[Thoracic empyema. Focus on bacteriology and therapy]

Treatment of empyema thoracis is a difficult one, especially when it occurs in a large residual pleural cavity or with a bronchopleural fistula. Sixty three patients have been studied: 39 post-surgical cases (pneumonectomy 21, lobectomy 14, therapeutic pneumothorax 4) and 24 cases without previous surgical procedure. Bacteriologic findings were as follows: 19% of the cultures were negative; Staphylococcus aureus has been isolated in 43% of the positive cultures, Gram negative bacilli in 40%, anaerobic germs in 21.5% and Streptococcus pneumoniae in one case. In 55 patients (87%) initial treatment was pleural drainage and local irrigations associated with systemic antibiotherapy. Enzymatic debridement with streptokinase was necessary in 25 patients (40%) and intrapleural antibiotherapy in 19 patients (30%). Twenty two patients needed subsequent surgical treatment: 12 pleural debridements, 2 pleuropneumonectomies and 12 open-window thoracostomies were performed. Fourty three patients were cured; 11 died (7 related to the primary disorder) and 8 developed chronic infections. Effective pleural drainage must always be the first treatment in empyema thoracis. When this fails, surgical treatment is imperative. Pleural debridement is the procedure of choice when there is no residual pleural cavity and when the lung can be reexpanded. Pleuropneumonectomy must be reserved to extensive pulmonary destructions. Open-window thoracostomy is the best technique when large residual pleural space or bronchopleural fistula occurs (e.g. after pneumonectomy), and after the failure of all other treatments.