Bacteriology and Comorbidities in Patients Requiring Surgical Management of Empyema

Concern over the changing bacteriology of empyema has led to numerous attempts to characterize the most common locoregional bacterial isolates. The purpose of this study is to better characterize the bacteriology and demographics in patients with community-acquired pneumonia (CAP) and hospital-acquired pneumonia requiring surgery for empyema. All patients diagnosed with empyema preoperatively and had either a video-assisted thoracoscopic or open decortication surgery from January 2010 to September 2015 were reviewed. Forty-seven patients were identified with a mean age of 54.7 ± 16.8 years (X ± SD). Sixty per cent of patients had CAP. Anaerobes were the most common isolate at 21 per cent, followed by Streptococcus species and Staphylococcus aureus (50% Methicillin Resistant). Coagulase-negative Staphylococcus species were the next most frequent at 13 per cent. Hospital-acquired pneumonia patients had a higher incidence of S. aureus infections (P = 0.047). Cancer history had higher rates of both fungal (P = 0.004) and gram-negative infections (P = 0.03). Older patients had increased incidence of gram-negative infections (P = 0.05). The median length of stay for CAP patient who were intravenous drug abusers (n = 3) were 31 days (95% confidence interval (CI) [15, NA]), which was significantly longer than the others (median 12 days, 95% CI: [9, 18], P = 0.014). Streptococcus pneumoniae was not found in any of the isolates. Our data reveal that anaerobes and Staphylococcus species have replaced S. pneumoniae as the major regional pathogens in surgically treated empyema. In addition, anaerobic isolates were found in higher incidence in CAP than previously reported.

Human pleural fluid is a potent growth medium for Streptococcus pneumoniae

Empyema is defined by the presence of bacteria and/or pus in pleural effusions. However, the biology of bacteria within human pleural fluid has not been studied. Streptococcus pneumoniae is the most common cause of pediatric and frequent cause of adult empyema. We investigated whether S. pneumoniae can proliferate within human pleural fluid and if growth is affected by the cellular content of the fluid and/or characteristics of pneumococcal surface proteins. Invasive S. pneumoniae isolates (n = 24) and reference strain recovered from human blood or empyema were inoculated (1.5×10⁶CFU/mL) into sterile human malignant pleural fluid samples (n = 11). All S. pneumoniae (n = 25) strains proliferated rapidly, increasing by a median of 3009 (IQR 1063–9846) from baseline at 24hrs in all pleural effusions tested. Proliferation was greater than in commercial pneumococcal culture media and concentrations were maintained for 48hrs without autolysis. A similar magnitude of proliferation was observed in pleural fluid before and after removal of its cellular content, p = 0.728. S. pneumoniae (D39 strain) wild-type, and derivatives (n = 12), each with mutation(s) in a different gene required for full virulence were inoculated into human pleural fluid (n = 8). S. pneumoniae with pneumococcal surface antigen A (ΔpsaA) mutation failed to grow (2207-fold lower than wild-type), p<0.001, however growth was restored with manganese supplementation. Growth of other common respiratory pathogens (n = 14) across pleural fluid samples (n = 7) was variable and inconsistent, with some strains failing to grow. We establish for the first time that pleural fluid is a potent growth medium for S. pneumoniae and proliferation is dependent on the PsaA surface protein and manganese.

Empyema caused by a colopleural fistula: A case report

RATINALE

Empyema is a condition in which pus gathers in the area between the lungs and the inner surface of the chest wall. An empyema caused by colo-pleural fistula is a rare but potentially life-threatening condition.

PATIENT CONCERNS

We describe a case of 42-year-old man was brought to our Emergency Department for chest pain with dyspnea and fever.

DIAGNOSES

The final diagnoses are empyema caused by colo-pleural fistula and colon cancer.

INTERVENTIONS

The patient underwent laparotomy surgery, during which a tumor was found in the splenic flexure of the descending colon. The tumor penetrated the colonic serosa and invaded the left side of the diaphragm. A left hemicolectomy was performed.

OUTCOMES

After the operation, the patient recovered smoothly and was discharged on postoperative day 14. It's been over 3 years now, CT and colonoscopy assessments show no recurrence or metastasis.

LESSONS

This case serves as a reminder to test for pathogens in patients with an unexplained empyema. If normal intestinal bacteria are detected, the empyema may be derived from intestinal disease. In addition, an abdominal examination should be performed in patients with an empyema of unknown origin.

