Outcomes of Operative and Nonoperative Treatment of Thoracic Empyema: A Population-Based Study

Long-term outcomes in surgically intervened empyema patients: a systematic review

BACKGROUND

Pleural empyema is significant cause of morbidity and mortality. Debate in the literature exists regarding the best initial and definitive therapy, with recent research demonstrating superior short-term outcomes with initial surgical intervention. Despite this, the impact of surgical intervention on long-term outcomes has been incompletely described. A systematic review was undertaken to assess the current evidence evaluating the long-term impact of surgical intervention.

METHODS

A systematic review was undertaken according to PRISMA guidelines utilizing three databases. Articles included all papers where patients received surgical intervention for empyema with outcomes evaluated beyond 90 days. Two reviewers extracted and reviewed the articles. Grey literature was included.

RESULTS

Eleven studies and two abstracts were extracted. One study and two abstracts evaluated the quality of life outcomes, two studies evaluated dyspnoea outcomes, seven studies evaluated long-term lung function and two studies evaluated mortality and re-admissions. 60-65% of patients had no dyspnoea between 2 and 7 years follow-up. In six of seven studies, normal lung function was achieved in patients with chronic fibrothorax with FEV1% and FVC% improvements between 14-30% and 13-50%, respectively. The results from such biased cohorts could not be extrapolated to conclude that surgical intervention results in better outcomes than ICC drainage. Risk of bias was severe for all 11 studies.

CONCLUSION

Surgical intervention potentially improves post-operative lung function, long-term dyspnoea, and mortality. The impact this has on quality of life remains unknown. Future prospective trials with homogenous comparative groups are required to better define the role of surgery and its impact on long-term outcomes.

Evaluation of the RAPID score as a predictor of postoperative morbidity and mortality in patients undergoing pulmonary decortication for stage III pleural empyema

OBJECTIVE

This study aims to correlate the RAPID score with the 3-month survival and surgical results of patients undergoing lung decortication with stage III pleural empyema.

METHODS

This was a retrospective study with the population of patients with pleural empyema who underwent pulmonary decortication between January 2019 and June 2022. Data were collected from the institution's database, and patients were classified as low, medium, and high risk according to the RAPID score. The primary outcome was 3-month mortality. Secondary outcomes were the length of hospital stay, readmission rate, and the need for pleural re-intervention.

RESULTS

Of the 34 patients with pleural empyema, according to the RAPID score, patients were stratified into low risk (23.5 %), medium risk (47.1 %), and high risk (29.4 %). The high-risk group had a 3-month mortality of 40 %, while the moderate-risk group had a 6.25 % and the low-risk group had no deaths within 90 days, confirming a good correlation with the RAPID score (p < 0.05). Sensitivity and specificity for the primary outcome in the high-risk score were 80.0 % and 79.3 %, respectively. The secondary outcomes did not reach statistical significance.

CONCLUSIONS

In this retrospective series, the RAPID score had a good correlation with 3-month mortality in patients undergoing lung decortication. The morbidity indicators did not reach statistical significance. The present data justifies further studies to explore the capacity of the RAPID score to be used as a selection tool for treatment modality in patients with stage III pleural empyema.

Clinical Risk Factors for Death in Patients With Empyema and Active Malignancy

Background Pleural infection is a common clinical problem resulting in prolonged hospitalization and increased mortality. In patients with active malignancy, management decisions are based on the need for further immunosuppressive therapies, the ability to tolerate surgery, and consideration of the limited life expectancy. Identifying patients at risk for death or poor outcomes is very important as it will guide care. Study design and methods This is a retrospective cohort study of all patients with active malignancy and empyema. The primary outcome was time to death from empyema at three months. The secondary outcome was surgery at 30 days. Standard Cox regression model and cause-specific hazard regression model were used to analyze the data. Results A total of 202 patients with active malignancy and empyema were included. The overall mortality rate at three months was 32.7%. On multivariable analysis, female gender and higher urea were associated with an increased risk of death from empyema at three months. The area under the curve (AUC) of the model was 0.70. The risk factors for surgery at 30 days included the presence of frank pus and postsurgical empyema. The AUC of the model was 0.76. Interpretation Patients with active malignancy and empyema have a high probability of death. In our model, the risk factors for death from empyema included female gender and higher urea.

