Case Presentation of Empyema

Empyema is a term used to describe pockets of pus that have collected inside a body cavity, most commonly in the pleural space (slim space between the inside of the chest cavity and the outside of the lung) (1). If left untreated, empyemas can lead to a bacterial infection forming, and although rare can even be life threatening if not picked up (1).

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The main risk factor for empyemas is pneumonia, which is caused by a bacterial lung infection (1). If a patient with pneumonia can fails to respond to treatment properly, an empyema can form. However, even though it is the most common cause of empyemas, less than one percent of children with pneumonia develop an empyema. Other causative factors include a pneumothorax, bronchiectasis, surgery to the chest and blood clots (1).
The main causative pathogen of an empyema is the organism Streptococcus intermedius, which is a species in the Streptococcus milleri group. This is usually due to a complication of community acquired pneumonia (CAP). However other organisms can also less commonly cause an empyema to form, such as Staphylococcus aureus and Streptococcus pneumoniae (2).
The symptoms of an empyema are generally generic respiratory symptoms. These include difficulty breathing, chest pain, and a productive cough containing mucus and pus. There are also more generic symptoms associated with an empyema such as a fever, night sweats, weight loss and a lack of energy (1).
Diagnosis of an empyema usually begins on suspicion of the symptoms mentioned above, coupled with a patient not improving despite treatment for one of the above risk factors. If the patient has a productive cough, then samples of the produce (mucus or pus) can be taken for microscopy (1). Blood cultures can also be taken to determine the bacteria causing the empyema, and bloods will also be taken for a white cell count to diagnose infection, with C reactive protein (CRP) and erythrocyte sedimentation rate (ESR) also looked at. An x-ray and an ultrasound scan can also be taken to show the empyema and how much there is (1).
There are a number of ways to treat an empyema. Majority of patients would be treated with beta lactamase inhibitors antibiotics such as piperacillin-tazobactam, however this can lead to an increased stay in hospital. In addition to antibiotics, a chest drain can also be inserted, to enable complete drainage of the empyema (1). Uncommonly, patients may elect to have a stoma in the chest, to collect the fluid that leaks from the empyema (1). If these measures are unsuccessful, surgery may be carried out to remove the lining of the lung (1).
Case Presentation
A 55-year old female presented to the GP with a one-week history of an occasional cough, with accompanying chest pain. Upon visiting the GP, she was referred for an x-ray. A further week after the x-ray the patient was called into the hospital urgently for treatment and hospital stay until further notice. Upon speaking to the patient, she was relatively confused and unaware of why she was in hospital. Her past medical history included hypertension and hypothyroidism. Her only regular medication is levothyroxine, which she is compliant with.
On presentation to the hospital the patient had a GCS of 15 and was alert and orientated. She had no peripheral oedema and her jugular venous pulse was not raised. Upon auscultation of the chest there were no abnormalities. At presentation the patient’s saturations were 97% on room air, temperature was 38.3 degrees, and her blood pressure was 120/51. All other observations were normal.
Blood tests showed no abnormalities other than a raised CRP of 48, and blood cultures were also carried out. Following this, a chest x-ray was carried out, and this showed abnormal accumulation of fluid along with air in the pleural space, along with extension of the air fluid level to the chest wall. This, along with the blood culture results of Streptococcus intermedius in the pleural fluid, gave a diagnosis of a left sided pneumothorax with a loculated empyema.
When discussed with the consultant microbiologist, the treatment plan for this patient was teicoplanin (IV) and levofloxacin (oral) antibiotics, coupled with a chest drain inserted to drain the empyema. The regular treatment for this type of bacterial empyema was amoxicillin, however this drug was contraindicated due to the patient’s penicillin allergy.
Upon examination of the patient’s current status, the patient was confused as to the reason they were still in hospital, as their symptoms of a cough and chest pain had subsided. The patient was compliant with her oral medication, however refused any IV medication. A chest drain was also connected to the patient under ultrasound guidance (10-french locking pigtail drain). The chest drain was left on free drainage, and around 50-60mls of pus as well as air was aspirated. This specimen was sent off for further testing, however no complications arose.
Discussion of the treatment of a loculated empyema
This section will discuss the treatment options for patients with a loculated empyema, and how it differs to the treatment of a regular empyema, with reference to the case presented. Empyemas are usually treated in a straight-forward manor, however if they become loculated this can pose multiple problems regarding treatment and for the curation of the patient.
If the patient develops a simple empyema, the treatment for an empyema begins with antibiotics being prescribed, followed by a chest drain. When an empyema is suspected, broad spectrum antibiotics are usually initiated, until results of the causative bacteria of the empyema is established. Once results are obtained, more narrow spectrum antibiotics can be started to speed up clinical improvement and to prevent microbial resistance. Multiple agent beta lactamase inhibitors are usually the choice of antibiotic against empyemas, specifically amoxicillin- clauvanate or piperacillin- tazobactam) (3). However other antibiotics can be used such as amoxicillin (depending on the cause of the empyema, or as shown above, alternatives if penicillin allergic. This is because the use of single agent antibiotics is considered suboptimal treatment as they do not work as well, hence is discouraged. A recent study showed that of 51 patients treated in hospital with antibiotics for an empyema, 90% were considered completely sterile after treatment (4). Although this can be effective, mortality rate of empyemas is between 6-24% (5). Therefore, antibiotics alone may be insufficient, particularly for more complex cases of empyemas.
In simple cases of an empyema, percutaneous thoracentesis can be used (2). This involves drainage of the fluid by inserting a needle into the pleural space. In a more complex empyema, such as a loculated empyema, a thoracostomy is the preferred method of treatment, which is where a tube is connected to a suction device and used to remove the fluid (2). In a study where 103 patients had an empyema, 80 of those patients were successfully treated using a chest drain under ultrasound guidance (3). The complication with a loculated empyema is the loculations that cause divisions in the empyema. If percutaneous thoracentesis is used, it will only aspirate the part of the empyema within that locule, and the rest of the pus will not be drained. Similarly, with antibiotics, the bacteria targeted will only be inside one of the locules, with the medication unable to penetrate the loculation tissue, hence leading to a failure to treat the loculated empyema. Therefore, it is crucial to identify whether the empyema is loculated early, as it will improve the efficiency of the treatment for the patient and prevent further complications for the patient regarding the empyema.
References:

Empyema [Internet]. nhs.uk. 2020 [cited 11 February 2020]. Available from: https://www.nhs.uk/conditions/empyema/
Empyema: Causes, Types, and Symptoms [Internet]. Healthline. 2020 [cited 11 February 2020]. Available from: https://www.healthline.com/health/empyema#causes
Ahmed O, Zangan S. Emergent management of empyema. Semin Intervent Radiol. 2012;29(3):226–230. doi:10.1055/s-0032-1326933
K Ryaa Storm H, Krasnik M, Bang K, Frimodt-M0ller N. Treatment of pleural empyema secondary to pneumonia: thoracocentesis regimen versus tube drainage [Internet]. Ncbi.nlm.nih.gov. 2020 [cited 11 February 2020]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC464066/pdf/thorax00370-0057.pdf
Ahmed AE, Yacoub TE. Empyema thoracis. Clin Med Insights Circ Respir Pulm Med. 2010;4:1–8. Published 2010 Jun 17. doi:10.4137/ccrpm.s5066