A47-09 When Empyema Won’t Wait: Early Video-Assisted Thoracoscopic Surgery for Rapidly Progressive Pleural Infection

Introduction Empyema remains a significant clinical challenge, with rapid progression and multiloculation often necessitating prompt intervention. Recent advances emphasize the importance of early risk stratification using the RAPID score (Renal, Age, Purulence, Infection source, Dietary factors) to guide management decisions and improve outcomes. Early video-assisted thoracoscopic surgery (VATS) has emerged as a preferred approach for select patients, offering reduced morbidity and length of stay compared to delayed or open procedures. Case Description A 47-year-old male with diabetes mellitus, hypertension, benign prostatic hyperplasia, depression, GERD, and erectile dysfunction presented with acute right lower chest pain radiating to the right shoulder, associated with chills and sputum production. Initial CT imaging revealed right lower lobe pneumonia and a moderate-sized right pleural effusion. Despite IV antibiotics, the patient’s symptoms worsened, and repeat imaging demonstrated rapid progression to a multiloculated, complicated parapneumonic effusion. Bedside ultrasound confirmed loculated effusions with thickened pleura and no safe window for percutaneous drainage. Pleural fluid cultures grew ESBL-producing E. coli (primary pathogen), with additional coagulase-negative staphylococci, actinomyces, and candida likely representing contaminants. The patient’s RAPID score was calculated as 1, indicating low predicted mortality risk. Given the rapid clinical and radiographic progression, and the absence of a safe drainage pocket, early surgical intervention was pursued. He underwent right VATS with total decortication and chest tube placement, resulting in prompt clinical improvement and resolution of the empyema. Postoperative recovery was uneventful, and the patient was discharged on appropriate antimicrobial therapy. Discussion This case highlights the utility of the RAPID score in guiding early intervention for empyema. Low RAPID scores are associated with improved outcomes following early surgery, including decreased organ failure and shorter hospital stays. Multicenter studies and consensus guidelines support early VATS as a definitive therapy for rapidly progressing, multiloculated empyema, particularly when source control cannot be achieved by less invasive means. Early VATS is associated with superior clinical outcomes, reduced morbidity, and expedited recovery compared to delayed or open procedures. Incorporating the RAPID score into the management algorithm facilitates individualized, evidence-based decision-making and optimizes patient outcomes in complex pleural infections.