of parapneumonic
effusion and empyema in children" and "Management and prognosis of
parapneumonic effusion and empyema in children".)

DEFINITIONS A parapneumonic effusion refers to the accumulation of fluid

in the pleural space in the setting of an adjacent pneumonia.

●An uncomplicated or simple parapneumonic effusion refers to a free-
flowing effusion that is sterile.
●A complicated parapneumonic effusion refers to an effusion that has been
infected with bacteria or other micro-organisms (eg, positive gram stain or
biochemical evidence of marked inflammation). (See "Epidemiology,
clinical presentation, and diagnostic evaluation of parapneumonic effusion
 and empyema in adults", section on 'Complicated parapneumonic effusion
and empyema'.)
●An empyema refers to a collection of pus within the pleural space, which
can develop when pyogenic bacteria invade the pleural space, from an
adjacent pneumonia, direct inoculation (eg, from blunt trauma) or other
source. Empyema that develops from an adjacent pneumonia is a
subclass of a complicated parapneumonic effusion. While a complicated
parapneumonic effusion and empyema represent a spectrum of infection
within the pleural space, no pus is directly visualized in patients with a
complicated parapneumonic effusion.
●A complex effusion refers to an effusion with internal loculations (septae).
●A uniloculated effusion is one where the effusion is without internal septae
(it is not necessarily free-flowing).

GENERAL APPROACH TO MANAGEMENT The management of

parapneumonic effusions and empyema generally includes prompt antibiotic

initiation and drainage of infected pleural fluid.
●For most patients with known or suspected parapneumonic effusions or
empyema, we start empiric antibiotics immediately. Antibiotic selection
varies based on the site of acquisition (ie, community versus hospital-
acquired), severity of illness, local epidemiology, and patient risk factors for
drug-resistant pathogens or infection with other specific organisms. In
general, empiric regimens should include antibiotics that target anaerobes
and other likely pathogens (eg, streptococci if community-acquired;
methicillin-resistant Staphylococcus aureus [MRSA] and Pseudomonas if
hospital-acquired) when a complicated parapneumonic effusion or
empyema is suspected. Patients with known or suspected uncomplicated
effusions can generally be treated similarly to other patients with CAP.
(See 'Antibiotic therapy' below.)
●Because of the high morbidity and mortality associated with acute
pneumonia and infected pleural effusions, antibiotics should not be
delayed pending diagnostic testing or drainage of the effusion. However,
an exception includes selected stable patients with indolent illness onset
who lack signs or symptoms of systemic infection, it is reasonable to drain
the effusion and send for microbiologic testing before starting antibiotic
treatment. The spectrum of pathogens that cause subacute and chronic
pleural effusions and empyema differs from acute empyema (eg, includes
mycobacteria, fungi). Deferring antibiotic therapy until microbiologic testing
has been obtained may enhance diagnostic yield and allow for targeted
therapy.

The approach to drainage depends on the type, size, and complexity of the effusion.

●For patients with small uncomplicated parapneumonic effusions (ie, sterile

effusions), drainage is generally not necessary unless the effusion is
sizeable enough to impair respiratory function. Close clinical and
radiographic monitoring should be performed to ensure that the effusion is
resolving. Larger effusions have increased risk of complications (algorithm
 1). (See 'Uncomplicated parapneumonic effusion (antibiotics
alone)' below.)
●For patients with complicated parapneumonic effusions (ie, with clinical or
laboratory evidence of infection) or empyema, drainage should be
performed as soon as possible for source control (algorithm 2). This is
particularly true for empyema, which carries a worse prognosis. Loculated
effusions, large free-flowing effusions (eg, ≥0.5 hemithorax), and effusions
with a thickened pleural membrane should also be drained. When the
collection is free-flowing, a single tube or catheter thoracostomy is the
procedure of choice. When the collection is loculated, the approach to
drainage is individualized depending on the complexity of the effusion and
the patient’s severity of illness. A common approach is to place a single
tube or catheter in the largest locule, and reassess the need for placement
of additional drains and/or surgical intervention based on clinical and
radiographic response. (See 'Complicated pleural effusion and empyema
(antibiotics plus drainage)' below.)

Because a substantial proportion of patients require more than one procedure to

achieve adequate evacuation of the effusion and lung re-expansion, the need for
close clinical monitoring and serial imaging to assess treatment response cannot be
overstated [1]. (See 'Assessment of response' below and 'Treatment failure' below.)

Our approach is generally similar to that outlined by the American Association for
Thoracic Surgery (AATS), the European Association for Cardio-Thoracic Surgery
(EACTS), the American College of Chest Physicians (ACCP), and the British
Thoracic Society (BTS) [2-5]. However, the original categories outlined by the ACCP
have largely fallen out of favor.

ANTIBIOTIC THERAPY In general, antibiotic therapy mirrors that

selected for the underlying pneumonia. However, attention should also be paid to the
appropriate coverage of anaerobic bacteria and to choosing antibiotics that have
good penetration in to the pleural space.

Empiric therapy (agent choice) — For most patients, empiric antibiotic therapy

should be started as soon as the diagnosis of a parapneumonic effusion or
empyema is known or suspected. While drainage of infected fluid within the pleural
space is critical to care, antibiotic initiation should not be delayed while awaiting
diagnostic procedures (eg, thoracentesis) or drainage. Exceptions can be made for
selected stable patients with long-standing effusions since the pathogens that cause
subacute and chronic empyema differ from those associated with acute pneumonia
(eg, mycobacteria and fungi); in such situations, deferring antibiotic therapy until
microbiologic testing has been obtained may enhance diagnostic yield and allow for
targeted therapy.

Generally, empiric antibiotic regimens should include an antibiotic that targets

anaerobic bacteria, which are common causes of complicated parapneumonic
effusions and empyema. Additional antibiotics should be selected based on the site
of acquisition (eg, community- versus hospital-acquired), mode of acquisition (eg,
aspiration, trauma), and local epidemiology.

Nearly all antibiotics adequately penetrate the pleural space. Aminoglycosides

(eg, gentamicin, amikacin, tobramycin) are exceptions. Because their pleural
penetration is poor and because they may be inactivated in acidic environments (eg,
empyemas), we generally avoid them when alternatives are available [6].

Initial antibiotic therapy should be given intravenously. Transition to oral therapy can
be considered once the patient has demonstrated clear clinical improvement and
adequate drainage has been achieved. There is no role for routine use of intrapleural
antibiotics.

Community-acquired — For most community-acquired complicated parapneumonic

effusions or empyema, we select an empiric IV antibiotic regimen that
targets Streptococcus pneumoniae and the pathogens that colonize the oropharynx,
including microaerophilic streptococci (eg, S. anginosus, S. intermedius) and
anaerobic bacteria (table 1). Reasonable options include:

●A third-generation cephalosporin
(eg, ceftriaxone or cefotaxime) plus metronidazole
●A beta-lactam/beta-lactamase inhibitor combination (eg, ampicillin-
sulbactam)

For patients with penicillin hypersensitivity who cannot tolerate cephalosporins

(algorithm 3), alternate options include monotherapy with a carbapenem
(eg, imipenem, meropenem), combination therapy with a respiratory fluoroquinolone
(eg, levofloxacin, moxifloxacin) plus metronidazole or a monobactam
(eg, aztreonam) plus metronidazole. Although clindamycin has been used historically
for the treatment of anaerobic lung infections, resistance rates to clindamycin among
anaerobes now consistently exceed 20 percent across treatment settings. For this
reason, we no longer routinely use clindamycin for empiric treatment of anaerobic
infections. (See "Anaerobic bacterial infections", section on 'Antimicrobial
resistance'.)

Modifications to these regimens may be needed for severely-ill patients or for those
with risk factors for specific pathogens. As examples, we may expand coverage to
include methicillin-resistant Staphylococcus aureus (MRSA) in patients with
antecedent influenza infection or other MRSA risk factors (table 2). For patients with
concurrent necrotizing community-acquired pneumonia (CAP), we may include
coverage for both MRSA and Pseudomonas.

