Empyema is pus in the pleural space, most often a complication of a bacterial pneumonia that does not improve. It needs both antibiotics and drainage, because antibiotics alone rarely clear an infected collection.
Key symptoms
- Fever that persists or returns despite antibiotics for pneumonia
- Sharp chest pain on breathing in
- Shortness of breath
- Cough, sweats, fatigue and weight loss
What you find on exam
- Dullness to percussion over the fluid
- Reduced breath sounds and reduced tactile fremitus
- Fever, fast heart rate and low oxygen saturation
- Signs of sepsis: low blood pressure, confusion
Tests
- Chest X-ray and bedside ultrasound to find the fluid; CT chest for pockets (loculations)
- Thoracentesis: pus, positive Gram stain or culture, pH below 7.2, low glucose
- Blood cultures, blood count and CRP
- Pleural fluid protein and LDH (Light's criteria)
Treatment basics
- Chest tube drainage, with daily checks of the tube and output
- IV antibiotics that cover anaerobes, such as ampicillin-sulbactam, adjusted to cultures
- Alteplase with dornase alfa into the pleural space for loculated fluid
- Surgery (VATS decortication) if drainage fails
- Long antibiotic course, often 2 to 6 weeks
Red flags
- Signs of sepsis or septic shock
- Worsening breathing or rising oxygen needs
- No improvement after 48 to 72 hours of drainage
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.