Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

adults (culture results pending)

1st line – empirical intravenous antibiotics

Back
INITIAL
|
adults (culture results pending)
|
with community-acquired empyema
1st line – 

empirical intravenous antibiotics

All adults should initially receive empirical intravenous antibiotics based on local microbiology guidelines to cover the likely causative organisms, both aerobic and anaerobic. Clinicians should keep in mind differences between community-acquired and hospital-acquired pathogens. Once culture results from the pleural fluid are obtained, antibiotics may be tailored to the sensitivities of the grown culture.[8]

For patients with community-acquired empyemas in whom the risk for methicillin-resistant Staphylococcus aureusand highly resistant gram-negative infection is low, the recommended treatment is with a second- or third-generation cephalosporin (e.g., cefuroxime, ceftriaxone) or an aminopenicillin with a beta-lactamase inhibitor (e.g., amoxicillin/clavulanate). However, due to emerging resistance patterns, clinicians should familiarise themselves with a local antibiogram. Amoxicillin/clavulanate is active against a range of anaerobes, but ceftriaxone requires the addition of an antibiotic with anaerobic cover, such as metronidazole. Clindamycin may be used as an alternative to metronidazole.[8]

In general, empirical antibiotics with activity against atypical organisms are not necessary.[8]

Primary options

cefuroxime: 750-1500 mg intravenously every 6-8 hours

or

ceftriaxone: 1-2 g intravenously every 12-24 hours

-- AND --

metronidazole: 15 mg/kg intravenously as a loading dose, followed by 7.5 mg/kg every 6 hours, maximum 4000 mg/day

or

clindamycin: 600 mg intravenously every 6-12 hours; or 900 mg intravenously every 8-12 hours

OR

amoxicillin/clavulanate: 1.2 g intravenously every 8 hours

More

Plus – chest tube drainage

Back
INITIAL
|
adults (culture results pending)
|
with community-acquired empyema
Plus – 

chest tube drainage

Treatment recommended for ALL patients in selected patient group

Urgent chest drain insertion is essential in all adults with empyema or complicated parapneumonic effusion.[8]

Insertion of intercostal drain, Seldinger technique: animated demonstration
Insertion of intercostal drain, Seldinger technique: animated demonstration

How to insert an intercostal (chest) drain using the Seldinger technique. Video demonstrates: how to identify a safe site for insertion; use of an introducer needle, guidewire, dilators, and intercostal drain; how to confirm drain position; and post-procedure care.

Chest drains should be inserted by competent personnel under imaging (ultrasound) guidance to reduce the risk of complications that include organ damage, haemorrhage, subcutaneous emphysema, and death.[8][40]​​

There is no consensus on the optimal chest tube size for drainage, although it is likely that small-bore chest drains (10-14F) are as effective as large-bore drains (20-28F).[8][41] Small-bore drains have also been shown to be less painful for patients.[42]​ Regular flushing with saline is recommended for small-bore chest drains and if the chest drain becomes blocked.[8]

The chest drain should remain in place until the effusion has resolved and drainage has stopped.

Plus – supportive care

Back
INITIAL
|
adults (culture results pending)
|
with community-acquired empyema
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Antipyretics and analgesics should be administered as indicated. The authors make no recommendations for specific antipyretics and analgesics. Agents should be used in accordance with local protocols.

Good nursing care, ensuring maintenance of appropriate dietary intake with nutritional supplements if necessary, is paramount. Early mobilisation is also essential.

Consider – fluid resuscitation

Back
INITIAL
|
adults (culture results pending)
|
with community-acquired empyema
Consider – 

fluid resuscitation

Additional treatment recommended for SOME patients in selected patient group

Patients may be septic at presentation and require emergency fluid resuscitation and urgent intravenous antibiotics even before the diagnosis is established.