Local epidemiology should also be taken into account when selecting empiric
antibiotics because the prevalence of pathogens that cause parapneumonic
effusions vary with geography. Prominent examples include Burkholderia
pseudomallei (cause of melioidosis) in Southeast Asia and tuberculosis in
developing regions of the world. (See "Melioidosis: Treatment and
prevention" and "Tuberculous pleural effusion".)

In general, we do not include an agent that targets atypical pathogens

(eg, Legionella, Chlamydia, Mycoplasma spp) in our empiric treatment regimens, as
these pathogens rarely cause complicated parapneumonic effusions and empyema.
(See "Epidemiology, clinical presentation, and diagnostic evaluation of
parapneumonic effusion and empyema in adults", section on 'Microbiology'.)

Generally, patients with uncomplicated parapneumonic effusions can be treated

similarly to other patients with CAP. (See "Overview of community-acquired
pneumonia in adults", section on 'Treatment'.)

Hospital-acquired — For most hospital-acquired infections (eg, empyema

secondary to healthcare-associated pneumonia or postprocedural empyema), we
select an empiric IV antibiotic regimen that targets MRSA, gram-negative bacteria
(including Pseudomonas spp), and anaerobic bacteria (table 1). For example,
combining vancomycin with metronidazole and an antipseudomonal cephalosporin
(eg, cefepime, ceftazidime) is appropriate. Combining vancomycin with an anti-beta-
lactam/beta-lactamase inhibitor (eg, piperacillin-tazobactam, ticarcillin-
clavulanate [limited supply]) is an alternative. However, there is growing concern that
the combination of vancomycin plus piperacillin-tazobactam is nephrotoxic [7]. Thus,
some clinicians use linezolid in place of vancomycin when piperacillin-tazobactam is
used. For those who are penicillin-allergic, we suggest combining vancomycin with
metronidazole and an antipseudomonal fluoroquinolone (eg, ciprofloxacin);
alternatively, combining vancomycin with an antipseudomonal carbapenem
(eg, imipenem or meropenem) is appropriate.

Others — The treatment of less common causes of parapneumonic effusions and

empyema, such as Candida species, other fungi, melioidosis, and tuberculous
empyema is discussed separately. (See "Candida infections of the abdomen and
thorax", section on 'Empyema' and "Tuberculous pleural effusion", section on
'Management' and "Cryptococcus neoformans infection outside the central nervous
system" and "Cryptococcus neoformans infection outside the central nervous
system", section on 'Pulmonary infection in immunocompromised
adults' and "Melioidosis: Treatment and prevention".)

Directed therapy — Definitive therapy should be based on culture results and

clinical suspicion for a monomicrobial or a polymicrobial infection.
●When suspicion for a monomicrobial infection is high (ie, isolation of S.
pneumoniae or S. aureus as sole pathogens from pleural fluid), it is
reasonable to direct therapy at the isolated pathogen.
●In most other circumstances (eg, aspiration pneumonia, negative cultures,
or isolation of a constituent of the oral/gastrointestinal [GI] flora such as S.
milleri), we consider the infection to be polymicrobial and inclusive of
multiple anaerobic bacteria. In these circumstances, we select a regimen
based on the likely source of infection (eg, healthcare associated
pneumonia, community acquired pneumonia, or aspiration) that also
targets the isolated pathogen as well as any other anaerobic bacteria.
Because anaerobic bacteria can be difficult to culture and are common
causes of parapneumonic effusions and empyema, most experts include
an antibiotic that targets anaerobes for the duration of therapy regardless
of culture results.

Duration of therapy — The optimal duration of therapy is not known. We generally

individualize the duration of therapy based upon the type of effusion, the adequacy
of drainage, clinical and radiographic response to treatment, and the patient’s
immune status.

In general, for self-resolving uncomplicated bacterial parapneumonic effusions,

therapy may last one to two weeks, while therapy for complicated parapneumonic
effusions and empyema are often longer (eg, two to three weeks for a complicated
parapneumonic effusion and four to six weeks for empyema). While we take
radiographic response into account when determining the duration of therapy,
complete radiographic resolution may take many weeks or months and residual
pleural thickening can persist for longer periods. Thus, treating with the goal of
complete radiographic resolution is not necessary.

The initial IV antibiotic regimen can be switched to an oral regimen with a similar
treatment spectrum when clinical response is clear (eg, patient is afebrile,
hemodynamically stable, clinically improving), no further drainage procedures are
needed, and the patient is able to tolerate oral medications.

The duration of antifungal and antituberculous therapies for empyema is discussed

separately. (See "Candida infections of the abdomen and thorax", section on
'Treatment' and "Treatment of drug-susceptible pulmonary tuberculosis in HIV-
uninfected adults" and "Treatment of pulmonary tuberculosis in adults with HIV
infection: Follow-up after initiation of therapy", section on 'Duration of therapy'.)

APPROACH TO DRAINAGE

Uncomplicated parapneumonic effusion (antibiotics alone) — Uncomplicated

parapneumonic effusions are small to moderate-sized (ie, less than half the
hemithorax) free-flowing effusions with no evidence of infection by culture or
chemistry [2] that generally resolve with antibiotics alone and generally do not need
drainage. In such cases, the diagnosis and therapy with antibiotics alone are empiric
(algorithm 1).

In some cases, thoracentesis may be performed. For example, if the effusion is

sizeable enough to impair respiratory function (eg, typically in patients with
underlying lung disease), drainage can be performed for symptomatic relief. Other
indications may include patients with a severe clinical presentation, or patients in
whom the pleural space is the suspected source of infection. If after thoracentesis,
suspicion remains for infection in the pleural space despite a negative Gram stain,
culture, or pleural fluid chemistries (eg, patient with septic shock), we generally
proceed with drainage and treat the patient as if they have a complicated (ie,
infected) parapneumonic effusion. (See 'Complicated pleural effusion and empyema
(antibiotics plus drainage)' below.)

All patients with uncomplicated parapneumonic effusion should be followed clinically

and with serial chest radiographs or ultrasound examinations to assess for
improvement or deterioration. The optimal frequency of radiographic follow-up is
unknown but it is appropriate that the first follow-up imaging be obtained within 48
hours if thoracentesis was not performed. If thoracentesis was performed and
confirms an uncomplicated parapneumonic effusion, serial radiographs can be
repeated within one week of the diagnosis and followed every one to two weeks until
resolution since progression to empyema while appropriate antibiotics are being
administered is rare. Details regarding the diagnosis of an uncomplicated effusion
are provided separately. (See 'Definitions' above and "Epidemiology, clinical
presentation, and diagnostic evaluation of parapneumonic effusion and empyema in
adults", section on 'Uncomplicated parapneumonic effusion'.)

Should patients fail to improve, the effusion enlarges, or new fever develops, repeat
imaging with chest computed tomography should be performed to evaluate for the
development of a complicated parapneumonic effusion that may need to undergo
sampling and drainage. (See "Epidemiology, clinical presentation, and diagnostic
evaluation of parapneumonic effusion and empyema in adults", section on
'Diagnostic evaluation'.)

Complicated pleural effusion and empyema (antibiotics plus drainage) — In

addition to appropriate antibiotic therapy, PROMPT drainage is indicated in patients
when there is clinical concern for or evidence of infection in the pleural space, based
upon the following features (algorithm 2):
●Empyema (ie, overtly purulent pleural fluid)
●Positive pleural fluid Gram stain or culture
●Loculated pleural effusion
●Large free-flowing effusions (ie, ≥0.5 hemithorax)
●Effusions associated with thickened parietal pleura
●Sepsis from a pleural source

This approach is based upon the rationale that without drainage (ie, source control),
patients have poor outcomes including an increased requirement for more than one
procedure, eventual need for surgery, and longer hospitalization. This is particularly
important for empyema, which carries the poorest prognosis and highest mortality.

A pleural fluid pH of <7.2 is also an indicator of infection in the pleural space.

