Thoracic empyema: aetiology, diagnosis, treatment, and prevention.

PURPOSE OF REVIEW: The aim of this study was to review current key points in the aetiology, diagnosis, treatment, and prevention of empyema thoracis. Early postpandemic trends have seen an increasing global incidence and evolution in the aetiology of empyema. Due to varied aetiology and typically lengthy treatment, empyema will be disproportionately affected by the rising tide of antimicrobial resistance (AMR), thus warranting attention and further research. RECENT FINDINGS: Multiple novel biomarkers (e.g. IL-36γ) are under investigation to aid diagnosis, while oral health assessment tools are now available for prognosticating and risk-stratifying patients with thoracic empyema. There exists an ongoing lack of evidence-based guidance surrounding antibiotic treatment duration, surgical intervention indication, and prognostic scoring utility. SUMMARY: Understanding aetiologies in different global regions and settings is pivotal for guiding empirical treatment. Antimicrobial resistance will make thoracic empyema increasingly challenging to treat and should prompt increased awareness of prescribing practices. Novel biomarkers are under investigation which may speed up differentiation of pleural effusion types, allowing faster cohorting of patients.Although newly identified predictors of morbidity and mortality have been suggested to be beneficial for incorporation into clinical practice, further work is required to prognosticate, risk-stratify, and standardize treatment.

Causes, management and treatment of empyema.

Infections in the pleural space have been a significant problem since ancient times and continue to be so today, with an incidence of 52% in patients with post-pneumonia syndrome. Typically, these effusions require a combination of medical treatment and surgical drainage, including debridement and decortication. Researchers have been studying the use of intrapleural fibrinolytics in managing complicated pleural effusions and empyema, but there is still ongoing debate and controversy among clinicians. Empyema has traditionally been considered a surgical disease, with antibiotics and chest tube drainage being the initial treatment modality. However, with advances in minimally invasive procedures such as video-assisted thoracoscopic surgery (VATS) and the use of intrapleural fibrinolytics, medical management is now preferred over surgery for many cases of empyema. Surgical options, such as open thoracotomy, are reserved for patients who fail conservative management and have complicated or chronic empyema. This comprehensive review aims to explore the evolution of various management strategies for pleural space infections from ancient times to the present day and how the shift from treating empyema as a surgical condition to a medical disease continues.

A Case of Thoracic Empyema Caused by Actinomyces naeslundii.

BACKGROUND Actinomycosis is a clinically significant but uncommon infectious disease caused by anaerobic commensals of Actinomyces species, and the incidence of thoracic empyema is rare. We report an extremely rare case of empyema caused by Actinomyces naeslundii (A. naeslundii). CASE REPORT A 39-year-old man presented to our hospital with fever and dyspnea. He had massive pleural effusion and was diagnosed with a left lower-lobe abscess and left thoracic empyema. Thoracic drainage was performed and Ampicillin/Sulbactam was administered for 3 weeks. Four years later, the patient presented with back pain, and chest X-ray showed increased left pleural effusion. After close examination, malignant pleural mesothelioma was suspected, and computed tomography-guided needle biopsy was performed, which yielded a viscous purulent pleural effusion with numerous greenish-yellow sulfur granules. A. naeslundii was identified through anaerobic culture. Thoracoscopic surgery of the empyema cavity was conducted, and Ampicillin/Sulbactam followed by Amoxicillin/Clavulanate was administered for approximately 6 months. No recurrence has been observed for 1 year since the surgical procedure. CONCLUSIONS Actinomyces empyema is a rare condition, and this case is the second reported occurrence of empyema caused by A. naeslundii. The visual identification of sulfur granules contributed to the diagnosis. Long-term antibiotic therapy plays a crucial role in treatment.

A comparative analysis between next-generation sequencing and conventional culture method to detect empyema-associated microorganisms: A systematic review.