ERS/ESTS statement on the management of pleural infection in adults

Pleural infection is a common condition encountered by respiratory physicians and thoracic surgeons alike. The European Respiratory Society (ERS) and European Society of Thoracic Surgeons (ESTS) established a multidisciplinary collaboration of clinicians with expertise in managing pleural infection with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified: 1) epidemiology of pleural infection, 2) optimal antibiotic strategy, 3) diagnostic parameters for chest tube drainage, 4) status of intrapleural therapies, 5) role of surgery and 6) current place of outcome prediction in management. The literature revealed that recently updated epidemiological data continue to show an overall upwards trend in incidence, but there is an urgent need for a more comprehensive characterisation of the burden of pleural infection in specific populations such as immunocompromised hosts. There is a sparsity of regular analyses and documentation of microbiological patterns at a local level to inform geographical variation, and ongoing research efforts are needed to improve antibiotic stewardship. The evidence remains in favour of a small-bore chest tube optimally placed under image guidance as an appropriate initial intervention for most cases of pleural infection. With a growing body of data suggesting delays to treatment are key contributors to poor outcomes, this suggests that earlier consideration of combination intrapleural enzyme therapy (IET) with concurrent surgical consultation should remain a priority. Since publication of the MIST-2 study, there has been considerable data supporting safety and efficacy of IET, but further studies are needed to optimise dosing using individualised biomarkers of treatment failure. Pending further prospective evaluation, the MIST-2 regimen remains the most evidence based. Several studies have externally validated the RAPID score, but it requires incorporating into prospective intervention studies prior to adopting into clinical practice.

Duration of antimicrobial therapy after video-assisted thoracoscopic surgery for thoracic empyema and complicated parapneumonic effusion: A single-center study

BACKGROUND

There are no evidence-based reports on the proper duration of antimicrobial therapy following video-assisted thoracoscopic surgery debridement (VATS-D) in thoracic empyema (TE) or complicated parapneumonic effusion (PPE). This study aimed to investigate the optimal duration of antimicrobial therapy after VATS-D.

METHODS

Between January 2011 and December 2019, 33 patients corresponding to American College of Chest Physicians (ACCP) category 3 or 4 undergoing VATS-D were included. The times until the body temperature (BT) was confirmed to be less than 37.5 °C and 37.0 °C, white blood cell count (WBC) less than 10,000/μl, segmented neutrophils (seg) less than 80%, and C-reactive protein (CRP) level less than 25% of the preoperative value were retrospectively analyzed.

RESULTS

The median time from the onset of TE/PPE to surgery was 13 days. The median durations of preoperative and postoperative antibiotic use were five and seven days, respectively. Major complications occurred in four cases (three and one cases of respiratory failure and cerebral infarction, respectively). The median postoperative hospital stay was 14 days. Recurrence or progression to chronic empyema was seen in four cases. The median numbers of days until the conditions were met were three days for BT < 37.5 °C, six days for BT < 37.0 °C, four days for WBC<10,000, seven days for seg<80% and seven days for CRP<25%.

CONCLUSIONS

The proper duration of antimicrobial therapy after VATS-D for TE/PPE is approximately three to seven days. Urgent VATS-D may shorten the total antibiotic usage.

Does the time to diagnosis and treatment influence outcome in adults with pleural infections

Objective

To investigate the effect of early diagnosis and intervention in adult patients with complicated parapneumonic pleural effusion or pleural empyema and the impact on outcomes.

Methods

A systematic review based on a literature search of the PubMed database was performed.