However, other pleural diseases can have a low pleural fluid pH (eg, malignant
effusions, rheumatoid and lupus pleurisy, urinothorax, and saline from a misplaced
central venous catheter) (see "Epidemiology, clinical presentation, and diagnostic
evaluation of parapneumonic effusion and empyema in adults", section on
'Differential diagnosis'). Therefore, the decision to drain fluid from the pleural space
based on a low pleural fluid pH alone should be made after pleural fluid analysis is
complete.

The initial procedure of choice is a single tube or catheter thoracostomy. Importantly,

this recommendation applies to those in whom residual effusion remains following
diagnostic thoracentesis. However, when an effusion is loculated, choosing to drain
the largest locule (usually guided by ultrasound or chest computed tomography [CT])
is appropriate; in such situations, consideration should be given to the prompt
insertion of a second or third drain during follow-up. Early thoracic surgical
consultation is appropriate because some of these patients will require thoracoscopic
or open surgery [3-5,8]. Diagnosis of an uncomplicated effusion is discussed
separately. (See 'Definitions' above and "Epidemiology, clinical presentation, and
diagnostic evaluation of parapneumonic effusion and empyema in adults", section on
'Uncomplicated parapneumonic effusion' and 'Intrapleural tPA +/- additional
drainage' below.)
Initial drainage (tube or catheter thoracostomy) — Chest tube or catheter
thoracostomy drainage is the least invasive option for drainage of infected pleural
fluid in patients with a complicated parapneumonic effusion or empyema. It is best
suited for patients with free-flowing or uniloculated effusions (ie, effusion without
internal septae), but is also frequently used to drain complex effusions (ie, effusions
with internal septations or locules). Details of tube or catheter thoracostomy
management that are specific to patients with parapneumonic effusion and
empyema are discussed in this section. The technique of insertion, general
management, and complications of tube thoracostomy are discussed separately.
(See "Placement and management of thoracostomy tubes and catheters in adults
and children".)

●Image guidance – When draining infected pleural fluid, thoracostomy

tubes are typically placed using either ultrasound or CT guidance.
However, many experts place chest tubes blindly at the bedside, especially
when the effusion is large or free-flowing.
●Size – There is no consensus on the size of chest tube or catheter for
drainage and guidelines vary on their recommendations [2-5]. In general,
we prefer small-bores tubes (10 to 14 French [Fr]) based upon data that
suggest similar efficacy and less pain when compared with large-bore
thoracostomy tubes. However, in practice the choice may be dependent
upon factors including physician and patient preference, institutional policy,
and available expertise. Some experts prefer larger bore tubes in patients
with effusions that have multiple locules since larger tubes may penetrate
locules more readily than smaller tubes.
Traditionally, larger bore tubes (>28 Fr) were preferred for drainage of
more viscous empyema fluid and smaller bore tubes were reserved for
less viscous fluid. However, in a prospective, nonrandomized study of 454
patients who underwent chest tube drainage for empyema as part of the
Multi-center Intrapleural Streptokinase Trial (MIST1), no significant
difference was found in mortality or need for thoracic surgery between
large (15 to 20 Fr), medium (10 to 14 Fr), or small (<10 Fr) bore tubes
[9,10]. Pain was markedly less with the smaller sized tubes. However, data
suggest that smaller bore tubes (up to 14 Fr) may be more prone to
blockage with viscus empyema fluid as well as with blood or fibrinous
debris, with one study reporting that drain occlusion occurs more
commonly in those with empyema (11 to 30 percent) [11]. Given the
propensity for small-bore catheters to become blocked, periodic flushing
(eg, 30 mL of sterile saline every six hours via a three-way valve) may help
to maintain tube patency [12]. Large-bore chest tubes do not need to be
flushed (unless blockage is suspected) and often do not have a three-way
tap for frequent flushing.  
●Suction – The application of suction is typical to assure maximal and
consistent pleural fluid removal since pleural fluid output is the major
determinant that suggests that any tube can be removed. However,
suction is not necessary unless the pleural space fails to drain or an air
leak is present. Once an air leak is excluded, the chest tube or catheter
can be placed to water seal. In rare cases, some catheters empty directly
into a drainage bag without the option of suction, similar to percutaneous
catheters commonly used for abdominal abscess drainage.
 ●Efficacy – Although some patients with complicated parapneumonic
effusions may improve with antibiotics alone, the response is variable and
drainage is not always successful. No controlled studies are available to
guide selection of patients for drainage. All of the features that comprise a
complicated effusion and empyema (loculations, large size, pleural fluid
acidosis) are associated with an increased risk of progression and poor
outcomes including the requirement for more than one procedure, eventual
need for surgery, and longer hospitalization [13-16]. One meta-analysis of
seven observational studies reported that pleural pH <7.2 was the most
useful predictor of a complicated clinical course [17]. If pleural pH is not
measured, a pleural fluid glucose value <40 mg/dL (2.2 mmol/L) and/or
pleural fluid lactate dehydrogenase (LDH) value >1000 international
units/L, or significant loculations also appear predictive of the need for tube
thoracostomy. Thus, most experts agree that drainage is indicated in this
population. Thoracic empyema (ie, pus in the pleural space) invariably
requires drainage (akin to draining a pyogenic abscess for source control)
because among those with an infected pleural space, patients with
empyema have the highest mortality.

Assessment of response — Immediately following drainage, patients typically

undergo chest radiographic imaging for a rudimentary assessment of tube or
catheter placement and response. Patients are then followed clinically (signs and
symptoms, laboratory values, and drainage volume) for the next 24 to 48 hours.
Chest CT imaging is typically performed within that time frame since CT provides
accurate details regarding chest tube position and adequate drainage of the effusion
or empyema [18], thereby helping to inform the clinician regarding the next-steps in
decision-making.

●If imaging shows that the chest tube is not in a good position, then it can
be manipulated or replaced (typically under image guidance), following
which drainage volume should be monitored and a repeat chest CT
obtained.
●If the drainage tube is in good position but the drainage is inadequate
and/or the lung has not re-expanded adequately, then several options
need to be explored, the details of which are provided below.
(See 'Treatment failure' below.)
●If imaging reveals marked improvement, removing the drainage tube
should be considered, the details of which are discussed below.
(See 'Discontinuing drainage' below.)

Bronchoscopy is rarely indicated unless there is suspicion for endobronchial

obstruction or a bronchopleural fistula.

Discontinuing drainage — Chest tubes can generally be removed when drainage

volume falls below 50 to 100 mL/day (for two to three days assuming there is no
blockage), pleural imaging shows reasonable size reduction of the effusion, and the
patient has no or resolving signs of clinical infection. Complete resolution of pleural
thickening radiologically is not required as this may require months. The patient is
typically discharged on antibiotics and evaluated as an outpatient with follow-up
imaging (typically chest CT) in about two weeks. A small fraction of patients may be
discharged with a temporary catheter in place for clearance of residual fluid,
provided adequate follow-up in outpatient clinic is assured. Antibiotics should be
discontinued once clinical and radiologic improvement is observed and it is assured
that the effusion has not worsened or reaccumulated. Infectious disease experts are
helpful in determining the point at which antibiotics can be stopped. (See 'Duration of
therapy' above.)

Treatment failure — Failure to improve after antibiotics and tube thoracostomy

drainage (eg, the effusion persists or worsens, fever persists or new fever develops,
persistent or worsening leukocytosis) may indicate that antibiotic coverage and/or
that drainage is inadequate. While some patients in this category require surgical
intervention (see 'Video-assisted thoracic surgery (VATS)' below), many patients (50
to 80 percent) may respond to nonsurgical alternatives such as antibiotic adjustment,
additional drainage procedures, and/or intrapleural tissue plasminogen activator
(tPA) with /deoxyribonuclease (DNase). This approach is based upon the high
success rate of tPA/DNase treatment which decreases the likelihood of intervention
and shortens the duration of hospitalization. (See 'Assess adequate antibiotic
coverage and drainage' below.)