1st line – empirical intravenous antibiotics

Back
INITIAL
|
adults (culture results pending)
|
with hospital-acquired empyema
1st line – 

empirical intravenous antibiotics

All adults should initially receive empirical intravenous antibiotics based on local microbiology guidelines to cover the likely causative organisms, both aerobic and anaerobic. Clinicians should keep in mind differences between community-acquired and hospital-acquired pathogens. Once culture results from the pleural fluid are obtained, antibiotics may be tailored to the sensitivities of the grown culture.[8]

Empirical antibiotic treatment for hospital-acquired empyema should include antibiotics active against methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa (e.g., vancomycin plus cefepime, and metronidazole; or vancomycin plus piperacillin/tazobactam) and keep in mind increasing resistance patterns. Clindamycin may be used as an alternative to metronidazole. Vancomycin plus meropenem may be indicated if there is a history or suspicion of extended spectrum beta-lactamase-producing organisms.[8] As up to 25% of cases of hospital-acquired empyema are associated with MRSA, all patients (particularly postoperative and post-traumatic) should receive anti-staphylococcal cover.[8]

In general, empirical antibiotics with activity against atypical organisms are not necessary.[8]

Primary options

vancomycin: 500 mg intravenously every 6 hours; or 1000 mg intravenously every 12 hours

-- AND --

cefepime: 2 g intravenously every 8 hours

-- AND --

metronidazole: 15 mg/kg intravenously as a loading dose, followed by 7.5 mg/kg every 6 hours, maximum 4000 mg/day

or

clindamycin: 600 mg intravenously every 6-12 hours; or 900 mg intravenously every 8-12 hours

OR

vancomycin: 500 mg intravenously every 6 hours; or 1000 mg intravenously every 12 hours

and

piperacillin/tazobactam: 4.5 g intravenously every 6 hours

More

OR

vancomycin: 500 mg intravenously every 6 hours; or 1000 mg intravenously every 12 hours

and

meropenem: 1 g intravenously every 8 hours

Plus – chest tube drainage

Back
INITIAL
|
adults (culture results pending)
|
with hospital-acquired empyema
Plus – 

chest tube drainage

Treatment recommended for ALL patients in selected patient group

Urgent chest drain insertion is essential in all adults with empyema or complicated parapneumonic effusion.[8]

Insertion of intercostal drain, Seldinger technique: animated demonstration
Insertion of intercostal drain, Seldinger technique: animated demonstration

How to insert an intercostal (chest) drain using the Seldinger technique. Video demonstrates: how to identify a safe site for insertion; use of an introducer needle, guidewire, dilators, and intercostal drain; how to confirm drain position; and post-procedure care.

Chest drains should be inserted by competent personnel under imaging (ultrasound) guidance to reduce the risk of complications that include organ damage, haemorrhage, subcutaneous emphysema, and death.[8][40]​​

There is no consensus on the optimal chest tube size for drainage, although it is likely that small-bore chest drains (10-14F) are as effective as large-bore drains (20-28F).[8][41] Small-bore drains have also been shown to be less painful for patients.[42]​ Regular flushing with saline is recommended for small-bore chest drains and if the chest drain becomes blocked.[8]

The chest drain should remain in place until the effusion has resolved and drainage has stopped.

Plus – supportive care

Back
INITIAL
|
adults (culture results pending)
|
with hospital-acquired empyema
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Antipyretics and analgesics should be administered as indicated. The authors make no recommendations for specific antipyretics and analgesics. Agents should be used in accordance with local protocols.

Good nursing care, ensuring maintenance of appropriate dietary intake with nutritional supplements if necessary, is paramount. Early mobilisation is also essential.

Consider – fluid resuscitation

Back
INITIAL
|
adults (culture results pending)
|
with hospital-acquired empyema
Consider – 

fluid resuscitation

Additional treatment recommended for SOME patients in selected patient group

Patients may be septic at presentation and require emergency fluid resuscitation and urgent intravenous antibiotics even before the diagnosis is established.

children (culture results pending)

1st line – empirical intravenous antibiotics

Back
INITIAL
|
children (culture results pending)
1st line – 

empirical intravenous antibiotics

All children should initially receive empirical intravenous antibiotics based on local microbiology guidelines to cover the likely causative organisms.[26]

Antibiotics covering Streptococcus pneumoniae and Staphylococcus aureus[26][27] should be given.

