Benefit of intrapleural fibrinolytic therapy in the treatment of complicated parapneumonic effusion and empyema

Our study aimed to assess the benefit of intrapleural fibrinolysis before resorting to surgery to treat complicated parapneumonic effusion and empyema. We conducted a retrospective and descriptive study, including all patients hospitalized in the intensive care unit (ICU) of the Abderhaman Mami hospital, Tunisia for empyema treated with instillation of intrapleural fibrinolytic therapy between the 1st January 2000 and 31st December 2016. In all patients, empyema was diagnosed on clinical features, imaging findings (chest X-ray, thoracic echography and/or computed tomography (CT), and microbiological data. The fibrinolytic agent used was streptokinase. The efficiency of intrapleural fibrinolytic therapy was judged on clinical and paraclinical results. Among 103 cases of complicated parapneumonic effusion and empyema, 34 patients were included. The mean age was 34 years [15-81] with a male predominance (sex ratio at 2.77). Median APACH II score was 9. Fifty (50%) of the patients (n=17) had no past medical history; addictive behavior was described in 17 patients (50%). All patients were admitted for acute respiratory failure and one patient for septic shock. Pleural effusion was bilateral in 7 patients. Bacteria isolated were Streptococcus pneumonia (6 cases), Staphylococcus aureus (3 cases, including one which methicillin-resistant), Staphylococcus epidermidis (1 case), anaerobes (5 cases), and Klebsiella pneumoniae (1 case). First-line antimicrobial drug therapy was amoxicillin-clavulanate in 20 patients. A chest drain was placed in all cases in the first 38 hours of ICU admission. The median number of fibrinolysis sessions was 4 [2-9] and the median term of drainage was 7 days [3-16]. No side effects were observed. Video-assisted thoracoscopic surgery was proposed in 5 patients. The median length of hospitalization stay was 15 days [6-31]. One patient died due to multi-organ failure.

Clostridioides difficile recovered in pleural fluid: Contamination or infection? A case report of a proven empyema and a literature review

INTRODUCTION

Pleural empyema is an infrequent manifestation of extraintestinal Clostridioidesdifficile infection, with just eight cases reported in literature.

METHODS

We report a new case in a 70-year-old male without comorbidities or evidence of concomitant gastrointestinal disease, and review the previous cases reported in the literature.

RESULTS

The isolate was susceptible to all antimicrobial tested and was negative for A+B toxins. The patient fully recovered after drainages and antimicrobial therapy with amoxicillin-clavulanate and doxycycline.

CONCLUSION

As in the previously reported cases, aspiration was the most plausible hypothesis of mechanism of infection in our patient. Empyema by Clostridioidesdifficile is a diagnostic challenge, since it is necessary to rule out that the isolation of this microorganism in pleural fluid is not a contamination. Furthermore, more evidence is needed for its treatment since data regarding this entity are still scarce.

Association between intrapleural urokinase monotherapy and treatment failure in patients with pleural infection: a retrospective cohort study

BACKGROUND

Pleural infection, an infection of the pleural space, is frequently treated with antibiotics and thoracic tube drainage. In case of insufficient drainage, an intrapleural fibrinolytic agent is considered before surgical intervention. However, the effectiveness of fibrinolytic monotherapy is still controversial. Therefore, we aimed to examine the association between urokinase monotherapy and treatment failure in patients with pleural infection.

METHODS

In this retrospective observational study, patients with pleural infection underwent chest tube insertion were divided into two groups including patients treated with or without intrapleural instillation of urokinase. The propensity score overlap weighting was used to balance the baseline characteristics between the groups. Treatment failure was defined by the composite primary outcome of in-hospital death and referral for surgery.

RESULTS

Among the 94 patients, 67 and 27 patients were in the urokinase and non-urokinase groups, respectively. Urokinase monotherapy improved the composite outcome between the groups (19.4% vs. 48.1%, p = 0.01). After adjusting using propensity score overlap weighting, urokinase monotherapy improved the composite outcome compared to the non-urokinase group (19.0% vs. 59.5%, p = 0.003).

CONCLUSIONS

Urokinase monotherapy can be an important nonsurgical treatment option for patients with pleural infection.

TRIAL REGISTRATION

The participants were retrospectively registered.

Fifteen-minute consultation: A structured approach to children with parapneumonic effusion and empyema thoracis

Parapneumonic effusion is defined as the accumulation of pleural fluid associated with lung infection/pneumonia. Parapneumonic effusions can be uncomplicated or complicated. They are caused by the spread of infection and inflammation to the pleural space, and can develop into empyema thoracis-frank pus in the pleural space. Chest radiograph and thoracic ultrasound are the key imaging modalities for the diagnosis of parapneumonic effusion. Management aims are reducing inflammation and bacteria in the pleural cavity, and enabling full lung expansion. Broad-spectrum intravenous antibiotics, with the addition of chest tube drainage and fibrinolytic therapy for larger collections, are the mainstays of management. This article provides a clear, evidence-based and structured approach to the assessment and management of parapneumonic effusion/empyema thoracis in children and young people.

