Healing Hand

The past 20 years have witnessed the identification of a host of common new pulmonary infections includ­ing Legionnaires’ disease, Pneumocystis carinii, and cytomegalovirus, to name but a few. The current decade has also seen the development of new diag­nostic modalities, including transbronchial biopsy and bronchoalveolar lavage (BAL). The introduction of new therapeutic modalities, particularly unique anti­bacterial, antifungal, and antiviral agents, is a major advance in the treatment of these infectious problems. While new antibiotics often show improved, if short­lived, efficacy in treating pulmonary parenchymal infections, we must remember that antibiotic treat­ment is not adequate initial therapy for empyema. Recent studies illustrate the lack of adequate penetra­tion of certain antibiotics in pleural empyema fluid. Indeed, even the initial management of pediatric empyema, once thought to be highly sensitive to simple drainage and antibiotic administration, is un­dergoing change to include more aggressive surgical management in selected patients.

Disturbing developments in the routine manage­ment of empyema include longer delays prior to definitive therapy and the introduction of new invasive techniques for drainage, such as catheter placement using Seldinger technique and thoracoscopy with irrigation to break down loculations in complicated empyema. These new modalities must not supplant early and adequate operative intervention when indi­cated. A variety of recent reports underscore the usefulness of early thoracotomy in the treatment of empyema. Although simple drainage and antibiotic therapy remain the norm, an enlarging group of patients, particularly those with complicated or post­operative empyema, will require aggressive surgical intervention. Early recognition of these patients and institution of surgical intervention as primary therapy rather than as a last resort will likely result in improved survival and shortened hospital stay. canada pharmacy mall

Failure to consider aggressive surgical intervention for empyema, particularly in patients for whom such therapy provides the best prognosis, is not in keeping with current standards of clinical practice. The Code of Hammurabi no longer applies—physicians should be held responsible for their actions even when not wielding the knife in the management of their patients.