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PROMPT Management of Effusion Empyema

What management is recommended for patients with a clinically significant complicated CAP?


-We strongly recommend based on moderate quality evidence consultation with surgical or interventional radiology for evaluation of clinically significant effusion/empyema for drainage with thoracentesis or Video-Assisted Thoroscopic Surgery (VATS)

Prompt evaluation of an effusion by thoracentesis is essential in the diagnosis and management of complicated CAP. Evaluation of the fluid should include studies to assist in diagnosis with recommendations to obtain gram stain and culture, cell count with differential and PCR or antigen testing if available. Other tests including pH, LDH and glucose are not routinely recommended as their likelihood to change management is minimal (Bradley, Byington et al. 2011). Early identification of a complicated pneumonia can improve pathogen identification on culture. In a study out of Brazil, 75% of patients with complicated pneumonia were pretreated with antibiotics prior to a drainage procedure and only 7 (33%) grew a pathogen on standard culture (Menezes-Martins, Menezes-Martins et al. 2005). 
  
For patients with a simple parapneumonic effusion, with fluid evaluation indicating effusion without empyema, thoracentesis alone may be sufficient management, although the risk of fluid re-accumulate is a concern. The PIDS/IDSA guideline recommends that the size of the effusion is an important factor in determining management strategies and that small, uncomplicated effusions be treated with antibiotics alone. The PIDS/IDSA guideline defines significant effusion as a >10mm rim of fluid on a lateral decubitus film or greater than one-fourth of the hemithorax opacified on an upright chest radiograph (Bradley, Byington et al. 2011).
  
Large effusions or effusions associated with respiratory distress require drainage. Utilization of chest tube with fibrinolytic agents is our recommended first line intervention with consideration of VATS procedure based on clinical response and determined by the discretion of the consulting expert. Chest tube with fibrinolysis has been shown to pose less risk of clinical deterioration without any decrease in therapeutic response for patients identified with empyema (St Peter, Tsao et al. 2009). The PIDS/IDSA guideline identifies that utilization of VATS or chest tube with fibrinolytic agents have been shown to decrease morbidity compared to chest tube alone with evidence suggests that treatment with VATS or chest tube plus fibrinolysis decreases the duration of fever and hospital length of stay (Doski, Lou et al. 2000; Thomson, Hull et al. 2002; Avansino, Goldman et al. 2005; Kurt, Winterhalter et al. 2006; Sonnappa, Cohen et al. 2006; Bradley, Byington et al. 2011)

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.