Overview
Pleural empyema with fistula involves a severe, infected pleural space often complicating parapneumonic effusions, characterized by loculations and potential communication with deeper structures or skin. 1Diagnosis
Clinical Presentation: Fever, dyspnea, chest pain, and signs of systemic infection.
Imaging: Chest CT or ultrasound showing loculated fluid, air-fluid levels, and possible fistulae.
Laboratory Tests: Elevated inflammatory markers (CRP, ESR).
Fluid Analysis: Pleural fluid pH < 7.2, LDH/CR ratio > 0.6, and positive Gram stain/culture.
Bacterial Etiology: Identification of causative organisms via pleural fluid cultures; pneumococcal decline noted post-PCV13 implementation. 1Management
Antibiotics: Initial broad-spectrum coverage followed by targeted therapy based on culture results.
Pleural Drainage: Indicated for loculated effusions; chest tube or image-guided procedures.
Decortication: Surgical intervention for refractory cases with extensive pleural thickening.
Fistula Management: Surgical repair or endoscopic interventions for persistent fistulae.
Supportive Care: Oxygen, fluid management, and monitoring for complications.Special Populations
Pediatrics: Post-PCV13 implementation, group A streptococcus is increasingly recognized as a leading cause of empyema 1.Key Recommendations
Implement targeted antibiotic therapy based on pleural fluid culture results (Evidence: Strong 1).
Use imaging (CT/ultrasound) to guide management decisions in pleural empyema with suspected fistulae (Evidence: Moderate 1).
Consider surgical decortication for patients with persistent loculations unresponsive to medical management (Evidence: Moderate 1).References
1 Madhi F, Levy C, Morin L, Minodier P, Dubos F, Zenkhri F et al.. Change in Bacterial Causes of Community-Acquired Parapneumonic Effusion and Pleural Empyema in Children 6 Years After 13-Valent Pneumococcal Conjugate Vaccine Implementation. Journal of the Pediatric Infectious Diseases Society 2019. link