http://pedsccm.wustl.edu/All-Net/template/template-1.

htm

empyema
/incidence & epidemiology
Empyema is the presence of gross pus in the pleural cavity; it consists of an
effusion containing polymorphonuclear leukocytes and fibrin. The Greek philosopher, Aristotle, recognized empyema and described the drainage of pus with incision and a metal tube as early as 300 BC. A parapneumonic process is defined as a pleural effusion associated with pneumonia, lung abscess or bronchiectasis. Not all parapneumonic processes are empyemas.
anatomy & physiology

The pleural space is actually a potential space created by the visceral and parietal pleura. It normally contains a scant amount of fluid which facilitates movement of the lung with the diaphragm and chest wall. Several mechanisms contribute to the development of an effusion. Pleural fluid can accumulate when alterations in hydrostatic and oncotic pressure accompany cardiac, renal, hepatic or metabolic disease, or when there are changes in pleural fluid permeability secondary to inflammation, infection, toxin, malignancy or trauma. Common provocations that increase permeability include:
congestive heart failure (increased capillary hydrostatic pressure) nephrotic syndrome (decreased plasma oncotic pressure) post thoracentesis (decreased hydrostatic pressure of the pleural space), and malignancy (impaired lymphatic drainage).

A pleural effusion provides a rich culture medium in which white blood cell defenses can be impaired and an empyema may flourish.
stages in the development of an empyema

By convention, the formation of an empyema can be divided into three phases: exudative, fibrinopurulent and organizing. During the first or exudative phase, pus accumulates. This is followed by fibrin deposition and loculation of pleural fluid known as the fibrinopurulent phase. The last phase, the organizing phase, is characterized by fibroblast proliferation; at this time there is the potential for lung entrapment by scarring.
incidence & epidemiology

Pleural effusions are most common in children with pneumonia. However, empyema is a rare complication of pneumonia. The reported incidence of empyema following pneumonia varies (0.7% to 9%) in the pediatric literature. A recent review of 50 cases of pediatric empyema reported that the incidence of empyema is increasing and the epidemiology is changing. In the 1940's, before the development of penicillin and sulfa antibiotics, empyema was usually caused by

Streptococcus pneumonia. Over the next two decades, Staphylococcus aureus bacteria was reported as the most frequently cultured organism from empyema fluid until the discovery of penicillinase resistant penicillins. In the 1980's Haemophilus influenza type b caused a majority of pediatric empyema but with the development of the H. flu vaccine, Streptococcus pneumonia has again taken the lead as the most frequent pathogen cultured from empyema fluid in children. The age of patients presenting with empyema is also changing. Twenty years ago, the average child with empyema was less than 2 years old and recently the median age was reported as 7 years. Empyema still affects both males and females equally and has a seasonal distribution, occurring more frequently in the winter and spring. we found a good related case on the web:

empyema
http://pedsccm.wustl.edu/All-Net/template/template-2.htm

/diagnosis
Most children with empyema will have persistent symptoms despite
antibiotic therapy for pneumonia. Symptoms include fever, cough, dyspnea, and pleuritic chest pain. A chest radiograph will demonstrate a parapneumonic effusion; a sample of the fluid should be obtained by thoracentesis. The diagnosis of empyema is made when gross inspection of the pleural fluid reveals pus. A positive gram stain by microscopic analysis also clinches the diagnosis. Other tests routinely ordered include pleural fluid analysis for glucose, CBC with differential, lactate dehydrogenase (LDH) and culture. These additional tests can assist in distinguishing an exudate from a transudate but are not pathognomonic for the diagnosis of empyema. Pleural fluid cultures are often negative in patients with empyema and may be negative secondary to antibiotic therapy or inability to grow the organism. Radiographs including a posterior, lateral, and lateral decubitus films, ultrasound and CT scan determine if an effusion is free flowing (suggestive of an transudate) or walled off, loculated, or abscess-like. Although loculated fluid is suggestive of an exudate, it is not specific for an empyema.
transudate versus exudate: criteria adapted from: Wilson, Braunwald, Isselbacher et al. Harrisons Priciples of Internal Medicine 12th edition. 1991 Mc Graw Hill. p 1111. transudate exudate clear, cloudy, appearance clear bloody protein < 3.0 gm/dL > 3.0 gm/dL pleural fluid : < 0.6 > 0.6

serum protein ratio lactate dehydrogenase glucose leukocytes polymorphonuclear WBC's erythrocytes

< 200 IU/L > 60 mg/dL < 1000 /mL < 50% < 5000/mL

> 200 IU/L variable (same as blood) > 1000 /mL > 50% variable

empyema
http://pedsccm.wustl.edu/All-Net/template/template-3.htm

/management
Controversy remains in the management of empyema. Current practice
for pediatric empyema is largely based on the personal experience of pediatricians and surgeons and thus varies from institution to institution. Most of the literature on the therapy of empyema consists of case reviews and retrospective studies. In 1992, Light attempted to identify those patients with a parapneumonic effusion who would require tube thoracostomy or have positive bacterial cultures. He suggested that empyemas usually have the following characteristics:
Light's criteria for empyema pH glucose LDH < 7.0 < 40 mg/dL > 1000 IU/l

