J W Kelly, M J Morris
Empyema thoracis: medical aspects of evaluation and treatment.
South Med J. 1994 Nov;87(11):1103-10.
Abstract/Text
Empyema thoracis is a disease that, despite centuries of study, still causes significant morbidity and mortality. Sixty-five cases were seen at Brooke Army Medical Center over an 8-year period (March 1, 1985, through March 1, 1993). The majority of the patients were men, older than 50 years of age, with significant underlying diseases. Pneumonia remains the most common single proximate cause of empyema. Gram-positive cocci are the most frequently isolated organisms; however, empyemas due to gram-negative organisms and anaerobes are associated with higher mortality. Pleural fluid gram stains proved to be an accurate but neglected diagnostic tool in guiding initial therapy. The choice of antibiotics seemed to have no discernible impact on mortality. Closed tube thoracostomy was the initial method of drainage in most patients and had an overall success rate of 50%. Empyemas that could not be effectively drained by a single chest tube were unlikely to be drained by additional closed maneuvers. There was an overall 22% case-fatality rate with most deaths related to our inability to eradicate the empyema.
R W Light, W M Girard, S G Jenkinson, R B George
Parapneumonic effusions.
Am J Med. 1980 Oct;69(4):507-12.
Abstract/Text
In this study the incidence and course of pleural effusions (parapneumonic effusions) in patients with acute bacterial pneumonia were prospectively evaluated. Bilateral decubitus chest x-ray films were obtained within 72 hours of admission in 203 patients with an acute febrile illness, purulent sputum and an infiltrate evident on the chest film. Ninety of the 203 patients (44 percent) had pleural effusions. Parapneumonic effusions, which required chest tubes for resolution and/or on which the pleural fluid cultures were positive, were classified as complicated parapneumonic effusions. The 10 patients with complicated parapneumonic effusions had clinical characteristics similar to the remainder of the group and could be separated from the 80 with uncomplicated effusions only by pleural fluid analysis. A pleural fluid pH below 7.00 and/or a glucose level below 40 mg/100 ml are indications for immediate tube thoracostomy. In patients with pleural fluid pH between 7.00 and 7.20 or lactic dehydrogenase (LDH) above 1,000 IU/1,000 ml, tube thoracostomy should be considered, but each case should be individualized; serial studies of the pleural fluid are useful in some of these cases. Patients with pleural fluid pH above 7.20 and pleural fluid LDH below 1,000 mg/100 ml rarely have complicated parapneumonic effusions and do not require serial therapeutic thoracenteses.
H Moudgil, G Sridhar, A G Leitch
Reactivation disease: the commonest form of tuberculous pleural effusion in Edinburgh, 1980-1991.
Respir Med. 1994 Apr;88(4):301-4.
Abstract/Text
From 1980-1991 82 (7.2%) of 1134 tuberculosis notifications in Edinburgh were for pleural effusion. Study of the available records of 62 cases satisfying defined diagnostic criteria identified 14 cases (6 M, 8 F) with a mean age of 27.6 years (range 11-51 years) of primary tuberculous effusion and 25 cases (21 M, 4 F) with a mean age of 51 years (range 19-79 years) with pleural effusion due to reactivation disease. Twenty-three patients (19 M, 4 F) with a mean age of 48.9 years (range 25-85 years) defied classification. Symptoms, associated and diagnostic test findings were similar in all three groups of patients. Parenchymal radiographic shadowing was seen in 1/14 primary, 16/25 reactivation and 3/25 unclassified pleural effusions. Twenty-three of 30 patients treated with corticosteroids showed no residual radiographic abnormality compared to 17/30 not so treated (P < 0.06). Reactivation disease is currently a commoner cause of tuberculous pleural effusion than primary disease in Edinburgh. We suggest that the unclassified cases, so similar in age and sex to the defined reactivation disease cases, also represent largely extrapulmonary reactivation disease occurring in middle age.
C S D Roxburgh, G G Youngson, J A Townend, S W Turner
Trends in pneumonia and empyema in Scottish children in the past 25 years.
Arch Dis Child. 2008 Apr;93(4):316-8. doi: 10.1136/adc.2007.126540. Epub 2007 Nov 15.
Abstract/Text
BACKGROUND: The incidence of childhood empyema, a complication of pneumonia, is increasing, and the underlying mechanisms are not understood. Whether a rise in pneumonia incidence could account for the increase in empyema remains to be seen.
OBJECTIVE: To report trends for empyema admissions in the context of pneumonia and croup admissions in Scottish children over a 25-year period to 2005.
DESIGN: Whole-population study with retrospective analysis using diagnosis codes (International classification of diseases, 9th and 10th revisions).
SETTING: All non-obstetric and non-psychiatric hospitals in Scotland.
PARTICIPANTS: Patients <15 years admitted with a diagnosis of empyema, pneumonia or croup (the latter included for reference) between 1 January 1981 and 31 December 2005.
