• Most organisms are anaerobic bacteria: bacteroides, fusobacterium, peptococcus
• Staphylococcus is cause in > 90% of children under 2 years; common cause in adults also
• E coli, Pseudomonas cause 66% of aerobic, gram-negative empyemas
• Rarely fungi and Entamoeba histolytica can cause empyemas
• Average number of bacterial species isolated: 3.2 per patient
• Incidence of complications with Staph pneumonias in adults:
• Incidence of complications with Staph pneumonias in kids:
• Rarely asymptomatic
• Fever, pleuritic chest pain, dyspnea, hemoptysis, cough
• Tachycardia, anemia, tachypnea, diminished breath sounds, clubbing
• Chest CT: May be necessary if loculated
• Bronchoscopy: Performed to exclude presence of endobronchial obstruction
• Thoracentesis: Diagnostic
Treatment Algorithm: Empyema
• Clear thoracentesis
-Check Gram stain and culture
-If positive, thoracentesis/chest tube
-If negative, check pH, glucose, LDH; chest tube if indicated
• Pus on thoracentesis
-Place chest tube
-Convert to open drainage
-Perform sinogram: No cavity, then withdraw tube; small cavity, evaluate how well drained—if well drained, then slowly advance tube—if not well drained, then consider rib resection, thoracoscopy, or new chest tube; large cavity, if well drained, slowly advance tube—if no reexpansion, consider decortication—if not well drained, consider early decortication, rib resection, or Eloesser procedure
• Residual spaces, continued sepsis: Consider open drainage procedures 10-14 days after chest tube (allows time for pleural fusion
• Rib resection: Of short segments of 1-3 ribs in dependent portion
• Eloesser procedure: Simple rib resection and open flap drainage
• Creation of U-shape flap: Chest wall sewn to parietal pleura with rib resection
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