Outcome of Pediatric Empyema Thoracis Managed by Tube Thoracostomy

The proper management of empyema thoracis in children continues to be a source of debate. This study assessed the clinical profile and outcome of patients managed by tube thoracostomy. Chart review was performed in 31 patients managed from January 1989 to December 2003. Outcome measures were duration and outcome of thoracostomy, number of days to radiologic lung re-expansion, length of hospitalization, and microbiologic flora involved. The mean age was 9 years (male/female, 2:1) and the most commonly affected group were those aged 1 year and below. Staphylococcus aureus was the most frequent infecting organism. A few (6%) achieved lung re-expansion 1 week postoperatively, but 64% did not achieve full lung re-expansion even after 3 weeks. Most (71%) of the thoracostomies were converted to open drainage. Half (52%) of the patients were hospitalized for at least 5 weeks. There were 3 recurrences and 3 deaths, 2 of which were most likely associated with empyema. Empyema managed by tube thoracostomy alone showed evidence of delayed lung re-expansion, prolonged drainage and hospitalization, and unfavorable outcome.

[ANALYSIS OF MICROFLORA OF PLEURAL CAVITY IN PLEURAL EMPYEMA]

In the pleural empyema (PE) treatment, not depending on introduction of multiple operative procedures and the medicinal preparations application, some issues remain unsolved, including the infection agents verification, the most rapid bronchial fistula elimination and the lung volume restoration. The EP infection agents spectrum, their sensitivity to preparations were revealed, as well as the enhanced rate of the methicillin-resistant stamms (MRSA) and the microorganisms associations verification. A reduction of the infection agents sensitivity towards "simple" antibacterial preparations was established, so the physicians, treating PE, must prescribe "hard" antibiotics, what enhances its cost.

Fungal empyema thoracis in cancer patients

OBJECTIVES

Fungal empyema thoracis (FET) is a rare life-threatening infection. We sought to describe the clinical characteristics of FET in a large academic cancer center.

METHODS

We conducted a retrospective chart review of all cancer patients who had a fungal isolate from the pleural fluid culture between 1/2005 and 8/2013.

RESULTS

A total of 106 fungal isolates were identified in 97 patients. Yeasts accounted for 62% of the isolates whereas 38% were identified as molds. The most frequent pathogens were Candida spp. (58%) and Aspergillus spp. (12%). All patients with Aspergillus and 83% with Candida met criteria for proven fungal disease. Compared to the Aspergillus group, Candida FET was associated with recent abdominal or thoracic surgical procedures (44% vs. 0%, p = 0.01). Overall, 6-week mortality was high, with no significant differences between Candida and Aspergillus (31% vs. 45%, respectively [p = 0.48]). Only 1 out of 11 patients with uncommon molds died at 6 weeks, despite only 2 of them received appropriate antifungal therapy.

CONCLUSIONS

Development of FET carries a high mortality in cancer patients. A history of a recent surgical procedure is a risk factor for FET due to Candida. Isolation of uncommon molds is likely to represent a contamination of the pleural fluid.

Paediatric empyema in New Zealand: a tale of two cities

AIMS

We aimed to identify the causative organisms and sensitivities in community-acquired paediatric empyema at Starship Children's Hospital and Christchurch Hospital and to determine if current antibiotic recommendations are appropriate.

METHODS

Retrospective analysis was undertaken of all cases with clinical, radiological, and microbiological evidence of empyema at Starship Children's Hospital and Christchurch Hospital between June 2009 and March 2013 (3.8 years), and January 2009 and May 2014 (5.4 years) respectively.

RESULTS

Ninety-eight children were managed with empyema at Starship Children's Hospital and 30 children at Christchurch Hospital. Staphylococcus aureus was the most common pathogen identified at both sites followed by Streptococcus pneumoniae. A significant proportion had no pathogen identified. Amongst S.aureus isolates, 1/5th were methicillin-resistant, contributing 8% of all culture positive empyema cases. Māori and Pacific groups were over-represented. Cases occurred more often in boys and those <5 years. Blood cultures and S.pneumoniae pleural antigen were important in diagnosis.

