[The treatment of parapneumonic effusions and pleural empyemas]

Pleural effusions of infectious origin usually present as a complication of pneumonia, or, more rarely, of thoracic surgical procedures. Treatment is based upon the clinical picture, the appearance of the pleural fluid, on certain laboratory parameters, and upon the success of therapeutic interventions. The initial antibiotic regimen should cover the causative organisms that may empirically be expected in the individual setting of the patient. Similar to the situation in pneumonias, the spectrum of organisms in community-acquired effusions or empyemas differs substantially from that in hospital-acquired pleural infections. The management of pleural empyemas should follow an interdisciplinary strategy which involves the pulmonologist and the thoracic surgeon. The single most important intervention is the early and effective drainage of the pleural cavity. Loculated effusions that do not promptly improve after drainage can additionally be treated by a trial of intrapleural fibrinolysis for a period of approximately three days. However, the precise role of fibrinolytics in the setting of complicated pleural effusions and empyemas remains to be better defined. Early definitive surgical treatment, preferentially by video-assisted thoracoscopic surgery (VATS), should be the goal in all patients who do not promptly respond to drainage and/or intrapleural fibrinolytic therapy and who qualify for a surgical intervention.