[A Case of Pleural Empyema with Fistula Caused by Endobronchial Metastasis of Renal Cell Carcinoma]

A 52-year-old man complained of asymptomatic gross hematuria and cough. Chest and abdominal computed tomography (CT) revealed a right renal tumor, mediastinal lymph node metastasis, and right endobronchial metastasis. The right endobronchial metastasis was causing obstructive atelectasis in the lower lobe of the right lung. After tumor biopsy, the pathological diagnosis was clear cell renal cell carcinoma. Combination immunotherapy with ipilimumab and nivolumab was initiated, but CT showed enlargement of the metastatic lesion and lung abscess after two courses of treatment. The therapy was then switched to axitinib. Six days after initiation of axitinib, the lung abscess perforated into the pleural cavity, which resulted in the formation of pleural empyema with fistula. Ten days after initiation of axitinib, obstruction of the bronchus was relieved due to shrinkage of the right endobronchial metastasis, which resulted in development of a pneumothorax. Placement of a thoracic drainage tube and administration of an antimicrobial agent improved the pneumothorax and inflammatory response, but the drainage tube could not be removed. Long-term insertion of the thoracic drainage tube considerably diminished the patient's quality of life, and after 4 months, he was transferred to another hospital to receive the best supportive care.

The role of interventional pulmonology in pleural disease diagnosis and management

PURPOSE OF REVIEW

Pleural disease guidelines have not been updated in a decade. Advances have been made in the diagnosis and management of pleural diseases since, with expanding evidence of the utility of medical thoracoscopy (MT) as a safe and effective tool.

RECENT FINDINGS

Although thoracic ultrasound has improved early determination of pleural disease etiology, thoracentesis remains limited, and pleural tissue is necessary for the diagnosis of undifferentiated exudative pleural effusions. Medical thoracoscopy has been shown to be superior to traditional closed pleural biopsy, and recent literature is focused on which technique is best. A recent randomized controlled trial (RCT) found rigid mini-thoracoscopy was not superior to semirigid thoracoscopy. Meta-analyses have not found pleural cyrobiopsy to be superior to forceps biopsies. As a therapeutic tool, meta-analysis suggests MT as a possible first-line tool for the treatment of complicated parapneumonic effusions (CPE) and early empyema. A RCT comparing MT to intrapleural fibrinolytic therapy demonstrated that the former technique is safe, effective, and may shorten hospital length of stay in patients with CPE/empyema.

SUMMARY

The implications of the recent findings in the medical literature are that medical thoracoscopy, particularly by trained Interventional Pulmonologists, will find an expanded role in future iteration of pleural disease guidelines.

Management of pleural empyema in a 12-year-old obese patient with COVID-19: a pediatric case report

BACKGROUND

With the ongoing coronavirus disease (COVID-19) pandemic, along with the development of new mutations of the virus and an increase in the number of cases among pediatrics, physicians should be aware and alerted on the atypical presentations of the disease, especially in less expected individuals.

CASE PRESENTATION

Here we present a 12-year-old obese boy (BMI = 37.5 kg/m2) who presented with empyema, which was following SARS-CoV-2 infection. The patient had no history of fever. Due to the onset of dyspnea, a chest tube was inserted for him which was later altered to a pleural drainage needle catheter.

CONCLUSION

Our case is the first report of COVID-19 presenting as empyema among pediatrics. Pleural empyema should be considered as a rare complication of COVID-19. Since there is still no guideline in the management of empyema in the context of COVID-19, delay in diagnosis and intervention may cause morbidity and mortality in children.

Sepsis in the Postpneumonectomy Space: Pathogenesis, Recognition, and Management

Empyema may occur in the pleural space after pulmonary resection. Subsequent bacterial contamination results in infection and development of frank empyema. Pneumonectomy-surgical removal of the entire lung-is the treatment of choice for centrally located bronchogenic carcinoma, diffuse malignant mesothelioma, and chronic inflammatory lung diseases with destroyed lung from pulmonary tuberculosis, fungal infections, and bronchiectasis. In the uncomplicated case, on the pneumonectomy side, the diaphragm becomes elevated as the air-fluid level decreases with chest wall deformation and gradual disappearance of hydrothorax. The pneumonectomy space is at potential risk for getting infected from bacterial contamination and developing empyema.

Clinico-radiological profile of the patients with empyema thoracis: A prospective analytical study

BACKGROUND

Empyema thoracis is defined as the presence of pus in the pleural cavity and carries significant morbidity and mortality. This study aimed to explore the demographic and clinico-radiological characteristics of patients with empyema thoracis.

MATERIAL AND METHODS

The present study was conducted in a tertiary care teaching hospital in North India. The patients diagnosed with empyema thoracis were included in the study. Demographic, etiologic, clinical, radiographic, and outcome data were prospectively collected and analyzed.

RESULTS

The study included 48 patients. The median age of empyema thoracis patients was 37(IQR 26-45) years. Common presenting symptoms were breathlessness (n = 37,77%) and chest pain (n = 34,70%). Contrast-enhanced computed tomography (CECT) of the chest showed type III empyema in 52% (21) patients followed by type 1 and type II in 25% and 22%, respectively. CECT thorax showed the collapse of lung and consolidation in (n = 28, 70%) and (n = 24, 60%) patients, respectively. All the patients, except for one, were managed with underwater seal intercostal tube drainage (ICD) procedure for the management of empyema. The median time to remove the ICD tube among 35 patients was 14 (IQR 9-21) days. Forty patients (83.3%) responded to the treatment and were discharged. Eight patients (16.7%) deteriorated and succumbed to the disease.

