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The incidence of empyema as a thoracic surgical site infection (SSI) is relating low, but empyema related to MRSA poses an unenviable therapeutic challenge. We review 3 cases of MRSA-related empyema as SSI seem in the last 10 years, and evaluate therapeutic measures. All 3 subjects began being administered vancomycin (VCM) systemically once the diagnosis was established. Subject 1 developed MRSA-related empyema following pulmonary segmentectomy for small-cell lung cancer.

The ability to completely drain the thoracic cavity, break up loculations of pleural fluid, completely visualize all aspects of the pleural space, and avoid the morbidity of a thoracotomy has made thoracoscopy attractive in the management of empyema and hemothorax.

Patients proven to have an infected pleural effusion by thoracentesis and who satisfy laboratory criteria for intervention are candidates for thoracoscopic decortication.

CT scan of the chest provides information on the location, degree of loculation, the extent of the empyema, and the underlying lung parenchyma (Figure 1). It is not unusual for an organism not to be identified on the pleural fluid culture and therefore broad-spectrum antibiotic coverage should be instituted when the diagnosis of empyema is made. This can be modified if the culture data identifies an organism.  The antibiotics are continued for the perioperative period.

An assessment of the patient’s nutritional status should be made and supplemental feedings are initiated if necessary. Bronchoscopy should be performed prior to decortication to rule out endobronchial obstruction in the portion of the lung that is trapped by the empyema.

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