How should we manage empyema: antibiotics alone, fibrinolytics, or primary video-assisted thoracoscopic surgery (VATS)?

Empyema is a well-recognized complication of pneumonia and its prevalence is increasing in the childhood population. The management of these patients requires a strategy for diagnosis and treatment that results in prompt resolution of infection and discharge with minimal morbidity. Traditionally conservative treatment has been the standard with insertion of a chest drain and intravenous antibiotics and, for those who fail to respond, an open thoracotomy and formal decortication. Since the 1990s two new treatment modalities have been described; fibrinolysis (promoting pleural drainage and circulation) and early VATS (video-assisted thoracoscopic surgery). Many institutions are now using one of these methods as first-line therapy. Both of these treatments result in shorter hospital stay and fewer complications than the conservative approach. In this review we will appraise the evidence for all three treatments and consider which treatment is optimal in children.

[Epidemiology and clinical characteristics of childhood parapneumonic empyemas]

Several studies have reported an increasing incidence of childhood parapneumonic empyemas in various countries.

AIM OF THE STUDY

The aim of our study was to estimate the annual incidence of complicated community-acquired pneumonias in children during a 9-year period in a French area and to describe the epidemiological and clinical characteristics of these complications.

POPULATION AND METHODS

We have listed the children from 28 days to 15 years old, hospitalized in the 2 children hospitals of the Isere district for a community-acquired pneumonia complicated with a pleural empyema or a pulmonary abscess from 1995 to 2003.

RESULTS

During the study period, 90 children were hospitalized for a complicated pneumonia including 83 pleural empyemas and 7 isolated lung abscess. The average number of cases was 4 per year from 1995 to 1998 then increased since 1999 to reach 34 cases in 2003, according to a linear model (P<0,001). The incidence of the complicated pneumonia, plotted to the paediatric population of the area has gone up from 0.5 per 100000 to 13 per 100000 children between 1995 and 2003.

CONCLUSION

The incidence of the complicated pneumonias in children increased since 1999 in a French area. Additional investigations are necessary to identify the causes of this increase.

Parapneumonic effusion and empyema in children: retrospective review of the duPont experience

Management of pediatric parapneumonic effusions and empyema remains controversial. Treatment includes antibiotics, chest tube, fibrinolytic therapy, video-assisted thoracoscopy and debridement, and open thoracotomy and decortication. A retrospective 10-year study was done to identify patient selection variables for specific therapies. Charts (n = 101) with diagnoses of empyema without comorbidity were reviewed, a database was developed, and variables between patients who did and did not receive thoracoscopic debridement were compared at admission and during hospitalization. The difference in positive culture reports with video-assisted thoracoscopy compared with medical management was significant (P < .018). Postsurgical patients used the intensive care unit and had 2 or more chest tubes with greater frequency than medically managed patients (P < .014, P < .002). Antibiotics, video-assisted thoracoscopy, and chest tube within 48 hours of admission shortened hospitalization by 4 days (P < .001) compared with delayed video-assisted thoracoscopy done after 48 hours of admission.

[Experience with treatment of thoracic empyema during seven years period]

The authors prospectively assembled group of 157 patients treated for empyema thoracic during seven years period. They followed applied methods of the diagnostics and therapy, the length of hospital stay after surgical intervention and its successfulness. The parameters were statistically evaluated. The results showed that surgical intervention substantially influences shortening of the hospital stay and successful cure. In the early stages of the disease thoracoscopic treatment is often sufficient to eliminate the infection. When is indicated later then three weeks after onset of the effusion, then facilitates early decontamination of the empyema cavity and possibility to perform lung decortication. In patients with thoracic empyema, where adequate effusion evacuation can not be reached, the conservative treatment results in prolongation of the hospitalization. Surgical intervention on the contrary the hospital stay, without increase in morbidity or mortality, shortens.

Pleural space sterilization using gentian violet irrigation for postbullectomy empyema associated with artificial material infection

Postoperative empyema associated with artificial material infection involves several treatment problems. We report the successful treatment of a case of post-bullectomy empyema with a small alveolar fistula that was associated with artificial material infection by Streptococcus viridans. In this case, complete empyema space sterilization was obtained by tube drainage and daily pleural irrigation using 0.1% gentian violet solution. This treatment circumvented the need for invasive surgery, including removal of the infected artificial materials and space-filling and/or collapse procedures. Consequently, gentian violet irrigation may be a useful treatment option in selected cases with complicated thoracic empyema.