Suitable choices include cefotaxime or ceftriaxone or ampicillin, depending on local guidelines or antibiograms.[26] The addition of vancomycin or linezolid is usually reserved for culture-proven or severe suspected MRSA infection.[26]

Once culture results from the pleural fluid are obtained, antibiotics may be tailored to the sensitivities of the grown culture.

Primary options

cefotaxime: body weight <50 kg: 150-180 mg/kg/day intravenously given in divided doses every 8 hours, maximum 8 g/day; body weight ≥50 kg: 1-2 g intravenously every 6-8 hours

OR

ceftriaxone: 50-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day

OR

ampicillin: 150-400 mg/kg/day intravenously given in divided doses every 6 hours, maximum 12 g/day

OR

cefotaxime: body weight <50 kg: 150-180 mg/kg/day intravenously given in divided doses every 8 hours, maximum 8 g/day; body weight ≥50 kg: 1-2 g intravenously every 6-8 hours

or

ceftriaxone: 50-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4 g/day

or

ampicillin: 150-400 mg/kg/day intravenously given in divided doses every 6 hours, maximum 12 g/day

-- AND --

vancomycin: 60 mg/kg/day intravenously given in divided doses every 6 hours

or

linezolid: children <12 years of age: 10 mg/kg (maximum 600 mg/dose) intravenously every 8 hours; children ≥12 years of age: 600 mg intravenously every 12 hours

Plus – chest tube drainage

Back
INITIAL
|
children (culture results pending)
Plus – 

chest tube drainage

Treatment recommended for ALL patients in selected patient group

Urgent chest drain insertion is essential in all children with empyema or complicated parapneumonic effusion.[8][50]

Insertion of intercostal drain, Seldinger technique: animated demonstration
Insertion of intercostal drain, Seldinger technique: animated demonstration

How to insert an intercostal (chest) drain using the Seldinger technique. Video demonstrates: how to identify a safe site for insertion; use of an introducer needle, guidewire, dilators, and intercostal drain; how to confirm drain position; and post-procedure care.

Chest drains should be inserted by competent personnel under imaging (ultrasound) guidance to reduce the risk of complications that include organ damage, haemorrhage, subcutaneous emphysema, and death.[40]

Small drains should be used whenever possible to minimise patient discomfort.

The chest drain should remain in place until the effusion has resolved and drainage has stopped.

Plus – supportive care

Back
INITIAL
|
children (culture results pending)
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Supplemental oxygen should be provided to children with SaO₂ <93%.[27]

Antipyretics and analgesics should be administered as indicated. The authors make no recommendations for specific antipyretics and analgesics. Agents should be used in accordance with local protocols.

Good nursing care, ensuring maintenance of appropriate dietary intake with nutritional supplements if necessary, is paramount. Early mobilisation is also essential.

Consider – fluid resuscitation

Back
INITIAL
|
children (culture results pending)
Consider – 

fluid resuscitation

Additional treatment recommended for SOME patients in selected patient group

Patients may be septic at presentation and require emergency fluid resuscitation and urgent intravenous antibiotics even before the diagnosis is established.

ACUTE

adults (culture results available)

1st line – antibiotics according to culture sensitivity

Back
ACUTE
|
adults (culture results available)
1st line – 

antibiotics according to culture sensitivity

Once culture results from the pleural fluid are obtained, antibiotics should be tailored to the sensitivities of the grown culture.[8]

Antibiotics should not be discontinued following a negative culture, as pleural fluid cultures are negative in 40% of cases. In these patients, prolonged empirical antibiotic therapy may be required.[50] Even when anaerobic cultures are negative, continuation of empirical antibiotics covering both common community-acquired bacterial pathogens and anaerobic organisms should be considered, because anaerobes frequently infect empyemas and because anaerobes are not always cultured successfully.[8]

