To further analyze the need for immediate drainage in complicated parapneumonic effusions, we com­bined our data with cases previously reported. In 1976, Potts et al reported seven cases of complicated parapneumonic effusions. The clinical course of two of the seven cases was presented. One patients pleural fluid became loculated and eventually required decor­tication for improvement. Another patient, while on antibiotic therapy alone, developed a positive pleural fluid Gram stain and culture. This patients condition eventually improved with drainage. The other five patients all received early chest tube drainage without mention of whether conservative therapy had been tried first. In 1973, Light et al reported five cases with complicated parapneumonic effusions. Three of these patients were treated with antibiotics alone and died. The fourth patients condition improved after chest tube drainage, but there was prolonged hospi­talization. The fifth patient was initially discharged but was readmitted three months later with empyema. In another study, Light et al described 11 patients with complicated effusions. Four of these patients had a pleural fluid pH between 7.10 and 7.20 but were negative on Gram stain and culture. The condition of all four of these patients improved with antibiotic therapy alone. Another patient had a positive pleural fluid culture for Strep pyogenes and a pH of 7.20. This patients pneumonitis and pleural disease “resolved without undue delay” with antibiotic therapy alone. In the remaining six patients, little discussion was given to the clinical course of the complicated effusion prior to surgical drainage. None of these reports clearly compared the clinical course following antibi­otic therapy alone vs immediate drainage.

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The major finding of our retrospective study was that antibiotic therapy without chest tube drainage was sufficient for most of our patients with complicated parapneumonic effusions. The initial response to ther­apy and the long-term outcome were not different in patients treated with antibiotics alone or antibiotics plus immediate chest tube drainage. Although delayed empyema formation has been reported up to three months following treatment with antibiotics alone for complicated parapneumonic eflusions, none of our 13 patients whose condition responded to antibiotic ther­apy had a delayed recurrence of their infection of the pleural space.

There has also been concern that delay in draining complicated parapneumonic eflusions would result in empyema formation and the inability to drain the efiusion with a chest tube. Two patients with Gram- negative rod pneumonias had failure of initial therapy with antibiotics alone; however, both of these patients were successfully drained with chest tubes and did not require thoracotomy. Therefore, antibiotics alone are not sufficient therapy for all patients with compli­cated parapneumonic eflusions. It is possible that these two patients would have had a shorter hospital­ization if the efiusion had been immediately drained. Furthermore, given larger numbers of patients, it is likely that some patients who received delayed drain­age might have required rib resection and decortica­tion for resolution of the infection of the pleural space.

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Clinical Course of Complicated Parapneumonic Effu­sions Treated with Antibiotics Alone

All 16 cases of complicated parapneumonic effusions treated with antibiotics alone were closely reviewed. There was one death in an 88-year-old patient with a pneumococcal pneumonia. He refused aggressive therapy. The follow-up period for all 15 remaining patients was greater than three months (mean, 16.5 ±3.5 months). Two patients eventually required chest tube drainage during the initial hospitalization due to persistent fever, leukocytosis, and persistently positive fluid cultures. Both patients had Gram-nega­tive rod pneumonias requiring 11 and 14 days of drainage; however, neither required open thoracotomy for resolution.

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Clinical Course of Empyema and Complicated and Uncomplicated Parapneumonic Effusions

Of the 161 charts reviewed, there were 62 cases included in the study (Fig 1). There was no significant difference in the duration of hospitalization or duration of elevated temperature in patients with complicated or uncomplicated parapneumonic eflusions; however, the group with empyema had a significantly longer duration of fever and hospitalization than the other two groups (Fig 2). Similarly, there was a longer duration of elevated serum WBC count and duration of intravenous antibiotic therapy in patients with empyema, compared to those with complicated para­pneumonic eflusions (Fig 3). Thus, the clinical course of a complicated efiusion more closely resembles that of an uncomplicated efiusion.

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Clinical Course of Empyema and Complicated and Uncomplicated Effusions

We determined if the clinical course of complicated parapneu­monic effusions more closely followed the course of empyema, which required chest tube drainage, or of uncomplicated parapneu­monic effusions, which do not require drainage. The clinical course was determined by the duration of hospitalization due to the primary pneumonia and parapneumonic efiusion, the duration of temperature elevation above 38.1°C (100.5°F), the duration of elevated serum WBC count above 10,500/cu mm, with greater than 70 percent granulocytes, and the duration of intravenous antibiotic therapy. Because there has been some suggestion that complicated effusions secondary to Pneumococcus have a more benign course, data were reexamined excluding infections secondary to Pneumo­coccus.

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Parapneumonic effusions are a common complica­tion of bacterial pneumonia. The treatment re­quired for parapneumonic effusions has been largely determined by the characteristics of the pleural fluid. Grossly purulent pleural fluid (ie, empyema) requires drainage and does not resolve with antibiotic therapy alone. Pleural fluid which neither is purulent, Gram- stain positive, or culture-positive, nor has a pH less than 7.20 (ie, uncomplicated effusion), requires only antibiotic therapy and does not require drainage for resolution; however, the treatment required for non­purulent pleural fluid which either is Gram-stain positive or culture-positive or has a pH less than 7.20 (ie, complicated effusion) is controversial. Many phy­sicians include immediate drainage in their treatment for these complicated effusions; however, at some medical centers, standard practice is to treat compli­cated parapneumonic effusions with antibiotics alone. A prospective study comparing antibiotics vs antibi­otics plus immediate drainage for complicated para­pneumonic effusions has never been performed. The purpose of this preliminary retrospective study was to determine if antibiotic therapy alone can be sufficient treatment for complicated parapneumonic effusions.

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