CONCLUSION

Patients of empyema thoracis required a prolonged period of chest tube drainage and carried significant morbidity and mortality.

High Occurrence of Thrombo-Embolic Complications During Long-Term Follow-up After Pleural Infections-A Single-Center Experience with 536 Consecutive Patients Over 17 Years

Purpose

Pleural infections are associated with significant inflammation, long hospitalizations, frequent comorbidities, and are often treated operatively—all of which are consequential risk factors for thrombo-embolic complications. However, their occurrence following the treatment of pleural infection is still unknown. The aim of the study was to ascertain the early and long-term occurrence of thrombo-embolic events in patients treated for pleural infections.

Methods

The study included all patients that were treated for pleural infections in Tampere University Hospital between January 2000 and December 2016. Data regarding later treatment episodes due to pulmonary embolisms and/or deep vein thromboses as well as survival data were requested from national registries. The rates were also compared to a demographically matched reference population adjusted for age, sex, and the location of residence.

Results

The final study population comprised 536 patients and 5318 controls (median age 60, 78% men). The most common etiology for pleural infection was pneumonia (73%) and 85% underwent surgical treatment for pleural infection. The occurrence of thrombo-embolic complications in patients and controls was 3.8% vs 0.1% at three months, 5.0% vs 0.4% at one year, 8.8% vs 1.0% at three years, and 12.4% vs 1.8% at five years, respectively, p < 0.001 each. Female sex, advanced age, chronic lung disease, immunosuppression, video-assisted surgery, and non-pneumonic etiology were associated with a higher incidence of thrombo-embolism.

Conclusions

The occurrence of thrombo-embolic events—particularly pulmonary embolism but also deep vein thrombosis—was significant in patients treated for pleural infections, both initially and during long-term follow-up.

A CARE-compliant article: a case report of pleural empyema secondary to Klebsiella pneumoniae liver abscess with a hepatopleural fistula

INTRODUCTION

Klebsiella pneumoniae liver abscess (KPLA) is often associated with accompanying metastatic complications such as septic pulmonary embolism, brain abscess, and endophthalmitis. Pleural empyema secondary to a KPLA is a very unusual finding, made even more rare with the presence of a hepatopleural fistula.

PATIENT CONCERNS

An 81-year-old woman presented with aggravated dyspnea.

DIAGNOSIS

The patient was diagnosed with KPLA with empyema through computed tomography (CT) scan findings and pleural fluid culture.

INTERVENTIONS

The empyema was drained by thoracostomy, and treatment with empirical antibiotics was initiated. After early removal of the chest tube, the liver abscess as well as the empyema increased. An additional liver abscess drainage procedure was performed.

OUTCOMES

The fever resolved and dyspnea improved following drainage of effusion. Three days later, the follow-up chest radiograph showed decreased pleural effusion.

CONCLUSION

Pleural empyema is a rare but fatal complication secondary to KPLA. Additionally, the discovery of a hepatopleural fistula on a CT scan (multiplanar reconstruction image) made this case even more rare. Both, the liver abscess and pleural empyema, were effectively drained through the fistula tract with drainage procedure, thoracostomy, and additional liver abscess drainage. Prompt diagnostic evaluation, using an imaging modality such as CT, and early drainage management with intravenous antibiotics can improve clinical outcome.

Ambulatory drainage and management of a pleural empyema

A 61 year old male presented to chest clinic with a lung abscess. This ruptured and resulted in an empyema that required a small bore chest drain. Pus started bypassing the drain, spilling out subcutaneously. This was probably due to the impending formation of an empyema necessitans. To stem the flow, a large bore drain was inserted. An ambulatory bag was connected to the end of that drain which enabled outpatient management through the ambulatory care unit over a ten week period. The chest drain stayed in for nine weeks. Risk stratification using the RAPID score was applied. This is a routine medical presentation with well-known and accepted investigations with routine organisms (mixed aerobic and anaerobic microbiota) and treatment with classical broad spectrum antibiotics. The striking feature of the case is that with strict supervision, patient education and motivation, ambulatory management is perfectly feasible and safe.

Clinical observation of bronchoscopy alveolar lavage combined with thoracoscopy in the treatment of empyema in children

The objective of this study was to investigate the therapeutic effects of bronchoscopy alveolar lavage (BAL) combined with thoracoscopy in the treatment of empyema in children.Retrospectively analyzed 174 cases of pediatric empyema treated with thoracoscopy combined with BAL from January 2010 to December 2016 in our hospital. All the cases, according to admission order, were randomly divided into 2 groups, the control group (group A), which contained 89 cases, was treated with thoracoscopy; and the experimental group (group B), which contained 85 cases, was treated with BAL combined with thoracoscopy. The results of BAL treatment, the inflammatory indexes including body temperature, total leukocyte count in peripheral blood and CRP, and the therapeutic effect and prognosis including the days of antibiotic use, hospital stay, the incidence of thoracotomy and lobectomy were compared between the 2 groups.There was statistical difference in all the therapeutic indexes (P < .05).Bronchoscopy alveolar lavage combined with thoracoscopy has a higher success rate in the treatment of pediatric empyema, and is more comprehensive, safe and effective in controlling inflammation.

