Treatment of complicated parapneumonic effusions and pleural empyema: a four-year prospective study

We studied prospectively the microbiologic findings, management, including the use of intrapleural streptokinase to improve pleural drainage, and outcome of 33 patients with complicated parapneumonic effusions (6) frank empyema (27) treated by our unit over a 4-year period. The mean age was 61 years, with more male (26) than female (7) patients. Seventy-nine percent of the patients had some form of underlying illness, especially chronic lung disease (46%), followed by diabetes mellitus (23%). Fifteen percent of the pleural collections were loculated. Pleural fluid cultures were positive in 58%, Staph aureus and Kleb pneumoniae being the most prevalent aerobic isolates. The incidence of anaerobic isolates was 32%. Besides empirical antibiotics, all patients had drainage of the pleural collections at diagnosis. Four patients were treated with needle aspiration; 28 (85%) required thoracostomy tube drainage for a mean of 8 days, 5 of these went on to surgical decortication. Thirteen patients received intrapleural streptokinase (SK) to facilitate drainage, with significant increase in the volume drained. The mean duration of stay for the whole group was 22 days. The administration of intrapleural SK did not significantly shorten the duration of hospital stay. There were six deaths (18%), none as a direct result of the empyema. We describe a therapeutic approach to parapneumonic effusions and empyema which tailors the interventional modality to the clinical stage of disease.