Thoracic Empyema: A Narrative Review of Pathophysiology, Diagnosis, and Management
DOI:
10.29303/jbt.v26i2.13067Published:
2026-08-12Downloads
Abstract
Thoracic empyema is a pleural-space infection characterized by purulent pleural fluid or microbiological evidence of infection. It commonly arises from parapneumonic effusion but may also follow aspiration, trauma, thoracic procedures, abdominal infection, fungal infection, or tuberculosis-related pleural disease. This narrative review synthesizes recent evidence on the pathophysiology, diagnosis, and management of thoracic empyema, with attention to decision points relevant to resource-variable health facilities. Literature was identified through PubMed/MEDLINE, NCBI Bookshelf, Thorax/BMJ, European Respiratory Society publications, SpringerLink, MDPI, Google Scholar, and Indonesian databases using terms related to empyema, pleural infection, parapneumonic effusion, drainage, intrapleural therapy, and surgery. Empyema progresses through exudative, fibrinopurulent, and organizing phases; each stage influences pleural-fluid chemistry, loculation, lung expansion, and treatment response. Diagnosis requires an integrated clinical assessment, imaging, and pleural fluid analysis. Frank pus, positive Gram stain or culture, pleural-fluid pH ≤ 7.20, low glucose, and high LDH support drainage. Management combines prompt antibiotics, image-guided pleural drainage, selected intrapleural tissue plasminogen activator/deoxyribonuclease, and timely surgical referral when initial therapy fails. Early ultrasound-based assessment and multidisciplinary escalation may improve outcomes.
Keywords:
empyema; parapneumonic effusion; pleural drainage; pleural infection; thoracic empyemaReferences
Abdulelah, M., & Abu Hishmeh, M. (2024). Infective pleural effusions-A comprehensive narrative review article. Clinics and Practice, 14(3), 870-881. https://doi.org/10.3390/clinpract14030068
Addala, D. N., Bedawi, E. O., & Rahman, N. M. (2021). Parapneumonic effusion and empyema. Clinics in Chest Medicine, 42(4), 637-647. https://doi.org/10.1016/j.ccm.2021.08.001
Akulian, J., Bedawi, E. O., Abbas, H., Yarmus, L., et al. (2022). Bleeding risk with combination intrapleural fibrinolytic and enzyme therapy in pleural infection: An international, multicenter, retrospective cohort study. Chest, 162(6), 1384-1392. https://doi.org/10.1016/j.chest.2022.06.008
Alghamdi, M. K., Beaudoin, S., & Alwakeel, A. J. (2025). Pleural infection. CMAJ, 197(20), E569. https://doi.org/10.1503/cmaj.241633
Arnold, D. T., Read, L., Waddington, O., Hamilton, F. W., Patole, S., Hughes, J., Milne, A., Noel, A., Bayliss, M., Maskell, N. A., et al. (2024). Antibiotic pharmacokinetics in infected pleural effusions. Thorax, 79(9), 883-885. https://doi.org/10.1136/thorax-2023-220402
Arnold, D. T., Tucker, E., Morley, A., Milne, A., Stadon, L., Patole, S., Nava, G. W., Walker, S. P., & Maskell, N. A. (2022). A feasibility randomised trial comparing therapeutic thoracentesis to chest tube insertion for the management of pleural infection: Results from the ACTion trial. BMC Pulmonary Medicine, 22, 221. https://doi.org/10.1186/s12890-022-02002-5
Bedawi, E. O., Ricciardi, S., Hassan, M., Gooseman, M. R., Asciak, R., Castro-Anon, O., Armbruster, K., Bonifazi, M., Poole, S., Harris, E. K., et al. (2023). ERS/ESTS statement on the management of pleural infection in adults. European Respiratory Journal, 61(2), 2201062. https://doi.org/10.1183/13993003.01062-2022
Chrysou, K., Halat, G., Hoksch, B., & Schmid, R. A. (2017). Lessons from a large trauma center: Impact of blunt chest trauma in polytrauma patients-still a relevant problem? Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 25, 42. https://doi.org/10.1186/s13049-017-0384-y
Corcoran, J. P., Psallidas, I., Gerry, S., et al. (2020). Prospective validation of the RAPID clinical risk prediction score in adult patients with pleural infection: The PILOT study. European Respiratory Journal, 56(5), 2000130. https://doi.org/10.1183/13993003.00130-2020
Corcoran, J. P., Wrightson, J. M., Belcher, E., DeCamp, M. M., Feller-Kopman, D., & Rahman, N. M. (2015). Pleural infection: Past, present, and future directions. The Lancet Respiratory Medicine, 3(7), 563-577. https://doi.org/10.1016/S2213-2600(15)00185-X
Dyrhovden, R., Nygaard, R. M., Patel, R., Ulvestad, E., & Kommedal, O. (2019). The bacterial aetiology of pleural empyema: A descriptive and comparative metagenomic study. Clinical Microbiology and Infection, 25(8), 981-986. https://doi.org/10.1016/j.cmi.2018.11.030
Elsheikh, A., Bhatnagar, M., & Rahman, N. M. (2023). Diagnosis and management of pleural infection. Breathe, 19(4), 230146. https://doi.org/10.1183/20734735.0146-2023
Foley, S. P. F., & Parrish, J. S. (2023). Pleural space infections. Life, 13(2), 376. https://doi.org/10.3390/life13020376
