[Spinal epidural empyema. Limited surgical treatment combined with continuous irrigation and drainage]

Epidural empyema of the spinal column is a rare, but in some cases devastating, disease. Surgery can be excessive or very limited. We want to report our results of combined therapy of limited surgical treatment and continuous irrigation with antibiotic solution and drainage. In the last 5 years we have operated on 12 patients (7 female, 5 male, median age: 61.5 years, range: 22-89 years) with spinal epidural empyema. All surviving patients were evaluated after 3 months including MRI. Six infections were caused by injections, two by spontaneous discitis, two by chronic systemic infections, and in two patients the cause remained unknown. In every case we implanted two catheters, one for irrigation with antibiotic solution and one for drainage. On average the catheters were used for 3 days. For evacuation in seven patients interlaminar fenestration in one, two, or three levels was enough. Only in one patient was a laminectomy performed. Five patients recovered totally, three partially, one did not recover at all, and three died. The autopsy of two dead patients showed complete healing of the operated area; they died because of lethal infections in other parts of their body. In only one case did a reoperation have to be done. The cause was an additional subdural empyema. In spite of the limited surgical procedure without relevant operative morbidity the reported method is an effective and safe therapy.

Effect of cotrimoxazole on causes of death, hospital admissions and antibiotic use in HIV-infected children

BACKGROUND

Cotrimoxazole prophylaxis reduces morbidity and mortality in HIV-1-infected children, but mechanisms for these benefits are unclear.

METHODS

CHAP was a randomized trial comparing cotrimoxazole prophylaxis with placebo in HIV-infected children in Zambia where background bacterial resistance to cotrimoxazole is high. We compared causes of mortality and hospital admissions, and antibiotic use between randomized groups.

RESULTS

Of 534 children (median age, 4.4 years; 32% 1-2 years), 186 died and 166 had one or more hospital admissions not ending in death. Cotrimoxazole prophylaxis was associated with lower mortality, both outside hospital (P = 0.01) and following hospital admission (P = 0.005). The largest excess of hospital deaths in the placebo group was from respiratory infections [22/56 (39%) placebo versus 10/35 (29%) cotrimoxazole]. By 2 years, the cumulative probability of dying in hospital from a serious bacterial infection (predominantly pneumonia) was 7% on cotrimoxazole and 12% on placebo (P = 0.08). There was a trend towards lower admission rates for serious bacterial infections in the cotrimoxazole group (19.1 per 100 child-years at risk versus 28.5 in the placebo group, P = 0.09). Despite less total follow-up due to higher mortality, more antibiotics (particularly penicillin) were prescribed in the placebo group in year one [6083 compared to 4972 days in the cotrimoxazole group (P = 0.05)].

CONCLUSIONS

Cotrimoxazole prophylaxis appears to mainly reduce death and hospital admissions from respiratory infections, supported further by lower rates of antibiotic prescribing. As such infections occur at high CD4 cell counts and are common in Africa, the role of continuing cotrimoxazole prophylaxis after starting antiretroviral therapy requires investigation.

Management of empyema after lung resections (pneumonectomy/lobectomy)

Empyemas that complicate lung resection are an uncommon but morbid and too-often deadly sequela, particularly after pneumonectomy. Knowledge of the conditions that place patients at high risk for this complication and of the well-established principles of bronchial stump closure are crucial to preventing empyemas. One should be familiar with the various options of stump reinforcement and should use them aggressively, particularly in high-risk situations. Prompt recognition of this complication demands immediate intervention and drainage of the empyema space to minimize the risks of aspiration to the remaining lung. The principles that guide the management of these empyemas are those established by Clagett and Geraci 40 years ago [37]. Modern variations of these guidelines have allowed improved results and a more timely recovery and should be considered in low-risk patients.

Unsuspected Toxoplasma gondii empyema in a bone marrow transplant recipient

Toxoplasma gondii is an opportunistic parasite that can cause severe disease in immunosuppressed individuals. We report a case of unsuspected T. gondii empyema in a bone marrow transplant recipient that was diagnosed by the visualization of numerous intracellular and extracellular tachyzoites in Giemsa- and Gram-stained smears. The patient was treated with pyrimethamine, sulfadiazine, clindamycin, and atovaquone, and she survived 110 days after diagnosis, despite having a large parasite burden.