Intra-pleural fibrinolytic therapy versus placebo, or a different fibrinolytic agent, in the treatment of adult parapneumonic effusions and empyema

BACKGROUND

Pleural infection, including parapneumonic effusions and thoracic empyema, may complicate lower respiratory tract infections. Standard treatment of these collections in adults involves antibiotic therapy, effective drainage of infected fluid and surgical intervention if conservative management fails. Intrapleural fibrinolytic agents such as streptokinase and alteplase have been hypothesised to improve fluid drainage in complicated parapneumonic effusions and empyema and therefore improve treatment outcomes and prevent the need for thoracic surgical intervention. Intrapleural fibrinolytic agents have been used in combination with DNase, but this is beyond the scope of this review.

OBJECTIVES

To assess the benefits and harms of adding intrapleural fibrinolytic therapy to standard conservative therapy (intercostal catheter drainage and antibiotic therapy) in the treatment of complicated parapneumonic effusions and empyema.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase, ClinicalTrials.gov and the World Health Organization (WHO) trials portal. We contacted trial authors for further information and requested details regarding the possibility of unpublished trials. The most recent search was conducted on 28 August 2019.

SELECTION CRITERIA

Parallel-group randomised controlled trials (RCTs) in adult patients with post-pneumonic empyema or complicated parapneumonic effusions (excluding tuberculous effusions) who had not had prior surgical intervention or trauma comparing an intrapleural fibrinolytic agent (streptokinase, alteplase or urokinase) versus placebo or a comparison of two fibrinolytic agents.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. We contacted study authors for further information. We used odds ratios (OR) for dichotomous data and reported 95% confidence intervals (CIs). We used Cochrane's standard methodological procedures of meta-analysis. We applied the GRADE approach to summarise results and to assess the overall certainty of evidence.

MAIN RESULTS

We included in this review a total of 12 RCTs. Ten studies assessed fibrinolytic agents versus placebo (993 participants); one study compared streptokinase with urokinase (50 participants); and one compared alteplase versus urokinase (99 participants). The primary outcomes were death, requirement for surgical intervention, overall treatment failure and serious adverse effects. All studies were in the inpatient setting. Outcomes were measured at varying time points from hospital discharge to three months. Seven trials were at low or unclear risk of bias and two at high risk of bias due to inadequate randomisation and inappropriate study design respectively. We found no evidence of difference in overall mortality with fibrinolytic versus placebo (OR 1.16, 95% CI 0.71 to 1.91; 8 studies, 867 participants; I² = 0%; moderate certainty of evidence). We found evidence of a reduction in surgical intervention with fibrinolysis in the same studies (OR 0.37, 95% CI 0.21 to 0.68; 8 studies, 897 participants; I² = 51%; low certainty of evidence); and overall treatment failure (OR 0.16, 95% CI 0.05 to 0.58; 7 studies, 769 participants; I² = 88%; very low certainty of evidence, with evidence of significant heterogeneity). We found no clear evidence of an increase in adverse effects with intrapleural fibrinolysis, although this cannot be excluded (OR 1.28, 95% CI 0.36 to 4.57; low certainty of evidence). In a sensitivity analysis, the reduction in referrals for surgery and overall treatment failure with fibrinolysis disappeared when the analysis was confined to studies at low or unclear risk of bias. In a moderate-risk population (baseline 14% risk of death, 20% risk of surgery, 27% risk of treatment failure), intra-pleural fibrinolysis leads to 19 more deaths (36 fewer to 59 more), 115 fewer surgical interventions (150 fewer to 55 fewer) and 214 fewer overall treatment failures (252 fewer to 93 fewer) per 1000 people. A single study of streptokinase versus urokinase found no clear difference between the treatments for requirement for surgery (OR 1.00, 95% CI 0.13 to 7.72; 50 participants; low-certainty evidence). A single study of alteplase versus urokinase showed no clear difference in requirement for surgery (OR alteplase versus urokinase 0.46, 95% CI 0.04 to 5.24) but an increased rate of adverse effects, primarily bleeding, with alteplase (OR 5.61, 95% CI 1.16 to 27.11; 99 participants; low-certainty evidence). This translated into 154 (6 to 499 more) serious adverse events with alteplase compared with urokinase per 1000 people treated.

AUTHORS' CONCLUSIONS

In patients with complicated infective pleural effusion or empyema, intrapleural fibrinolytic therapy was associated with a reduction in the requirement for surgical intervention and overall treatment failure but with no evidence of change in mortality. Discordance between the negative largest trial of this therapy and other studies is of concern, however, as is an absence of significant effect when analysing low risk of bias trials only. The reasons for this difference are uncertain but may include publication bias. Intrapleural fibrinolytics may increase the rate of serious adverse events, but the evidence is insufficient to confirm or exclude this possibility.

Update in the Management of Pleural Effusions

Pleural effusions are a common clinical problem for the primary care physician. Over the past 10 years, there has been a paradigm shift in the field due to emergence of new evidence, which includes the ubiquitous use of thoracic ultrasound, the reemergence of pleuroscopy as a diagnostic and therapeutic modality, the widespread use of indwelling pleural catheters for malignant pleural effusions, and the evidence-based approach to management of complex parapneumonic effusions. This review focuses on these advancements with an emphasis on practical clinical application.