If the patient has responded to intravenous treatment, the source of infection has been controlled, the organism is susceptible to oral antibiotics, and the patient’s oral intake is acceptable, then a transition to oral treatment can be made.[8]

Although the optimum duration of treatment is unknown, antibiotic therapy is generally continued for at least 3 weeks. The Working Group of the American Association for Thoracic Surgery recommends a minimum of 2 weeks from the time of drainage and settling of the fever, and states that clinical response, source control, and pathogen should all play a role in treatment decisions.[8]

Inflammatory markers (WBC count and CRP) are useful as guides to the required duration of antibiotic treatment.

Plus – chest tube drainage

Back
ACUTE
|
adults (culture results available)
Plus – 

chest tube drainage

Treatment recommended for ALL patients in selected patient group

Urgent chest drain insertion is essential in all adults with empyema or complicated parapneumonic effusion.[8]

Insertion of intercostal drain, Seldinger technique: animated demonstration
Insertion of intercostal drain, Seldinger technique: animated demonstration

How to insert an intercostal (chest) drain using the Seldinger technique. Video demonstrates: how to identify a safe site for insertion; use of an introducer needle, guidewire, dilators, and intercostal drain; how to confirm drain position; and post-procedure care.

Chest drains should be inserted by competent personnel under imaging (ultrasound) guidance to reduce the risk of complications that include organ damage, haemorrhage, subcutaneous emphysema, and death.[8][40]​​

There is no consensus on the optimal chest tube size for drainage, although it is likely that small-bore chest drains (10-14F) are as effective as large-bore drains (20-28F).[8][41]​ Small-bore drains have also been shown to be less painful for patients.[42]

Regular flushing with saline is recommended for small-bore chest drains and if the chest drain becomes blocked.[8]

The chest drain should remain in place until the effusion has resolved and drainage has stopped.

Plus – supportive care

Back
ACUTE
|
adults (culture results available)
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Intravenous fluid treatment for sepsis should be continued as required.

Antipyretics and analgesics should be administered as indicated. The authors make no recommendations for specific antipyretics and analgesics. Agents should be used in accordance with local protocols.

Good nursing care, ensuring maintenance of appropriate dietary intake with nutritional supplements if necessary, is paramount. Early mobilisation is also essential.

Consider – intrapleural enzyme therapy

Back
ACUTE
|
adults (culture results available)
Consider – 

intrapleural enzyme therapy

Additional treatment recommended for SOME patients in selected patient group

Intrapleural enzyme therapy consists of a combination of tissue plasminogen activator (t-PA) and dornase alfa (deoxyribonuclease [DNAse]). The medicines are instilled into the chest tube and allowed to dwell for 1 hour.

Should be considered in haemodynamically unstable and older patients, patients who are not candidates for surgery (e.g., due to comorbidity), in those with a large effusion not relieved with chest tube drainage and causing respiratory compromise, and in institutions where video-assisted thoracoscopic surgery is not available.[45][46]​ American Association for Thoracic Surgery guidelines do not support routine use of intrapleural fibrinolytics for complicated pleural effusions and early empyemas.[8]

Some experts support routine consideration of intrapleural enzyme therapy for either initial or subsequent treatment of empyema, but only following multidisciplinary risk-benefit discussion and depending on local expertise and the availability of minimally invasive surgical services.[43]

Most experts recommend use of a combination of a fibrinolytic and dornase alfa in place of monotherapy.