Pleural complications in lung transplant recipients

Pleural complications occurred in 30 (22%) of 138 patients after 53 single and 91 double lung transplants between September 1986 and February 1993. These were defined for the purpose of this study as pneumothorax persisting beyond the first 14 postoperative days, recurrent pneumothorax, or any other pleural process that necessitated diagnostic or therapeutic intervention. Overall, a higher pleural complication rate was seen in double lung transplantation (25 of 30) than in single lung transplantation (5 of 30) with no differences noted in the frequency among preoperative diagnostic groups (p > 0.05). Pneumothorax was the most frequent complication, affecting 14 of 30 patients, with 6 of 14 cases occurring after transbronchial biopsy. All pneumothoraces in single (n = 4) and double lung transplantation (n = 10) resolved spontaneously or with chest tube thoracostomy. One patient required placement of a Clagett window after open lung biopsy and another required thoracotomy and pleural abrasion after transbronchial biopsy. Parapneumonic effusion was observed in 4 of 30 double lung transplantations with spontaneous resolution in all cases. Empyema affected 7 of 30 patients and occurred exclusively in the double lung transplant group. Sepsis developed in three of the patients with this complication and they subsequently died. The risk of empyema was independent of preoperative diagnosis (p > 0.05). Of interest, all patients with cystic fibrosis (n = 3) with complicating empyema had Pseudomonas cepacia in the pleural fluid. Other miscellaneous complications included subpleural hematoma, chylothorax, and hemothorax. The latter two necessitated thoracic duct and bronchial artery ligation, respectively. In summary, a significant proportion of lung transplant recipients will have pleural space complications. The vast majority of these will resolve spontaneously or with conservative procedures. These complications were not related to preoperative diagnosis nor associated with a significant prolongation of hospital stay (p > 0.05). Empyema is the only pleural space complication associated with increased patient mortality and, as such, is an important clinical marker for those at risk for sepsis and death.

Empyema in infancy and childhood

A study of 108 cases of empyema during 18 months period showed the incidence of empyema to be 2.17%. Staph. aureus (17.6%) was the common causative organism. Response to a combination of cloxacillin and gentamicin was better than that of crystalline penicillin and gentamicin. Only 30.3% cases needed intercostal drainage for more than 2 weeks. Almost 43% cases could be discharged by 3-4 weeks after hospitalisation and 38.1% by 30-57 days. The mortality rate was 12.1%. Among the survivors, excluding 8 children who left against medical advice, all had complete recovery excepting one child in whom AFB was isolated and who developed bronchiectasis and recurrent hemoptysis, inspite of antituberculous treatment. Age of the child, antibiotic combination given and nutritional status appear to be the main factors influencing the recovery and prognosis.

[Life expectancy and disability following pleural empyema]

The pleural empyema, e.g. postpneumonial or postoperative, has, in an acute state of being, to be treated before all by an aimed intensive puncture, irrigation, and drainage therapy. Removing the cause of the empyema you can expect a cure as a rule, but in certain cases an operative intervention is still necessary. The chronic empyema often needs a decortication for an operative correction. The trials of medical treatment being often conservative and the chronic intoxication most often cause a strong impairment of the general condition. A lot of other organic affections or damages reduce the chances of cure and increase lethality. The chronic empyema not available for an operative correction has, as a whole, a bad long-term prognosis with a high morbidality and lethality. The qualities of living of these patients are often reduced a lot.

Empyema thoracis in Nigerians: experience with a policy of conservative operative management

A combined retrospective and prospective review of 150 children and 28 adult Nigerian empyema thoracis patients was conducted between 1978 and 1986. Comorbidity requiring additional treatment was present in 145 patients (82.5%) while 175 patients (98.3%) had no, low or medium family income. In addition to medical management 161 out of 178 patients (90.4%) had tube thoracostomy while eight (4.4%) and seven (3.9%) respectively required additional minor and major thoracic procedures for failure of tube thoracostomy and arrest of, or failure to achieve, progressive pulmonary re-expansion and resolution of concomitant illness. Mean period of in-patient care was 30.5 days +/- 30.3. In spite of limitation of resources and poor clinical condition of most patients reduction of onset-diagnosis and diagnosis-treatment intervals and our overall management significantly reduced the perioperative mortality from 15.1% during the retrospective study period to 4.8% during the prospective period for a 9% overall perioperative mortality rate.