While some experts also consider sizeable residual loculations and poor lung
reexpansion as possible evidence of treatment failure, other experts do not use
these parameters as indicators of treatment failure but rather rely on clinical
assessment only. The former approach is more aggressive and focused on a more
rapid resolution of the parapneumonic effusion whereas the latter approach is based
upon the rationale that many parapneumonic effusions should resolve over time with
antibiotics alone.

Assess adequate antibiotic coverage and drainage

●Assessing antibiotic coverage – For patients with evidence of ongoing or

worsening infection (eg, new fever, increasing white blood cell count,
worsening effusion, development of sepsis), options include reculturing
pleural fluid directly from the pleural space (not from the tube or catheter)
or undrained locule and adjustment of antibiotic coverage ensuring
adequate anaerobic coverage or coverage of resistant organisms.
Consideration should also be given to the presence of underlying necrotic
lung as a focus of infection.
●Assessing adequate drainage – For patients in whom treatment failure is
considered due to inadequate drainage, further drainage of the infected
pleural space should be performed. Several drainage options exist, which
are discussed in the section below.

Drainage options

Choosing among drainage options — Choosing among the drainage options is

often provider-specific and recommendations vary among clinicians, institutions, and
guideline committees. Factors that influence the decision include the clinician’s
specialty, expertise availability, patient values, patient prognosis from comorbidities,
and candidacy for select surgical procedures as well as the number and size of
locules and degree of pleural thickening on chest CT.

Some general rules can provide guidance:

 ●In most cases of treatment failure, when imaging reveals that the tube or
catheter is in a good position but the effusion is only partially improved (ie,
a significant amount of fluid remains) or is complex (ie, loculated) and
poorly drained, most experts administer intrapleural tPA/DNase and give
consideration to placing a second (or third) chest tube or catheter before
resorting to video-assisted thoracic surgery (VATS). The rationale for this
approach is that this strategy reduces the need for surgery and shortens
the duration of hospitalization. A repeat chest CT should be performed 24
hours following the completion of the chosen intervention(s) and early
thoracic surgical consultation is also advisable. (See 'Intrapleural tPA +/-
additional drainage' below.)
●Nonsurgical treatments may be the only option in those who are not
surgical candidates; this is supported by one retrospective study that
reported nonsurgical interventions occurred more frequently in those with
medical comorbidities (eg, congestive heart failure, chronic lung disease,
peripheral vascular disease, metastatic cancer, diabetes with
complications, coagulopathy anemia of chronic disease, sepsis) [1].
(See 'Intrapleural tPA +/- additional drainage' below.)
●Patients with empyema from a bronchopleural fistula should preferably
undergo surgical or endoscopic repair procedures after an adequate
course of antibiotics have been administered. (See 'Postsurgical
empyema' below and "Bronchopleural fistula in adults".)
●In patients who have clear evidence of significant organization or an
established fibrothorax (eg, no pleural fluid, excessively thickened pleura
on chest CT with or without calcification), or evidence of trapped lung (air
replaces fluid after drainage), many experts proceed directly with VATS for
decortication rather than attempt a trial of tPA/DNase. In such cases,
surgery is not urgently needed and preoperative assessment with
pulmonary function testing can proceed on an elective basis. (See 'Video-
assisted thoracic surgery (VATS)' below and "Diagnosis and management
of pleural causes of nonexpandable lung".)

Intrapleural tPA +/- additional drainage — Nonsurgical approaches involve the

intrapleural instillation of fibrinolytics (typically tPA) together with DNase and/or the
placement of additional chest tubes. Most experts attempt tPA/DNase first but no
data exist to support choosing one over the other. The increasing use of fibrinolytics
was reflected in a retrospective analysis of over 4000 patients undergoing an
intervention for empyema, which reported that over half of patients underwent
nonsurgical therapies (including antibiotics, thoracostomy, and fibrinolytics); a
quarter of these patients needed VATS and one-fifth needed open surgery,
suggesting a 55 percent response rate to nonsurgical therapies [1].

