Pleural fluid alkalosis can occur in empyema if the infection is caused by a urea-splitting organism such as Proteus . Gram's stains of the pleural fluid will often reveal the causative organisms. Stains and cultures for mycobacteria and fungi are important in selected cases. Antibiotics should be selected on the basis of the causative pathogens. High-dose parenteral therapy is required, and prolonged antibiotic courses of three weeks or more are often needed.
Adequate drainage is of paramount importance.
In acute empyemas, the pleural cavity is lined by acute fibrinous inflammation, and percutaneous drainage of free-flowing fluid may be possible by repeated thoracentesis or tube thoracostomy. Closed chest tube drainage is the traditional method for draining empyemas, but image-guided catheter drainage is also effective, particularly when the fluid is loculated. Resolution of fever generally signifies satisfactory drainage. Enzymatic debridement with streptokinase may enable some patients to avoid surgery.