今日の臨床サポート

膿胸

著者: 大路剛 神戸大学大学院医学研究科微生物感染症学講座感染治療学分野

監修: 具芳明 東京医科歯科大学大学院医歯学総合研究科 統合臨床感染症学分野

著者校正/監修レビュー済:2020/03/26
参考ガイドライン:
  1. The American Association for Thoracic Surgery consensus guidelines for the management of empyema.2017
患者向け説明資料

概要・推奨   

  1. 胸水貯留の診断には胸水穿刺が必須。著明な出血傾向、凝固異常などがなければ、必ず行う。
  1. 手術部位感染予防目的での術後抗菌薬投与は胸部外科手術後においても不要であろう。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
大路剛 : 特に申告事項無し[2021年]
監修:具芳明 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、治療についての加筆修正、図表の追加などを行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 膿胸は、胸腔内スペースの肺外の感染症である。
  1. 肺炎に続発する膿胸では、黄色ブドウ球菌(Staphylococcus aureus)、肺炎レンサ球菌(Streptococcus pneumoniae)、化膿レンサ球菌(Streptococcus pyogenes)などの頻度が高い。小児では、インフルエンザ菌(Haemophilus influenzae)がこれに加わる[1][2]
  1. 肺切除後や外傷後では、S. aureusとグラム陰性桿菌の頻度が高くなる[3]
  1. 結核も注意が必要な膿胸の原因微生物の1つである。
  1. 日本における膿胸の詳細な疫学情報は不明であり、北米、各国とも詳細な情報はない。小児においては北米、米国などで1998年以後肺炎と関係なく膿胸の合併症が増えている[4]
問診・診察のポイント  
  1. 膿胸の診断は、まず、膿胸を鑑別診断に入れることが重要である。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: J W Kelly, M J Morris
雑誌名: 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.

PMID 7973893  South Med J. 1994 Nov;87(11):1103-10.
著者: R W Light, W M Girard, S G Jenkinson, R B George
雑誌名: 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.

PMID 7424940  Am J Med. 1980 Oct;69(4):507-12.
著者: H Moudgil, G Sridhar, A G Leitch
雑誌名: 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.

PMID 8036293  Respir Med. 1994 Apr;88(4):301-4.
著者: C S D Roxburgh, G G Youngson, J A Townend, S W Turner
雑誌名: 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.

PMID 18006562  Arch Dis Child. 2008 Apr;93(4):316-8. doi: 10.1136/adc.・・・
著者: R N Wichelhausen, R L McLean, F B Lowrey
雑誌名: Am Rev Respir Dis. 1966 Feb;93(2):288-90. doi: 10.1164/arrd.1966.93.2.288.
Abstract/Text
PMID 5908095  Am Rev Respir Dis. 1966 Feb;93(2):288-90. doi: 10.1164/・・・
著者: C W Davies, S E Kearney, F V Gleeson, R J Davies
雑誌名: 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.

PMID 10556140  Am J Respir Crit Care Med. 1999 Nov;160(5 Pt 1):1682-7.・・・
著者: A D Ferguson, R J Prescott, J B Selkon, D Watson, C R Swinburn
雑誌名: 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.

PMID 8733515  QJM. 1996 Apr;89(4):285-9.
著者: 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
雑誌名: 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.
PMID 15745977  N Engl J Med. 2005 Mar 3;352(9):865-74. doi: 10.1056/NE・・・
著者: K S Miller, S A Sahn
雑誌名: Chest. 1987 Feb;91(2):258-64.
Abstract/Text
PMID 3542404  Chest. 1987 Feb;91(2):258-64.
著者: 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
雑誌名: 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.

