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Guidelines
Pathogens
Antimicrobials
Uncomplicated parapneumonic effusion
Exudative effusion, pH >7.2, culture and gram stain negative
Generally resolves with treatment of pneumonia and does not require modification of pneumonia therapy
Follow with serial Chest X-ray to significant improvement
Complicated parapneumonic effusion
Any parapneumonic effusion that is loculated, or culture positive, or pH < 7.2, but is not frankly purulent or gram stain positive
Consult Thoracic Surgery for drainage
Empyema
Frank pus or organisms on gram stain in pleural fluid
May be culture negative
Light’s criteria for exudative effusions
One of:
Pleural protein to serum protein ratio > 0.5
Pleural LDH to serum ratio >0.6
Pleural LDH > 0.6 x the upper limit of normal for serum LDH
Imaging
Chest X-ray
Can reveal loculated fluid suggesting either empyema or complicated effusions
Ultrasound
Can help to characterize location, and consistency of the fluid (i.e. echogenic fluid more likely empyema)
CT with Contrast
Can characterize the fluid location, loculation, and demonstrate thickened/enhancing pleura consistent with empyema or complicated effusions
Sampling/Drainage
Indications for sampling
All parapneumonic effusions >10mm depth should be sampled (smaller effusions generally resolve without intervention)
Indications for drainage
Positive gram stain or culture, or frank pus
Loculated collections, or thickened/enhancing pleura on imaging
Effusion causing significant respiratory compromise or sepsis
Large, fee-flowing effusions
Send pleural fluid for:
Gram stain and aerobic/anaerobic culture
Cell count and differential
Chemistry - pH, total protein, LDH, glucose
± TB/fungal depending on risk factors
Pleural Effusion
Uncomplicated, Community-Acquired Empyema
Complicated or Hospital-Acquired Empyema
Lung Abscess