●Intrapleural tissue plasminogen activator with DNase — The

indications, dosing, follow-up, and efficacy of tPA/DNase are discussed in
this section. It is important to administer both agents in combination rather
than either agent alone.  
•Indications – Intrapleural tPA/DNase is frequently administered to
patients with complicated parapneumonic effusion or empyema who
fail antibiotic therapy and initial drainage. It is also a suitable option in
patients who are not candidates for or do not want surgery.
Predicting a response to this strategy is difficult. One study suggested
that pleural thickening and the presence of an abscess/necrotizing
pneumonia may help to predict failure [19]. In theory, this strategy is
probably best suited to patients with multiloculated effusions in whom
septae are suspected to be early and amenable to breakdown. In
contrast, it is less effective for those with significant organization (ie,
stage 3 disease) (see "Epidemiology, clinical presentation, and
diagnostic evaluation of parapneumonic effusion and empyema in
adults", section on 'Stage 3 (chronic organization)'). While a thickened
pleural space may indicate significant organization, in reality, it can be
difficult to determine how organized a parapneumonic effusion or
empyema is by chest CT scan, or to determine whether locules are in
communication with another; thus, many experts administer
tPA/DNase empirically and decide whether surgery is needed
depending on the response. Because there is often a diagnostic delay
in recognition of a parapneumonic effusion, there are no data that
define a time after which fibrinolytic/mucolytic therapy will not work.
•Dosing – Although several agents and several doses of fibrinolytics
have been used (urokinase, streptokinase, tPA), most institutions use
a regimen that is similar to that described in the largest randomized
trial that showed a reduction in the need for surgery when tPA was
combined with DNase [20]. Both tPA (10 mg) and DNase (5 mg) are
administered via the chest tube or catheter twice daily for three days
[20]. In the trial, tPA and DNase were administered separately and
tubes were clamped for one hour after each agent had been given,
although newer data suggest that the simultaneous administration of
both agents may be as efficacious [21]. Once a course of tPA/DNase
has been administered, it is not typically repeated, since this is
thought to increase the risk of pleural bleeding. However,
consideration may be given to administering a second course if no
additional options are available and a response was noted previously.
Options in refractory cases are discussed below. (See 'Refractory
cases' below.)
•Follow-up – Follow-up involves assessing clinical findings, chest
tube/catheter drainage volume, and radiographic imaging with chest
CT. However, drainage volume can be a misleading measure of
response because fibrinolytics can increase fluid production de novo,
without decreasing empyema size.
-If the effusion improves dramatically or resolves and the
drainage is minimal, then consideration should be given to
removing the drainage tube. (See 'Discontinuing
drainage' above.)
-If the patient experiences minimal or no response, then VATS is
typically indicated. (See 'Video-assisted thoracic surgery
(VATS)' below.)
-If the patient experiences a partial response, the decision
regarding how to proceed is individualized. In our experience,
much of the decision is dependent upon the presence of
comorbidities, patient preferences, and the degree of clinical
 response to treatment. Those who demonstrate a significant
response may not need to proceed to VATS, while those with a
marginal response should probably be evaluated for VATS.
•Adverse effects – Side effects of intrapleural administration of
fibrinolytic agents include chest pain, fever, allergic reactions (more
frequent with streptokinase), and pleural hemorrhage [9,22-25].
Pleural hemorrhage is the most worrisome side effect, since blood
loss can be significant. In addition, blood in the pleural space can
intensify the inflammatory response and increase the risk for lung
entrapment; it is, therefore, frequently an indication for evacuation by
VATS. The incidence ranges from one to seven percent. The risk for
pleural hemorrhage is highest in those who are already at risk of
bleeding (eg, renal failure, thrombocytopenia, anticoagulation) [24].
Thus, one should be cautious administering fibrinolytics in those with a
known coagulopathy. Hemothorax will be detected relatively quickly by
seeing blood in the thoracostomy tube output. Any coagulopathy
should be reversed, if feasible, and thoracic surgery should be
consulted for a VATS evaluation.
Fibrinolytics are quickly neutralized (usually within an hour) by
plasminogen activator inhibitors that are increased during pleural
infection [24,26,27]. Consequently, they rarely cause systemic
bleeding, although a few case reports have been described [28,29].
•Efficacy – The administration of intrapleural fibrinolytic agents is
based upon the rationale that they break down fibrinous adhesions
that are part of the organization process and are responsible for locule
(septae) formation. DNase, by breaking down DNA (released from
tissue and bacteria), reduces the viscosity of pleural fluid. In theory,
these agents, when administered together, should improve the
efficacy of pleural drainage by thoracostomy tube/catheters. Data
show that when administered together [20,21,30,31], they are more
efficacious than when fibrinolytics are administered alone [32-38].
These agents typically decrease the need for surgery (by
approximately 30 to 80 percent) but a mortality benefit has not been
proven.
-Fibrinolytics plus DNase – One trial randomly assigned 210
patients with empyema to one of four intrapleural treatments: 10
mg intrapleural tPA twice daily for three days, 5 mg intrapleural
DNase twice daily for three days, a combination of tPA and
DNase twice daily for three days, or double placebo [20].
Combination tPA-DNase therapy resulted in a greater decrease in
radiographic pleural opacity (-7.9 percent change in pleural
opacity; 95% CI -13.4 to -2.4), an 83 percent reduction in the rate
of surgical referral (odds ratio 0.17; 95% CI 0.03-0.87), and a
shorter hospital stay (-6.7 days; 95% CI -12.0 to -1.9) compared
with placebo. Neither of the individual agents performed better
than placebo. Two episodes of pleural hemorrhage and one
episode of hemoptysis were seen with combined tPA-DNase
therapy, although the rate of adverse effects was not different
across study groups. In preplanned subgroup analyses, there
were no differences in the outcomes between those with purulent
 versus non-purulent effusions, large- versus small-bore drainage
tubes, or patients with evidence of loculations versus no
loculations. On the basis of this study, most institutions use this
protocol when administering tPA/DNase to patients with
complicated pleural effusion or empyema.
A Cochrane meta-analysis of 10 randomized trials found a similar
reduction in surgical intervention with the use of tPA-DNase
compared with placebo (odds ratio [OR] 0.37; 95% CI 0.21-0.68)
[39]. There were fewer treatment failures (OR 0.16, 95% CI 0.05 -
0.58) but no clear mortality benefit was identified (OR 1.16, 95%
CI 0.71-1.91). However, most of the trials were at high risk of
bias, and the efficacy was diminished when only trials at low or
unclear risk of bias were included in the analysis. Thus, per 1000
people, tPA-DNase may lead to 19 more deaths (36 fewer to 59
more), 115 fewer surgical interventions (150 to 55 fewer), and
214 fewer treatment failures (252 to 93 fewer).
-Fibrinolytics alone – While early retrospective studies
suggested benefit [9,32-34,36,37], newer data suggest mixed or
no benefit when fibrinolytic agents are administered alone [9,38].
One randomized, double-blinded trial of 454 patients
parapneumonic effusion or empyema showed no benefit from
streptokinase in any category, including mortality, referral for
surgery, imaging outcome, or hospital stay [9]. A subsequent
meta-analysis of seven trials that included 761 patients with
parapneumonic effusion or empyema reported that compared
with conservative therapy alone (tube thoracostomy), intrapleural
fibrinolytics did not result in a mortality benefit (28 versus 33
percent; relative risk [RR] 1.08; 95% CI 0.69-1.68) but did reduce
the need for surgical intervention (RR 0.63; 95% CI 0.46-0.85)
[40]. However, not all included studies were blinded. Another
2012 meta-analysis showed similar results [41].
●Additional drainage tubes — In some patients in whom drainage is
inadequate with a single chest tube or catheter, particularly those with
complex (ie, multiloculated) effusions and those who fail fibrinolytic
therapy, the placement of additional chest tubes is appropriate. In the
majority of cases, a second (and occasionally third) catheter is placed
under image-guidance, typically chest CT. Occasionally, replacement of a
small-bore catheter with a larger chest tube is performed by some experts,
but the efficacy of this approach is unproven. Placement of additional
drainage tubes is more likely to succeed if there is a small number of
locules (eg, two to three, especially if large) or if it is known or suspected
that one particular locule is infected. However, it is unlikely to work if
patients have multiple small locules which are difficult to access and the
location of infected locule(s) is along the mediastinal pleura or interlobar
fissures. Lung abscesses should not be drained since these usually drain
by the bronchial route with adequate antibiotics. (See "Lung abscess".)  

Video-assisted thoracic surgery (VATS) — VATS is often indicated in

symptomatic patients with parapneumonic effusion or empyema that fails to resolve
with antibiotics, tube thoracostomy, and a course of tPA/DNase [8,42,43].
(See 'Treatment failure' above.)

VATS is preferred over open thoracotomy since outcomes are similar and morbidity
and hospital length of stay is lower [44-46]. While some surgeons prefer to proceed
directly with open thoracotomy in some cases (eg, patients with significant
adhesions, greater visceral pleural thickness, or larger empyema cavity size), others
prefer to start with VATS and convert intraoperatively to open thoracotomy [47-49];
for example, some patients in whom stage 2 disease is suspected (fibropurulent
stage) who turn out to have components of stage 3 (chronic organization) may need
an open procedure for complete decortication; conversion is also appropriate in
those with intolerance of single lung ventilation, uncontrollable bleeding, or needing
access to structures not amenable to VATS repair. Conversion rates of up to 44
percent have been reported (on average, conversion rates are approximately 10
percent) [44,45,47-50]. Conversion to thoracotomy was more common in patients
with delayed referral (>2 weeks) for VATS and those who had gram-negative
bacteria causing empyema. In some cases, if underlying necrotic lung is discovered,
parenchymal resection may need to be performed together with decortication.

Data suggest that the efficacy of VATS for treating patients with parapneumonic
effusion and empyema is mixed [47-56]. While several small series suggest that
thoracoscopy is superior to intrapleural fibrinolysis [53-56], a meta-analysis of seven
randomized trials reported that when compared with tube thoracostomy (with or
without fibrinolytics), VATS did not result in a mortality benefit but did result in a
reduced length of hospital stay [52]. Most studies report successful resolution of the
effusion in response to VATS.

Postoperative pain is managed in a similar fashion to other thoracic surgeries and

although epidural catheterization is generally avoided due to the risk of infecting the
epidural space there are no data to support this potential adverse effect. The
technique, postoperative care, and complications of VATS are discussed separately.
(See "Overview of minimally invasive thoracic surgery".)  

REFRACTORY CASES In rare patients who fail antibiotics, tube

thoracostomy, and fibrinolytic/mucolytic therapy, who are not candidates for VATS,
options are limited but may include persisting with conservative care (antibiotics and
multiple drains) and in some cases, performing an open-window thoracostomy.

An open thoracostomy involves a vertical incision through the chest wall with rib
resection to permit open drainage at the inferior border of the empyema cavity. The
empyema can drain directly through the chest wall if a skin flap is pulled into the
opening (an Eloesser flap) or can drain through a chest tube that is gradually
advanced outward as the tract closes. This process takes approximately 60 to 90
days. Although this procedure is less invasive than decortication, the risks of general
anesthesia and the morbidity of prolonged chest tube drainage remain. Some
experts use multiple daily dressing changes or a wound vacuum-assisted closure
(VAC) device instead of a chest tube to facilitate drainage of the empyema, although
a wound VAC may worsen a bronchopleural fistula, if present, and should be
avoided under those circumstances.

SPECIAL POPULATIONS

Postsurgical empyema — Empyema can complicate resective thoracic surgery (ie,

lobectomy or pneumonectomy) and often occurs in association with a bronchopleural
fistula. These infections once relegated the patient to a life of continued open
thoracostomy; however, other options of closure are now available to the
experienced thoracic surgeon [4,5,57]. These include combinations of pleural space
sterilization with antibiotic irrigation, space-filling muscle pedicles, thoracoplasty with
rib resection, and surgical or endoscopic closure of a bronchopleural fistula and/or
open thoracostomy incisions. Further details are provided separately.
(See "Sequelae and complications of pneumonectomy", section on 'Pleural space
complications' and "Bronchopleural fistula in adults".)