Empyema with Multiple Bronchopleural Fistulae Improved by Bronchial Occlusion Using an Endobronchial Watanabe Spigot with the Push and Slide Method

The push and slide method is a method of endoscopic bronchial occlusion using an endobronchial Watanabe spigot that facilitates occlusion of the target bronchus rapidly and accurately using a guidewire. We herein report the case of a man who was diagnosed with empyema forming bronchopulmonary fistulae that was successfully treated by endoscopic bronchial occlusion. Because of the multiple fistulae, balloon occlusion was not a favorable therapeutic approach. Instead, the push and slide method was used in order to detect the fistulae. Endoscopic occlusion, particularly that using the push and slide method, may be a valid treatment option for empyema with multiple bronchopulmonary fistulae.

Risk Stratification in Patients with Complicated Parapneumonic Effusions and Empyema Using the RAPID Score

PURPOSE

Complicated parapneumonic effusions and empyema are a leading cause of morbidity in the United States with over 1 million admissions annually and a mortality rate that remains high in spite of recent advances in diagnosis and treatment. The identification of high risk patients is crucial for improved management and the provision of cost-effective care. The RAPID score is a scoring system comprised of the following variables: renal function, age, purulence, infection source, and dietary factors and has been shown to predict outcomes in patients with pleural space infections.

METHODS

In a single center retrospective study, we evaluated 98 patients with complicated parapneumonic effusions and empyema who had tube thoracostomy (with or without Intrapleural fibrinolytic therapy) and assessed treatment success rates, mortality, length of hospital stay, and direct hospitalization costs stratified by three RAPID score categories: low-risk (0-2), medium risk (3-4), and high-risk (5-7) groups.

RESULTS

Treatment success rate was 71%, and the 90 day mortality rate was 12%. There was a positive-graded association between the low, medium and high RAPID score categories and mortality, (5.3%, 8.3% and 22.6%, respectively), length of hospital stay (10, 21, 19 days, respectively), and direct hospitalization costs ($19,909, $36,317 and $43,384, respectively).

CONCLUSION

Our findings suggest that the RAPID score is a robust tool which could be used to identify patients with complicated parapneumonic effusions and empyema who may be at an increased risk of mortality, prolonged hospitalization, and who may incur a higher cost of treatment. Randomized controlled trials identifying the most effective initial treatment modality for medium- and high-risk patients are needed.

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.

Rapid developing empyema by group F beta Streptococcus anginosus group

A 43-year-old male had progressive pleuritic left-sided chest tightness with shortness of breath. He had dental caries and tenderness on palpation of the left lateral chest. Complete blood count showed leucocytosis. CT scan of the chest with pulmonary emboli protocol showed multiple pulmonary nodules and nodular pleural thickening at left posterior lateral pleura. Forty-eight hours post CTPE scan, CT scan of the chest, abdomen and pelvis displayed right lower lobe consolidation and left-sided pleural effusion with superimposed compressive atelectasis. Ceftaroline intravenous was initiated, with CT-guided pigtail chest tube insertion. Pleural fluid later grew group F beta-haemolytic Streptococcus anginosus Patient improved significantly and was discharged 11 days later with intravenous ertapenem. Patients with group F beta-haemolytic streptococci should be managed aggressively with early and accurate diagnosis, antibiotics, drainage and possible surgery.

[Management of Postoperative Wound Infection and Empyema]

Postoperative wound infection and empyema after pulmonary surgery is considered surgical site infection. Postoperative empyema (PE) is a rare but potentially fatal complication of pulmonary resections and proper management is essential. Appropriate antibiotics and surgical treatment is necessary to cure the PE. PE is often associated with bronchopleural fistula, which makes the management of PE difficult. The treatment of empyema has the basic way of thinking, but there are various cures, closed tube thoracostomy, video-assisted thoracoscopy, emergency open window thoracostomy, and Endoscopic conservative treatment may necessary.

Surgical versus non-surgical management for pleural empyema

BACKGROUND

Empyema refers to pus in the pleural space, commonly due to adjacent pneumonia, chest wall injury, or a complication of thoracic surgery. A range of therapeutic options are available for its management, ranging from percutaneous aspiration and intercostal drainage to video-assisted thoracoscopic surgery (VATS) or thoracotomy drainage. Intrapleural fibrinolytics may also be administered following intercostal drain insertion to facilitate pleural drainage. There is currently a lack of consensus regarding optimal treatment.

OBJECTIVES

To assess the effectiveness and safety of surgical versus non-surgical treatments for complicated parapneumonic effusion or pleural empyema.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 9), MEDLINE (Ebscohost) (1946 to July week 3 2013, July 2015 to October 2016) and MEDLINE (Ovid) (1 May 2013 to July week 1 2015), Embase (2010 to October 2016), CINAHL (1981 to October 2016) and LILACS (1982 to October 2016) on 20 October 2016. We searched ClinicalTrials.gov and WHO International Clinical Trials Registry Platform for ongoing studies (December 2016).

