Management

• accurate assessment of the size of the effusion and, where necessary, loculations using ultrasound or CT scanning
• early diagnostic pleural aspiration, to assess fluid appearance, bacteriology and biochemistry
• antibiotic therapy - depends on the bacteriology of the aspirated fluid; often requires metronidazole because organisms may not be revealed by culture
• pleural fluid is drained - if this is not possible then surgery is indicated (surgical evacuation and lung decortication so that it may be fully expanded and so obliterate the pleural space)
• consider the possibility of tuberculosis

Reference:

1. Shen KR, Bribriesco A, Crabtree T, et al. The American Association for Thoracic Surgery consensus guidelines for the management of empyema. J Thorac Cardiovasc Surg. 2017 Jun;153(6):e129-46.