Infected malignant effusion with indwelling catheter — Patients with an

indwelling tunneled catheter for drainage of a malignant pleural effusion (MPE) can
develop pleural infection that can progress to empyema. These infections often are
due to staphylococcal species and typically resolve on a prolonged course of
directed antibiotic therapy while leaving the catheter in place [58].

COMPLICATIONS Long-term complications of infection in the pleural

space include residual pleural thickening on chest computed tomography (CT) and,
when untreated, fibrothorax and pleural calcification. A thickened pleura (also known
as a “pleural peel”) generally begins to regress once the pleural infection is
adequately controlled. However, in rare cases, it may progress to pleural fibrosis as
the effusion resolves; this can limit re-expansion of the lung and results in varying
degrees of pulmonary restriction and unexpandable lung (ie, trapped lung)
[42,46,59]. Of importance, any surgical approach (eg, decortication)
is not considered unless pulmonary restriction is still present after six months and
limits the patient's exercise tolerance and quality of life.

Rarely, bronchopleural fistula formation and empyema necessitans (rupture of the

empyema through the chest wall) can occur.

Pleural lymphoma associated with longstanding chronic pleural infection has been
described particularly in Japanese patients [60,61].

PROGNOSIS The long-term survival of patients with parapneumonic

effusion and empyema is good, provided therapy is adequate and prompt.

In patients with pneumonia, the presence of a parapneumonic effusion is associated

with an increased likelihood of being admitted and results in a longer hospital stay
and increased mortality [62]. Mortality is highest in those with empyema with
retrospective series reporting a mortality of approximately 15 percent among
empyema patients who are admitted to hospital [63,64]. One series reported that
mortality was highest among those who require open surgery or decortication and
30-day readmission rates were highest in those who were managed with chest
thoracostomy tubes alone (21 percent) compared with those treated with video-
assisted thoracic surgery (VATS; 11 percent) and open surgery (13 percent) [1]. In
contrast, another retrospective analysis of over 9000 patients with a discharge
diagnosis of empyema reported that over a 20-year period, patients treated with
chest tube drainage with or without fibrinolytics had a higher mortality than those
treated with VATS decortication (17 versus 11 percent); in addition there were no
differences in readmission rates at 90 days [65]. In another prospective series of 85
patients, the mortality at four years was 14 percent with most deaths occurring in the
first 400 days after drainage but many deaths were due to comorbid conditions or
surgical complications rather than due to the empyema itself [14].

SOCIETY GUIDELINE LINKS Links to society and government-

sponsored guidelines from selected countries and regions around the world are
provided separately. (See "Society guideline links: Pleural effusion".)

SUMMARY AND RECOMMENDATIONS

●Allpatients with suspected (or diagnosed) parapneumonic effusion or

empyema should be treated with antibiotics. Antibiotic therapy should be
administered promptly and not delayed for sampling or drainage
procedures. (See 'Antibiotic therapy' above.)
•Empiric antibiotic selection varies based upon the site of acquisition
(ie, community versus hospital-acquired), severity of illness, local
epidemiology, and patient risk factors for drug-resistant pathogens or
infection with other specific organisms. For complicated
parapneumonic effusions and empyema, empiric regimens should
generally include antibiotics that target anaerobes (table 1) and other
likely pathogens (eg, streptococci if community-acquired; methicillin-
resistant Staphylococcus aureus [MRSA] and Pseudomonas if
hospital-acquired).
•For infections in the pleural space that are acquired in the community,
we suggest use of a third-generation cephalosporin
(eg, ceftriaxone or cefotaxime [3rd]) plus metronidazole or single agent
therapy with a beta-lactam/beta-lactamase inhibitor combination
(eg, ampicillin-sulbactam) (Grade 2C). For those who are penicillin
allergic who cannot tolerate cephalosporins, we use single agent
therapy with a carbapenem (eg, imipenem, meropenem) or combine
metronidazole with either a fluoroquinolone (eg, levofloxacin) or a
monobactam (eg, aztreonam).
•For hospital-acquired infections (eg, healthcare-associated
pneumonia or post procedural empyema), we suggest
 combining vancomycin with metronidazole and an antipseudomonal
cephalosporin (eg, cefepime, ceftazidime) or combining vancomycin
with a beta-lactam/beta-lactamase inhibitor (eg, piperacillin-
tazobactam, ticarcillin-clavulanate [limited supply]) (Grade 2C). For
those who are penicillin-allergic who cannot tolerate cephalosporins,
we suggest combining vancomycin with metronidazole and an
antipseudomonal quinolone (eg, ciprofloxacin); alternatively,
combining vancomycin with an antipseudomonal carbapenem
(eg, imipenem or meropenem) is appropriate.
•The duration of antibiotic therapy for parapneumonic effusion and
empyema is individualized. For most patients, we suggest continuing
antibiotic therapy until there is clinical and radiographic improvement.
In general, for self-resolving parapneumonic effusions, therapy may
last one to two weeks, while therapy for complicated parapneumonic
effusions and empyema are often longer (eg, two to three weeks for a
complicated parapneumonic effusion and four to six weeks for
empyema).
●Patients with uncomplicated parapneumonic effusions (ie, typically small
or moderate sized, free-flowing effusion (table 3)), do not generally require
drainage and are treated with antibiotics alone (algorithm 2 and algorithm
1). This approach is based upon the rationale that most of these effusions
do not have direct micro-organism invasion of the pleural space and
resolve with antibiotics alone. Should patients or the effusion not improve,
repeat imaging with chest computed tomography (CT) should be
performed to evaluate for the development of a complicated
parapneumonic effusion that may need to undergo sampling and drainage.
(See 'Uncomplicated parapneumonic effusion (antibiotics alone)' above.)
●For patients with a complicated parapneumonic effusion, we suggest
prompt drainage of pleural fluid in addition to antibiotic therapy (Grade
2C). A complicated parapneumonic effusion is one that has gram
microbiologic or biochemical evidence of infection (algorithm 2). Although
high quality data are lacking to guide selection of patients for drainage,
such patients appear to be at risk for poorer outcomes including an
increased requirement for more than one procedure, eventual need for
surgery, and longer hospitalization. For patients with empyema, we
recommend antibiotics and prompt drainage together with antibiotic
treatment (Grade 1C), based upon the rationale that among those with
parapneumonic effusion, those with empyema have the highest mortality.
(See 'Complicated pleural effusion and empyema (antibiotics plus
drainage)' above.)
•The initial procedure of choice is a single tube or catheter
thoracostomy. Image-guided placement of a catheter(s) may be
needed when pleural loculations prevent adequate drainage by a
single tube. During the next 24 to 48 hours, patients should be
followed clinically (signs and symptoms, laboratory values, and
drainage volume) and radiologically with chest CT to assess the
response to drainage (degree of evacuation and re-expansion).
(See 'Initial drainage (tube or catheter thoracostomy)' above
and 'Assessment of response' above.)
•For those who clinically improve and in whom imaging reveals
significant improvement or resolution of the effusion with adequate re-
expansion of the lung, and the drainage rate has fallen to below 50 to
100 mL/day for two to three days, the chest tube or catheter can be
removed, antibiotics continued, and the patient can be followed up as
an outpatient in two weeks with repeat imaging. (See 'Discontinuing
drainage' above.)  
•For patients who fail antibiotics and thoracostomy drainage from a
well-placed chest tube (eg, the effusion persists or worsens, fever
persists or new fever develops, persistent or worsening leukocytosis),
attention should be paid to reassessing antibiotic coverage and need
for additional drainage options. (See 'Treatment failure' above.)
-For patients with evidence of ongoing or worsening infection,
options include re-culturing pleural fluid directly from the pleural
space or undrained locule (not from the tube or catheter) and
adjustment of antibiotic coverage ensuring adequate anaerobic
coverage or coverage of resistant organisms. Consideration
should also be given to the presence of underlying necrotic lung
as a focus of infection. (See 'Assess adequate antibiotic coverage
and drainage' above.)
-For patients who require additional drainage, options include
nonsurgical approaches using intrapleural tissue plasminogen
activator/deoxyribonuclease (tPA/DNase) and/or placement of an
additional drainage tube(s), OR surgery, typically video-assisted
thoracoscopic surgery (VATS). Choosing among the options is
often provider-specific and recommendations vary among
clinicians, institutions, and guideline committees. Factors that
influence the decision include the clinician’s specialty, expertise
availability, patient values, patient prognosis from comorbidities,
and candidacy for select surgical procedures as well as the
number and size of locules and degree of pleural thickening on
chest CT. (See 'Choosing among drainage options' above.)
-As an initial strategy, we suggest intrapleural administration of a
combination of tPA 10 mg and DNase 5 mg, twice daily for three
days rather than surgery (Grade 2C). The rationale for this
approach is based upon data that report lower rates of referral for
surgery (by 30 to 80 percent) when tPA/DNase are used.
Drainage of residual locules is also appropriate, especially in
those who fail tPA/DNase therapy. A repeat chest CT should be
performed 24 to 48 hours after the chosen intervention(s) to
evaluate the response. (See 'Assess adequate antibiotic
coverage and drainage' above and 'Intrapleural tPA +/- additional
drainage' above and 'Video-assisted thoracic surgery
(VATS)' above.)
-Patients who fail tPA/DNase and/or additional drainage
procedures should be evaluated for VATS. (See 'Video-assisted
thoracic surgery (VATS)' above.)
•In patients refractory to nonsurgical therapy who are not candidates
for or decline VATS, options are limited but may include persisting
 with conservative care (antibiotics and multiple drains) and in some
cases, an open-window thoracostomy can be performed.
(See 'Refractory cases' above.)
●Patients with an infected pleural space following resective thoracic
surgery (ie, lobectomy or pneumonectomy) require special attention since
infection is often associated with a bronchopleural fistula that may also
require surgical or endoscopic closure. Patients with malignant pleural
effusion and an indwelling catheter who have an infected pleural space
should be treated conservatively with continued indwelling catheter
drainage and a prolonged course of antibiotics. (See 'Special
populations' above and "Sequelae and complications of pneumonectomy",
section on 'Pleural space complications' and "Bronchopleural fistula in
adults".)
●Apart from complications associated with medical and surgical
treatments, long-term complications of infection in the pleural space
include residual pleural thickening on chest CT and rarely, when,
untreated, fibrothorax and pleural calcification. The pleural changes usually
resolve over three to six months and patients should not be considered for
decortication unless they fail to improve and are symptomatic after six
months. Rare complications include bronchopleural fistula formation,
empyema necessitans (rupture of the empyema through to the chest wall),
and pleural lymphoma. (See 'Complications' above.)
●The long-term survival of patients with parapneumonic effusion and
empyema is good, provided therapy is adequate and prompt. Mortality is
highest in those with empyema as well as in those who require open
surgery or decortication. Death is highest during the first 400 days and is
often due to comorbid conditions or surgical complications rather than due
to the empyema itself.
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urokinase in the treatment of childhood empyema. Thorax 2002; 57:343.
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Nonoperative Treatment of Thoracic Empyema: A  Population-Based Study.
Ann Thorac Surg 2019; 108:1456.