RESULTS: There were 217 admissions for empyema in children (76 1-4-year olds), 24,312 admissions for pneumonia (11,299 1-4-year olds), and 31 120 (20,332 1-4-year olds) for croup. Empyema admissions increased after 1998 from <10 per million children per annum to reach a peak of 37 per million in 2005. In the 1-4-year age group, empyema admissions rose in the late 1990s and 2000s from an average of 6.5 per million per year between 1981 and 1998 to 66 per million in 2005. Overall annual admission rates for pneumonia remained unchanged in most age groups. However, among 1-4-year olds, admissions rose steadily by an average of 50 per million per year between 1981 and 2005. Admission rates for croup in Scottish children (<15 years) remained stable over the preceding 25 years.
CONCLUSIONS: This whole-population study shows that the incidence of childhood empyema has risen since 1998 and continues to rise independently of pneumonia. Croup admissions remained stable, suggesting that changes in coding or admission policies are not likely to explain the observed trends. The observations suggest that the rise in empyema is not related to an increase in pneumonia. Changes in bacterial pathogenicity and/or host susceptibility may be important.
Mandell GL, et al.: Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 8th ed.Churchill Livingstone, 2014:Chapter 65 Pleural Effusion and Empyema, (改変なし).
R N Wichelhausen, R L McLean, F B Lowrey
Reinforcement of diagnostic value of pleural biopsies by culture in liquid medium.
Am Rev Respir Dis. 1966 Feb;93(2):288-90. doi: 10.1164/arrd.1966.93.2.288.
Abstract/Text
C W Davies, S E Kearney, F V Gleeson, R J Davies
Predictors of outcome and long-term survival in patients with pleural infection.
Am J Respir Crit Care Med. 1999 Nov;160(5 Pt 1):1682-7. doi: 10.1164/ajrccm.160.5.9903002.
Abstract/Text
In pleural infection, medical treatment failure (chest-tube drainage and antibiotics) requires surgery and increases mortality. It would be helpful to predict which patients will fail this approach. We examined clinical predictors in 85 consecutive patients with pleural infection receiving chest drainage and intrapleural fibrinolytics, and recorded age, length of history, antibiotic delay and choice, time to drainage, blood/pleural fluid (PF) bacteriology, PF pH, lactate dehydrogenase (LDH), glucose and appearance, effusion size, pleural thickness on computed tomographic (CT) scan, and survival from time of drainage. Failures (surgery/death) were compared with successes. There were 13 (15%) medical failures. PF purulence was more frequent in medical failures (10 of 13 versus 29 of 72 successes, p < 0.02 chi-square). Absence of purulence was a useful predictor of success (positive predictive value [PPV] 93%). Purulence was not useful in predicting medical failure (PPV 26%). There was a trend for positive blood culture to predict failure (5 of 13 failures versus 11 of 72 successes, p = 0.05 chi-square), but no significant differences in other endpoints. Twelve (14%) patients died in follow-up, all with comorbidity within 400 d after drainage. Probability of survival at 4 yr was 86%. Of endpoints considered in this study, PF purulence was the only useful predictor of outcome with medical therapy in pleural infection. There is good long-term survival from pleural infection.
A D Ferguson, R J Prescott, J B Selkon, D Watson, C R Swinburn
The clinical course and management of thoracic empyema.
QJM. 1996 Apr;89(4):285-9.
Abstract/Text
We report a prospective multi-centre study of the clinical course and hospital management of thoracic empyema in 119 patients (mean age 54.8). The commonest presenting symptom was malaise (75%), 55% were febrile; 31% were previously well with no predisposing condition. Initial treatments were antibiotics alone (5), needle aspirations (46), intercostal tube drainage (61), rib resection (3) and decortication (4). Overall, intercostal drainage was used in 77 patients (16 failed aspirations), surgical rib resection in 24 (1 failed aspirations, 20 failed drainage), and surgical decortication in 28 (6 failed aspirations, 17 failed drainage). Only 4 patients received intrapleural fibrinolytic agents. Aspiration and drainage were likely to fail if the empyema was > 40% of the hemithorax. Median time from treatment start to discharge was: aspirations, 26 days; drainage, 23 days; resection 11 days; decortication, 12 days. Overall 21 patients died (12 with empyema as the major cause); two had been surgically treated. Mortality correlated with age, diabetes, heart failure, and low serum albumin at admission. Infecting organisms, identified in 109 patients (92%) included anaerobes (37), Str. melleri (36), and Str. pneumoniae (28). Six months after discharge, all but six survivors had regained their previous health.
Nicholas A Maskell, Christopher W H Davies, Andrew J Nunn, Emma L Hedley, Fergus V Gleeson, Robert Miller, Rhian Gabe, Glyn L Rees, Timothy E A Peto, Mark A Woodhead, Donald J Lane, Janet H Darbyshire, Robert J O Davies, First Multicenter Intrapleural Sepsis Trial (MIST1) Group
U.K. Controlled trial of intrapleural streptokinase for pleural infection.
