The debate over when and in whom a thoracostomy tube should be placed still continues. Overall, clinicians agree that all patients should be placed on antibiotics and a sample of pleural fluid obtained. However, there is no consensus on when and in whom to place a chest tube, instill urokinase or take to the operating room. The general consensus is that patients who are not defervescing clinically after a few days of therapy may require alternative or more aggressive therapy. Also, a delay in antibiotic therapy and drainage has been associated with a longer hospital stay and the increased likelihood of surgical intervention.
Pleural cultures are positive in approximately one half of pediatric patients with empyema.
Currently, Streptococcus pneumoniae is the most common isolate from community acquired empyema, followed by Staphylococcus aureus and Haemophilus influenza. IV Cefuroxime or a similar second-generation cephalosporin is recommended as first line therapy . If an organism is identified, antibiotics can be tailored to culture and sensitivity results. High dose penicillin, third generation cephalosporins or vancomycin may be considered for drug resistant pneumococcal empyema. In a hospital acquired empyema or an empyema in a compromised host, there is a greater possibility of gram negative, anaerobic or opportunistic organism.