CONCLUSIONS

Our audit confirms the important role of S.aureus in paediatric empyema in New Zealand and a high rate of this disease, particularly in the North Island. Antimicrobial susceptibilities of the pathogens of empyema demonstrate current initial antibiotic recommendation.

Video assisted thoracic surgery in a second trimester pregnant woman with thoracic empyema: a case report

BACKGROUND

An empyema is an infection of the pleural space that occurs most frequently secondary to the progression of pneumonia. The stages of empyema are based on pleural characteristics and reflect the risks of the condition for morbidity and mortality. Pregnancy is a risk factor for major complications of pneumonia, including empyema.

CASE

A pregnant woman at 25 weeks' gestation with a community-acquired Streptococcus pneumoniae pneumonia underwent video-assisted thoracotomy decortication and debridement of a large loculated, gelatinous empyema after conservative medical therapy failed.

CONCLUSION

Conservative medical therapy with antibiotics alone may not be adequate for advanced bacterial empyema in pregnancy.

Surgical intervention for thoracic infections

Multidisciplinary management of thoracic infection, including experts in thoracic surgery, pulmonology, infectious disease, and radiology, is ideal for optimal outcomes. Initial assessment of parapneumonic effusion and empyema requires computed tomographic evaluation and consideration for fluid sampling or drainage. Goals for the treatment of parapneumonic effusion and empyema include drainage of the pleural space and complete lung reexpansion. Pulmonary abscess is often successfully treated with antibiotics and observation. Surgical intervention for the treatment of fungal or tuberculous lung disease should be undertaken by experienced surgeons following multidisciplinary assessment. Sternoclavicular joint infection often requires joint resection.

[Empyema é deux]

This is a case of a married couple with a cluster of empyema. Clusters are rarely seen, but have previously been described in children. Reasons for clustering of empyemas include close relationship between patients, increased susceptibility in patients, increased virulence of the bacteria, co-morbidity and age. Drainage and relevant antibiotic treatment remain key therapies.

Experimental pleural empyema model in rabbits: Why, how and what are the next steps

BACKGROUND/AIM

The use of new therapeutic methods to prevent development of fibrothorax as the final complication of the human pleural infections requires research with experimental animals. The aim of this study was to standardize the procedures for the establishment of our own experimental model of empyema in rabbits, since it should be able to offer similar conditions found in human pleural infections.

METHODS

This experiment included 15 chinchilla rabbits, weighing from 2.3 to 2.8 kg. There were 12 rabbits in the experimental group, while 3 rabbits formed the control group. On the first day, we administered 0.4-0.5 mL of turpentine in the right pleural space of the rabbits from the experimental group in order to provoke sterile exudative pleurisy. After 24 h we injected 1 mL of Staphylococcus aureus and 1 mL of Escherichia coli bacteria in the same concentration of 4.5 x 10(8) bacteria/mL. Thoracocentesis for the pleural fluid analysis was performed 24, 48, 72, and 96 h after bacteria instillation. In these pleural samples we estimated the number of leucocytes and the values of lactate dehydrogenase (LDH), glucose and pH in pleural fluid, as well as the presence of bacteria. We did not protect the animals with antibiotics, and on the day 7 of the experiment they were sacrificed with the lethal dose of barbiturate (iv). The lung from the empyemic side of all experimental animals and the lung of one control animal were histopathologically examined.

RESULTS

A total of 4 animals had a small amount of clear pleural fluids or there was no fluid obtained with thoracocentesis 24 and 48 h after the bacteria instillation. after the bacteria instillation. In the remaining 8 rabbits 24 h after bacteria administration the mean values (± SD) of the parameters monitored were as follows: Le 34.75 ± 6.13 x 109/L, LDH 17,000 ± 4,69 U/L, glucose 1.23 ± 0.45 mmol/L, and pH 6.975 ± 0.15. The obtained values met the criteria for the evaluation of effusion as pleural empyema or complex and complicated pleural effusion (LDH > 1000 U/L, glucose < 2.31 mmol/L and pH < 7.20). Bacterial cultures were positive in 5 out of 8 first pleural samples and in only 2 samples after 48 h of bacteria administration. There was a positive correlation between the number of leukocytes and the LDH value (r = 0.071, p < 0.001), and a negative correlation between the number of leukocytes and the glucose level (r = 0.864, p < 0.001), and the leukocytes number and pH of the pleural fluid (r = 0.894, p < 0.001). The mean glucose value increased after 48 h (3.23 ± 0.44 mmol/L), and the pH value rose after 72 h (7.22 ± 0.03) which was beyond the empyema level.