Empyema poses a significant global health concern, yet identifying responsible bacteria remains elusive. Recent studies question the efficacy of conventional pleural fluid culture in accurately identifying empyema-causing bacteria. The aim of this study was to compare diagnostic capabilities of next-generation sequencing (NGS) with conventional pleural fluid culture in identifying empyema-causing bacteria. Five databases (Google Scholar, Science Direct, Cochrane, Research Gate, and PubMed) were used to search studies comparing conventional pleural fluid culture with NGS for identifying empyema-causing bacteria using keywords. Positive results identified through conventional pleural fluid culture and NGS were extracted. In addition, bacterial profiles identified by NGS were also documented. Joanna-Briggs Institute (JBI) critical appraisal tool was employed to assess quality of included studies. Descriptive analysis was employed to present outcome of interests. From five databases, three studies, with 354 patients, were included. Findings from three studies showed that NGS outperformed conventional pleural fluid culture in detecting empyema-causing bacteria even in culture-negative samples. Moreover, dominant bacterial profiles identified through NGS included Streptococcus pneumoniae, Staphylococcus aureus, and anaerobic bacteria. In conclusion, NGS outperforms conventional pleural fluid culture in detection empyema-causing bacteria, yet further studies with larger samples and broader bacterial profiles are needed to increase confidence and urgency in its adoption over conventional pleural fluid culture.

Evaluation of a multiplex-qPCR for paediatric pleural empyema-An observational study in hospitalised children.

Pleural empyema is a serious complication of pneumonia in children. Negative bacterial cultures commonly impede optimal antibiotic therapy. To improve bacterial identification, we developed a molecular assay and evaluated its performance compared with bacterial culture. Our multiplex-quantitative PCR to detect Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus and Haemophilus influenzae was assessed using bacterial genomic DNA and laboratory-prepared samples (n = 267). To evaluate clinical performance, we conducted the Molecular Assessment of Thoracic Empyema (MATE) observational study, enrolling children hospitalised with empyema. Pleural fluids were tested by bacterial culture and multiplex-qPCR, and performance determined using a study gold standard. We determined clinical sensitivity and time-to-organism-identification to assess the potential of the multiplex-qPCR to reduce the duration of empiric untargeted antibiotic therapy. Using spiked samples, the multiplex-qPCR demonstrated 213/215 (99.1%) sensitivity and 52/52 (100%) specificity for all organisms. During May 2019-March 2023, 100 children were enrolled in the MATE study; median age was 3.9 years (IQR 2-5.6). A bacterial pathogen was identified in 90/100 (90%) specimens by multiplex-qPCR, and 24/100 (24%) by bacterial culture (P <0.001). Multiplex-qPCR identified a bacterial cause in 68/76 (90%) culture-negative specimens. S. pneumoniae was the most common pathogen, identified in 67/100 (67%) specimens. We estimate our multiplex-qPCR would have reduced the duration of untargeted antibiotic therapy in 61% of cases by a median 20 days (IQR 17.5-23, range 1-55). Multiplex-qPCR significantly increased pathogen detection compared with culture and may allow for reducing the duration of untargeted antibiotic therapy.

Transforming growth factor beta1 (TGF-ß1) levels in a rat model of induced pleural empyema

Abstract Purpose: To evaluate the concentration of transforming growth factor beta 1 (TGFB1) levels in a rat pleural effusion obtained by inoculation of intrapleural bacteria or turpentine through thoracentesis. Methods: Thirty-Nine Wistar rats were divided into three groups: Staphylococcus aureus (SA, n = 17); Streptococcus pneumoniae (SP, n = 12); and turpentine (control, n = 10). Pleural fluid was collected through ultrasound-guided thoracentesis 12 h, 24 h, and 36 h after instillation of bacteria or turpentine. Levels of TGFB1 were measured in pleural fluid. Results: At 12 h, mean TGFB1concentrations were 5.3450 pg/mL in the SA group, 5.3449 pg/mL in the SP group, and 5.3450 pg/mL in controls. At 24 h, they were 4.6700 pg/mL in the SA group, 4.6700 pg/mL in the SP group, and 4.6700 pg/mL in controls. At 36 h, they were 4.6699 pg/mL in the SA group and in control. No difference was observed among the groups in mean TGFB1concentration (p = 0.12); however, a significant intragroup reduction in mean TGFB1 was observed between 12 and 24 h (p < 0.01). Conclusion: The transforming growth factor beta 1 concentrations were not useful as a diagnostic tool or an early marker of infected pleural effusion.

