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Spontaneous Bacterial Empyema — RACP Adult Medicine MCQ

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HardGeneral Internal MedicineSpontaneous Bacterial EmpyemaRACP Adult Medicine

A 55-year-old man with chronic liver disease develops a large spontaneous bacterial empyema (infected pleural effusion) with Escherichia coli cultured from pleural fluid. He has no evidence of pneumonia. What is the underlying mechanism?

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Correct answer: A — Transdiaphragmatic spread of SBP-associated bacterial translocation from ascites

Spontaneous bacterial empyema (SBEM) in cirrhotic patients occurs through transdiaphragmatic lymphatic spread of bacteria from infected ascites (SBP) or from bacteraemia associated with gut bacterial translocation. It presents similarly to SBP but involves the pleural space (typically hepatic hydrothorax). Pleural fluid PMN count ≥250 cells/mm³ or positive culture with PMN ≥500 defines SBEM. Treatment is the same as SBP – IV third-generation cephalosporin plus albumin. Chest tube drainage is generally NOT recommended in SBEM due to the risk of massive fluid shifts and protein depletion.

Reference: eTG – 2025 – Gastrointestinal; EASL – 2018 – Decompensated Cirrhosis Guidelines