CONCLUSION

The creation of the experimental empyema model is a very delicate work with uncertain success. Its value and importance are crucial for pleural pathology research. With the intention to obtain a more empyemic pleural reaction we created a model with two different human pathogen bacteria. We generated the satisfactory results, but not as good as those contained in some of the reference literature data.

Clinical characteristics and outcomes of patients with pleural infections due to Stenotrophomonas maltophilia at a medical center in Taiwan, 2004-2012

Stenotrophomonas maltophilia can cause various clinical diseases; however, pleural infections due to S. maltophilia are rare. We evaluated the clinical characteristics and outcomes of patients with pleural infections (complicated parapneumonic effusion or empyema) due to S. maltophilia who were treated at a medical center in Taiwan from 2004 to 2012. During the study period, 40 patients were treated for pleural infections due to S. maltophilia. The incidence of S. maltophilia pleural infections ranged from 2.66 per 1,000,000 patient-days in 2009 to 12.44 per 1,000,000 patient-days in 2011. Most of the patients with S. maltophilia pleural infections were immunocompromised male adults and all of the infections were acquired in healthcare settings. The majority of patients had polymicrobial pleural infections (n = 31, 77.5 %) and the most common pathogen was Pseudomonas aeruginosa (n = 12). The causes of pleural infections due to S. maltophilia were pneumonia due to S. maltophilia in two patients (5 %), post-surgical/tube thoracostomy in 26 (65 %) patients, and fistula (bronchopleural, esophagopleural and biliopleural) in 12 (30 %) patients. The 14-day and 30-day mortality rates were 32.5 % and 42.5 %, respectively. Pleural infections due to S. maltophilia are most commonly the result of surgical procedures, thoracostomy, and underlying fistulas. These infections are associated with a high mortality rate, especially among immunocompromised patients.

Pneumonia and empyema caused by Streptococcus intermedius that shows the diagnostic importance of evaluating the microbiota in the lower respiratory tract

The bacterial species in the Streptococcus anginosus group (S. constellatus, S. anginosus, S. intermedius) are important causative pathogens of bacterial pneumonia, pulmonary abscesses and empyema. However, the bacteria in this group are primarily oral resident bacteria and unable to grow significantly on ordinary aerobic culture media. We experienced a case of pneumonia and empyema caused by Streptococcus intermedius detected using a 16S rRNA gene sequencing analysis of bronchoalveolar lavage fluid and pleural effusion, but not sputum. Even when applying the molecular method, sputum samples are occasionally unsuitable for identifying the causative pathogens of lower respiratory tract infections.

Empyema with pleuropulmonary mucormycosis

Pleuropulmonary mucormycosis is relatively rare disease and that too localised disease is very rare but has got better prognosis. Maintaining a high level of suspicion is important in right clinical setting with pleuropulmonary involvement that fails to antibacterial agent either clinically or radiologically.

Chest tube tip culture as a predictor of postoperative infection in lung cancer operations

BACKGROUND

Postoperative infection is one of the most frequently observed complications after lung resection and should be addressed in perioperative management. This study evaluated the clinical significance of chest tube tip culture relevant to postoperative infection.

METHODS

From September 2002 to December 2011, 1,438 patients who underwent lung cancer operations in Shizuoka Cancer Center Hospital were evaluated. Postoperative infections, including surgical site infection, postoperative pneumonia, and postoperative empyema without fistula, were defined as those occurring within 30 days of thoracotomy.

RESULTS

Postoperative infections developed in 84 of the 1,438 patients (5.8%), including 42 (2.9%) with surgical site infection, 36 (2.5%) with pneumonia, and 13 (0.9%) with empyema. The sensitivity, specificity, and positive predictive value of chest tube tip culture were 23%, 98%, and 41.3%, respectively. Multivariate analysis demonstrated that the independent risk factors associated with the development of postoperative infections were coexisting diabetes mellitus and positive chest tube tip culture. Positive chest tube tip culture was the only independent risk factor associated with surgical site infection. The independent risk factors associated with postoperative pneumonia were age 70 years or older, coexisting diabetes mellitus, and positive chest tube tip culture. Finally, positive chest tube tip culture was the only independent risk factor associated with postoperative empyema.

