Challenging Management of Postoperative Empyema: A Case Report with Literature Review Article Swipe

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Hemn H. Kaka Ali , Abeer A. Abass , Ahmed H. Ahmed , Naser Abdullah Mohammed , Yadgar H. Hamakarim , Shvan H. Mohammed , Hussein M. Hamasalih , Fahmi H. Kakamad · YOU? · · 2025 · Open Access · · DOI: https://doi.org/10.70955/jcj.2025.16

Introduction: Pleural empyema is the collection of pus within the pleural cavity, typically arising as a complication of pneumonia, chest trauma, thoracic surgery, or bacterial invasion of the pleural space. This report presents a case of post-surgical pleural empyema caused by Pseudomonas aeruginosa, successfully managed with a targeted combination of fosfomycin and colistin, with intrapleural lavage. Case presentation: A 37-year-old male developed epigastric pain 12 days after a laparoscopic near-total gastrectomy. A chest computed tomography scan revealed a right-sided pleural empyema. Ultrasound-guided drainage was performed, followed by the intrapleural instillation of alteplase to facilitate breakdown of the loculated empyema. Pseudomonas aeruginosa was identified as the causative agent. Based on antimicrobial susceptibility, the patient received intravenous fosfomycin and colistin, along with daily pleural lavage using colistin. Inflammatory markers declined, and the patient showed notable clinical improvement. Literature review: A review of five cases of Pseudomonas aeruginosa pleural empyema was conducted, including two carbapenem-resistant and one extensively drug-resistant case. The mean patient age was 53.8 years, and 60% (3/5) were female. Four of the five cases (80%) were confirmed using computed tomography, and all patients received antimicrobial therapy, most frequently ceftolozane/tazobactam (60%), ciprofloxacin (60%), and colistin (40%). Surgical management was required in 60% of cases, whereas bacteriophage therapy was utilized in 20%. During follow-up, 60% of patients remained stable, 20% experienced repeated hospital admissions during which antibacterial therapy was withheld, and 20% died due to infectious disease. Conclusion: Pleural lavage combined with antibiotics such as fosfomycin and colistin may provide an effective treatment for postoperative pleural empyema, with early intervention being critical to prevent clinical deterioration. Introduction Pleural empyema is the accumulation of pus within the pleural cavity. Although its pathogenesis is not entirely clear, it typically arises from pneumonia, chest trauma, postoperative complications following thoracic surgery, or bacterial invasion from adjacent infection [1]. Epidemiological data from France report an incidence of approximately 0.78 cases per 10,000 people annually [2]. Mortality is not uncommon, with overall rates around 17%, and most patients require hospitalization [2]. Approximately 25–50% of patients with pneumonia develop a parapneumonic effusion, which may progress to empyema in some cases [3]. The factors contributing to the progression of pneumonia to empyema remain poorly understood [4]. However, pleuritic pain, higher severity scores for community-acquired pneumonia, multilobar involvement on imaging, and elevated inflammatory markers have been associated with an increased risk of progression. In contrast, administration of systemic corticosteroids at the time of admission has been linked to a reduced risk, possibly by decreasing pleural inflammation [5]. The use of corticosteroids in community-acquired pneumonia remains debated: the Infectious Diseases Society of America recommends them only for septic shock unresponsive to vasopressors, whereas European guidelines suggest their use more broadly in cases of shock [5]. Pseudomonas aeruginosa is a widely distributed Gram-negative bacterium that can be found in various environmental settings and hosts [6]. It can cause various infections in humans, especially affecting the respiratory tract of patients with cystic fibrosis [7]. Its clinical impact is amplified by intrinsic antibiotic resistance, mediated through biofilm formation, antibiotic-modifying enzymes, multiple efflux pumps, and low cell permeability, making infections particularly challenging in immunocompromised or chronically ill patients [6]. This report presents a case of pleural empyema due to Pseudomonas aeruginosa approximately two weeks after a laparoscopic near-total gastrectomy, successfully managed with a combination of fosfomycin and colistin alongside intrapleural lavage. This report was prepared in accordance with CaReL guidelines, and all references cited have been carefully assessed for credibility [8, 9]. Case presentation Patient Information A 37-year-old male smoker presented with epigastric pain, low-grade fever, anorexia, and generalized weakness following 12 days after laparoscopic near-total gastrectomy with spleen-preserving D2 lymph node dissection for gastric cancer. The patient had a recent influenza infection three weeks prior to surgery. Other than the gastrectomy, no significant medical or surgical history was reported. Clinical Findings Upon examination, he appeared agitated and fatigued, with a generally ill appearance. Vital signs showed tachycardia (heart rate 105 bpm) and tachypnea (25 breaths