He concluded that if pleural fluid analysis met the above criteria or if Gram stain was positive, then a thoracostomy tube should be placed. In a follow up study in adults, Light's criteria were applied to 91 patients. The authors concluded that the criteria were specific but not sensitive in identifying patients who would benefit from chest tube placement. Some patients who had a negative gram stain or pleural fluid that did not meet the above criteria still developed an empyema requiring chest tube drainage or surgery. The debate over when and in whom a thoracostomy tube should be placed still continues. Other treatment modalities include urokinase/ streptokinase infusion into catheter drainage systems, thorascopic adhesiolysis, and open chest thoracotomy with lysis of adhesions/decortication. Overall, clinicians agree that all patients should be placed on antibiotics and a sample of pleural fluid obtained. However, there is no consensus on when and in whom to place a chest tube, instill urokinase or take to

the operating room. The general consensus is that patients who are not defervescing clinically after a few days of therapy may require alternative or more aggressive therapy. Also, a delay in antibiotic therapy and drainage has been associated with a longer hospital stay and the increased likelihood of surgical intervention. link to related sub-chapter (esp. highlight controveries or alternative theories/opinions)
..\english/pulmpage/infect/empyema4.htm..\english/pulmpage/infect/empyema4.htmMicheal microbiology & appropriate antibiotics

J Romano

MD: an alternative view

Pleural cultures are positive in approximately one half of pediatric patients with empyema. Blood culture and urine latex agglutination / counterimmunoelectropheresis may help to identify a bacterial pathogen. Currently, Streptococcus pneumoniae is the most common isolate from community acquired empyema, followed by Staphylococcus aureus and Haemophilus influenza. IV Cefuroxime or a similar second-generation cephalosporin is recommended as first line therapy. If an organism is identified, antibiotics can be tailored to culture and sensitivity results. There appears to be an increasing incidence of Streptococcal pneumococcal drug resistance; one recent article notes the following resistances: penicillin (15%), erythromycin (15%), chloramphenicol (31%), and cefotaxime (23%). High dose penicillin, third generation cephalosporins or vancomycin may be considered for drug resistant pneumococcal empyema. In a hospital acquired empyema or an empyema in a compromised host, there is a greater possibility of gram negative, anaerobic or opportunistic organism.
outcome

The hospital stay for children with empyema varies but the mean has been reported between 13 and 26 days. Children treated for empyema generally recover and have no residual sequela. Radiographs at the time of discharge usually show pleural thickening which later resolves. Follow up pulmonary function tests and physical exam are also usually normal. Infants, patients with nosocomial disease, Staphylococcus aureus, or polymicrobial infection and those with underlying deficiency have an increased morbidity and mortality.

http://pedsccm.wustl.edu/All-Net/english/reading/empyema.htm

empyema

/treatment options
Empyema presents a troublesome challenge to the intensivist. While many
cases respond to closed thoracostomy drainage and antibiotics, some advocate the addition of fibrinolytic therapy. Surgical referral is common, although medical management is often not optimized prior to referral for surgery. The median duration of hospitalization for S. pneumonia empyema has been reported as 11.5 days. The best data on natural history and duration of fever in pediatric empyema can be found in McLaughlin et al (mean 14 days) and Murphy (7.1 days). It is difficult to make a case for the failure of medical management after 3-4 days of fever. Likewise, Gocmen reports that the chest x-ray does not change early in management, but almost invariably resolves with time. These three pediatric references suggest that long term restrictive lung disease is uncommon in children. Fibrinolytic therapy. In the case of loculated pleural effusions, it may be helpful to instill a fibrinolytic agent into the chest cavity. Kornecki reports the use of urokinase: 100,000 units (diluted in 100 mL normal saline) is instilled, the thoracostomy tube is clamped for 12 hours, and then re-opened for another 12 hours. While fibrinolytics will certainly increase pleural fluid drainage, there has been no prospective trial demonstrating shorter resolution of fever, or shorter hospitalizations. Surgical intervention. There is one prospective controlled trial of immediate surgical intervention vs. medical management. Video-assisted thoracoscopic surgery (VATS) was compared to pleural drainage and fibrinolytics. The study found a benefit to early VATS. Two comments about this trial:
the main criterion for failure of medical management (and cross-over to surgery) was persistence of more than 50% of pleural fluid on chest x-ray. It is difficult to convincingly measure pleural fluid and separate it from pleural reaction on a plain film chest x-ray. This criterion might favor crossing patients over to surgery the recovery from a formal thoracotomy or even 'mini-thoractomy" is much longer than from VATS. Unless an institution offers VATS these results are not applicable