Malnutrition: an important determinant of fatal outcome in surgically treated pulmonary suppurative disease

Eighty patients required surgical drainage of infections in the pleural space or lung during a four-year period (1984-1987). Thirty-nine patients had a history of heavy intravenous drug use and 28 of those not addicted to drugs were addicted to alcohol. Impaired immunity was believed to be present in 72 (90%) due to malnutrition (45 patients), acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (13), hepatic cirrhosis (1), diabetes (1), or multiple causes (12). Sixty-four patients had acute purulent empyema; 9, tuberculous empyema (often a mixed infection); 2, tuberculous pleural effusion with complications; 2, lung abscesses requiring open drainage; 2, chronic bronchopleural fistulae; and 1, empyema secondary to an esophageal perforation. Fifty-three (66%) were treated with tube thoracostomy only and 27 required additional procedures, including open drainage (19 patients), decortication (5), lung resection (2), chest wall resection (1), and parietal pericardiectomy (1). Overall mortality was high (30%); mortality had a strong correlation with malnutrition or immune deficiency. Very low serum albumin levels were common and were the most important single determinant of a fatal outcome: (table; see text) Other important determinants of mortality were: total lymphocytes less than 1000 (50% mortality); anergy to tests for delayed hypersensitivity (39% mortality); AIDS or AIDS-related complex (54% mortality). Analysis of the records of the 24 patients who died has led to the conclusion that despite the advanced disease present and the poor condition of most patients at least one third of the deaths could have been avoided if important errors in diagnosis and medical or surgical management could have been prevented.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of refractory empyema with early decortication

One hundred consecutive patients underwent surgical procedures for empyema. Sixty-six patient acquired empyema from pneumonia, 16 from trauma, 11 from abdominal sepsis, and 7 from other causes. If tube thoracostomy failed, computerized tomography and ultrasonography were used to demonstrate a loculated empyema. After a median observation period of 11 days, 91 patients underwent thoracotomy and decortication and 9 patients underwent either rib resection, an Eloesser flap procedure, or both. The mortality rate was 6 percent 30 days postoperatively, the in-hospital mortality rate was 9 percent, and the overall morbidity rate was 17 percent. An excellent result was achieved in 85 percent of the patients with a recurrence rate of 4 percent. Gram-positive aerobes were the most common organisms cultured, but several opportunistic infections were encountered. We have concluded that early thoracotomy and decortication of empyema results in eradication of difficult pleural infections with hospital stays of an acceptable length and reasonably low morbidity and mortality rates.

Pseudomonas thoracic empyema secondary to nosocomial rhinosinusitis

Three cases of Pseudomonas thoracic empyema occurring in nasotracheally intubated patients are reported. Paranasal rhinosinusitis, a well documented complication of prolonged nasotracheal intubation, could be the primary infectious location. Massive respiratory tract colonization leads to extensive necrotizing pulmonary lesions. Failure of diagnosis and treatment of sinus involvement could be responsible for persistent or recurrent pleural empyema. Treatment includes continuous pleural drainage, sinusitis treatment and antibiotics. This complication should be considered in the choice between early tracheostomy and prolonged nasotracheal intubation in Intensive Care Unit (ICU) patients.

Streptococcal sepsis and death caused by empyema

A case is presented of a young man who complained of pain in the pectoral area secondary to empyema, which was not recognized. The patient subsequently died of Streptococcal sepsis. Empyema of the thorax is a well known suppurative disease of the chest. The incidence of empyema has declined dramatically since the advent of antibiotics. It is rarely encountered in the modern emergency department.

Empyema: analysis of treatment techniques

Empyema is associated with a high mortality. To study the factors responsible for the failure of treatment, the authors reviewed 90 cases of nontuberculous thoracic empyema seen at the University of Western Ontario in London, between 1970 and 1980. The most common causes of empyema were bronchopulmonary infections (63%), complications of pulmonary surgery (14%) and secondary infections of hydrothoraces or hemothoraces (13%). In 51 patients (57%) the condition was acquired in hospital or was related to previous medical therapy. Nine cases were recognized only at autopsy. The treatment of empyema was assessed in 81 patients, who received an average of 2.2 antibiotics during the course of treatment. Five patients received antibiotics as the only therapy; one died. Seventy-two patients were treated by surgical drainage; 35 (49%) were cured and 18 (25%) subsequently died. Twelve of 18 decortication procedures were successful including 4 performed as a primary procedure and 8 as a secondary procedure. Five of seven patients who underwent thoracoplasty were cured. The overall mortality in the series was 23%. Prevention and early recognition of empyema may reduce the mortality. Patients who do not improve promptly with surgical drainage may benefit from early decortication.