Tratamiento quirúrgico del empiema pleural / Surgical treatment of pleural empyema

Empyema in children occurs mainly in association with an underlying pneumonia. The causative microorganisms have changed with the introduction of vaccines; Streptococcus pneumoniae remains the predominant organism. Symptoms and physical examination can not differentiate between pneumonia with or without pleural effusion, when this one is of small amount. So the chest radiograph is essential. Failure to respond to 48 hours of pneumonia treatment should suggest pleural empiema. If the chest radiograph shows parapneumonic pleural effusion, ultrasound should be performed to confirm the presence of fluid in the pleural space and evaluate the first loculations and wall septations. If liquid is clear and sufficient, pleurocentesis for cytochemical and microbiological analysis must be made. If pleural effusion reproduces or has septations, a pleuropulmonary debridement with videothoracoscopy must be done to cure the child in less time and with less consequences.

El empiema en pediatría se produce principalmente en asociación con una neumonía subyacente. Los organismos causantes han cambiado con la introducción de vacunas, siendo el Streptococcus pneumoniae el microorganismo predominante. Tanto los síntomas como el examen físico no permiten diferenciar entre una neumonía con o sin derrame pleural, cuando éste es de poca cuantía, por lo que la radiografía de tórax es fundamental. La falta de respuesta a 48 horas de terapia de la neumonía debe hacer sospechar empiema. Si la radiografía muestra derrame debe realizarse una ecografía torácica para confirmar la presencia de líquido en el espacio pleural y evaluar las primeras loculaciones y tabiques. Si el líquido está libre y en cantidad suficiente debe realizar una pleurocentesis para análisis citoquímico y microbiológico. Si el derrame se reproduce o está tabicado se debe realizar una debridamiento pleuropulmonar videotoracoscópico que mejora al niño en menor tiempo y con menos secuelas.

Infección del líquido pleural y ascítico por Listeria monocytogenes: caso clínico / Pleural and ascitic fluid infection by Listeria monocytogenes: report of one case

Ascitic and pleural fluids infection by Listeria monocytogenes is uncommon. The association of spontaneous bacterial peritonitis and empyema caused by this microorganism has been seldom reported. A 61 year-old male with an alcoholic cirrhosis and an upper right ¡obectomy for a lung cáncer, consulted because of an exacerbation of dyspnea, abdominal pain and fever. Listeria monocytogenes was isolated from ascitic and pleural fluids and from blood cultures. He was successfully treated with ampicillin and a chest tube for drainage.

Neumonía complicada en pediatría, su manejo: un reto / Treatment of empyema thoracis and necrotizing pnueumonia in children

Complicated pneumonia with pleural effusion or empyema is a condition that its incidence has been increasing in recent years. Its early diagnosis and timely management reduce costs and shorten hospital stays for patients. The optimized diagnostic aids treatments. In recent years the intervention and fibrinolytic substances as VATS surgery have opened a positive outlook in handling controversies exist yet at the time of application. This article reviews these aspects.

La neumonía complicada con derrame pleural o empiema es una patología que ha ido incrementando su incidencia en los últimos años. Su diagnóstico temprano y su manejo oportuno disminuyen los costos y acortan las estancias hospitalarias de los pacientes. Las ayudas diagnósticas optimizan los tratamientos. En los últimos años la intervención con sustancias fibrinolíticas y las intervenciones quirúrgicas como la videotoracoscopia han abierto un panorama positivo en el manejo sin embargo, existen controversias en el momento de su aplicación. Este artículo hace una revisión de estos aspectos.