Primary options

alteplase: 10 mg intrapleurally twice daily for 3 days

and

dornase alfa: 5 mg intrapleurally twice daily for 3 days

2nd line – video-assisted thoracoscopic surgery (VATS)

Back
ACUTE
|
adults (culture results available)
2nd line – 

video-assisted thoracoscopic surgery (VATS)

Patients who do not respond to antibiotics and tube thoracostomy (chest drain insertion) should be referred to a thoracic surgeon for consideration of surgical intervention. Failure to respond is a clinical decision based on ongoing fever, failure of pleural fluid drainage, and persistently raised inflammatory markers. Approximately 30% of patients will require surgery.[23]

The optimal time at which to refer for surgery is unclear. Some authorities advocate immediate surgery for all patients, but this is debated. The American Association for Thoracic Surgery recommends VATS as the first-line approach in all patients with stage 2 acute empyema.[8] However, some experts support a trial of combination therapy with a fibrinolytic agent and dornase alfa before considering surgery for patients with stage 2 empyema, or for patients with stage 3 empyema awaiting a surgical consultation.[43]

The first-line surgical option is VATS, as it is a less invasive procedure, with less post-operative pain, shorter hospital length of stay, less blood loss, less respiratory compromise, fewer post-operative complications, and lower cost compared with open thoracotomy.[8]

In patients with ineffective effusion drainage and persistent sepsis who cannot tolerate general anaesthesia, re-evaluation with re-imaging of the thorax and, after discussion with a thoracic surgeon, placement of another image-guided small-bore catheter or a larger bore chest tube, or intrapleural fibrinolytic may be considered.[8]

Plus – supportive care + continued antibiotics

Back
ACUTE
|
adults (culture results available)
Plus – 

supportive care + continued antibiotics

Treatment recommended for ALL patients in selected patient group

Intravenous fluid treatment for sepsis should be continued as required.

Antipyretics and analgesics should be administered as indicated. The authors make no recommendations for specific antipyretics and analgesics. Agents should be used in accordance with local protocols.

Good nursing care, ensuring maintenance of appropriate dietary intake with nutritional supplements if necessary, is paramount. Early mobilisation is also essential.

Antibiotics should be continued. If the patient has responded to intravenous treatment, the source of infection has been controlled, the organism is susceptible to oral antibiotics, and the patient’s oral intake is acceptable, then a transition to oral treatment can be made.[8]

Although the optimum duration of treatment is unknown, antibiotic therapy is generally continued for at least 3 weeks. The Working Group of the American Association for Thoracic Surgery recommends a minimum of 2 weeks from the time of drainage and settling of the fever, and states that clinical response, source control, and pathogen should all play a role in treatment decisions.[8] Inflammatory markers (WBC count and CRP) are useful as guides to the required duration of antibiotic treatment.

3rd line – intrapleural enzyme therapy

Back
ACUTE
|
adults (culture results available)
3rd line – 

intrapleural enzyme therapy

Intrapleural enzyme therapy consists of a combination of alteplase (recombinant tissue plasminogen activator [t-PA]) and dornase alfa (deoxyribonuclease [DNAse]). The medicines are instilled into the chest tube and allowed to dwell for 1 hour.

May be indicated for the decompression of multiloculated and tube drainage-resistant pleural effusions that are responsible for dyspnoea or respiratory failure if a thoracic surgeon identifies that surgery is not immediately possible (e.g., patient co-morbidity or other clinical or logistical reasons).[44] Some experts support routine consideration of intrapleural enzyme therapy for either initial or subsequent treatment of empyema, but only following multidisciplinary risk-benefit discussion and depending on local expertise and the availability of minimally invasive surgical services.[43]

Intrapleural therapy should be considered in haemodynamically unstable and older patients, patients who are not candidates for surgery (e.g., due to comorbidity), in those with a large effusion not relieved with chest tube drainage and causing respiratory compromise, and in institutions where VATS is not available.[45][46]​ American Association for Thoracic Surgery guidelines do not support routine use of intrapleural fibrinolytics for complicated pleural effusions and early empyemas.[8]

Most experts recommend use of a combination of a fibrinolytic and dornase alfa in place of monotherapy.

Primary options

alteplase: 10 mg intrapleurally twice daily for 3 days

and

dornase alfa: 5 mg intrapleurally twice daily for 3 days

Plus – supportive care + continued antibiotics

Back
ACUTE
|
adults (culture results available)
Plus – 

supportive care + continued antibiotics

Treatment recommended for ALL patients in selected patient group

Intravenous fluid treatment for sepsis should be continued as required.