Early thoracotomy and decortication for nontuberculous empyema in adults with and without underlying disease. A twenty-five year review

The present review deals with 63 adult patients having acute nontuberculous empyema treated by early thoracotomy and decortication, during the period from 1955 through 1979. Group I (38 patients) had postpneumonic empyema, but no underlying disease. Group II (25 patients) had acute empyema and one or more serious associated diseases. Positive cultures were present in 45 of 63 patients (71.4%). Most surgeons have customarily recommended conservative management, especially for patients in Group II, because of the supposedly "high risk" involved in decortication. Consequently, the mortality is extremely high. The empyema must be cured; a "well drained" or "controlled" empyema will not suffice. The severely ill patient can better withstand the ordeal of a major operation than the deleterious effects of a lingering empyema. The critically ill patient is best managed by the primary procedure of open thoracotomy and decortication. The author's experience confirms that such patients can expect an outlook (8% mortality) approaching the zero mortality of Group I patients.

Reevaluation of early evacuation of clotted hemothorax

During an 181/2 year period, we encountered 14,300 patients with blunt or penetrating thoracic or thoracicoabdominal trauma. In 155 patients, residual clotted hemothorax or empyema developed later. Thirty-nine patients underwent early evacuation of clotted hemothorax with no mortality and an average hospital stay of only 10 days. When progression to empyema occurred, the mortality rate increased to 9.4 percent and the average hospital stay to 37.9 days. The most common related event in the development of empyema was concurrent injury to intraabdominal organs and the inevitable bacterial contamination of the thorax. In a small number of patients, tube thoracostomy drainage is inadequate and results in residual clotted hemothorax. Despite recent pleas for conservative, expectant management, it is our experience that early evacuation of clotted hemothorax is not only cost-effective, it is also associated with lower morbidity, lower mortality, and reduces the chance of development of empyema.

[Medical complications in lung resections]

The complications of pulmonary resections are discussed with reference to a group of 82 patients. Arrhythmias, infections of pleural space and post-operative atelectasis occur with major frequency. Pleuropulmonary infections are most serious events because they are associated with significant mortality.

Mortality in thoracic empyema

With a view of elucidating factors influencing mortality in patients with thoracic empyema, which varies widely (10-50%) in reported case series, a retrospective analysis was made. The series comprised 259 patients treated for thoracic empyema at Bispebjerg Hospital in the period 1965-1980. The mortality was 33% in the total case series, 61% when the underlying pathology was malignant and 25% when it was benign. As malignancy was apparently cured in only 17% of the cases, the investigation was focused on the 200 patients with benign conditions underlying the empyema. The mortality then ranged from nil in spontaneous pneumothorax and thoracic trauma to 50% in lung abscess. Most of the patients with empyema were elderly, but there was no clear difference in mortality between younger and older groups. Concomitant, other disease was present in 80% of the patients who died, but in only 40% of the survivors. Mortality showed no significant difference in relation to primary treatment. Staphylococcus aureus was statistically predominant among the fatal cases. It is concluded that empyema occurring, as in the present study, mainly in elderly and enfeebled patients, is a serious complication with high mortality.

Postpneumonectomy empyema does not improve survival in bronchogenic carcinoma

There is much disagreement in the literature about the beneficial effect of postpneumonectomy empyema on survival following operation for bronchogenic carcinoma. We had the opportunity to gather data on 407 patients with this serious complication. The survival data for a group of patients with postpneumonectomy empyema and fistula were compared with those for another group without such complications. Our statistical analysis confirms that postpneumonectomy empyema does not improve life expectancy.

Empyema thoracis

Seventy-five adult and 25 pediatric patients with empyema thoracis are reported upon herein. A high incidence of postpneumonectomy and postlobectomy empyema were found in the adult population, 15.5 and 3.7 per cent, respectively. The causal factors of such a high incidence are unknown. Faulty surgical techniques and poor clinical judgment in the management of patients undergoing thoracic operations will invariably lead to a significant mortality and morbidity. Morbidity was indirectly evaluated by the length of hospitalization, the mean being 56.8 days for the adult population and 22.6 days for the pediatric group. These figures barely expose the degree of frustration and suffering that patients with empyema thoracis go through. To decrease the incidence of iatrogenic empyema with its associated mortality and morbidity, good clinical judgment and impeccable surgical techniques must be used in the management of patients having thoracic operations. An aggressive approach to drain the empyemic space to allow pulmonary expansion of sterilization of the postpneumonectomy space must be taken once faced with this complication. Children require no more than repeat thoracentesis or placement of an intercostal chest tube to obtain sufficient drainage and recovery. Antibiotic therapy must be selected according to the bacteria encountered and the results of the sensitivity test. Close supervision is mandatory to detect overgrowth, frequently encountered with the use of broad spectrum antibiotics. Anaerobic bacteria as well as fungus and acid-fast bacilli must be searched for during the routine bacteriologic workout.

