Pleural empyema
ICD-10 J86 · ICD-11 CA44
Next-Step Protocol

Pleural Empyema with Penicillin Allergy: What to Do When Intrapleural Fibrinolytic Therapy Has Failed

This protocol applies to patients with community-acquired pleural infection and a history of penicillin allergy, where a prior course of intrapleural fibrinolytic therapy (IPFT) has not achieved the required response.

Previous Treatment — Insufficient Response

Intrapleural fibrinolytic therapy (IPFT) was the preceding intervention. Escalation to this protocol is indicated when IPFT has failed to produce improvement in radiographic clearance and effective drainage of the infected pleural space.

Next Step — Surgical Intervention

At this stage, management moves to surgical intervention. Video-assisted thoracoscopic surgery (VATS) is the preferred approach, though additional or alternative procedures may be indicated depending on the stage and characteristics of the disease. The full procedural hierarchy, selection criteria, and clinical thresholds are available in the complete protocol.

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Clinical goals: Lung re-expansion and maintenance of a sterile pleural space.

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References

DOI: 10.1183/20734735.0146-2023

  1. In the community-acquired infection setting, treatment should target both Gram-positive aerobes and anaerobes until results of cultures become available.
  2. For patients that are penicillin-allergic, clindamycin alone, or in combination with ciprofloxacin or a cephalosporin, is likely to provide a good alternative.
  3. This usually includes those with residual persistent fluid collection, ongoing sepsis or stage 2 or 3 empyema.
  4. The principles of surgery in management of empyema focus on debridement and evacuation of the infected material from the pleural cavity.
  5. Surgery for pleural infection ranges from the less invasive video-assisted thoracoscopic surgery (VATS) to the more invasive surgical procedures of open thoracotomy (decortication), thoracoplasty and open window thoracotomy.
  6. Advances in surgery have led to an increase in the use of VATS as the preferred approach in managing pleural infection.
  7. In advanced stages of pleural infection, the visceral pleura develops a thick rind; therefore, decortication is required to allow lung re-expansion and to maintain a sterile pleural space thereafter.
  8. However, in clinical scenarios where chronic empyema and a bronchopleural fistula are present, and previous intervention has failed or candidates are deemed unfit for further intervention, open window thoracotomy and thoracoplasty are favoured approaches.
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