Topic 119384 Version 8.0

GRAPHICS
Treatment of uncomplicated parapneumonic effusion

* While most uncomplicated effusions may be treated with antibiotics alone, there may be an indication

for drainage in select circumstances. For example, drainage may need to be considered when it is

thought that the effusion is causing symptoms (especially in patients with poor underlying respiratory

reserve) or in patients in whom the effusion is a suspected source of infection. A 7-day course of

antibiotics is often sufficient and in most cases anaerobic coverage is not needed.

¶ A good clinical response is one where symptoms and signs (eg, fever and leukocytosis) improve.

Radiographic improvement generally takes longer than 2 to 4 days, especially if a drain is not in place.

However, an uncomplicated parapneumonic effusion should not worsen (eg, increase in size and/or

development of worsening symptoms). Worsening clinical or radiographic features suggest the

development of a complicated parapneumonic effusion.

Δ This typically involves imaging by contrast chest computed tomography and culture (or re-culture) of

pleural fluid.
Graphic 122293 Version 1.0

Treatment of complicated parapneumonic effusion and empyema

 IV: intravenous; CT: computed tomography; tPA: tissue plasminogen activator; DNase:

deoxyribonuclease; VATS: video-assisted thoracoscopic surgery.

* Chest tube or catheter thoracostomy drainage is best suited for patients with free-flowing or

uniloculated effusions (ie, effusions without internal septae), but is also frequently used to drain complex

effusions (ie, effusions with internal septations or locules). In general, we prefer small-bore tubes (10 to

14 French [Fr]) but some experts prefer larger-bore tubes in patients with effusions that have multiple

locules to enhance the efficacy of drainage. However, in practice the choice may be dependent upon

factors including physician and patient preference, institutional policy, and available expertise.

¶ Failure to improve or worsening after antibiotics and tube thoracostomy drainage (eg, the effusion

worsens, fever persists or new fever develops, persistent or worsening leukocytosis) may indicate that

antibiotic coverage and/or drainage is inadequate.

Δ Placing drainage tubes under image guidance helps decrease the frequency of tube misplacement and

increases the likelihood of draining locules suspected to be infected.

◊ Choosing among the drainage options is often provider-specific. Factors that influence the decision

include the clinician's specialty, expertise availability, patient values, patient prognosis from

comorbidities, and candidacy for select surgical procedures as well as the number and size of locules and

degree of pleural thickening on chest CT. However, most experts administer intrapleural tPA/DNase and

give consideration to placing a second (or third) chest tube or catheter before resorting to VATS.

Exceptions include patients with empyema from a bronchopleural fistula who should preferably undergo

VATS repair after an adequate course of antibiotics, and patients who have clear evidence of significant

organization/fibrothorax (eg, no pleural fluid, excessively thickened pleura on chest CT with or without

calcification) or patients with evidence of unexpandable lung (air replaces fluid after drainage); in such

cases proceeding directly to VATS for decortication rather than attempting a trial of tPA/DNase is

appropriate.

§ Patients should be followed clinically. Some patients can be discharged with a mechanism in place for

continued drainage. Imaging is generally obtained at approximately three to four weeks after discharge

to ensure continued resolution of the effusion. Antibiotics may be continued for several weeks (eg, 2 to

3 weeks for a complicated parapneumonic effusion and 4 to 6 weeks for empyema).

Graphic 122291 Version 1.0

Activity of antimicrobial agents against anaerobes

Comments

Inactive versus microaerophilic streptococci (eg, S. milleri), Cutibacterium (formerly Propionibacterium), and Actinomyces species; bactericidal versus most gram

Resistant to most Bacteroides beta-lactamases, although a novel beta-lactamase that cleaves carbapenems was found in rare B. fragilis strains[1]

The addition of a beta-lactamase inhibitor to a beta-lactam dramatically increases activity against anaerobes that produce a beta-lactamase
B. fragilis group: 19 to 60 percent of strains resistant; some Clostridia other than C. perfringens are resistant[2]

B. fragilis group: 0 to 23 percent of strains resistant with considerable institutional variation at least partly reflecting use patterns; poor activity versus Clostridia [2]

Inactive versus some or most penicillinase-producing anaerobes, including most of the B. fragilis group and many strains of Prevotella melaninogenica, P. interme

Less activity in vitro than penicillin G versus most anaerobes and limited published clinical experience to document efficacy other than cefamycins

Inactive versus many anaerobes and most strains of B. fragilis; doxycycline and minocycline are somewhat more active than tetracycline

Active against gram-positive anaerobes; inactive versus gram-negative anaerobes

Inactive versus many Fusobacterium spp and some B. fragilis spp

Moxifloxacin is the best in this class for anaerobic infections, but the B. fragilis group shows increasing resistance and moxifloxacin is no longer recommended in

Active against some anaerobes, including strains of B. fragilis that are resistant to beta-lactams, clindamycin, and quinolones [2]

IDSA: Infectious Diseases Society of America.