Características clínicas, diagnósticas y terapéuticas del empiema pleural en niños hospitalizados durante los años2000 - 2004 en el Hospital Nacional Cayetano Heredia / Clinical, diagnostic and therapeutic characteristics of pleural empyema in children hospitalized during years 2000-2004 at National Hospital Cayetano Heredia

Objetivo: Describir las características clínicas, diagnósticas y terapéuticas de los pacientes pediátricos con diagnóstico al alta de empiema pleural internados en el Hospital Nacional Cayetano Heredia desde enero 2000 hasta diciembre 2004. Material y Métodos: Se revisaron las historias clínicas, las variables investigadas fueron edad, sexo, estudio de líquido pleural, cultivos, tratamiento, complicaciones y tiempo de hospitalización. Se usó X2 de Pearson para el análisis estadístico. Resultados: Hubo 22 pacientes con diagnóstico de empiema la relación hombres/mujeres fue de 9/2; la mediana de edad fue 3 años (1 a 10 años), la mediana de días de hospitalización fue 11.5 días (3 a 28 días). En 8 pacientes (36.3 por ciento) hubo complicaciones: 7 bulas, 3 neumotórax, 1 fístula broncopleural y 1 absceso pulmonar. Se halló más tiempo de hospitalización asociado al tratamiento quirúrgico (p<0.05). Se identificó el germen en 12 casos (54.5 popr ciento) (hemocultivo: 2, cultivo líquido pleural:10, coaglutinación enlíquido pleural: 1); siendo Streptococcus pneumoniae el más frecuente (58.3 por ciento) seguido por Haemophilus influenzae (25 por ciento) y Staphylococcus aureus (16.6 por ceinto). En 1 paciente con tratamiento quirúrgico se encontró bacilo ácido alcohol resistente positivo en biopsia pleural. Conclusiones: El empiema es más común en pacientes varones menores de 5 años (77 por ciento), siendo el germen más comúnmente aislado Streptococcus pneumoniae seguido de Haemophilus influenzae y Staphylococcus aureus. Hubo coexistencia de empiema bacteriano y bacilo ácido alcohol resistente positivo en biopsia pleural en 1 paciente con tratamiento quirúrgico. El 31.8 por ciento de pacientes con tratamiento médico fracasó por lo que requirieron tratamiento quirúrgico. No hubo diferencias estadísticamente significativas al comparar el tratamiento médico (15 casos) versus tratamiento quirúrgico (7 casos) respecto a complicaciones.

Objective: To describe the clinical, diagnostic and therapeutic characteristics of pediatric patients with diagnosis of pleural empyema hospitalized at National Hospital Cayetano Heredia from january2000 to december 2004. Material and methods: Clinical histories were reviewed being the investigated variables age, sex, study of pleural liquid, cultures, treatment, complications and time of hospitalization. For the statistical analysis it was used x2 of Pearson. Results: There were 22 patients with diagnosis of empyema. The ratio male/female was of 9/2; the median of age was 3 years (1 to 10 years), the median of days of hospitalization was 11. 5 days (3 to 28 days). In 8 patients (36.3 per cent) there were complications (bullae: 7, pneumothorax: 3. bronchopleural fistula: 1. pulmonary abscess: 1). The time of hospitalization was longer associated to the surgical treatment (p<0.05). The germ was identified in 12 cases (54.5 per cent) (Blood culture: 2, pleural liquid Culture: 10. Agglutination in pleural liquid: 1) being Streptococcus pneumoniae, the most frequent (58.3 per cent) followed by Haemophilus influenzae (25 per cent) and Staphylococcus aureus (16.6 per cent). In 1 patient with surgical treatment acid alcohol resistant bacillus positive was isolated in pleural biopsy. Conclusions: Empyema is the most common in male patient younger than 5 years (77 per cent) being the germ more commonly isolated Streptococcus pneumoniae followed by Haemophilus influenzaeand Staphylococcus aureus. There was coexistence of empyema and acid alcohol resistant bacillus positive in pleural biopsy of one patient with surgical treatment. Medical treatment failured in 31.8 per cent of patients and requiered surgical treatment. There were no predictive factors at the entrance or in pleural liquid when comparing medical treatment (15 cases) versus surgical ...