per minute), while oxygen saturation and blood pressure remained within normal limits. Chest auscultation revealed diminished breath sounds over the right lower lung. Diagnostic Approach Laboratory investigations revealed markedly elevated inflammatory markers, with a C-reactive protein (CRP) level of 180 mg/L (Normal range: < 3 mg/L) and an erythrocyte sedimentation rate (ESR) of 95 mm/hr (Normal range: < 15 mm/hr). Chest computed tomography (CT) confirmed the presence of a right-sided pleural empyema (Figure 1), while abdominal CT ruled out an anastomotic leak. These findings suggested the empyema likely resulted from postoperative pneumonia progressing to a complicated pleural infection rather than a direct surgical complication. Therapeutic Intervention Ultrasound-guided drainage was performed, and a chest tube was inserted, initially draining 100 cc of pus. The following day, 50 mg of alteplase diluted in 100 cc of normal saline was administered through the tube. After a 4-hour dwell time, drainage increased to 500 cc, indicating effective fibrinolysis and breakdown of loculated empyema. Empirical broad-spectrum antibiotic therapy with meropenem (1 g every 8 hours) was initiated pending culture results, and the patient maintained a regular oral diet. Culture Results and Targeted Antimicrobial Therapy ​Microbiological analysis of the drained pus, performed using the advanced VITEK-II Compact (bioMérieux) diagnostic system, identified Pseudomonas aeruginosa as the causative agent. Antimicrobial susceptibility testing showed that the strain was multidrug-resistant (MDR), with sensitivity limited to colistin, aztreonam, and fosfomycin (Table 1). The patient received intravenous fosfomycin (4 g every 8 hours for 7 days) and colistin (initially 3 million units every 8 hours for 7 days, followed by 1 million units every 8 hours for 12 days). Pleural lavage with colistin was performed every 12 hours for 5 days, once daily for 7 days, and then on alternate days for an additional 7 days to enhance local antibiotic concentrations. Table 1. Antimicrobial susceptibility testing results Antimicrobials Inhibition zone (mm) Interpretation Antimicrobials Inhibition zone (mm) Interpretation Cefixime 0 Resistant Moxifloxacin 0 Resistant Cefuroxime 0 Resistant Levofloxacin 0 Resistant Cefotaxime 0 Resistant Doxycycline 0 Resistant Ertapenem 0 Resistant Minocycline 0 Resistant Cefpodoxime–clavulanate 0 Resistant Tigecycline 0 Resistant Aztreonam 20 Sensitive Nitrofurantion 0 Resistant Rifampin 0 Resistant Streptomycin 0 Resistant Colistin 19 Sensitive Azithromycin 0 Resistant Fosfomycin 24 Sensitive Clarithromycin 0 Resistant Monitoring and Outcome Daily clinical assessments and serial inflammatory marker measurements were performed. Vital signs normalized, CRP returned to normal, and ESR decreased to 40 mm/hr. Follow-up cultures from the chest drain were negative. Given significant clinical improvement, the chest tube was removed, and the patient was discharged in stable condition. He was subsequently referred to an oncology for ongoing management of gastric cancer. At 10 months post-treatment, there was no evidence of recurrence. The patient has completed adjuvant chemotherapy and continues to undergo regular follow-up with upper gastrointestinal endoscopy and chest and abdominal CT scans. Discussion Empyema has increasingly been recognized as a reservoir for resistant bacteria, largely because many antibiotics penetrate the pleural space at subtherapeutic concentrations, thereby promoting resistance development [10]. Clinically, the disease progresses through three distinct stages—uncomplicated parapneumonic effusion, complicated parapneumonic effusion, and established empyema—which highlight its dynamic pathophysiology and the need for timely intervention [1]. In parallel with this progression, the incidence of MDR and XDR Pseudomonas aeruginosa has risen substantially. This trend is driven by the organism’s ability to cause severe healthcare-associated infections, its exceptional capacity to accumulate and spread resistance determinants within the host, and the global dissemination of high-risk clones. As a result, infections caused by these strains pose significant clinical challenges and are associated with increased morbidity and mortality due to limited therapeutic options [11]. The severity of empyema and its outcomes are reflected in epidemiologic data. Bobbio et al. studied adults hospitalized with pleural infections in France between 2013 and 2017, identifying 25,512 empyema cases with an annual incidence of 7.15–7.75 per 100,000 inhabitants. Mortality rates varied substantially depending on underlying conditions, reaching 30% in cancer patients, 18% after lung resection, and 11% among patients without these comorbidities [2]. This variability underscores the importance of understanding pathogen behavior in the contex

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Challenging Management of Postoperative Empyema: A Case Report with Literature Review

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Hemn H. Kaka Ali, Abeer A. Abass, Ahmed H. Ahmed, Naser Abdullah Mohammed, Yadgar H. Hamakarim, Shvan H. Mohammed, Hussein M. Hamasalih, Fahmi H. Kakamad

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