Antipyretics and analgesics should be administered as indicated. The authors make no recommendations for specific antipyretics and analgesics. Agents should be used in accordance with local protocols.

Good nursing care, ensuring maintenance of appropriate dietary intake with nutritional supplements if necessary, is paramount. Early mobilisation is also essential.

Antibiotics should be continued. If the patient has responded to intravenous treatment, the source of infection has been controlled, the organism is susceptible to oral antibiotics, and the patient’s oral intake is acceptable, then a transition to oral treatment can be made.[8]

Although the optimum duration of treatment is unknown, antibiotic therapy is generally continued for at least 3 weeks. The Working Group of the American Association for Thoracic Surgery recommends a minimum of 2 weeks from the time of drainage and settling of the fever, and states that clinical response, source control, and pathogen should all play a role in treatment decisions.[8] Inflammatory markers (WBC count and CRP) are useful as guides to the required duration of antibiotic treatment.

4th line – mini-thoracotomy, decortication, or open thoracic drainage

Back
ACUTE
|
adults (culture results available)
4th line – 

mini-thoracotomy, decortication, or open thoracic drainage

If there is inadequate resolution of the empyema following video-assisted thoracoscopic surgery or intrapleural enzyme therapy, further surgical options should be discussed with a thoracic surgeon.

These include mini-thoracotomy, decortication (a major thoracic operation involving the evacuation of pus and debris from the pleural space and removal of fibrous tissue from the visceral and parietal pleura), and open thoracic drainage.

Local anaesthetic thoracoscopy may be useful for the treatment of empyema, allowing division of septations and adhesions and facilitating accurate tube placement and drainage, but is not routinely used, as large prospective randomised trials are still needed to elucidate its role for empyema.

A thoracic surgeon should be involved in assessment of the patient, even for anaesthesia. Less radical surgical interventions, depending on surgical expertise and access, such as rib resection and placement of a large-bore drain, may be considered in unstable patients and can be performed in some cases with epidural or local anaesthesia.

Plus – supportive care + continued antibiotics

Back
ACUTE
|
adults (culture results available)
Plus – 

supportive care + continued antibiotics

Treatment recommended for ALL patients in selected patient group

Intravenous fluid treatment for sepsis should be continued as required.

Antipyretics and analgesics should be administered as indicated. The authors make no recommendations for specific antipyretics and analgesics. Agents should be used in accordance with local protocols.

Good nursing care, ensuring maintenance of appropriate dietary intake with nutritional supplements if necessary, is paramount. Early mobilisation is also essential.

Antibiotics should be continued. If the patient has responded to intravenous treatment, the source of infection has been controlled, the organism is susceptible to oral antibiotics, and the patient’s oral intake is acceptable, then a transition to oral treatment can be made.[8]

Although the optimum duration of treatment is unknown, antibiotic therapy is generally continued for at least 3 weeks. The Working Group of the American Association for Thoracic Surgery recommends a minimum of 2 weeks from the time of drainage and settling of the fever, and states that clinical response, source control, and pathogen should all play a role in treatment decisions.[8] Inflammatory markers (WBC count and CRP) are useful as guides to the required duration of antibiotic treatment.

5th line – indwelling pleural catheter

Back
ACUTE
|
adults (culture results available)
5th line – 

indwelling pleural catheter

May rarely have a role in maintaining drainage of a chronically infected pleural space that is not readily treated in other ways such as surgery.

Plus – supportive care + continued antibiotics

Back
ACUTE
|
adults (culture results available)
Plus – 

supportive care + continued antibiotics

Treatment recommended for ALL patients in selected patient group

Intravenous fluid treatment for sepsis should be continued as required.

Antipyretics and analgesics should be administered as indicated. The authors make no recommendations for specific antipyretics and analgesics. Agents should be used in accordance with local protocols.