SELECTION CRITERIA

Randomised controlled trials that compared a surgical with a non-surgical method of management for all age groups with pleural empyema.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked the data for accuracy. We contacted trial authors for additional information. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included eight randomised controlled trials with a total of 391 participants. Six trials focused on children and two on adults. Trials compared tube thoracostomy drainage (non-surgical), with or without intrapleural fibrinolytics, to either VATS or thoracotomy (surgical) for the management of pleural empyema. Assessment of risk of bias for the included studies was generally unclear for selection and blinding but low for attrition and reporting bias. Data analyses compared thoracotomy versus tube thoracostomy and VATS versus tube thoracostomy. We pooled data for meta-analysis where appropriate. We performed a subgroup analysis for children along with a sensitivity analysis for studies that used fibrinolysis in non-surgical treatment arms.The comparison of open thoracotomy versus thoracostomy drainage included only one study in children, which reported no deaths in either treatment arm. However, the trial showed a statistically significant reduction in mean hospital stay of 5.90 days for those treated with primary thoracotomy. It also showed a statistically significant reduction in procedural complications for those treated with thoracotomy compared to thoracostomy drainage. We downgraded the quality of the evidence for length of hospital stay and procedural complications outcomes to moderate due to the small sample size.The comparison of VATS versus thoracostomy drainage included seven studies, which we pooled in a meta-analysis. There was no statistically significant difference in mortality or procedural complications between groups. This was true for both adults and children with or without fibrinolysis. However, mortality data were limited: one study reported one death in each treatment arm, and seven studies reported no deaths. There was a statistically significant reduction in mean length of hospital stay for those treated with VATS. The subgroup analysis showed the same result in adults, but there was insufficient evidence to estimate an effect for children. We could not perform a separate analysis for fibrinolysis for this outcome because all included studies used fibrinolysis in the non-surgical arms. We downgraded the quality of the evidence to low for mortality (due to wide confidence intervals and indirectness), and moderate for other outcomes in this comparison due to either high heterogeneity or wide confidence intervals.

AUTHORS' CONCLUSIONS

Our findings suggest there is no statistically significant difference in mortality between primary surgical and non-surgical management of pleural empyema for all age groups. Video-assisted thoracoscopic surgery may reduce length of hospital stay compared to thoracostomy drainage alone.There was insufficient evidence to assess the impact of fibrinolytic therapy.A number of common outcomes were reported in the included studies that were not directly examined in our primary and secondary outcomes. These included duration of chest tube drainage, duration of fever, analgesia requirement, and total cost of treatment. Future studies focusing on patient-centred outcomes, such as patient functional scores, and other clinically relevant outcomes, such as radiographic improvement, treatment failure rates, and amount of fluid drainage, are needed to inform clinical decisions.

[Endobronchial Watanabe Spigot in Treating Pleural Empyema with Fistula]

For pleural empyema with fistula, fenestration and subsequent omental plombage, and thoracoplasty are frequently necessary. A 57-year-old man was transported by ambulance because of impaired consciousness and septic shock due to pleural empyema on the right caused by a ruptured lung abscess. We performed empyema curettage urgently, drained 800 ml of purulent pleural effusion, and inserted 3 chest tubes. Postoperative air leakage from the ruptured lung abscess of the middle lobe was noted, and respiratory failure was prolonged. We inserted an Endobronchial Watanabe Spigot (EWS) into bronchus B5b on postoperative day 11. The air leak stopped, and the inflammatory response was gradually reduced. Computed tomography revealed decrease in free air space. We removed the chest tubes on postoperative day 35, and was able to wean off the ventilator on postoperative day 60. He was discharged on postoperative day 102. Bronchial plombage with EWS is a procedure of choice in treating pleural empyema with fistula caused by pulmonary abscess rupture, and can avoid fenestration in these patients.

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.

An Approach to the Management of Pleural Empyema with Early Video-assisted Thoracoscopic Surgery and Early Transition to Oral Antibiotic Therapy

Practice variation exists in the management of children with bacterial pneumonia complicated by empyema. The success of video-assisted thoracoscopic surgery (VATS) versus chest tube insertion for drainage and fibrinolysis may be dependent on the stage of disease. There is little published experience with early transition to oral (PO) antibiotics, and many children are treated with intravenous (IV) antibiotics at home. To describe a cohort of children with pneumonia and empyema in a primarily rural state managed with early VATS and transition to PO antibiotics. This was a retrospective medical record review of children managed by the pediatric infectious diseases and surgery services at Kosair Children's Hospital from 2008 through 2012. Sixty-one children met inclusion criteria. The majority underwent VATS on the first or second hospital day. No organism was identified in 67 per cent of cases. All patients received IV antibiotics at admission and all were discharged on PO antibiotics. The median time to transition was five days (interquartile range [IQR], 4-6), and the median duration of PO therapy was 16 days (IQR, 14-21). Ninety-eight per cent did not require further IV therapy. There were no deaths and clinical outcomes were good. In conclusion, children with pneumonia and empyema can be managed effectively with early VATS and early transition from IV to PO antibiotic therapy.

Retrospective comparison of costs between medical and surgical treatment of canine pyothorax

This study compared costs of treating dogs with pyothorax medically versus surgically. Medical records from the University of Wisconsin School of Veterinary Medicine were searched for cases of pyothorax that underwent either medical or surgical treatment. Patients undergoing surgery were subdivided into early (ES; < 48 h) and late (LS; > 48 h) surgery groups. Costs and length of stay were compared between treatment groups. Treatment costs were adjusted for inflation. Nineteen dogs were included in analysis; 7 in the medical group (MG), 5 in the ES group, and 7 in the LS group. Total costs were significantly lower in the MG than in the LS group. Total costs were less for the MG than the ES group, and for ES than LS, but the differences did not achieve significance. Preoperative costs were higher in the LS than the ES group. We conclude that surgery for canine pyothorax is less costly if pursued earlier than later.

