B73-44 To Pull or Not to Pull? Successful Empyema Therapy Despite Persistent Drainage

Background Determining when to remove a chest tube in empyema remains debated, particularly when daily drainage exceeds traditional thresholds. While conventional practice favors removal when output is < 100-150 mL/day, individualized and clinically-guided decisions are increasingly warranted and supported. Case Presentation A 62-year-old man with PMH of Type I Gaucher disease, chronic thrombocytopenia, HTN, and obesity presented with a three-week history of productive cough and fatigue. Chest CT revealed a multiloculated right-sided pleural effusion with adjacent area of necrosis in the right lower lobe [FIGURE-1]. Pleural fluid was pinkish-brown and turbid with pH <6.8, WBC 259,000/µL (91% neutrophils), RBC 278,000/µL, LDH >7500 U/L, and protein 3.9 g/dL. Findings were consistent with a complicated exudative pleural effusion. Etiology was likely anerobic empyema & pneumonia with visceral pleural perforation leading to hydropneumothorax. He underwent CT-guided chest tube placement for source control with three days of intrapleural tPA/DNase therapy to assist with drainage. Additionally, he received IV vancomycin and piperacillin-tazobactam during his one-week hospital stay. The patient showed marked clinical and radiographic improvement, allowing transition to oral amoxicillin-clavulanate and doxycycline. The chest tube remained in place for six days, with persistent output of approximately 200 mL/day of non-purulent serous fluid at the time of removal. Given stability, improved imaging, and normalization of inflammatory markers, the chest tube was safely removed. He completed an additional seven weeks of oral antibiotic therapy following discharge. Outpatient follow-up CT demonstrated continued resolution of the pleural space infection with no recurrence and no further complications [FIGURE-2]. Discussion This case underscores the evolving paradigm in empyema management, where clinical trajectory and imaging findings often outweigh fixed numeric thresholds for chest tube removal. Although traditional criteria recommend drainage <150 mL/day for chest tube removal, several studies suggest that sterile and non-purulent serous output may not necessitate prolonged drainage if radiographic improvement and patient recovery are evident. Prolonged tube placement can increase pain, infection risk, complication risk, and hospital stay. In this patient, early removal despite moderate output resulted in full resolution and no recurrence. Individualized, multidisciplinary decision-making—incorporating pleural fluid characteristics, patient comorbidities, and dynamic imaging assessment—can optimize outcomes and reduce unnecessary interventions in complex pleural infections. This abstract is funded by: None