Background: This study was undertaken to determine whether all adult patients with primary empyema thoracis need decortication.
Methods: A management algorithm was developed and analyzed in a prospective, longitudinal, nonblinded study of 179 consecutive adult patients. The treatment options included thoracentesis, closed (tube) thoracostomy, image-guided catheter drainage, and decortication. We reviewed the outcomes of these procedures as they related to the pleural fluid cultures isolated and the antibiotic regimens used.
Results: Of the 179 patients, 20 had thoracentesis as the primary procedure, and 18 (90%) were cured. Ninety patients underwent closed thoracostomy as the primary procedure with a cure rate of 62% (56 patients) and a mortality rate of 11% (10 patients), and 24 patients required a secondary procedure. Seventy-six patients underwent decortication as either the primary or the secondary procedure with a cure rate of 88% (67 patients) and a mortality rate of 1.3% (1 patient); 8 patients required conversion to open thoracostomy. Hospital stay for decortication was 14+/-1 days and for closed thoracostomy, 17+/-1 days (p < 0.05). Decortication was necessary in 55% of patients with anaerobic infections and in 50% with aerobic infections. Clindamycin in combination with gentamicin sulfate was the most efficacious regimen with a success rate of 82% (51 of 62 patients); only 33% (17 of 52) were cured with penicillin. The overall mortality rate in this study was 6.7% (12 of 179 patients).
Conclusions: Forty-two percent of patients with primary empyema thoracis ultimately require decortication. Decortication is more frequently necessary for anaerobic, tuberculous, staphylococcal, and pneumococcal infections. Although the overall mortality in this study was low, mortality remains high in elderly patients and patients with comorbid disease.