[A Case Report of Pyothorax Due to Pyonephrosis]

A 77-year-old woman was referred to our hospital with complaints of fever and left chest pain. Computed tomography showed left pyothorax and left pyonephrosis with left ureter calculus. After admission, drainage of the left thoracic cavity was performed and she was treated with antibiotics. On the third hospital day, debridement for pyothorax was performed because her condition had not improved. During surgery, we found perforation of the diaphragm, and abscess appeared from the perforated area. We suspected that perforation of the diaphragm from the left pyonephrosis caused left pyothorax, and performed left nephrectomy. After the operation, relapse of the pyothorax and surgical wound infection occurred, but her condition improved and she discharged on the 46 th hospital day. Relapse of the abscess has not occurred.

[Endoscopic surgery accelerates recovery from empyema]

The incidence of thoracic empyema is increasing. Early treatment of empyema should focus on optimal drainage and antibiotics. If conventional therapy fails, surgical intervention has to be considered and approximately 30% of all patients require surgery. In a three-year period (2011-2013), 182 patients were operated at Helsinki University Hospital due to pleural empyema. Thoracoscopic decortication was performed on 44% of the patients and 56% underwent open surgery. After thoracoscopy, the patients had a shorter hospital stay and fewer reoperations. Thoracoscopic decortication should therefore be the first-line procedure in the surgical treatment of pleural empyema.

Factors predictive of the failure of medical treatment in patients with pleural infection

BACKGROUND/AIMS

The clinical outcomes of some patients with pleural infection may be favorable with medical treatment alone, but in others, the disease progresses and requires additional surgical treatment. However, little is known about the factors affecting this difference. The aim of this study was to investigate the factors predictive of failure of medical treatment in patients with pleural infection.

METHODS

A cohort of 127 consecutive patients who were admitted to the hospital with pleural infection was studied. Clinical manifestations and laboratory findings in patients in whom medical treatment succeeded or failed were reviewed.

RESULTS

In univariate analysis, the significant factors associated with medical treatment outcome were age, smoking history, duration of chief complaint, serum albumin level, and pleural fluid glucose and lactate dehydrogenase levels (p < 0.05). Multivariate logistic regression analysis identified age and duration of chief complaint as independent predictive factors for failure of medical treatment, with odds ratios of 0.871 (p = 0.013) and 0.797 (p = 0.026), respectively. Receiver operating characteristic curve analysis determined cutoff values of 50.5 years for age and 4.5 days for duration of chief complaint.

CONCLUSIONS

We demonstrated that a younger age < 50.5 years and shorter duration of chief complaint < 4.5 days were independent predictive factors for the failure of medical treatment in patients with pleural infection. This suggests their role as evaluative criteria in setting indications for the optimal treatment in patients with pleural infection. A larger, prospective study is required to confirm these findings.

[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.

[Complex case with respiratory, endocrine and digestive manifestations--late complications after a colic replacement of the esophagus for lye ingestion]

Long term complications after colic replacement of the esophagus are well known and their managment is known as being difficult, due to multiple associated comorbidities; we present the case of a 26-year-old patient with multiple late complications after a coloesophagoplaty for lye ingestion during childhood. The patient finally died despite all the eforts of treatement during a prolonged hospitalisation. We will try to analyse the key moments on patient's evolution and discuss other possible options in this case.

[Acute empyema with fistula successfully treated by curettage and endobronchial Watanabe spigot (EWS)]

A 49-year-old woman was referred to our hospital because of empyema. A chest drainage tube inserted and lavage performed. Her general condition improved but the infection and a major air leakage remained. On the 10th day after chest drainage, we performed thoracoscopic debridement and occlusion of bronchopleural fistulas using cellulose oxidized( Surgicel) and fibrin glue. Expansion of the lung and the improvement of inflammation were observed. but a major air leakage remained. On 29th postoperative day, we performed bronchial embolization using endobronchial Watanabe spigot (EWS). The leakage stopped the 7 days after bronchial embolization, we removed chest tube and 10 days after bronchial embolization she was discharged.

Descending necrotizing mediastinitis: a conservative approach

Descending necrotizing mediastinitis (DNM) is a now-rare complication of dental and pharyngeal infections. Reports in the literature have emphasized the need for early, aggressive surgical intervention. We present a case of DNM with bilateral empyemas that arose secondary to a perforated pharyngeal abscess. The patient was successfully managed conservatively with intravenous antibiotics and intercostal drainage. We conclude that conservative management with antibiotics and image-guided percutaneous pleural drainage may be initially appropriate for the stable patient.

Concurrent Salmonella mycotic abdominal aneurysm and empyema thoracis: a rare coincidence

OBJECTIVE

To present a case of Salmonella bacteremia with a rare metastatic focus.

CLINICAL PRESENTATION AND INTERVENTION

A 61-year-old male presented with a suicide attempt after ingestion of half a bottle of toilet cleaner. He had a medical history of intravenous drug abuse and major depression. Persistent Salmonella enteritidis bacteremia occurred during his hospitalization, and a search for the primary source of infection disclosed a mycotic abdominal aortic aneurysm. A suppurative lesion was also noted over the left pleural space, and Salmonella empyema was confirmed after thoracentesis. He underwent video-assisted thoracoscopic surgery and endovascular repair of the abdominal aortic aneurysm and was placed on long-term antibiotics, without recurrence.

