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Parapneumonic effusion and empyema

Key sources
The following summarized guidelines for the evaluation and management of parapneumonic effusion and empyema are prepared by our editorial team based on guidelines from the British Thoracic Society (BTS 2023), the American Association for Thoracic Surgery (AATS 2017), the Infectious Diseases Society of America (IDSA 2011; 2007), the Infectious Diseases Society of America (IDSA/PIDS 2011), and the European Association for the Study of the Liver (EASL 2010).


1.Classification and risk stratification

Risk assessment: use the RAPID score for risk-stratifying adult patients with pleural infection to inform discussions regarding potential outcomes from infection.
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2.Diagnostic investigations

Indications for evaluation
Evaluate for the presence of pleural effusion in all patients presenting with signs and symptoms of pneumonia or unexplained sepsis.
Evaluate for the presence of pleural effusion in patients with community- or healthcare-associated pneumonia not responding to appropriate antibiotic therapy.

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  • Diagnostic imaging

  • Laboratory tests

3.Diagnostic procedures

Pleural fluid analysis: as per BTS 2023 guidelines, obtain immediate pH analysis in patients with parapneumonic effusion or suspected pleural infection if diagnostic aspiration does not identify frank pus.
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  • Pleural fluid culture

4.Medical management

Antibiotic therapy: as per AATS 2017 guidelines, take into account the patient's clinical history, local antimicrobial resistance patterns, institutional antibiotic stewardship, and pharmacologic characteristics of the antibiotics to decide on appropriate empiric antibiotic therapy in patients with acute pleural empyema.
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5.Therapeutic procedures

Pleural fluid drainage, tube thoracostomy, indications: perform tube thoracostomy, followed by surgical intervention when appropriate, for the management of empyema (established based on the presence of pus, positiveGram stain, or culture in the pleural fluid).
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  • Pleural fluid drainage (tube thoracostomy, technical considerations)

  • Pleural fluid drainage (thoracoscopy and surgical drainage)

  • Intrapleural fibrinolytic therapy

  • Intrapleural saline irrigation

6.Surgical interventions

Indications for surgery, general principles
Ensure that the surgical technique can facilitate the optimal clearance of infected material and achieve lung reexpansion where appropriate when selecting surgical access for the management of pleural infection.
Tailor the extent of surgery according to the patient and empyema stage when the lung is not completely trapped (drainage versus debridement).

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  • Indications for surgery (video-assisted thoracoscopic surgery)

  • Indications for surgery (decortication)

7.Specific circumstances

Pediatric patients, evaluation: obtain a CXR (posteroanterior and lateral) to assess for complications of pneumonia, including parapneumonic effusion, in pediatric patients with community-acquired pneumonia not responding to initial antibiotic therapy.
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  • Pediatric patients (antibiotic therapy)

  • Pediatric patients (drainage and fibrinolytic therapy)

  • Pediatric patients (monitoring)

  • Patients with spontaneous bacterial empyema

  • Patients with chronic empyema

  • Patients with postresectional empyema

  • Patients with bronchopleural fistulas

8.Follow-up and surveillance

Follow-up: consider obtaining follow-up CT in patients presenting with pleural infection to exclude occult malignancy in case of ongoing symptoms or other clinically concerning features.