Thoracic empyema, application of video-assisted thoracic surgery and its current management

PURPOSE OF REVIEW

Pneumonia in children is frequently complicated by pleural effusions, which rarely progress to empyema. Appropriate clinical management depends on correctly diagnosing the stage of the disease process. Recently, increasing use of video-assisted thoracic debridement has altered the traditional management of pleural effusions and empyema in children, resulting in decreasing reliance on thoracentesis and earlier surgical intervention.

RECENT FINDINGS

We review the current literature supporting the clinical indications for video-assisted thoracic debridement compared with traditional management, including the use of thoracentesis, chest tube placement, fibrinolytic therapy and open thoracotomy in children with empyema. Recent studies support the early application of video-assisted thoracic debridement in children with empyema compared with traditional therapy, as it decreases the number of procedures and studies performed and the duration of chest tube drainage and is associated with less pain and shorter recovery period than open thoracotomy.

SUMMARY

We propose a clinical algorithm supporting the early use of video-assisted thoracic debridement in the management of empyema in children.

Treatment approaches for empyema in children

Empyema is an important cause of childhood morbidity with an increasing worldwide incidence. Despite many treatment options being available, there is no general consensus on the optimal management approach due to conflicting reports and lack of properly conducted studies to challenge the personal bias of a physician or surgeon. The reason for this is likely to be the fact that, irrespective of the treatment children receive, they ultimately make an excellent clinical recovery. This review summarises the current evidence and evaluates the clinical efficacy of various treatment modalities in the context of relevant outcome measures in an attempt to demonstrate the differences in treatment options for the child with empyema.

Contemporary empyema necessitatis

Empyema necessitatis is defined by the extension of an empyema through the parietal pleura, into surrounding tissue. Clinical manifestations are generally subacute, representing the indolent nature of the most commonly implicated pathogens (Mycobacterium tuberculosis and Actinomyces israelii). Treatment with antimicrobials and surgical debridement has drastically reduced mortality; however, with proper initial assessment and treatment of pulmonary infection, this rare complication can often be avoided. We describe a patient with empyema necessitatis to illustrate the importance of timely diagnosis and treatment of parapneumonic pleural effusion, and the need to consider this diagnosis in patients presenting with constitutional symptoms and a chest wall mass.

Empyema in adults and children: difference in surgical approaches, report of 139 cases

AIM

We investigated specific aetiology and different therapeutic approaches in patients with empyema in a General Thoracic Surgery Clinic.

MATERIAL AND METHODS

Charts of 139 patients admitted with empyema, between January 1998 and March 2005 were retrospectively reviewed. Although not completely comparable, patients were divided into two groups; Paediatric (n = 71) and adult (n = 68) cases. In addition to demographic characteristics, treatment options, complications and clinical outcomes were investigated according to the specific group.

RESULTS

The mean age was 5.6 years (4 mo - 17 y) for paediatric patients and 49.6 years (20-81 y) for adult patients. Overall, 65% of the patients (n = 91) were male. All paediatric cases had parapneumonic empyema, while 63% of the adult cases had parapneumonic and 23.5% had postoperative empyema. Of the paediatric cases, 50% received fibrinolytic treatment in addition to tube thoracostomy and 35% had decortication. In adults, 42% had tube thoracostomy and fibrinolytic treatment, and decortication was required in 9% only. Thoracomyoplasty was performed in 12% of the patients (n = 8). We had no mortality in paediatric patients, however mortality rate was 8% in the adult group. Morbidity, consisted mostly of prolonged air leakage and impaired lung expansion.

CONCLUSION

Early decortication and fibrinolytic treatment are sufficient for paediatric patients, while a variety of techniques including open drainage, rib resection and thoracomyoplasty are required in adult patients with empyema.

[Parapneumonic effusion and empyema]

The infectious effusion, one of the most frequent causes of pleural effusions in the clinical practice, is a sign of complication of the pneumonic disease. The early recognition of the parapneumonic effusion is crucial to determine the best treatment form and reduce the risk of morbidity and mortality. The evolution in the diagnostic methods and the contribution of several studies published in the literature allowed to establish evidence-based guidelines that are used to guide the treatment of the parapneumonic pleural effusion and empyema.

Management of pleural space infections: A population-based analysis

OBJECTIVE

Management options for pleural space infections have changed over the last 2 decades. This study evaluated trends over time in the incidence of disease and use of different management strategies and their associated outcomes.

METHODS

A retrospective study was performed by using a statewide administrative database of all hospitalizations for pleural space infections between 1987 and 2004.

