A pleural fluid analysis shows: pH 7.19, glucose 38 mg/dL, LDH 1200 U/L (serum LDH 240 U/L), protein 5.2 g/dL, and Gram stain positive for Gram-positive cocci in clusters. The most appropriate immediate management beyond antibiotics is:

• A Thoracocentesis alone with repeated aspirations to control the effusion
• B VATS decortication as first-line in all culture-positive empyemas
• C IV antibiotics alone with follow-up ultrasound at 48 hours
• D Chest tube drainage and intrapleural fibrinolytics with DNase (MIST-2 protocol) ✓

Explanation

This is a frank empyema (pus features: low pH < 7.2, glucose < 40 mg/dL, elevated LDH, positive Gram stain). The MIST-2 trial (NEJM 2011) showed that combination intrapleural alteplase 10 mg + DNase 5 mg twice daily for 3 days significantly reduced the need for surgical referral and hospital stay compared to either agent alone or placebo. Current BTS guidelines (2010) recommend this combination for pleural infection with non-draining loculated or free-flowing empyema unresponsive to chest tube alone. VATS is reserved for failure of medical management. Antibiotics alone are insufficient.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.