Empyema thoracis: medical aspects of evaluation and treatment

Empyema thoracis is a disease that, despite centuries of study, still causes significant morbidity and mortality. Sixty-five cases were seen at Brooke Army Medical Center over an 8-year period (March 1, 1985, through March 1, 1993). The majority of the patients were men, older than 50 years of age, with significant underlying diseases. Pneumonia remains the most common single proximate cause of empyema. Gram-positive cocci are the most frequently isolated organisms; however, empyemas due to gram-negative organisms and anaerobes are associated with higher mortality. Pleural fluid gram stains proved to be an accurate but neglected diagnostic tool in guiding initial therapy. The choice of antibiotics seemed to have no discernible impact on mortality. Closed tube thoracostomy was the initial method of drainage in most patients and had an overall success rate of 50%. Empyemas that could not be effectively drained by a single chest tube were unlikely to be drained by additional closed maneuvers. There was an overall 22% case-fatality rate with most deaths related to our inability to eradicate the empyema.