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)
• intrapleural fibrinolytic therapy - a systematic review stated " with complicated infective pleural effusion or empyema, intrapleural fibrinolytic therapy was associated with a reduction in the requirement for surgical intervention and overall treatment failure but with no evidence of change in mortality" (2)
• consider the possibility of tuberculosis

Reference:

1. Drug and Therapeutics Bulletin 2006; 44 (3): 17-20.
2. Altmann ES et al. Intra-pleural fibrinolytic therapy versus placebo, or a different fibrinolytic agent, in the treatment of adult parapneumonic effusions and empyema. Cochrane Systematic Review October 2019