Good nursing care, ensuring maintenance of appropriate dietary intake with nutritional supplements if necessary, is paramount. Early mobilisation is also essential.

Antibiotics should be continued. If the patient has responded to intravenous treatment, the source of infection has been controlled, the organism is susceptible to oral antibiotics, and the patient’s oral intake is acceptable, then a transition to oral treatment can be made.[8]

Although the optimum duration of treatment is unknown, antibiotic therapy is generally continued for at least 3 weeks. The Working Group of the American Association for Thoracic Surgery recommends a minimum of 2 weeks from the time of drainage and settling of the fever, and states that clinical response, source control, and pathogen should all play a role in treatment decisions.[8] Inflammatory markers (WBC count and CRP) are useful as guides to the required duration of antibiotic treatment.

children (culture results available)

1st line – antibiotics according to culture sensitivity

Back
ACUTE
|
children (culture results available)
1st line – 

antibiotics according to culture sensitivity

Once culture results from the pleural fluid are obtained, antibiotics may be tailored to the sensitivities of the grown culture.

Antibiotics should not be discontinued following a negative culture as pleural fluid cultures are negative in 40% of cases. In these patients, prolonged empirical antibiotic therapy may be required.[50]

When drainage has been completed, and the patient is clinically improving and off oxygen, the route of antibiotic administration may be changed to oral.[26]

Inflammatory markers (WBC count and CRP) are useful as guides to the required duration of antibiotic treatment.

Plus – chest tube drainage

Back
ACUTE
|
children (culture results available)
Plus – 

chest tube drainage

Treatment recommended for ALL patients in selected patient group

Urgent chest drain insertion is essential in all children with empyema or complicated parapneumonic effusion.[8][50]

Insertion of intercostal drain, Seldinger technique: animated demonstration
Insertion of intercostal drain, Seldinger technique: animated demonstration

How to insert an intercostal (chest) drain using the Seldinger technique. Video demonstrates: how to identify a safe site for insertion; use of an introducer needle, guidewire, dilators, and intercostal drain; how to confirm drain position; and post-procedure care.

Chest drains should be inserted by competent personnel under imaging (ultrasound) guidance to reduce the risk of complications that include organ damage, haemorrhage, subcutaneous emphysema, and death.[40]

Small drains should be used whenever possible to minimise patient discomfort.

The chest drain should remain in place until the effusion has resolved and drainage has stopped.

Plus – supportive care

Back
ACUTE
|
children (culture results available)
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Supplemental oxygen should be provided to children with SaO₂ <93%.[27]

Intravenous fluid treatment for sepsis should be continued as required.

Antipyretics and analgesics should be administered as indicated. The authors make no recommendations for specific antipyretics and analgesics. Agents should be used in accordance with local protocols.

Good nursing care, ensuring maintenance of appropriate dietary intake with nutritional supplements if necessary, is paramount. Early mobilisation is also essential.

2nd line – intrapleural enzyme therapy

Back
ACUTE
|
children (culture results available)
2nd line – 

intrapleural enzyme therapy

Most experts recommend use of a combination of a fibrinolytic and dornase alfa (deoxyribonuclease [DNAse]) in place of monotherapy.[43]​ The medicines are instilled into the chest tube and allowed to dwell for 1 hour.

Should be considered if antibiotics and chest tube drainage do not result in adequate resolution of the empyema.

Urokinase is the only fibrinolytic drug that has been studied and recommended in children.[51][52]​​​ It has been shown to shorten hospital stay and a small study also found chest drainage plus urokinase instillation to be as effective as video-assisted thoracoscopic surgery in the first-line treatment of septated parapneumonic effusion in children.[51][52]​​ If urokinase is not available, alteplase (recombinant tissue plasminogen activator) is a suitable alternative option.[26][27]​​ Although it has been successfully evaluated in paediatric patients with empyema, some data show no difference in length of hospital stay between chest tube drainage and use of intrapleural tissue plasminogen activator.[53]

Primary options

urokinase: consult specialist for guidance on intrapleural dose

and

dornase alfa: 5 mg intrapleurally twice daily for 3 days

Secondary options

alteplase: 10 mg intrapleurally twice daily for 3 days

and

dornase alfa: 5 mg intrapleurally twice daily for 3 days

Plus – supportive care + continued antibiotics

Back
ACUTE
|
children (culture results available)
Plus – 

supportive care + continued antibiotics

Treatment recommended for ALL patients in selected patient group

Supplemental oxygen should be provided to children with SaO₂ <93%.[27]

Intravenous fluid treatment for sepsis should be continued as required.

