Abstract Introduction Empyema due to difficult-to-treat resistant (DTR) Pseudomonas aeruginosa in a malignant trapped lung is therapeutically challenging when surgical decortication is unsafe and systemic antibiotics have limited efficacy or intolerable toxicity. Evidence for intrapleural antiseptics such as sodium hypochlorite (“Dakin’s solution”) remains sparse. Case Report A 65-year-old woman with stage IV hormone receptor-positive breast cancer developed a chronic right hydropneumothorax and empyema after outpatient catheter drainage overseas. On admission, pleural fluid repeatedly grew DTR P. aeruginosa; cytology was negative. CT imaging showed a large, loculated hydropneumothorax with pleural thickening consistent with lung entrapment. She underwent video-assisted thoracoscopic surgery (VATS) washout with intrapleural polymyxin irrigation; decortication was deferred due to high risk of bronchopleural fistula, bleeding, and prolonged air leak. Systemic cefiderocol and polymyxin B were trialed but discontinued for suspected neuromuscular weakness and uncertain benefit. As a local source-control strategy, she received intrapleural Dakin’s solution (0.125-0.25%, 50-150 mL per dose, up to three times daily) via chest tubes, with limited tissue plasminogen activator/deoxyribonuclease to enhance drainage. Drainage progressively decreased, effusion cleared, and chest tubes were sequentially removed. The patient was discharged without systemic antibiotics on oral diuretics, with close interventional pulmonology and oncology follow-up. Dakin’s instillation was used while outpatient bacteriophage therapy was being coordinated for her DTR P. aeruginosa. Discussion In malignant trapped-lung empyema due to DTR P. aeruginosa, when surgery is unsafe and systemic options are ineffective or toxic, carefully titrated intrapleural Dakin’s solution can serve as a salvage approach for pleural-space control. This case highlights the role of local antiseptic therapy to achieve partial pleural sterilization, minimize systemic antibiotic exposure, and allow successful chest-tube removal with symptom improvement—bridging to outpatient definitive strategies. While not curative of the underlying malignancy, intrapleural antiseptics may offer meaningful palliation and stability in select complex empyema cases. Further study of this approach for chronic DTR gram-negative infections is warranted. This abstract is funded by: none
Triana et al. (Fri,) studied this question.