What are the current guidelines for the management of empyema, including the use of antibiotics and drainage procedures?

Management of empyema involves prompt antibiotic therapy combined with appropriate drainage procedures to control infection and prevent complications.

Initial antibiotic treatment should be broad-spectrum, targeting common causative organisms including Streptococcus species and Staphylococcus aureus, with adjustments based on microbiological culture results. In cases where Pseudomonas aeruginosa or other resistant organisms are suspected, antibiotic regimens should be tailored accordingly, often requiring intravenous administration and specialist microbiological advice ¹ (Lee et al., 2010).

Drainage is a cornerstone of empyema management. For uncomplicated empyema, chest tube drainage (tube thoracostomy) is typically the first-line intervention to evacuate purulent pleural fluid. If drainage is inadequate or loculations are present, intrapleural fibrinolytic therapy or surgical options such as video-assisted thoracoscopic surgery (VATS) may be necessary to achieve complete drainage and lung re-expansion ¹ (Shen et al., 2017).

Early referral for specialist assessment is recommended when there is failure to improve with antibiotics and drainage, or if the empyema is complex or chronic. Surgical decortication may be required in advanced cases to remove fibrous peel and restore lung function ¹ (Balfour-Lynn et al., 2005).

Antibiotic duration is generally guided by clinical response and radiological improvement, often requiring several weeks of therapy. Intravenous antibiotics are usually started and may be switched to oral agents once clinical improvement is evident ¹.

Overall, the integrated approach combining targeted antibiotics and timely drainage procedures, with escalation to fibrinolytics or surgery as needed, aligns with both UK guidelines and international expert consensus to optimise outcomes in empyema management ¹ (Lee et al., 2010; Shen et al., 2017; Balfour-Lynn et al., 2005).