Hasan, H., & Ambarwati, D. (2018). Empiema: An update approach. Jurnal Respirasi, 4(1), 26-32. https://doi.org/10.20473/jr.v4-I.1.2018.26-32
Hassan, M., Cargill, T., Harriss, E., Asciak, R., Mercer, R. M., Bedawi, E. O., et al. (2019). The microbiology of pleural infection in adults: A systematic review. European Respiratory Journal, 54(3), 1900542. https://doi.org/10.1183/13993003.00542-2019
Hassan, M., Gad-Allah, M., El-Shaarawy, B., El-Shazly, A. M., Daneshvar, C., & Sadaka, A. S. (2023). The short versus long antibiotic course for pleural infection management (SLIM) randomised controlled open-label trial. ERJ Open Research, 9(2), 00635-2022. https://doi.org/10.1183/23120541.00635-2022
Hassan, M., Patel, S., Sadaka, A. S., Bedawi, E. O., Corcoran, J. P., & Porcel, J. M. (2021). Recent insights into the management of pleural infection. International Journal of General Medicine, 14, 3415-3429. https://doi.org/10.2147/IJGM.S292705
Herdiman, H., Fitrina, D. W., & Mizati, D. (2022). Diagnosis dan penatalaksanaan empiema. Human Care Journal, 7(1), 21-31. https://doi.org/10.32883/hcj.v7i1.1569
Kanellakis, N. I., Wrightson, J. M., Gerry, S., Ilott, N., Corcoran, J. P., Bedawi, E. O., et al. (2022). The bacteriology of pleural infection (TORPIDS): An exploratory metagenomics analysis through next-generation sequencing. The Lancet Microbe, 3(4), e294-e302. https://doi.org/10.1016/S2666-5247(21)00327-X
Lu, H. Y., & Liao, K. M. (2018). Risk of empyema in patients with COPD. International Journal of Chronic Obstructive Pulmonary Disease, 13, 317-324. https://doi.org/10.2147/COPD.S149835
Maskell, N. A., Batt, S., Hedley, E. L., Davies, C. W. H., Gillespie, S. H., & Davies, R. J. O. (2006). The bacteriology of pleural infection by genetic and standard methods and its mortality significance. American Journal of Respiratory and Critical Care Medicine, 174(7), 817-823. https://doi.org/10.1164/rccm.200601-074OC
Mastromarino, M. G., Lenzini, A., Rabazzi, G., Castaldi, A., et al. (2025). Surgical interventions for pleural infection. Breathe, 21, 250105. https://doi.org/10.1183/20734735.0105-2025
McNally, E., Ross, C., & Gleeson, L. E. (2023). The tuberculous pleural effusion. Breathe, 19(4), 230143. https://doi.org/10.1183/20734735.0143-2023
Rahman, N. M., Maskell, N. A., West, A., Teoh, R., Arnold, A., Mackinlay, C., Peckham, D., Davies, C. W. H., Ali, N., Kinnear, W., et al. (2011). Intrapleural use of tissue plasminogen activator and DNase in pleural infection. New England Journal of Medicine, 365(6), 518-526. https://doi.org/10.1056/NEJMoa1012740
Roberts, M. E., Rahman, N. M., Maskell, N. A., Bibby, A. C., Blyth, K. G., Corcoran, J. P., et al. (2023). British Thoracic Society guideline for pleural disease. Thorax, 78(11), 1143-1156. https://doi.org/10.1136/thorax-2022-219784
Senger, S. S., Thompson, G. R., Samanta, P., Ahrens, J., Galgiani, J. N., et al. (2021). Candida empyema thoracis at two academic medical centers: New insights into treatment and outcomes. Open Forum Infectious Diseases, 8(4), ofaa656. https://doi.org/10.1093/ofid/ofaa656
Shen, K. R., Bribriesco, A., Crabtree, T., Denlinger, C., Eby, J., Eiken, P., Jones, D. R., Keshavjee, S., Maldonado, F., Paul, S., et al. (2017). The American Association for Thoracic Surgery consensus guidelines for the management of empyema. Journal of Thoracic and Cardiovascular Surgery, 153(6), e129-e146. https://doi.org/10.1016/j.jtcvs.2017.01.030
Smith, S. J., & Pippard, B. J. (2025). A practical approach to pleural infection. Pulmonary Therapy, 11(3), 535-551. https://doi.org/10.1007/s41030-025-00308-z
Subedi, A., et al. (2023). Updates on British Thoracic Society Statement on Pleural Procedures and Guideline for Pleural Disease. Journal of Clinical Medicine, 13(8), 2340. https://doi.org/10.3390/jcm13082340
Zhou, L., Yao, M., & Li, J. (2026). Local management of pleural infection: A narrative review. European Journal of Medical Research, 31, 181. https://doi.org/10.1186/s40001-025-03786-8
License
Copyright (c) 2026 Lalu Dane Pemban Paerdoe, Philip Habib, Shira Putri Wardana, Arwinda Febri Yulianti, Moh. Rizky Yolanda B.S.
This work is licensed under a Creative Commons Attribution 4.0 International License.
Jurnal Biologi Tropis is licensed under a Creative Commons Attribution 4.0 International License.
The copyright of the received article shall be assigned to the author as the owner of the paper. The intended copyright includes the right to publish the article in various forms (including reprints). The journal maintains the publishing rights to the published articles.
Authors are permitted to disseminate published articles by sharing the link/DOI of the article at the journal. Authors are allowed to use their articles for any legal purposes deemed necessary without written permission from the journal with an acknowledgment of initial publication to this journal.