Results

Eleven eligible studies were included; nine observational studies and two randomised controlled trials totalling a study population of 10,717 patients. The studies were conducted from 1992 to 2018, all in Europe and Northern America except one. Results varied between studies, but a trend towards better outcome in patients with shorter duration of symptoms and quicker initiation of treatment was found. We found that duration of symptoms before treatment may affect length of hospital stay, rate of conversion to open surgery, and frequency of complications.

Conclusion

We found that an earlier intervention in adults suffering from complicated parapneumonic pleural effusion and pleural empyema may potentially improve the outcome of patients in terms of length of stay, conversion to open surgery, and general complications following treatment, but not regarding mortality. Further studies are required to specify the timing of each intervention, and direct comparison in early management of interventions.

Pneumococcal empyema: Resistance patterns, fitness cost and serotype distribution

BACKGROUND

Streptococcus pneumoniae is a recognized etiology of invasive infections including parapneumonic empyema, and its resistance to antibiotics is evolving worldwide, raising concerns of encountering untreatable strains. This study measured the serotype distribution, antimicrobial susceptibility and biological cost incurred by resistance of pneumococci from pleural samples.

METHODS

The serotype profiles, susceptibility results and growth rates were phenotypically determined for a panel of clinical strains of S. pneumoniae from cases of empyema between 2011 and 2019.

RESULTS

Of 24 empyema cases, the isolated strains belonged to seven serotypes in the following descending order; 19A, 11A/D, 19F, 3, 7F, 1/6B while two strains remained non-typable. Penicillin susceptibility was shown in <80% of the isolates, while parenteral cephalosporins (cefuroxime and ceftriaxone) demonstrated activity in 83.3 and 95.8% respectively. High resistance frequency was noted for macrolides and sulfonamides, but the strains were uniformly sensitive to respiratory fluroquinolones, vancomycin and linezolid. The macrolide-resistant strain exhibited a high growth rate, suggesting a possible beneficial effect. Phenotypes with mono-resistance to sulfonamides and clindamycin were equally fit as the susceptible counterpart strains. Resistance to multiple antimicrobial agents resulted in a high degree of fitness deficit, while other resistant phenotypes were less fit.

CONCLUSIONS

The pneumococcal conjugate vaccine PCV13 serotypes still circulate in the community. The data indicate that resistance to certain antimicrobials incurs an apparent fitness cost in pneumococci which may limit the dissemination of such strains while low fitness cost, seen in case of resistance to macrolides, may contribute to the spread of resistant clones.

Comparing Initial Surgery versus Fibrinolytics for Pleural Space Infections: A Retrospective Multicenter Cohort Study

Rationale: When drainage of complicated pleural space infections alone fails, there exists two strategies in surgery and dual agent-intrapleural fibrinolytic therapy; however, studies comparing these two management strategies are limited. Objectives: To determine the outcomes of surgery versus fibrinolytic therapy as the primary management for complicated pleural space infections (CPSI). Methods: A retrospective review of adults with a CPSI managed with surgery or fibrinolytics between 1/2015 and 3/2018 within a multicenter, multistate hospital system was performed. Fibrinolytics was defined as any dose of dual-agent fibrinolytic therapy and standard fibrinolytics as 5-6 doses twice daily. Treatment failure was defined as persistent infection with a pleural collection requiring intervention. Crossover was defined by any fibrinolytics after surgery or surgery after fibrinolytics. Logistic regression with inverse probability of treatment weighting (IPTW) were employed to account for selection bias effect of management strategies in treatment failure and crossover. Results: We identified 566 patients. Surgery was the initial strategy in 55% (311/566). The surgery group had less additional treatments (surgery: 10% [32/311] versus fibrinolytics: 39% [100/255], P < 0.001), treatment failures (surgery: 7% [22/311] versus fibrinolytics: 29% [74/255], P < 0.001), and crossovers (surgery: 6% [20/311] versus fibrinolytics: 19% [49/255], P < 0.001). Logistic regression analysis with IPTW demonstrated a lower odds of treatment failure with surgery compared with any fibrinolytics (odds ratio [OR], 0.20; 95% confidence interval [CI], 0.10-0.30; P < 0.001); and compared with standard fibrinolytics (OR, 0.20; 95% CI, 0.11-0.35; P < 0.001). Conclusions: Although there is a lack of consensus as to the optimal management strategy for patients with a CPSI, in surgical candidates, operative management may offer more benefits and could be considered early in the management course. However, our study is retrospective and nonrandomized; thus, prospective trials are needed to explore this further.