Other papers reporting surgical interventions fall into the descriptive category, or categorize surgery as rescue therapy. Commonly stated reasons for surgery are persistent fever (without stating what was the duration of fever was) or failure of the chest x-ray to clear, or concern about "trapped lung" and long term pulmonary abnormalities. An interesting study from Denmark compared outcomes of patients with empyema referred to medical vs. surgical services. Of the patients cared for by the medical service 3/51 patients received operations, compared to 24/43 patients cared for by

the surgical service. Duration of hospitalization was 2.3 weeks in the medical group vs. 5.0 weeks in the surgical group. Foglia and Randolph describe ten children over seven years at two large institutions who underwent thoracotomy after an average of 20 days of medical management. The discussion section after the article is most informative, suggesting that "...the indications for decortication in children are extraodinarily rare." One physician is quoted as remarking: "I do not remember any in the last nine years that have needed decortication." Ultrasound. Ultrasound has been used to evaluate empyema. A retrospective report describes its use in 46 patients over thirteen hospital-years at major pediatric programs (i.e., less than four patients/year). In summary, the vast majority of pediatric patients with empyema will recover with medical management consisting of tube thoracostomy drainage and antibiotics. Hospitalization lasts 1-2 weeks on average. The chest x-ray will eventually return to normal, but may take up to six months. The chance of restrictive lung disease is very low in previously healthy children. Fibrinolytic therapy will probably increase drainage through the thoracostomy tube, with urokinase possibly being safer than streptokinase.

http://pedsccm.wustl.edu/All-Net/template/template-4.htm

empyema
/other treatment options
Empyema presents a troublesome challenge to the intensivist. While many
cases respond to closed thoracostomy drainage and antibiotics, some advocate the addition of fibrinolytic therapy. Surgical referral is common, although medical management is often not optimized prior to referral for surgery. The median duration of hospitalization for S. pneumonia e empyema has been reported as 11.5 days. The best data on natural history and duration of fever in pediatric empyema can be found in McLaughlin et al (mean 14 days) and Murphy (7.1 days). It is difficult to make a case for the failure of medical management after 3-4 days of fever. Likewise, Gocmen reports that the chest x-ray does not change early in management, but almost invariably resolves with time. These three

pediatric references suggest that long term restrictive lung disease is uncommon in children. Fibrinolytic therapy. In the case of loculated pleural effusions, it may be helpful to instill a fibrinolytic agent into the chest cavity. Kornecki reports the use of urokinase: 100,000 units (diluted in 100 mL normal saline) is instilled, the thoracostomy tube is clamped for 12 hours, and then re-opened for another 12 hours. One problem with interpreting the usefulness of fibrinolytics has been the use of volume of drainage as an endpoint, which may or may not be clinically important if the urokinase for example, irritates the pleural surface, increasing transudation. Recently, urokinase was compared to normal saline in a blinded trial. Aside from more drainage, the urokinase group had a shorter duration of fever and hospitilization and much better success rate. Surgical intervention. There is one prospective controlled trial of immediate surgical intervention vs. medical management. Video-assisted thoracoscopic surgery (VATS) was compared to pleural drainage and fibrinolytics. The study found a benefit to early VATS. Two comments about this trial:
the main criterion for failure of medical management (and cross-over to surgery) was persistence of more than 50% of pleural fluid on chest x-ray. It is difficult to convincingly measure pleural fluid and separate it from pleural reaction on a plain film chest x-ray. This criterion might favor crossing patients over to surgery the recovery from a formal thoracotomy or even 'mini-thoractomy" is much longer than from VATS. Unless an institution offers VATS these results are not applicable

Other papers reporting surgical interventions fall into the descriptive category, or categorize surgery as rescue therapy. Commonly stated reasons for surgery are persistent fever (without stating what was the duration of fever was) or failure of the chest x-ray to clear, or concern about 'trapped lung' and long term pulmonary abnormalities. An interesting study from Denmark compared outcomes of patients with empyema referred to medical vs. surgical services. Of the patients cared for by the medical service 3/51 patients received operations, compared to 24/43 patients cared for by the surgical service. Duration of hospitalization was 2.3 weeks in the medical group vs. 5.0 weeks in the surgical group. Foglia and Randolph describe ten children over seven years at two large institutions who underwent thoracotomy after an average of 20 days of medical management. The discussion section after the article is most informative, suggesting that '...the indications for decortication in children are extraodinarily rare.' One physician is quoted as remarking: 'I do not remember any in the last nine years that have needed decortication.'

Ultrasound. Ultrasound has been used to evaluate empyema. A retrospective

report describes its use in 46 patients over thirteen hospital-years at major pediatric programs (i.e., less than four patients/year). In summary, the vast majority of pediatric patients with empyema will recover with medical management consisting of tube thoracostomy drainage and antibiotics. Hospitalization lasts 1-2 weeks on average. The chest x-ray will eventually return to normal, but may take up to six months. The chance of restrictive lung disease is very low in previously healthy children. Fibrinolytic therapy will probably increase drainage through the thoracostomy tube, with urokinase possibly being safer than streptokinase.