CONCLUSION

S. enteritidis involvement of the cardiovascular system is a rare coincidence and results in significant morbidity and mortality. In addition, the phenomenon of secondary metastatic infective foci involving the pleural space has an even lower frequency than that of cardiovascular involvement. Therefore, a high index of suspicion and prompt treatment from the treating physicians are strongly recommended.

[Diagnostics and surgical treatment of lung cancer in conditions of special thoracal department for patients with purulent lung diseases]

The authors investigated features of diagnostics and surgical treatment of lung cancer which was complicated by purulent destructive process. The possibilities of radical operative intervention were considered after preliminary adequate treatment of purulent complications in 226 patients. It was noted, that the diagnostic thoracotomy should be used in doubtful cases in order to estimate the resectability of lung cancer.

[Case of successful prevention of multiple organ dysfunctions in 74 years old patient with sepsis after Crawford surgery complicated with pleural empyema, chest wall tissues infection and osteomyelitis of ribs]

The article deals with a clinical case demonstrating that patient's elderly age is not an absolute contraindication for complex surgery in spite of high risk of postoperative complications. Early diagnostics, target treatment of the infection cite with vacuum-assisted therapy for wounds and the treatment of infectious complications based on individual characteristics of elderly patient with sepsis as an outcome of prosthetic thoracoabdominal aortic repair allowed avoiding multiple organ dysfunctions in the patient.

[Open drainage with Vacuum Assisted Closure( VAC) therapy for Aspergillus empyema after left upper lobectomy with adjuvant radiotherapy]

A 59-year-old man was diagnosed as Aspergillus empyema with fistula after left upper lobectomy and radiation therapy. His pyrexia was continued after conservative treatment with antifungal agents. Initially, fenestration and vacuum-assisted closure (VAC) therapy were performed. The Aspergillus terreusdisappeared and inflammatory reactions were normalized. Eight days after fenestration, pectoralis major muscle flap transposition was subsequently performed. His postoperative course was uneventful. No recurrent empyema was found 15 months after surgery.

[Nutritional treatment for bronchopleural fistula-promising effect of arginine as a pharmaconutrient]

Pharmaconutrition, which is a supportive nutritional care of surgical patients, has been proven to shorten hospital stay, decrease the incidence of infection, and reduce hospital costs in selected groups of patients. Arginine, one of the most essential pharmaconutrients, has also been proven to enhance would healing process. In severely malnourished patients like bronchopleural fistula with resultant empyema, aggressive nutritional approach should be mandatory. And management of the fistula is also important in stabilizing the ongoing infection. Our hypothesis was that basic nutritional support enhanced with arginine would be effective in not only improving the general condition including nutritional status but also in healing the fistula. We report a case of major bronchopleural fistula in which arginine-supplemented diet as well as aggressive nutritional support could accelerate the postoperative recovery after open thoracic window, ultimately leading to the healing of the fistula.

[Necrotizing fasciitis of the chest wall complicating an empyema]

La fasciite nécrosante est une infection sévère, rapidement progressive, mutilante, souvent fatale du tissu sous cutané et du fascia profond. Les auteurs rapportent et discutent un rare cas de fasciite nécrosante de la paroi thoracique antérieure secondaire à une pleurésie purulente chez un diabétique. Un diagnostic précoce avec incisions multiples chirurgicales et une antibiothérapie adaptée par voie veineuse diminuent la morbidité et la mortalité causées par cette pathologie.

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.

[Pulmonary mycobacterium intracellulare infection complicated with pneumothorax and chronic empyema]

A 75-year-old woman who had been treated for pulmonary Mycobacterium intracellulare infection was admitted to a nearby hospital because of hemoptysis, right pneumothorax, and empyema. She had been treated by thoracic drainage and pleural lavage, but was reffered to our hospital because of refractory empyema. Her chest radiograph and chest computed tomography( CT) showed right chronic empyema of which pleural aspirate was smear positive for acid-fast bacilli and positive for the polymerase chain reaction method(PCR)-Mycobacterium intracellulare. Serum levels of white blood cell and C-reactive protein(CRP) were found to be slightly elevated. She was treated with combined use of ethambutol, rifampicin, clarithromycin, and kanamycin and with pleural curettage by thoracoscopic surgery. After surgery additional treatment was done using urokinase which was administered into the thoracic cavity via an thoracic tube. Chronic empyema gradually improved with the treatment and the pleural effusion became bacterial free, enabling the patient to discharge from hospital without thoracic drainage.

[Intrathoracic washing with urokinase was effective for empyema with atelectasis]

A 60-year-old man had a medical examination because of fever in the emergency hospital and had a diagnosis of pneumonia and was treated, but he was admitted to our hospital 2 days later because there was not the improvement of his symptom. The chest computed tomography(CT)image showed multilocular pleural effusions and lower lobe atelectasis with the air bronchogram on the left side. We diagnosed the case as empyema and inserted a catheter, but drainage was very few and injected 60,000 urokinase units for 3 days from the next day. We removed a drain 2 days after the 3rd infusion, and the pleural thickening became mild, and atelectasis was gradually improved in the chest CT image, and the inflammatory reaction was reduced, too. The intrathoracic washing with urokinase was thought to be effective for empyema with atelectasis.