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In considering the possibilities of altering the management of empyema by the use of penicillin, the questions of adequate drainage and irrigation are most important. The prevailing tendency in penicillin-treated empyemas has been to delay drainage and therefore decrease the chance of premature operations in cases where the abscess is in a formative stage. Moreover, the use of penicillin will control quickly the pneumonic stage of the disease and consequently decrease the risk of any type of surgical intervention.
There is indisputable evidence that penicillin is a valuable adjunct in the treatment of empyema thoracis caused by penicillin-vulnerable organisms. Systemic administration of the drug alone will sometimes cause cultures of the fluid in the chest to become sterile. Intrapleural injections of penicillin will temporarily sterilize an empyema cavity in the great majority of cases. It is our impression, however, that combined systemic and intrapleural administration is desirable because the combined routes effect both the pulmonary and pleural lesions.
Probably penicillin will be extremely effectual in aborting empyema formation, but once pus is formed, and continues to form, even if sterile, the problem of cavity closure cannot be ignored. If healing is not rapid with disappearance of pus when conservative measures are employed, it is our opinion that surgical drainage is mandatory. Failure to observe the fundamental principle of adequate drainage of any pyogenic empyema, even if the pus is rendered temporarily sterile by penicillin, will invite the serious complication of chronicity. This occurred in two of twenty-four cases which we have observed. It should again be emphasized that the introduction of penicillin has not altered in any way the fundamental principles of treatment of empyema; only the details are changed.
As experiences with penicillin therapy accumulate, the therapeutic approaches will become more standardized. Based upon our own observations, a tentative working plan is suggested:
- 1.1. That an injection of intrapleural penicillin be given as soon as infected fluid appears in the pleura. It is important that local treatment be withheld until the organisms in the fluid are identified. This precaution will prevent waste of penicillin in infections which do not respond to the drug. An initial positive bacteriologic diagnosis will also rule out the possibility of a tuberculous effusion or empyema which may deserve consideration if no other bacteria are found.
- 2.2. If systemic penicillin has not been employed during the pneumonic stage of the disease, it should be combined with the local therapy. It might be argued that by the time an empyema becomes evident the pneumonic phase of the disease will have subsided and, therefore, systemic administration of penicillin would be superfluous. Florey and Cairns16 have emphasized the advantages of combined administration of penicillin in severe war wounds. The chief advantage of the systemic route is that the blood will contain a bacterial inhibitory substance which may control a spreading cellulitis or invasive infection. It is our opinion that the same principle is sound in the management of pneumonia complicated by empyema. This is particularly true in cases of streptococcal or staphylococcal empyema.
- 3.3. Probably three injections of 50,000 units of penicillin on alternate days are sufficient for local treatment. Before the penicillin is injected into the pleura, as much pus or infected fluid as possible should be removed by thoracentesis.
- 4.4. If pus continues to form and thicken, surgical drainage should be established. A sterile empyema is not a cured empyema, and evacuation of frank pus should not be unduly delayed because organisms cannot be found after the penicillin treatment has been started. Our experiences confirm the statement included in the report of the Committee on Chemotherapeutic and Other Agents, Division of Medical Sciences, National Research Council, by Keefer and associates,15 namely, that even when the pus in an empyema cavity is sterilized by penicillin it often becomes so thick that thoracostomy is necessary to furnish adequate drainage.
As an adjuvant to skillful surgery, penicillin has already revolutionized the management of many surgical diseases of the thorax. In their excellent paper on Major Complications of Penetrating Wounds of the Chest, D'Abreu, Litchfield, and Hodson17 give a brilliant account of the value of the mold both as a prophylactic and as a therapeutic agent. There is every reason to predict that with “penicillin protection” the dangers of practically all operations upon the chest will be reduced. This communication is not intended to depreciate the value of this remarkable agent, but to emphasize that it will not afford protection from violations of the fundamental principles of surgery.
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Received: December 23, 1944
© 1945 Published by Elsevier Inc.