Empiema y efusión pleural en niños / Empyema and pleural efussion in children

Introducción: El empiema pleural (EP) es una complicación grave de la neumonía adquirida en la comunidad (NAC). Objetivos: Describir las características de los pacientes hospitalizados por EP en el Servicio de Pediatría del Hospital de la Universidad Católica durante el período 2000-2005. Se identificaron 86 hospitalizaciones por NAC con efusión pleural, practicándose en 59 (70 por ciento), al menos una toracocentesis. Se consideró EP a la presencia de pus, tinción de Gram con bacterias, cultivo positivo o pH < 7,10 en el líquido pleural, siendo las efusiones para-neumónicas los controles. Resultados: Se analizaron 24 EP y 25 controles [promedio 2,9 años (rango: 8 meses - 14,3 años)], 78 por ciento de edad inferior a 5 años con diferencia entre los grupos EP y controles [1,6 vs 3,3 años, respectivamente (p = 0,01)]. El promedio global (días) de síntomas previo al ingreso en los EP fue 7 (rango: 2-21), siendo los más frecuentes fiebre (100 por ciento) y tos (96 por ciento). Se identificó algún microorganismo en 15/24 EP, Streptococcus pneumoniae fue el más frecuente (n: 9). En 48 niños, el manejo inicial fue conservador, requiriéndose cuatro rescates quirúrgicos luego del cuarto día. El promedio (días) de hospitalización fue significativamente superior en el grupo EP vs controles [15 (rango: 5-38) vs 9 (rango: 3-16) (p < 0,01)]. Requirieron drenaje pleural 83 por ciento del grupo EP y 36 por ciento de los controles (p = 0,002). No hubo diferencia en el número de días de empleo de oxígeno [6 vs 4,5 (p = 0,36)] o drenaje pleural [3 vs 2,5 (p = 0,29)]. No se registraron fallecidos. Conclusión: El EP en niños fue una condición respiratoria aguda que se asoció a estadías hospitalarias prolongadas, especialmente en los de menor edad, no requiriéndose, en la mayoría, una intervención quirúrgica de rescate.

Introduction: Pleural empyema (PE) is a serious complication of community-acquired pneumonia (CAP). Objectives: To describe the clinical profile of hospitalized patients with PE in the pediatric ward of the Catholic University Hospital between 2000-2005. Patients y methods: Retrospectively, all pediatric admission due to CAP and pleural effusion (86 children) were identified. In 59 (70 percent) children > 1 thoracocentesis were performed. We considered PE as the presence in the pleural effusion of pus, and/or a positive gram strain and/ or positive culture, and/or a pH < 7.10. Children with effusions not meeting any criteria were used as controls. Results: Twenty four PE and 25 controls were identified, with a global mean age of 2.9 years (range: 8 months to 14.3 years); 78 percent were < 5 years, with a significant difference between PE and controls [1.6 vs 3.3 years (p = 0.01)]. The mean duration of symptoms in PE patients before admission was 7 days (range: 2-21), and the most frequent symptoms were fever (100 percent) and cough (96 percent). In 15/24 cases a microorganism was identified being Streptococcus pneumoniae (n = 9) the most common. In 48 patients management was conservative and in 4 surgical procedures were required. The mean duration of hospitalization was significantly higher in the PE group vs controls group: 15 (range: 5-38) vs 9 days (range 3-16) (p < 0.01). A chest tube was inserted in 83 percent of children with EP compared with 36 percent in the control group (p = 0.002). There were no difference in number of days of oxygen use [6 vs 4.5 (p = 0.36)] or number of chest tubes per child [3 vs 2.5 (p = 0.29)]. No deaths were reported. Conclusion: PE in children represented an acute respiratory event associated with more prolonged hospitalization especially at younger ages; the majority of cases did not require surgical intervention.