PMID 23325435  JAMA Surg. 2013 May;148(5):440-6. doi: 10.1001/jamasurg・・・
著者: D Bouros, S Schiza, N Tzanakis, G Chalkiadakis, J Drositis, N Siafakas
雑誌名: Am J Respir Crit Care Med. 1999 Jan;159(1):37-42. doi: 10.1164/ajrccm.159.1.9803094.
Abstract/Text Intrapleural administration of fibrinolytic agents has been shown to be effective and safe in the treatment of loculated parapneumonic pleural effusions. However, controlled studies of the possible role of the activity of urokinase (UK) through the volume effect are lacking. We therefore investigated the hypothesis that UK is effective through the lysis of pleural adhesions and not through the volume effect. Thirty-one consecutive patients with multiloculated pleural effusions were randomly assigned to receive either intrapleural UK (15 patients) or normal saline (NS) (16 patients) for 3 d, in a double-blind manner. All patients had inadequate drainage through a chest tube (< 70 ml/24 h). UK was given daily through the chest tube in a dose of 100.000 IU diluted in 100 ml of NS. Controls were given the same volume of NS intrapleurally. Response was assessed by clinical outcome, fluid drainage, chest radiography, pleural ultrasonography (US) and/or computed tomography (CT). Clinical and radiographic improvement was noted in all but two patients in the UK group but in only four in the control group. The net mean volume drained during the 3-d treatment period was significantly greater in the UK group (970 +/- 75 ml versus 280 +/- 55 ml, p < 0.001). Pleural fluid drainage was complete in 13 (86.5%) patients in the UK group (two patients were treated through video-assisted thoracoscopy) but in only four (25%) in the control group. Twelve patients in the control group were subsequently treated with UK and six of them had complete drainage; the remaining six patients had complete drainage after video-assisted thoracoscopy. Our results suggest that UK is effective in the treatment of loculated pleural effusions through the lysis of pleural adhesions and not through the volume effect.

PMID 9872815  Am J Respir Crit Care Med. 1999 Jan;159(1):37-42. doi: ・・・
著者: Najib M Rahman, Nicholas A Maskell, Alex West, Richard Teoh, Anthony Arnold, Carolyn Mackinlay, Daniel Peckham, Chris W H Davies, Nabeel Ali, William Kinnear, Andrew Bentley, Brennan C Kahan, John M Wrightson, Helen E Davies, Clare E Hooper, Y C Gary Lee, Emma L Hedley, Nicky Crosthwaite, Louise Choo, Emma J Helm, Fergus V Gleeson, Andrew J Nunn, Robert J O Davies
雑誌名: N Engl J Med. 2011 Aug 11;365(6):518-26. doi: 10.1056/NEJMoa1012740.
Abstract/Text BACKGROUND: More than 30% of patients with pleural infection either die or require surgery. Drainage of infected fluid is key to successful treatment, but intrapleural fibrinolytic therapy did not improve outcomes in an earlier, large, randomized trial.
METHODS: We conducted a blinded, 2-by-2 factorial trial in which 210 patients with pleural infection were randomly assigned to receive one of four study treatments for 3 days: double placebo, intrapleural tissue plasminogen activator (t-PA) and DNase, t-PA and placebo, or DNase and placebo. The primary outcome was the change in pleural opacity, measured as the percentage of the hemithorax occupied by effusion, on chest radiography on day 7 as compared with day 1. Secondary outcomes included referral for surgery, duration of hospital stay, and adverse events.
RESULTS: The mean (±SD) change in pleural opacity was greater in the t-PA-DNase group than in the placebo group (-29.5±23.3% vs. -17.2±19.6%; difference, -7.9%; 95% confidence interval [CI], -13.4 to -2.4; P=0.005); the change observed with t-PA alone and with DNase alone (-17.2±24.3 and -14.7±16.4%, respectively) was not significantly different from that observed with placebo. The frequency of surgical referral at 3 months was lower in the t-PA-DNase group than in the placebo group (2 of 48 patients [4%] vs. 8 of 51 patients [16%]; odds ratio for surgical referral, 0.17; 95% CI, 0.03 to 0.87; P=0.03) but was greater in the DNase group (18 of 46 patients [39%]) than in the placebo group (odds ratio, 3.56; 95% CI, 1.30 to 9.75; P=0.01). Combined t-PA-DNase therapy was associated with a reduction in the hospital stay, as compared with placebo (difference, -6.7 days; 95% CI, -12.0 to -1.9; P=0.006); the hospital stay with either agent alone was not significantly different from that with placebo. The frequency of adverse events did not differ significantly among the groups.
CONCLUSIONS: Intrapleural t-PA-DNase therapy improved fluid drainage in patients with pleural infection and reduced the frequency of surgical referral and the duration of the hospital stay. Treatment with DNase alone or t-PA alone was ineffective. (Funded by an unrestricted educational grant to the University of Oxford from Roche UK and by others; Current Controlled Trials number, ISRCTN57454527.).

PMID 21830966  N Engl J Med. 2011 Aug 11;365(6):518-26. doi: 10.1056/N・・・

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