RESULTS

Four thousand four hundred twenty-four patients (age, 57.1 +/- 18.6 years; 67% male; comorbidity index, 1.1 +/- 1.9) were hospitalized with pleural space infections. The incidence rate increased 2.8% per year (95% confidence interval, 2.2%-3.4%; P < .001). Overall, 51.6% of patients underwent an operation, and the proportion increased from 42.4% in 1987 to 58.4% in 2004 (P < .001). The risk of death within 30 days was less for patients undergoing operations compared with that for patients not undergoing operations (5.4% vs 16.6%, P < .001); however, patients undergoing operations were younger (52.9 +/- 17.6 years vs 61.5 +/- 18.6 years, P < .001) and had a lower comorbidity index (0.8 +/- 1.6 vs 1.4 +/- 2.1, P < .001). After adjusting for age, sex, comorbidity index, and insurance status, patients undergoing operative therapy had a 58% lower risk of death (odds ratio, 0.42; 95% confidence interval, 0.32-0.56; P < .001) than those undergoing nonoperative management.

CONCLUSIONS

The incidence of pleural space infections and the proportion of patients undergoing operative management have increased over time. Patients undergoing operations were younger and had less comorbid illness than those not undergoing operations but had a much lower risk of early death, even after adjusting for these factors.

Less is best? The impact of urokinase as the first line management of empyema thoracis

To assess the impact of intrapleural urokinase and small tube thoracostomy on the management of childhood empyema thoracis. The study population included 38 children presenting consecutively to a regional surgical unit with empyema thoracis from January 2001 to December 2003. Children with malignancy, immunodeficiency and complex intercurrent illness were excluded. Primary outcome variables were the need for second intervention and duration of stay, with other variables including duration of antibiotics, serial CRP and amelioration of pyrexia. Interventions were: tube thoracostomy (16-20 Fr) alone (n=2), tube thoracostomy (6-10 Fr)+urokinase (n=17), thoracoscopy (tube: 20-24 Fr) (n=9), thoracotomy (tube: 16-24 Fr) (n=10). There were no differences in age, weight or length of prodromal symptoms, between treatment groups. There were no differences in primary outcome variables, although no child undergoing thoracotomy required further intervention. The duration of intravenous antibiotics was similar in all groups. Amelioration of pyrexia was more rapid in children undergoing thoracotomy. There were no differences seen with regard to decline in CRP level. Small tube thoracostomy and intrapleural urokinase had a similar outcome to more invasive therapies such as thoracotomy or thoracoscopy thereby supporting the evidence base for urokinase and tube drainage as first line intervention.

Efficacy and complications of small-bore, wire-guided chest drains

BACKGROUND

Small-bore Seldinger-type chest drains have become increasingly popular in recent years, but there are few data on their effectiveness.

METHODS

Data were collected prospectively at the time of drain insertion and continued until drain removal. Patients completed a visual analog score (VAS) of pain on drain insertion.

RESULTS

Fifty-two drains were inserted in 44 patients over 10 months. Drain sizes ranged from 12 to 20F. The mean (+/- SEM) patient age was 64 +/- 2 years, and mean duration of drainage was 4.5 +/- 0.5 days. Fourteen drains (27%) were inserted for pneumothoraces, 19 drains (37%) for malignant effusions, 10 drains (19%) for empyema, 5 drains (10%) for parapneumonic effusions, and 4 drains (8%) for other effusions. Pain VAS ranged from 3 to 66 mm (maximum, 100 mm; average [+/- SD], 23 +/- 16 mm). Although the overall drain failure rate was 37%, there was only one serious complication (empyema), and this compares well with historical control subjects. Success rate was highest when used to treat malignant effusions (83%) and pneumothoraces (64%); drains inserted for empyema were more likely to block (overall success rate, 20%). There was no correlation between the type of fluid or size of drain and likelihood of blockage.

CONCLUSIONS

Seldinger-type drains are a well-tolerated and effective method of draining pneumothoraces and uncomplicated effusions. They are more likely to block when draining empyemas but have a comparable failure rate in pneumothorax to large-bore drains.

[Post-pneumonectomic purulent bronchopleural complications in lung cancer: a solution of the problem]

A strategy providing for solution of a number of tactical and technical problems involved in prognosis, prevention and management of postoperative bronchopleural complication after pneumonectomy for lung cancer was suggested. It was followed by a significant decrease in the frequency of bronchopleural fistula, postoperative empyema and lethality from purulent bronchopleural complications.