Multifocal locules including the anterior mediastinum side as a surgical indicator in pleural infection

Background

The indication for and the timing of surgery in patients with pleural infection remains unclear. Determining the need for surgery in patients with pleural infection may help in the early consultation of surgeons.

Methods

Data of 167 consecutive patients with pleural infection were retrospectively reviewed. To detect a surgical indicator, the variables of patients who required surgery were compared with those of patients who were cured by non-surgical therapy (n=94) and patients resistant to the non-surgical therapy (n=73; 62 underwent surgery, and 11 showed recurrence or disease-related death after non-surgical treatment). Prognosis and timing of surgery were analyzed by comparing three groups: patients who underwent surgery within 7 days of admission (n=33), patients who underwent surgery after 7 days of admission (n=29), and patients who underwent non-surgical therapy (n=105).

Results

The presence of multifocal locules, including a locule on the anterior mediastinum side (LAMS) was a significant indicator of resistance to initial non-surgical therapy, as compared to the absence of locules (P<0.0001), a single locule (P<0.0001), or multifocal locules without a LAMS (P=0.0041). Recurrence and mortality were not observed in the patients who underwent surgery within 7 days of admission, and the hospitalization period (P=0.0071) and duration of C-reactive protein (CRP) improvement (P<0.0001) were significantly shorter in these patients compared with those who that underwent surgery after 7 days.

Conclusions

In patients with pleural infection, the presence of multifocal locules, including a LAMS, was associated with resistance to non-surgical therapy. Early surgery should be considered for these patients to shorten the hospitalization period and improve the prognosis.

Medical Thoracoscopy

Medical thoracoscopy is an effective and safe modality to visualize and sample contents of the pleural cavity. It is an outpatient procedure that can be performed while the patient is spontaneously breathing, with the use of local anesthesia and intravenous medications for sedation and analgesia. Medical thoracoscopy has indications in the management of a variety of pleural diseases. It is most commonly performed as a diagnostic procedure but has therapeutic applications as well. Although it has its advantages, management strategies of certain pleural diseases should take place within a multidisciplinary environment including general pulmonologists, interventional pulmonologists, and thoracic surgeons.

Management of complex pleural disease in the critically ill patient

Disorders of the pleural space are quite common in the critically ill patient. They are generally associated with the underlying illness. It is sometimes difficult to assess for pleural space disorders in the ICU given the instability of some patients. Although the portable chest X-ray remains the primary modality of diagnosis for pleural disorders in the ICU. It can be nonspecific and may miss subtle findings. Ultrasound has become a useful tool to the bedside clinician to aid in diagnosis and management of pleural disease. The majority of pleural space disorders resolve as the patient’s illness improves. There remain a few pleural processes that need specific therapies. While uncomplicated parapneumonic effusions do not have their own treatments. Those that progress to become a complex infected pleural space can have its individual complexity in therapy. Chest tube drainage remains the cornerstone in therapy. The use of intrapleural fibrinolytics has decreased the need for surgical referral. A large hemothorax or pneumothorax in patients admitted to the ICU represent medical emergencies and require emergent action. In this review we focus on the management of commonly encountered complex pleural space disorders in critically ill patients such as complicated pleural space infections, hemothoraces and pneumothoraces.

