3
|
Bedawi EO, Ricciardi S, Hassan M, Gooseman MR, Asciak R, Castro-Añón O, Armbruster K, Bonifazi M, Poole S, Harris EK, Elia S, Krenke R, Mariani A, Maskell NA, Polverino E, Porcel JM, Yarmus L, Belcher EP, Opitz I, Rahman NM. ERS/ESTS statement on the management of pleural infection in adults. Eur Respir J 2023; 61:2201062. [PMID: 36229045 DOI: 10.1183/13993003.01062-2022] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/22/2022] [Indexed: 02/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- Eihab O Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Sara Ricciardi
- Unit of Thoracic Surgery, San Camillo Forlanini Hospital, Rome, Italy
- PhD Program Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Maged Hassan
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Michael R Gooseman
- Department of Thoracic Surgery, Hull University Teaching Hospitals NHS Trust, Hull York Medical School, University of Hull, Hull, UK
| | - Rachelle Asciak
- Department of Respiratory Medicine, Queen Alexandra Hospital, Portsmouth, UK
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - Olalla Castro-Añón
- Department of Respiratory Medicine, Lucus Augusti University Hospital, EOXI Lugo, Cervo y Monforte de Lemos, Lugo, Spain
- C039 Biodiscovery Research Group HULA-USC, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Karin Armbruster
- Department of Medicine, Section of Pulmonary Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Martina Bonifazi
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
- Respiratory Diseases Unit, Azienda Ospedaliero-Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Sarah Poole
- Department of Pharmacy and Medicines Management, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Elinor K Harris
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Stefano Elia
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
- Thoracic Surgical Oncology Programme, Policlinico Tor Vergata, Rome, Italy
| | - Rafal Krenke
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Alessandro Mariani
- Thoracic Surgery Department, Heart Institute (InCor) do Hospital das Clnicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Jose M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, Lleida, Spain
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth P Belcher
- Department of Thoracic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Chinese Academy of Medical Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
5
|
Akulian J, Bedawi EO, Abbas H, Argento C, Arnold DT, Balwan A, Batra H, Uribe Becerra JP, Belanger A, Berger K, Burks AC, Chang J, Chrissian AA, DiBardino DM, Fuentes XF, Gesthalter YB, Gilbert CR, Glisinski K, Godfrey M, Gorden JA, Grosu H, Gupta M, Kheir F, Ma KC, Majid A, Maldonado F, Maskell NA, Mehta H, Mercer J, Mullon J, Nelson D, Nguyen E, Pickering EM, Puchalski J, Reddy C, Revelo AE, Roller L, Sachdeva A, Sanchez T, Sathyanarayan P, Semaan R, Senitko M, Shojaee S, Story R, Thiboutot J, Wahidi M, Wilshire CL, Yu D, Zouk A, Rahman NM, Yarmus L. Bleeding Risk With Combination Intrapleural Fibrinolytic and Enzyme Therapy in Pleural Infection: An International, Multicenter, Retrospective Cohort Study. Chest 2022; 162:1384-1392. [PMID: 35716828 PMCID: PMC9773231 DOI: 10.1016/j.chest.2022.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Combination intrapleural fibrinolytic and enzyme therapy (IET) has been established as a therapeutic option in pleural infection. Despite demonstrated efficacy, studies specifically designed and adequately powered to address complications are sparse. The safety profile, the effects of concurrent therapeutic anticoagulation, and the nature and extent of nonbleeding complications remain poorly defined. RESEARCH QUESTION What is the bleeding complication risk associated with IET use in pleural infection? STUDY DESIGN AND METHODS This was a multicenter, retrospective observational study conducted in 24 centers across the United States and the United Kingdom. Protocolized data collection for 1,851 patients treated with at least one dose of combination IET for pleural infection between January 2012 and May 2019 was undertaken. The primary outcome was the overall incidence of pleural bleeding defined using pre hoc criteria. RESULTS Overall, pleural bleeding occurred in 76 of 1,833 patients (4.1%; 95% CI, 3.0%-5.0%). Using a half-dose regimen (tissue plasminogen activator, 5 mg) did not change this risk significantly (6/172 [3.5%]; P = .68). Therapeutic anticoagulation alongside IET was associated with increased bleeding rates (19/197 [9.6%]) compared with temporarily withholding anticoagulation before administration of IET (3/118 [2.6%]; P = .017). As well as systemic anticoagulation, increasing RAPID score, elevated serum urea, and platelets of < 100 × 109/L were associated with a significant increase in bleeding risk. However, only RAPID score and use of systemic anticoagulation were independently predictive. Apart from pain, non-bleeding complications were rare. INTERPRETATION IET use in pleural infection confers a low overall bleeding risk. Increased rates of pleural bleeding are associated with concurrent use of anticoagulation but can be mitigated by withholding anticoagulation before IET. Concomitant administration of IET and therapeutic anticoagulation should be avoided. Parameters related to higher IET-related bleeding have been identified that may lead to altered risk thresholds for treatment.
