Timely therapy for empyema: what it constitutes and why.

The incidence and treatment of empyema historically have fluctuated with the introduction of new antibiotics. As resistant strains of bacteria emerge, a return to aggressive surgical therapy becomes necessary. Empyemas are most likely to occur in patients with an underlying factor such as alcoholism, bronchitis, asthma, emphysema, diabetes, tuberculosis, carcinoma, heroin addiction, or steroid therapy. The bacteriology is constantly changing. Recently, the importance of anaerobic organisms--which are now involved in three out of four cases of empyema--has been recognized. Diagnosis is established and antibiotics chosen on the basis of Gram staining and culture of pleural fluid. Surgical procedures include thoracentesis, closed chest tube drainage, open drainage plus rib resection, decortication, thoracoplasty, and excision of the empyema sac with an extrapleural dissection.