Empyema: The Daily PANCE Blueprint
A 61-year-old man was diagnosed with community-acquired pneumonia 9 days ago and started on oral antibiotics. He improved at first, but now has recurrent fever to 39.1°C (102.4°F), right-sided pleuritic chest pain, and night sweats. Chest x-ray shows a moderate right pleural effusion. Thoracentesis returns thick, cloudy, foul-smelling fluid with a pH of 6.9 and a glucose of 32 mg/dL, and the Gram stain shows gram-positive cocci. In addition to IV antibiotics, which is the most appropriate next step?
A. Chest tube drainage
B. Observation with serial chest x-rays
C. Repeat thoracentesis only if he becomes short of breath
D. Talc pleurodesis
E. IV furosemide
Answer and topic summary
The answer is A. Chest tube drainage
This is an empyema, pus in the pleural space, here from a parapneumonic effusion that has progressed. The fluid tells you drainage is needed: frank pus, a positive Gram stain or culture, a pleural pH below 7.20, or a glucose below 60 mg/dL each call for chest tube drainage plus antibiotics. Antibiotics alone cannot sterilize a closed space full of pus, which is why he relapsed. If the collection is loculated and drains poorly, the next steps are intrapleural tPA with DNase or video-assisted thoracoscopic surgery (VATS) for decortication. Watching and waiting lets the fluid organize into a thick peel that traps the lung. Talc pleurodesis is for recurrent malignant effusions and pneumothorax, not infection, and diuretics treat transudates from heart failure. Pearl: an uncomplicated parapneumonic effusion (free-flowing, pH 7.20 or higher, glucose 60 or higher, negative Gram stain) usually resolves with antibiotics alone.
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Covered under ⇒ PANCE Blueprint Pulmonary ⇒ ⇒