Management of Pleural Infection

Pleural infection is a millennia-spanning condition that has proved challenging to treat over many years. Fourteen percent of cases of pneumonia are reported to present with a pleural effusion on chest X-ray (CXR), which rises to 44% on ultrasound but many will resolve with prompt antibiotic therapy. To guide treatment, parapneumonic effusions have been separated into distinct categories according to their biochemical, microbiological and radiological characteristics. There is wide variation in causative organisms according to geographical location and healthcare setting. Positive cultures are only obtained in 56% of cases; therefore, empirical antibiotics should provide Gram-positive, Gram-negative and anaerobic cover whilst providing adequate pleural penetrance. With the advent of next-generation sequencing techniques, yields are expected to improve. Complicated parapneumonic effusions and empyema necessitate prompt tube thoracostomy. It is reported that 16-27% treated in this way will fail on this therapy and require some form of escalation. The now seminal Multi-centre Intrapleural Sepsis Trials (MIST) demonstrated the use of combination fibrinolysin and DNase as more effective in the treatment of empyema compared to either agent alone or placebo, and success rates of 90% are reported with this technique. The focus is now on dose adjustments according to the patient's specific 'fibrinolytic potential', in order to deliver personalised therapy. Surgery has remained a cornerstone in the management of pleural infection and is certainly required in late-stage manifestations of the disease. However, its role in early-stage disease and optimal patient selection is being re-explored. A number of adjunct and exploratory therapies are also discussed in this review, including the use of local anaesthetic thoracoscopy, indwelling pleural catheters, intrapleural antibiotics, pleural irrigation and steroid therapy.

Surgical treatment of pleural empyema in Coronavirus disease 19 patients: the Southern Switzerland experience

We report the first surgical series of patients developing pleural empyema after severe bilateral interstitial lung disease in confirmed severe acute respiratory syndrome coronavirus 2 infection. The empyema results in a complex medical challenge that requires combination of medical therapies, mechanical ventilation and surgery. The chest drainage approach was not successful to relieve the symptomatology and to drain the excess fluid. After multidisciplinary discussion, a surgical approach was recommended. Even though decortication and pleurectomy are high-risk procedures, they must be considered as an option for pleural effusion in Coronavirus disease-positive patients. This is a life-treating condition, which can worsen the coronavirus disease manifestation and should be treated immediately to improve patient’s status and chance of recovery.

Study protocol for DICE trial: Video-assisted thoracoscopic surgery decortication versus interventional radiology guided chest tube insertion for the management of empyema

Background

Empyema is a common thoracic surgery presentation, defined as pus in the pleural space. Despite the commonality of empyema, consensus on initial management remains ambiguous. Two standard of care treatment options include inserting a chest tube (thoracostomy) and the administration of intrapleural fibrinolytics, or an initial surgical approach, surgical decortication. Due to the complexity of this pleural space infection, often repeat interventions are required after initial management in order to achieve source control and resolution of clinical symptoms. This study aims to identify the most effective initial management option for empyema.

Study design

We present a study protocol for a randomized control trial (RCT) comparing adult individuals with empyema to one of two standard of care initial management options. Participants will be randomized into either interventional radiology guided chest tube insertion with intrapleural fibrinolytics (Dornase 5 mg and Alteplase 10 mg intrapleural twice daily for three days) or video-assisted thoracoscopic surgery (VATS) decortication.

Methods

All adults with empyema meeting inclusion criteria will be invited to participate. They will be randomized into one of two intervention groups; interventional radiology guided chest tube insertion with fibrinolytics or initial VATS decortication. Each intervention will take place within 48 hours of randomization. The primary outcome will be the rate of re-intervention within 30 days. Re-intervention is defined as repeat chest tube insertion, VATS decortication, or decortication via thoracotomy. Secondary outcomes include a change in the size of empyema, length of stay, morbidity, as well as 30-day and 90-day mortality, as well as quality of life measurements.

Anticipated impact

This study is aimed at identifying the most effective initial management option for individuals with empyema.