Factors associated with recurrent bacterial empyema thoracis

Empyema complicated with nephropleural fistula and perinephric abscess

The coexistence of empyema, nephropleural fistula and perinephric abscess is rare and presents diagnostic challenges, especially when patients exhibit atypical or mild symptoms. This case report details a female in her early 90s who presented with 3 weeks of chest pain and was found to have a left-sided pleural effusion. Further imaging revealed additional findings of a left-sided nephropleural fistula and left perinephric collection. The patient underwent thoracentesis and video-assisted thoracoscopic surgery, with cultures growing Streptococcus Anginosus Subsequently, she underwent a left nephrectomy, with pathology findings consistent with chronic pyelonephritis and a fistulous tract. The patient was discharged on intravenous antibiotics. Follow-up imaging showed improvement. The patient completed the antibiotic course and reported symptom resolution 2 weeks after discharge.

Empyema thoracis presented as giant back abscess

Empyema thoracis (ET) is defined as pus in the pleural space, either localized or involving the entire pleural cavity, due to diverse etiologies. In severe form, it may infiltrate the extrapulmonary region. Clinical guideline describes 3 stages of parapneumonic effusion before developing into an ET, namely the exudative stage, the fibrinopurulent stage, and the organizing/late stage. We highlight a 59-year-old gentleman who presented a back swelling masquerading as a deep-seated abscess, in which the diagnosis of ET had not been established early. The principles of treatment are treating the underlying condition such as pneumonia, pleural drainage and debridement, full re-expansion of the collapsed lung by performing chest physiotherapy, and improving nutrition. ET is a condition with a dynamic process due to diverse etiologies, either localized or involving the entire pleural cavity. The gold standard in diagnosing ET is the pleural aspiration of fluid from the pleural space, whereas the management of ET may include non-surgical and/or surgical treatments based on the basic principles of ET treatment.

Surgical outcome of empyema thoracis patients with special correlation to pre-operative contrast-enhanced computerized tomography (CECT) thorax morphometry

Purpose

Empyema thoracis is a very common disease. The surgical outcome of empyema patients depends upon various factors. To the best of our knowledge, there is no study in literature describing the surgical outcome of patients in relation to the contrast-enhanced computerized tomography (CECT) thorax morphometric findings. In this study, we examined the surgical outcome of empyema thoracis patients in relation to both clinical and radiological findings.

Materials and methods

It is a prospective hospital-based study conducted between October 2016 and August 2018. A total of 30 patients, who underwent decortication during the study period, were included. They were divided into three performance groups (excellent performance, average performance and poor performance groups) according to the outcome. The surgical outcome was correlated with the pre-operative clinical, radiological, intra-operative and post-operative parameters.

Results

Intra-operative ability to complete decortication, intra-operative expansion of the lungs and presence of broncho-pleural fistula were significantly different between the three performance groups. Duration of the disease, pre-operative duration of antitubercular therapy (ATT) intake and duration of pre-operative intercostal drain (ICD) were statistically insignificant between groups. In computed tomography (CT) morphometry, residual lung volume of the involved lung and volume of empyema were found to be significantly different between the performance groups. The residual volume of the involved lung (expressed in terms of the percentage of lung volume of the normal opposite lung) can predict the complete expansion of the lung with sensitivity of 71% and specificity of 70%.

Conclusion

The pre-operative residual lung volume of the involved lung, empyema volume, completeness of decortication, intra-operative expansion of the lung and presence or absence of broncho-pleural fistula can determine the surgical outcome in empyema thoracis patients.

The microbiology of pleural infection in adults: a systematic review

BACKGROUND AND OBJECTIVES

Pleural infection is a major cause of morbidity and mortality among adults. Identification of the offending organism is key to appropriate antimicrobial therapy. It is not known whether the microbiological pattern of pleural infection is variable temporally or geographically. This systematic review aimed to investigate available literature to understand the worldwide pattern of microbiology and the factors that might affect such pattern.

DATA SOURCES AND ELIGIBILITY CRITERIA

Ovid MEDLINE and Embase were searched between 2000 and 2018 for publications that reported on the microbiology of pleural infection in adults. Both observational and interventional studies were included. Studies were excluded if the main focus of the report was paediatric population, tuberculous empyema or post-operative empyema.

STUDY APPRAISAL AND SYNTHESIS METHODS

Studies of ≥20 patients with clear reporting of microbial isolates were included. The numbers of isolates of each specific organism/group were collated from the included studies. Besides the overall presentation of data, subgroup analyses by geographical distribution, infection setting (community versus hospital) and time of the report were performed.

RESULTS

From 20 980 reports returned by the initial search, 75 articles reporting on 10 241 patients were included in the data synthesis. The most common organism reported worldwide was Staphylococcus aureus. Geographically, pneumococci and viridans streptococci were the most commonly reported isolates from tropical and temperate regions, respectively. The microbiological pattern was considerably different between community- and hospital-acquired infections, where more Gram-negative and drug-resistant isolates were reported in the hospital-acquired infections. The main limitations of this systematic review were the heterogeneity in the method of reporting of certain bacteria and the predominance of reports from Europe and South East Asia.

CONCLUSIONS

In pleural infection, the geographical location and the setting of infection have considerable bearing on the expected causative organisms. This should be reflected in the choice of empirical antimicrobial treatment.

A systematic review of comorbidities and outcomes of adult patients with pleural infection

Background

Pleural infection remains an important cause of mortality. This study aimed to investigate worldwide patterns of pre-existing comorbidities and clinical outcomes of patients with pleural infection.

Methods

Studies reporting on adults with pleural infection between 2000 and 2017 were identified from a search of Embase and MEDLINE. Articles reporting exclusively on tuberculous, fungal or post-pneumonectomy infection were excluded. Two reviewers assessed 20 980 records for eligibility.

Results

211 studies met the inclusion criteria. 134 articles (227 898 patients, mean age 52.8 years) reported comorbidity and/or outcome data. The majority of studies were retrospective observational cohorts (n=104, 78%) and the most common region of reporting was East Asia (n=33, 24%) followed by North America (n=27, 20%). 85 articles (50 756 patients) reported comorbidity. The median (interquartile range (IQR)) percentage prevalence of any comorbidity was 72% (58–83%), with respiratory illness (20%, 16–32%) and cardiac illness (19%, 15–27%) most commonly reported. 125 papers (192 298 patients) reported outcome data. The median (IQR) length of stay was 19 days (13–27 days) and median in-hospital or 30-day mortality was 4% (IQR 1–11%). In regions with high-income economies (n=100, 74%) patients were older (mean 56.5 versus 42.5 years, p<0.0001), but there were no significant differences in prevalence of pre-existing comorbidity nor in length of hospital stay or mortality.

Conclusion

Patients with pleural infection have high levels of comorbidity and long hospital stays. Most reported data are from high-income economy settings. Data from lower-income regions is needed to better understand regional trends and enable optimal resource provision going forward.

In pleural infection, patients from higher-income countries tend to be older with more comorbidities and are more likely to be referred for fibrinolytic treatment in comparison to patients from lower-income countrieshttp://bit.ly/2K2M5HL