The presence of infection, as documented by Gram stain or culture, is an indication for admission and drainage. Image-guided drainage is selected by the availability and convenience of the various techniques and by the size and location of the fluid collection. Ultrasonography, CT, and fluoroscopy can all accurately guide drainage catheter placement. Ultrasonography is the technique of choice to guide thoracentesis and pleural drainage. Thoracic ultrasound is rapid and safe, and can differentiate solid from liquid components and detect subpulmonic or subphrenic pathologic conditions. CT is useful for specific characterization of complex intrathoracic processes, including loculated pleural collections associated with underlying parenchymal consolidation. CT can also be used to guide safe catheter placement into the collection. If fluoroscopy is readily available, it can be used to assess free-flowing loculated collections in supine patients. Radiographically guided pleural drainage procedures have shown success rates ranging from 72 to 80 percent.15

The optimal method of establishing external drainage remains controversial.15 Catheters ranging from 8 to 30 French in outer diameter may be placed under imaging guidance. For serous collections, a 10- or 12-French catheter provides adequate drainage. Thicker collections of purulent or bloody material may require catheters 24 to 48 French in diameter. Most empyema drainage tubes have large round or oval side holes to promote drainage of particulate matter.

Therapy for thoracic empyema requires appropriate antibiotics, prompt drainage of the infected pleural space and lung reexpansion. 17 Empirical antimicrobial therapy is initiated on the basis of its anticipated bactericidal activity against the suspected microbial pathogens. Broad-spectrum antibiotic therapy with clindamycin 450 mg to 900 mg every 8 h IV and a third-generation cephalosporin (e.g., ceftriaxone) can be started with the diagnosis of an empyema and modified according to Gram stain and culture results. In general, antibiotics are given in high doses for 2 to 4 weeks, but more prolonged therapy may be necessary if drainage is not optimal. 18

Successful treatment of empyema is determined by the stage of the disease process. Tube thoracostomy remains the first treatment option despite variable success rates in the treatment of chronic organizing empyema. Tube thoracostomy, image-directed catheterization, intrapleural thrombolytics, thorascopic drainage, decortication, and chronic open drainage have all been used with success rates ranging from 10 to 90 percent. 17 Generally, the initial exudative stage is amenable to antibiotics and thoracentesis or tube thoracostomy. In the fibrinopurulent stage, antibiotics with drainage by a properly positioned chest tube may resolve the empyema. Most patients with chronic empyema are not cured by medical therapy alone and require surgical intervention. A diffuse organized thick fibrous intrathoracic empyema may require thoracotomy, debridement, irrigation, pleurectomy, decortication, and prolonged open drainage.

The use of intrapleural thrombolytics as an adjunct to the evacuation of loculated pleural effusions has a success rate ranging from 50 to 100 percent, 20 and is associated with low morbidity and mortality rates. Fibrinolysis is likely to be more successful in patients with multiloculated empyemas. 21 Both streptokinase and urokinase are commonly used to convert plasminogen to plasmin. Plasmin dissolves fibrin and produces the dissolution of loculations and early peels, allowing complete evacuation of purulent pleural contents.21 Urokinase is the agent of choice due to the lower risk of anaphylaxis and to the complications typically associated with streptokinase. The optimal doses of streptokinase and urokinase are unknown; however, mean doses of 275,000 IU and 121,000 IU, respectively, have been used. These agents are injected through drainage tubes, which remain clamped for 6 to 8 h, prior to suction drainage. 11

Recently, thoracoscopy has been used for the evacuation of hemothorax and the drainage of thoracic empyema with a success rate of approximately 60 percent.17 Video-assisted thoracic surgery can effectively treat pleural empyema by lysing adhesions, draining the abscess cavity, and decorticating the pleural peel. 19

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