Antipyretics and analgesics should be administered as indicated. The authors make no recommendations for specific antipyretics and analgesics. Agents should be used in accordance with local protocols.

Good nursing care, ensuring maintenance of appropriate dietary intake with nutritional supplements if necessary, is paramount. Early mobilisation is also essential.

Antibiotics should be continued. When drainage has been completed, and the patient is clinically improving and off oxygen, the route of antibiotic administration may be changed to oral.[26] Inflammatory markers (WBC count and CRP) are useful as guides to the required duration of antibiotic treatment.

3rd line – video-assisted thoracoscopic surgery (VATS)

Back
ACUTE
|
children (culture results available)
3rd line – 

video-assisted thoracoscopic surgery (VATS)

Children who do not respond to antibiotics and tube thoracostomy (chest drain insertion) should be referred to a thoracic surgeon for consideration of VATS.[27][50]

Failure to respond is a clinical judgement based on ongoing fever, failure of pleural fluid drainage, and persistently raised inflammatory markers.[8]

Plus – supportive care + continued antibiotics

Back
ACUTE
|
children (culture results available)
Plus – 

supportive care + continued antibiotics

Treatment recommended for ALL patients in selected patient group

Supplemental oxygen should be provided to children with SaO₂ <93%.[27]

Intravenous fluid treatment for sepsis should be continued as required.

Antipyretics and analgesics should be administered as indicated. The authors make no recommendations for specific antipyretics and analgesics. Agents should be used in accordance with local protocols.

Good nursing care, ensuring maintenance of appropriate dietary intake with nutritional supplements if necessary, is paramount. Early mobilisation is also essential.

Antibiotics should be continued. When drainage has been completed, and the patient is clinically improving and off oxygen, the route of antibiotic administration may be changed to oral.[26] Inflammatory markers (WBC count and CRP) are useful as guides to the required duration of antibiotic treatment.

4th line – mini-thoracotomy, decortication, or open thoracic drainage

Back
ACUTE
|
children (culture results available)
4th line – 

mini-thoracotomy, decortication, or open thoracic drainage

If video-assisted thoracoscopic surgery (VATS) is not available or does not result in adequate resolution of the empyema, further surgical options should be discussed with a thoracic surgeon. VATS debridement is preferred over open thoracotomy.[8] Mini-thoracotomy is the first choice of other surgical procedures.

Organised empyemas in symptomatic children may require open surgery or decortication, a major thoracic operation involving the evacuation of pus and debris from the pleural space and removal of fibrous tissue from the visceral and parietal pleura.[50]

Plus – supportive care + continued antibiotics

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ACUTE
|
children (culture results available)
Plus – 

supportive care + continued antibiotics

Treatment recommended for ALL patients in selected patient group

Supplemental oxygen should be provided to children with SaO₂ <93%.[27]

Intravenous fluid treatment for sepsis should be continued as required.

Antipyretics and analgesics should be administered as indicated. The authors make no recommendations for specific antipyretics and analgesics. Agents should be used in accordance with local protocols.

Good nursing care, ensuring maintenance of appropriate dietary intake with nutritional supplements if necessary, is paramount. Early mobilisation is also essential.

Antibiotics should be continued. When drainage has been completed, and the patient is clinically improving and off oxygen, the route of antibiotic administration may be changed to oral.[26] Inflammatory markers (WBC count and CRP) are useful as guides to the required duration of antibiotic treatment.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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