Empyema / Complicated Parapneumonic Effusion

• CC: Pneumonia not improving, pleuritic chest pain, fever

• PP: Persistent fever, leukocytosis, dyspnea, pleuritic pain, loculated effusion

• PN: No PE/CHF-only picture unless present

• pertinent SHx: Aspiration risk, alcohol use, poor dentition, recent pneumonia

• Etiology: Infected pleural space complication of pneumonia/aspiration

• risk factors: Delayed pneumonia treatment, aspiration, immunosuppression, lung disease

• initial DATA: CBC, CMP, blood cultures if febrile, CXR, CT chest with contrast, thoracentesis

• pending DATA: Pleural fluid pH, glucose, LDH, protein, cell count, gram stain/culture

• prior data: Prior CXR/CT, antibiotics

• MEDS: Recent antibiotics, anticoagulation

• COURSE:

Plan:

• Antibiotics:

  • Community: Ceftriaxone + Metronidazole

  • Healthcare-associated/severe: Vancomycin + Cefepime + Metronidazole

  • Aspiration/oral anaerobes: Ampicillin-sulbactam or Ceftriaxone + Metronidazole

• Diagnostic thoracentesis if safe

• Chest tube if:

  • Frank pus

  • Positive gram stain/culture

  • pH <7.2

  • Low glucose

  • Loculated/large complicated effusion

• Pulm/IR consult for thoracentesis/chest tube

• Thoracic surgery if persistent loculations, trapped lung, failed drainage

• Trend CBC/O2 needs/fever curve

• Pulmonary hygiene/O2 support

• Duration: usually 2–6 weeks depending drainage and response