N Engl J Med. 2005 Mar 3;352(9):865-74. doi: 10.1056/NEJMoa042473.
Abstract/Text
BACKGROUND: Intrapleural fibrinolytic agents are used in the drainage of infected pleural-fluid collections. This use is based on small trials that did not have the statistical power to evaluate accurately important clinical outcomes, including safety. We conducted a trial to clarify the therapeutic role of intrapleural streptokinase.
METHODS: In this double-blind trial, 454 patients with pleural infection (defined by the presence of purulent pleural fluid or pleural fluid with a pH below 7.2 with signs of infection or by proven bacterial invasion of the pleural space) were randomly assigned to receive either intrapleural streptokinase (250,000 IU twice daily for three days) or placebo. Patients received antibiotics and underwent chest-tube drainage, surgery, and other treatment as part of routine care. The number of patients in the two groups who had died or needed surgical drainage at three months was compared (the primary end point); secondary end points were the rates of death and of surgery (analyzed separately), the radiographic outcome, and the length of the hospital stay.
RESULTS: The groups were well matched at baseline. Among the 427 patients who received streptokinase or placebo, there was no significant difference between the groups in the proportion of patients who died or needed surgery (with streptokinase: 64 of 206 patients [31 percent]; with placebo: 60 of 221 [27 percent]; relative risk, 1.14 [95 percent confidence interval, 0.85 to 1.54; P=0.43), a result that excluded a clinically significant benefit of streptokinase. There was no benefit to streptokinase in terms of mortality, rate of surgery, radiographic outcomes, or length of the hospital stay. Serious adverse events (chest pain, fever, or allergy) were more common with streptokinase (7 percent, vs. 3 percent with placebo; relative risk, 2.49 [95 percent confidence interval, 0.98 to 6.36]; P=0.08).
CONCLUSIONS: The intrapleural administration of streptokinase does not improve mortality, the rate of surgery, or the length of the hospital stay among patients with pleural infection.
Copyright 2005 Massachusetts Medical Society.
K S Miller, S A Sahn
Chest tubes. Indications, technique, management and complications.
Chest. 1987 Feb;91(2):258-64.
Abstract/Text
David A Oxman, Nicolas C Issa, Francisco M Marty, Alka Patel, Christia Z Panizales, Nathaniel N Johnson, J Humberto Licona, Shannon S McKenna, Gyorgy Frendl, Steven J Mentzer, Michael T Jaklitsch, Raphael Bueno, Yolonda Colson, Scott J Swanson, David J Sugarbaker, Lindsey R Baden
Postoperative antibacterial prophylaxis for the prevention of infectious complications associated with tube thoracostomy in patients undergoing elective general thoracic surgery: a double-blind, placebo-controlled, randomized trial.
JAMA Surg. 2013 May;148(5):440-6. doi: 10.1001/jamasurg.2013.1372.
Abstract/Text
OBJECTIVE: To determine whether extended postoperative antibacterial prophylaxis for patients undergoing elective thoracic surgery with tube thoracostomy reduces the risk of infectious complications compared with preoperative prophylaxis only.
DESIGN: Prospective, randomized, double-blind, placebo-controlled trial.
SETTING: Brigham and Women's Hospital, an 800-bed tertiary care teaching hospital in Boston, Massachusetts.
PARTICIPANTS: A total of 251 adult patients undergoing elective thoracic surgery requiring tube thoracostomy between April 2008 and April 2011.
INTERVENTIONS: Patients received preoperative antibacterial prophylaxis with cefazolin sodium (or other drug if the patient was allergic to cefazolin). Postoperatively, patients were randomly assigned (at a 1:1 ratio) using a computer-generated randomization sequence to receive extended antibacterial prophylaxis (n = 125) or placebo (n = 126) for 48 hours or until all thoracostomy tubes were removed, whichever came first.
MAIN OUTCOME MEASURES: The combined occurrence of surgical site infection, empyema, pneumonia, and Clostridium difficile colitis by postoperative day 28.
RESULTS: A total of 245 patients were included in the modified intention-to-treat analysis (121 in the intervention group and 124 in the placebo group). Thirteen patients (10.7%) in the intervention group and 8 patients (6.5%) in the placebo group had a primary end point (risk difference, -4.3% [95% CI, -11.3% to 2.7%]; P = .26). Six patients (5.0%) in the intervention group and 5 patients (4.0%) in the placebo group developed surgical site infections (risk difference, -0.93% [95% CI, -6.1% to 4.3%]; P = .77). Seven patients (5.8%) in the intervention group and 3 patients (2.4%) in the placebo group developed pneumonia (risk difference, -3.4% [95% CI, -8.3% to 1.6%]; P = .21). One patient in the intervention group developed empyema. No patients experienced C difficile colitis.
CONCLUSIONS: Extended postoperative antibacterial prophylaxis for patients undergoing elective thoracic surgery requiring tube thoracostomy did not reduce the number of infectious complications compared with preoperative prophylaxis only.
TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00818766.