Tratamiento de empiema paraneumónico / Treatment of empyema paraneumónico

El empiema paraneumónico (EP) o pus en el espacio pleural es una complicación rara de la neumonía bacteriana en niños; sin embargo ésta se ha incrementado en Estados Unidos y Europa en los últimos años. Los autores mencionan que en su institución (Primary Children’s Medical Center, Salt Lake City) trataron 500 pacientes con empiema en la última década. En Utah incrementó de 1/100.000 niños el año1993 a 14/100.000 el 2003

Síndrome de Claude Bernard-Horner associada ao empiema pleural / Claude Bernard-Horner syndrome resulting from pleural empyema

A síndrome de Claude Bernard-Horner apresenta várias etiologias, ocorre por interrupção do estímulo nervoso em qualquer ponto do trajeto do nervo e pode ser intra ou extratorácica. É relatado um caso dessa síndrome causado por empiema pleural septado, localizado em região paravertebral, no terço superior do hemitórax direito. O paciente foi submetido à toracotomia para drenagem da cavidade pleural. A evolução foi satisfatória, com regressão do quadro infeccioso, expansão pulmonar e remissão da síndrome.

Derrame pleural parapneumônico e empiema / Parapneumonic effusion and empyema

O derrame infeccioso, uma das causas mais freqüentes de derrame pleural obervados na pratica clinica, é um sinal de complicação do quadro pneumônico. O reconhecimento precoce do derrame parapneumônico é fundamental para determinar a melhor forma de tratamento, reduzindo o risco de morbidade e mortalidade. A evolução dos métodos diagnósticos e a experiência dos diversos estudos publicados na literatura permitiram estabelecer diretrizes baseadas em evidencias que orientam a conduta de abordagem terapêutica do derrame parapneumônico e empiema.

The infectious effusion, one of the most frequent causes of pleural effusions in the clinical practice, is a sign of complication of the pneumonic disease. The early recognition of the parapneumonic effusion is crucial to determine the best treatment form and reduce the risk of morbidity and mortality. The evolution in the diagnostic methods and the contribution of several studies published in the literature allowed to establish evidence-based guidelines that are used to guide the treatment of the parapneumonic pleural effusion and empyema.

Supuración pleuropulmonar por anaerobios en pediatría: presentación de cuatro casos / Anaerobial Pleuro-pulmonary Suppurative Disease in children: report of four cases

Las supuraciones pleuropulmonares en Pediatría habitualmente son producidas por gérmenes aeróbicos (S. pneumoniae, H. influenzae, S.aureus) y en edades tempranas. Durante un período de 2 años se detectaron 4 pacientes con supuración pleuropulmonar producida por flora mixta (aerobios + anaerobios); ello representa el 3,6 por ciento de los 106 pacientes con supuración pleropulmonar asistidos en el mismo período en el Hospital de Pediatría Garrahan. Los 4 pacientes tuvieron una prolongada evolución previamente al diagnóstico bacteriológico; en 3 casos se registraron como antecedentes convulsiones o trastornos de la deglución. En Pediatría, la infección pulmonar por anaerobios debe sospecharse en pacientes con evolución prolongada, tratados con antibióticos de actividad parcial frente a anaerobios y con antecedentes de enfermedad subyacente que predisponga a la aspiración, como alteraciones de la conciencia o de la deglución.

