Abstract Intrapleural antibiotic therapy is not routinely recommended for pleural infections; current guidelines emphasize systemic antibiotics and source control through drainage, fibrinolytics, or surgery. However, in patients with severe coagulopathy or thrombocytopenia, fibrinolytic therapy may be unsafe, and surgical intervention high-risk. In such cases, management becomes particularly challenging when the empyema fails to resolve with conventional measures. Historical experience with intrapleural antibiotic irrigation in post-surgical empyema has suggested potential efficacy in select refractory cases, though contemporary data remain limited. We present a case of methicillin-sensitive Staphylococcus aureus (MSSA) empyema that was unresponsive to standard therapy and successfully treated with intrapleural vancomycin when fibrinolysis and surgery were contraindicated. A 62-year-old woman with cirrhosis and immune thrombocytopenic purpura (platelets 1-5 × 10³/µL on admission) was admitted after a fall with rib fractures. She developed a new right pleural effusion with fever and dyspnea. Thoracentesis revealed purulent fluid, and cultures grew methicillin-sensitive Staphylococcus aureus (MSSA). Despite antibiotic therapy, the effusion reaccumulated with the patient continuing to be symptomatic. CT imaging showed loculated fluid collections consistent with empyema. A pigtail chest tube drained purulent fluid, but given profound thrombocytopenia, intrapleural fibrinolysis and surgical decortication were contraindicated.After multidisciplinary discussion, intrapleural antibiotic therapy was initiated. Vancomycin 500 mg diluted in 100 mL of normal saline was instilled daily via the chest tube, which was clamped for six hours before reopening to drain. This regimen was continued for ten consecutive days. The patient’s fever resolved, and repeat imaging showed marked reduction of the empyema. Pleural cultures were sterile by day 7. No bleeding or renal toxicity occurred. The chest tube was removed after day 10. Empyema management typically requires antibiotics and source control through drainage and, when needed, fibrinolytics or surgery. However, these are contraindicated in patients with coagulopathy or severe thrombocytopenia. Intrapleural antibiotic administration may be an effective alternative in such cases. Vancomycin achieves high local concentrations with limited systemic absorption, allowing targeted therapy within the pleural space. While not standard of care, our case demonstrates successful use of intrapleural vancomycin as a salvage approach. This therapy should be considered only when conventional interventions are precluded, and undertaken with multidisciplinary input and close monitoring. This case adds to growing evidence that intrapleural antibiotic therapy can be safe and effective as a last resort for refractory empyema. Further studies are needed to clarify indications, optimal dosing, and long-term outcomes. This abstract is funded by: none
El-Hajj et al. (Fri,) studied this question.