References:

1. Edwards R, Hawkyard CV, Garvey MT, Greenwood D. Prevalence and degree of expression of

the carbapenemase gene (cfiA) among clinical isolates of Bacteroides fragilis in Nottingham, UK. J

Antimicrob Chemother 1999; 43:273.

2. Snydman DR, Jacobus NV, McDermott LA, et al. Update on resistance of Bacteroides fragilis

group and related species with special attention to carbapenems 2006-2009. Anaerobe 2011; 17:147.

Graphic 73450 Version 13.0

Approach to the patient with a past penicillin reaction who requires

antibiotics
 This algorithm is intended for use in conjunction with the UpToDate content on choice of antibiotics

in penicillin-allergic hospitalized patients. It is oriented toward hospitalized patients but also

applies to outpatients if test dose procedures can be performed in an appropriately monitored

setting with the staff and equipment needed to manage allergic reactions, including anaphylaxis.

IgE: immunoglobulin E.

* Ask the following:

1. What exactly were the symptoms?

 Raised, red, itchy spots with each lesion lasting less than 24 hours (hives/urticaria)?

 Swelling of the mouth, eyes, lips, or tongue (angioedema)?

 Blisters or ulcers involving the lips, mouth, eyes, urethra, vagina, or peeling skin (seen

in SJS, TEN, other severe type IV reactions)?

 Respiratory or hemodynamic changes (anaphylaxis)?

 Joint pains (seen in serum sickness)?

 Did the reaction involve organs like the kidneys, lungs, or liver (seen in DRESS, other

severe type IV reactions)?

2. What was the timing of the reaction after taking penicillin: Minutes, hours, or days later? Was it

after the first dose or after multiple doses?

3. How long ago did the reaction happen? (After 10 years of avoidance, only 20% of patients with

IgE-mediated penicillin allergy will still be allergic).

4. How was the reaction treated? Was there a need for urgent care or was adrenaline/epinephrine

administered?

5. Has the patient tolerated similar medications, such as ampicillin, amoxicillin, or cephalexin since

the penicillin reaction?

¶ Isolated mild hives, without other symptoms of an IgE-mediated reaction, can often occur in the

setting of an infection. Patients with this history, especially if it occurred in childhood or >10 years ago,

may also be considered to be at minimal risk for a recurrent serious reaction.

Δ This algorithm is intended for use in conjunction with additional UpToDate content. For a description of

how to safely perform a TEST DOSE PROCEDURE, refer to the UpToDate topic on choice of antibiotics in

penicillin-allergic hospitalized patients.

 ◊ Consult allergist to perform skin testing. If skin testing is not possible, patient may still be able to

receive penicillins or first- or second-generation cephalosporins using a desensitization (also known as

tolerance induction) procedure. Refer to the UpToDate topic on rapid drug desensitization for immediate

hypersensitivity reactions.

Original figure modified for this publication. Blumenthal KG, Shenoy ES, Varughese CA, et al. Impact of

a clinical guideline for prescribing antibiotics to inpatients reporting penicillin or cephalosporin allergy.

Ann Allergy Asthma Immunol 2015; 115:294. Illustration used with the permission of Elsevier Inc. All

rights reserved.
Graphic 112936 Version 5.0

Risk factors for CAP caused by MRSA and Pseudomonas

MRSA

Known MRSA colonization Known Pseudomonas coloni

Prior MRSA infection Prior Pseudomonas infection

Detection of gram-positive cocci in clusters on a good-quality sputum Gram stain Detection of gram-negative r

Hospitalization with receipt o

nfection¶ Recent hospitalization or antibiotic use, particularly hospitalization with receipt of IV antibiotics in the prior 3 months Recent hospitalization or stay

Recent influenza-like illness Recent antibiotic use of any k

Necrotizing or cavitary pneumonia Frequent COPD exacerbation

EmpyemaΔ Other structural lung disease

Immunosuppression Immunosuppression

Risk factors for MRSA colonization, including:  

 End-stage kidney disease

 Crowded living conditions (eg, incarceration)Δ

 Injection drug useΔ

 Contact sports participationΔ

 Men who have sex with menΔ

CAP: community-acquired pneumonia; MRSA: methicillin-resistant Staphylococcus aureus; IV:

intravenous; COPD: chronic obstructive pulmonary disease.

* The presence of these risk factors generally warrant empiric treatment in patients with CAP of any

severity.

¶ The presence of these factors should raise suspicion for MRSA or Pseudomonas infection and generally

warrants treatment in those who are severely ill; in others, the need for empiric treatment should take
 into account local prevalence, severity of illness, and overall clinical assessment.

Δ This factor is associated with community-acquired MRSA infection, which can cause severe toxin-

mediated infection. Refer to the UpToDate topic on MRSA infections and treatment of CAP in patients

with risk factors for MRSA infection for further detail.

Graphic 118967 Version 3.0

Categorizing risk for poor outcome in patients with parapneumonic

effusions

Pleural fluid
ace anatomy   Pleural fluid bacteriology   Catego
chemistry*

cub film)¥ AND Bx Culture and Gram AND stain results AND Cx pH unknown 1

unknown

>10 mm and <1/2 hemithorax) AND B0 Neg culture and Gram stain¥¥ AND C0 pH ≥7.20 2

*, loculated effusion†††, or effusion with OR B1 Positive culture or Gram stain OR C1 pH <7.20 3

B2  pus 4

* pH is the preferred pleural fluid chemistry test, and pH must be determined by a blood gas analyzer. If

a blood gas analyzer is not available, pleural fluid glucose should be used (P0 = glucose ≥60 mg/dL; P1

= glucose <60 mg/dL). The expert panel cautions that the clinical utility and decision thresholds for pH

and glucose have not been well-established.

¥ Clinical experience indicates that effusions of this size do not require thoracentesis for evaluation, but

will resolve.

** If thoracentesis were performed in a patient with A0 category pleural anatomy and P1 or B1 status

found, clinical experience suggests that the P1 or B1 findings might be false-positive. Repeat

thoracentesis should be considered if effusion enlarges and/or clinical condition deteriorates.

†† If clinical condition deteriorates, repeat thoracentesis and drainage should be considered.

¥¥ Regardless of prior antibiotic use.

*** Larger effusions are more resistant to effective drainage, possibly because of the increased

likelihood that large effusions will also be loculated.

††† Pleural loculations suggest a worse prognosis.

¥¥¥ Thickened parietal pleura on contrast-enhanced CT suggests presence of empyema.

Adapted from Colice, GL, Curtis, A, Deslauriers, J, et al, Chest 2000; 118:1158.
Graphic 59099 Version 2.0

Contributor Disclosures
Charlie Strange, MDEmployment: AlphaNet [Alpha-1]. Grant/Research/Clinical Trial Support:
Novartis [LAM]; Grifols [Alpha-1]; CSL Behring [Alpha-1]; Takeda [Alpha-1]; Adverum [Alpha-1];
Vertex [Alpha-1]; Arrowhead[Alpha-1]. Consultant/Advisory Boards: CSL Behring [Alpha-1];
Dicerna [Alpha-1]; Takeda [Alpha-1]; Vertex [Alpha-1].V Courtney Broaddus, MDNothing to
discloseJulio A Ramirez, MD, FACPGrant/Research/Clinical Trial Support: Pfizer [Vaccines].
Speaker's Bureau: Pfizer [Vaccines]; Medicines Company [Respiratory infections]; Amgen
[Infections in immunocompromised hosts]; Paratek [Pneumonia]. Consultant/Advisory Boards: Pfizer
[Vaccines]; Nabriva [Respiratory infections]; Medicines Company [Respiratory infections]; Paratek
[Respiratory infections]; Achaogen [Respiratory infections]; Curetis [Diagnostic tests for respiratory
infections].Geraldine Finlay, MDConsultant/Advisory Boards: LAM Board of directors, LAM
scientific grant review committee for The LAM Foundation.Sheila Bond, MDNothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found,
these are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.

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