barw Judi Clinical Journal 3105-4102 1 2 2025 11 27 Challenging Management of Postoperative Empyema: A Case Report with Literature Review 126 130 10.70955/JCJ.2025.16 eng Hemn H. Kaka Ali Gastroenterology and Hepatology Department, Sulaimani Teaching Hospital, Zanko Street, Sulaymaniyah, Iraq Abeer K. Abass Unit of Radiology, Department of Surgery, Sulaymaniyah Teaching Hospital, Sulaymaniyah, Iraq Ali H. Hasan Department of Radiology, Sulaimani Directorate of Health, Sulaymaniyah, Iraq Ahmed H. Ahmed Scientific Affairs Department, Smart Health Tower, Madam Mitterrand Street, Sulaymaniyah, Iraq Naser A. Mohammed College of Medicine, University of Sulaimani, Madam Mitterrand Street, Sulaymaniyah Twana O. Saeed Scientific Affairs Department, Smart Health Tower, Madam Mitterrand Street, Sulaymaniyah, Iraq Marwan N. Hassan Kscien Organization for Scientific Research (Middle East Office), Hamdi Street, Azadi Mall, Sulaymaniyah, Iraq Yadgar H. Hamakarim College of Health and Medical Technology, Sulaimani Polytechnic University, Sulaymaniyah, Iraq Deari A. Ismaeil College of Medicine, University of Sulaimani, Madam Mitterrand Street, Sulaymaniyah, Iraq Shvan H. Mohammed Kscien Organization for Scientific Research (Middle East Office), Hamdi Street, Azadi Mall, Sulaymaniyah, Iraq Hussein M. Hamasalih Department of Nursing, Bright Technical and Vocational Institute, Sulaymaniyah, Iraq. Fahmi H. Kakamad Scientific Affairs Department, Smart Health Tower, Madam Mitterrand Street, Sulaymaniyah, Iraq 0000-0002-2124-9580 2025 08 20 Introduction: Pleural empyema is the collection of pus within the pleural cavity, typically arising as a complication of pneumonia, chest trauma, thoracic surgery, or bacterial invasion of the pleural space. This report presents a case of post-surgical pleural empyema caused by Pseudomonas aeruginosa, successfully managed with a targeted combination of fosfomycin and colistin, with intrapleural lavage. Case presentation: A 37-year-old male developed epigastric pain 12 days after a laparoscopic near-total gastrectomy. A chest computed tomography scan revealed a right-sided pleural empyema. Ultrasound-guided drainage was performed, followed by the intrapleural instillation of alteplase to facilitate breakdown of the loculated empyema. Pseudomonas aeruginosa was identified as the causative agent. Based on antimicrobial susceptibility, the patient received intravenous fosfomycin and colistin, along with daily pleural lavage using colistin. Inflammatory markers declined, and the patient showed notable clinical improvement. Literature review: A review of five cases of Pseudomonas aeruginosa pleural empyema was conducted, including two carbapenem-resistant and one extensively drug-resistant case. The mean patient age was 53.8 years, and 60% (3/5) were female. Four of the five cases (80%) were confirmed using computed tomography, and all patients received antimicrobial therapy, most frequently ceftolozane/tazobactam (60%), ciprofloxacin (60%), and colistin (40%). Surgical management was required in 60% of cases, whereas bacteriophage therapy was utilized in 20%. During follow-up, 60% of patients remained stable, 20% experienced repeated hospital admissions during which antibacterial therapy was withheld, and 20% died due to infectious disease. Conclusion: Pleural lavage combined with antibiotics such as fosfomycin and colistin may provide an effective treatment for postoperative pleural empyema, with early intervention being critical to prevent clinical deterioration.