The outcome determinants in tuberculous empyema: a 20-year multicenter cohort study

Objectives Tuberculous empyema (TE) remains a complex clinical entity with poorly defined determinants of outcomes. This study aimed to evaluate the relative impact of treatment strategy, microbiological characteristics, and disease stage on relapse, residual radiological changes, and duration of pleural exudation in a large multicenter cohort. Methods A retrospective multicenter study was conducted including patients treated between 2003 and 2023 across three specialized tuberculosis centers. Multivariable logistic regression was used to identify predictors of relapse and residual radiological alterations. Duration of pleural exudation was analyzed using a generalized linear model with gamma distribution and log link function. Collinearity between stage and treatment was addressed by constructing separate models. Results Of 1052 screened patients 420 met inclusion criteria. Localized empyema was associated with reduced residual disease (OR 0.30, p < 0.001) and relapse (OR 0.50, p = 0.001). Open surgery was associated with lower odds of residual radiological alterations (OR 0.14, p = 0.002) and relapse (OR 0.07, p < 0.001), as well as a shorter expected duration of pleural exudation (exp(B) 0.162). VATS was associated with lower odds of relapse (OR 0.09, p < 0.001) and a shorter expected duration of pleural exudation (exp(B) 0.186) but was not associated with residual radiological alterations. Conclusions Outcomes in TE were primarily associated with microbiological burden and treatment strategy. Surgical intervention, particularly open procedures, was associated with faster disease resolution and lower relapse rates, whereas AFB positivity and drug resistance were associated with persistent and prolonged disease. Early identification of high-risk patients and timely surgical management may be important for optimizing outcomes. Clinical registration number The present retrospective observational study was retrospectively registered with ISRCTN (ISRCTN11977620) on April 10, 2026.