Collapse
Affiliation(s)
- Jason Akulian
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; Carolina Center for Pleural Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Eihab O Bedawi
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, England; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, England.
| | - Hawazin Abbas
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL
| | - Christine Argento
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David T Arnold
- Division of Pulmonary and Critical Care, Duke University, Durham, NC
| | - Akshu Balwan
- Division of Pulmonary, Critical Care and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Hitesh Batra
- Division of Pulmonary, Allergy, and Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Juan Pablo Uribe Becerra
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Adam Belanger
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Kristin Berger
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY
| | - Allen Cole Burks
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; Carolina Center for Pleural Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Jiwoon Chang
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Ara A Chrissian
- Division of Pulmonary, Critical Care, Hyperbaric, Allergy, and Sleep Medicine, Loma Linda University, Loma Linda, CA
| | - David M DiBardino
- Section of Interventional Pulmonology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Yaron B Gesthalter
- Division of Pulmonary, Critical Care, Allergy and Sleep, The University of California San Francisco, San Francisco, CA
| | - Christopher R Gilbert
- Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute and Center for Lung Cancer Research in Honor of Wayne Gittinger, Seattle, WA
| | - Kristen Glisinski
- Division of Pulmonary and Critical Care, National Jewish Health, Denver, CO
| | - Mark Godfrey
- Division of Pulmonary and Critical Care, Yale University School of Medicine, New Haven, CT
| | - Jed A Gorden
- Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute and Center for Lung Cancer Research in Honor of Wayne Gittinger, Seattle, WA
| | - Horiana Grosu
- Division of Pulmonary and Critical Care, The University Texas MD Anderson Cancer Center, Houston, TX
| | - Mridul Gupta
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Fayez Kheir
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kevin C Ma
- Section of Interventional Pulmonology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Nick A Maskell
- Academic Respiratory Unit, Bristol Medical School, University of Bristol, Bristol, England
| | - Hiren Mehta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL
| | - Joshua Mercer
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John Mullon
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Darlene Nelson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Elaine Nguyen
- Division of Pulmonary, Critical Care, Hyperbaric, Allergy, and Sleep Medicine, Loma Linda University, Loma Linda, CA
| | - Edward M Pickering
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore, MD
| | - Jonathan Puchalski
- Division of Pulmonary and Critical Care, Yale University School of Medicine, New Haven, CT
| | - Chakravarthy Reddy
- Division of Pulmonary and Critical Care, University of Utah, Salt Lake City, UT
| | - Alberto E Revelo
- Interventional Pulmonology Section, Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Lance Roller
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ashutosh Sachdeva
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore, MD
| | - Trinidad Sanchez
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA
| | - Priya Sathyanarayan
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Roy Semaan
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michal Senitko
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Samira Shojaee
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA
| | - Ryan Story
- Interventional Pulmonology Section, Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jeffrey Thiboutot
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Momen Wahidi
- Division of Pulmonary and Critical Care, Duke University, Durham, NC
| | - Candice L Wilshire
- Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute and Center for Lung Cancer Research in Honor of Wayne Gittinger, Seattle, WA
| | - Diana Yu
- Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Aline Zouk
- Division of Pulmonary, Allergy, and Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, England; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, England
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | | |
Collapse
|