Pericarditis purulenta y empiema pleural por Streptococcus pneumoniae

We present the case of a 59 year old woman with no previous clinical history of disease who was admitted in our ICU due to respiratory failure and hemodynamic instability. She was found to have purulent pericarditis due to Streptococcus pneumoniae, complicated by massive pericardial effusion and pleural empyema. A pericardial tap was performed unsuccessfully and finally pericardial effusion was evacuated by surgical drainage. Pleural empyema was also evacuated. She received antibiotic treatment and recovered with normalisation of heart function.

Successful medical treatment of 15 dogs with pyothorax

OBJECTIVES

To review the success of non-surgical management, which included antibiotics and a single thoracocentesis, in 15 dogs presenting with pyothorax.

METHODS

Sixteen dogs were selected retrospectively from case files at the Veterinary Cardiorespiratory Centre.

RESULTS

One dog was diagnosed with a mass suspected to be a pulmonary abscess on ultrasound examination and was referred for surgery. Fifteen dogs were treated medically. Springer spaniels were the most commonly presented breed (six cases) followed by Labrador retrievers (three cases). Under sedation or general anaesthesia, thoracocentesis was performed unilaterally and as much purulent effusion as possible was removed. Lavage of the thorax was not undertaken. In most dogs, antibiotic treatment was ampicillin at a mean dose of 33 mg/kg administered three times daily and 25 mg/kg metronidazole administered twice daily. Antibiotics were provided for a minimum of six weeks. All dogs recovered completely and did not show relapse on prolonged follow-up. This included one dog, which had very widespread pleural adhesions and minimal effusion.

CLINICAL SIGNIFICANCE

In dogs that do not have evidence of pulmonary masses or consolidations and no evidence of granular pleural effusion, medical therapy may be curative even in chronic cases of pyothorax with pleural adhesions.

[Intensive care treatment following thoracic surgery]

Intensive care in thoracic surgery requires highly specialised abilities and knowledge in addition to usual intensive care standards. The operative chest intensivist must be experienced in special surgical methods, interventional bronchology, and tube management. Cooperating with chest physicians and anaesthesiologists, he takes the central position in intensive therapy. This is described in detail and explained by examples. Furthermore, aspects of education in this specialty will be emphasised.

[Streptococcus constellatusas a causative agent of empyema. Report of one case]

Streptococcus constellatus is a commensal microorganism in man but may cause infections in different locations. We report a 59 years old male with severe sequelae of a previous cerebrovascular accident that consulted in the emergency room for fever of 15 days of evolution. A right empyema was diagnosed. The bacteriological culture of the effusion disclosed the presence of Streptococcus constellatus and two anaerobic strains (Prevotella intermedia and Fusobacterium urealyticus). The patient was treated with a pleural drainage and received ceftriaxone and clindamycin during six weeks. He was discharged in good conditions and is asymptomatic after eight months of follow up.

Anaerobic bacterial empyema accompanying intrathoracic gas formation in anorexia nervosa

OBJECTIVE

Intrathoracic gas formation due to anaerobic pleuropulmonary infection is rare.

METHOD & RESULTS

We experienced a case of empyema with intrathoracic gas formation by an anaerobic bacterium in a young woman with anorexia nervosa (AN).

CONCLUSION

We should therefore be alert to the possibility of serious infection in patients with AN, even when they have few complaints or normal white blood cell counts.

Venovenous extracorporeal membrane oxygenation as an adjunct to surgery for empyema: report of a case

Empyema is a serious and often life-threatening condition. We report the case of a 45-year-old man with severe hypoxia caused by empyema after streptococcal pneumonia, which we successfully treated by surgical drainage assisted by a venovenous extracorporeal membrane oxygenation (ECMO) device. This device provided sufficient oxygenation during the perioperative period and was not associated with excessive bleeding under systemic heparinization. This case report shows the effectiveness of ECMO in allowing surgery and enhancing its benefits in patients with serious hypoxia.

Unusual presentations of coccidioidomycosis: a case series and review of the literature

Coccidioidomycosis is an emerging fungal infection of the southwestern United States. Although Coccidioides species infections are usually asymptomatic or result in a mild, flu-like illness, disseminated disease may occur in 1% of cases. While extrapulmonary disease usually involves the skin, central nervous system, bones, or joints, coccidioidomycosis is a great imitator, with the ability to infect any tissue or organ. Cases may be diagnosed outside of endemic areas, hence providers worldwide should be aware of the broad range of manifestations of coccidioidomycosis. We present a case series of unusual presentations of coccidioidomycosis including serous cavity infections with cases of pericarditis, empyema, and peritonitis, as well as unusual abscesses involving the retropharyngeal space and gluteal musculature. We provide a complete review of the literature and summarize the clinical presentations, diagnoses, and treatments of these rare forms of disseminated coccidioidomycosis.