Empiema por actinomyces: el gran simulador / Empyema due to Actinomyces: a diagnostic challenge

El derrame pleural aislado, como única manifestación de la actinomicosis es una situación muy rara y un desafío diagnóstico para el clínico, no sólo por su infrecuencia sino por la dificultad técnica para cultivar al gérmen. La típica apariencia microscópica de este bacilo Gram-positivo ramificado en los cultivos suele ser la clave del dianóstico. Se informa un caso de derrame pleural masivo izquierdo por Actinomyces israelii, sin afectación del parénquima pulmonar, de difícil diagnóstico, que mejoró clínica y radiológicamente en forma completa con el drenaje quirúrgico y tratamiento antibiótico prolongado.

Empiema pleural: a indicaçäo do uso da pleuroscopia / Pleural empyema: an indication of use of pleuroscopy

O arsenal terapêutico para o manuseio cirúrgico do Empiema Pleural constitui-se num dos mais fartos a serviço dos cirurgioes torácicos. A razao de tantas opçoes parece óbvias, visto que a infecçao do espaço pleural tem, caracteristicamente, três fases evolutivas com peculiaridades que impoem um ou outro método. A utilizaçao da pleuroscopia, como primeira atitude terapêutica nos casos de empiema multiloculado ou naqueles em que a drenagem simples foi inefetiva, tem se mostrado método eficaz e seguro.

Empiema pleural / Pleural empyema

El empiema pleural se define como acúmulo de pus en la cavidad pleural. Su pronóstico está directamente relacionado con la precocidad del diagnóstico y con un oportuno y adecuado tratamiento. Un mal manejo del empiema puede llevar a la cronicidad de la infección y poner en peligro la vida del paciente. En este artículo se analizan algunos aspectos de esta patología incluyendo su etiología y su clasificación, Se describe el cuadro clínico y los exámenes que contribuyen al diagnóstico. Se analizan los objetivos del tratamiento y los procedimientos terapéuticos actualmente en uso para tratar esta afección

Manejo del empiema bacteriano crónico

Presentamos nuestra experiencia en el manejo del empiema bacteriano crónico en el Hospital Militar Central de Santafé de Bogotá. Esta serie de casos incluye 30 pacientes tratados en el hospital entre 1985 y 1990. Todos los pacientes eran adultos jóvenes, de sexo masculino, en servicio militar activo. Todos tenían un diagnóstico previo de neumonía bacteriana y habían sido tratados en sus respectivos centros locales de atención médica. Los pacientes fueron trasladados a nuestro servicio debido al deterioro progresivo de su estado clínico y a su fiebre continua. Al examen físico así como con la radiografía de tórax evidenciaron la presencia de derrame pleural, y el aspirado pleural fue francamente purulento en todos los casos. El protocolo de manejo consistió en toracentesis inicial intentando remover el máximo posible de líquido pleural. El uso de antibióticos se descontinuó tan pronto como los pacientes fueron admitidos en el servicio. En caso de reaparición de la fiebre, se realizaban nuevas toracentesis entre el segundo y cuarto días luego del procedimiento inicial. Ninguno de los pacientes fue tartado con totacostomía cerrada ni con cirugía torácica. Los pacientes fueron dados de alta luego de la mejoría de los sintomas iniciales. Practicamos toracentesis repetidas ambulatoriamente, en caso de reaparición de fiebre o dolor torácico. Durante el manejo ambulatorio ninguno necesitó más de tres a cinco de estos procedimientos repetidos. El curso final en todos los casos fue la mejoría clínica. Se obtuvo normalización completa de la radiografía en 21 de los 30 pacientes. Los otros mostraron secuelas radiográficas menores, tales como borramiento del ángulo costofrénico o engrosamiento pleural. Sin embargo, ninguno mostró decremento funcional en la realización de sus actividades diarias, así como en tolerancia al ejercicio. Nuestra experiencia indica que el manejo no invasivo del empiema crónico en adultos jóvenes y por demás sanos, puede ser efectivo en algunos casos.