CONCLUSIONS

Positive chest tube tip culture strongly predicts postoperative infections in lung cancer surgery and necessitates careful observation in the perioperative period.

Empyema necessitans caused by Mycobacterium tuberculosis in an immunocompetent patient

A 22-year-old man, a recent immigrant from Mexico, was admitted to a Wisconsin hospital because of a swelling of the chest wall and right axilla. Originally, it was thought to be a skin infection with Staphylococcus aureus. When the treatment was unsuccessful, the patient returned to the hospital and the abscesses were found to have been caused by Mycobacterium tuberculosis. Furthermore, there were pleural collections and it was thought that he had a manifestation called empyema necessitans, an extension of purulent pleural liquid through adjacent tissues to form an abscess on the thoracic wall.

Streptococcus anginosus group disseminated infection: case report and review of literature

Streptococcus anginosus group is widely known for its ability to cause invasive pyogenic infections. There are very few reports of disseminated infections sustained by members of this streptococcal group. We report a case of a highly disseminated infection and analyse previous literature reports. Disseminated pyogenic infection has been defined as an infection affecting two or more of the following organs/systems: central nervous system, lung, liver and spleen. We performed a PubMed search using the terms: S. milleri, S. anginosus, brain abscess, pulmonary abscess, hepatic abscess, spleen abscess. We reviewed 12 case reports including the one presented in this paper. Underlying conditions such as dental infections, malignancy, gastrointestinal and respiratory tract disease accounted for 42% of cases. No definite endocarditis was encountered, even though positive blood cultures were found in 67% of patients. Concomitant brain-liver, brain-lung and brain-spleen involvement occurred in 50%, 42% and 8% of cases respectively. Ninety-one percent (91%) of patients were treated with β-lactams, and surgical procedures were performed in 67% of patients. Infections caused by S. anginosus group members are satisfactorily treated with penicillin G and cephalosporins. It is very important to associate surgery to antimicrobial chemotherapy in order to achieve a full or nearly full clinical recovery.

[Pyopneumothorax caused by Salmonella choleraesuis: a case report and review of the literature]

OBJECTIVE

To improve understanding of the clinical features, diagnosis and treatment of pyopneumothorax caused by Salmonella choleraesuis.

METHODS

One case of pyopneumothorax caused by Salmonella choleraesuis diagnosed and treated in our hospital in 2010 was reported and the related literatures were reviewed. As of May 2011, the literature review was carried out with "Salmonella choleraesuis" and "thoracic empyema" as the search terms in Wanfang Med Online and Pubmed Database.

RESULTS

A 43-year-old Chinese woman presenting with fever and chest pain for 4 days was admitted to our hospital. A CT scan of the chest revealed a massive shadow with mixed density in the right hemithorax, from the top of thorax to diaphragmatic surface, and there was air inside or surrounding the mass irregularly but without an air-fluid level. Blood culture and bronchial secretion culture by bronchoscope both showed some serotypes of Salmonella strains. At first intravenous antibiotic therapy (piperacillin-tazobactam, ceftazidime, and then imipenem-cilastatin) was ineffective. Open chest surgery was performed, and chest tube placed. Salmonella choleraesuis was isolated from the drained pleural fluid. Chest tube drainage remained in place for more than 6 weeks, and with prolonged antibiotic therapy, which contributed to a good outcome. Literature review found no related reports in Wanfang Med Online, while 3 literatures were found in Pubmed, including 2 of case report and 1 of retrospective study. Among 973 patients with empyema thoracis in the retrospective study, 12 of these patients, including 9 men and 3 women, were infected with Salmonella species. The median age was 49 years, and 10 patients were immunocompromised, including malignancy, liver cirrhosis, and diabetes mellitus. Seven patients were infected with Salmonella choleraesuis, and 4 (57%) of them died.

CONCLUSIONS

Pyopneumothorax or thoracic empyema is a rare complication of Salmonella choleraesuis infection. Higher rates of death were noted in this disease. Salmonella choleraesuis infection is even more serious in adult patients with underlying diseases. Early diagnosis, appropriate antimicrobial drug therapy, and aggressive drainage are necessary to improve the outcome of patients with pyopneumothorax or thoracic empyema due to Salmonella choleraesuis.