Acute empyema in children treated by open thoracotomy and decortication

Acute nontuberculous empyema treated conventionally by thoracentesis, thoracostomy drainage, and antibiotics has an unacceptably high rate of morbidity and mortality. Early open thoracotomy to eliminate the empyema with decortication of the fibrinous peel and reexpansion of the lung has proven safe and effective for 25 years. The goals of treatment of acute nontuberculous empyema are: (1) to save life, (2) to eliminate the empyema, (3) to reexpand the trapped lung, (4) to restore mobility of the chest wall and diaphragm, (5) to return respiratory function to normal, (6) to eliminate complications or chronicity, and (7) to reduce the duration of hospital stay. Our studies confirm the normal values to be expected in patients who have had complete recovery from the acute empyema, and we lay to rest any concern that decortication might, in time, limit pulmonary function. We present the cases of 21 children who had acute and mature empyemas that were treated by open thoracotomy and decortication, with an average follow-up of 18 years, among whom there were no deaths or complications.

Empyema following lung cancer resection: risk factors and prognostic value on survival

A retrospective evaluation of 199 consecutive patients undergoing resection for lung cancer revealed a significantly shorter long-term survival for those in whom empyema developed postoperatively. The overall five-year survival for the empyema group was 24% compared with 35% in the control group (patients without empyema), and the median survival was 15 months for the control group. These differences in survival were not found among patients with Stage I lung cancer. Pneumonectomy proved to be the main risk factor for the occurrence of empyema after operation, but a minor risk factor was the anatomical extent of disease. this correlation may be explained by major surgical contamination or manipulation as well as by lower immunological host reaction, all related to the extent of the tumor. A lower immunological defense could also explain the worse outcome for patients with Stage II or III lung cancer in whom empyema developed postoperatively.

Improved survival in management of empyema thoracis

Empyema thoracis following pneumonia, trauma, and surgical procedures continues to be a source of major morbidity and mortality. We retrospectively reviewed the hospital records of 100 patients treated for empyema thoracis at San Francisco General Hospital during the past 10 years. The causes of empyema in these patients were as follows: pneumonia 44%, trauma 24%, surgical and invasive procedures 15%, lung abscess 11%, and hematogenous spread 6%. Ten patients in this series died of sepsis from necrotizing pneumonia or overwhelming injuries caused by trauma. Streptococcus (31%), Staphylococcus (21%), and Bacteroides (15%) were the organisms most commonly isolated. Bacterial isolates were single in 55%, multiple 42%, and absent in 3%. The type of organism did not correlate with severity of disease or eventual requirement for thoracotomy, pleural débridement, or Eloesser procedure. Successful methods of treatment included aspiration in 9%, tube thoracostomy in 63%, pleural débridement and drainage in 7%, and an Eloesser procedure in 11%. Because our patients were often debilitated from chronic alcoholism, drug addiction, and major trauma, conservative management was initially tried. In most patients empyema resolved with tube thoracostomy. Pleural débridement should be reserved for patients with special problems such as multiple loculation or purulence inaccessible to percutaneous tube placement. the Eloesser procedure is indicated in patients who have an infected residual pleural space that persists despite adequate tube drainage.

Bronchogenic carcinoma and postoperative empyema: is survival really enhanced?

From 1959 to 1974, 542 patients underwent curative resection for bronchogenic carcinoma. Postoperative empyema occurred in 17 of these patients. The overall 5-year survival of these 17 patients was only 18%, compared with 27% in the 525 patients without empyema. We were unable to demonstrate by our study or by a review of the literature that postoperative empyema favorably influences survival in patients who have had pulmonary resection for bronchogenic carcinoma.

Postpneumonectomy empyema. The cloud with a silver lining?

I have reviewed the literature concerning the effect of postoperative sepsis on survival following resection for carcinoma of the bronchus and added to this my experience over a 12 year period. Surgeons agree that because of its morbidity and the morbidity of measures necessary for its treatment, postoperative empyema is to be avoided, but many still hope that some compensation might be afforded the unfortunate sufferer by improvement in long-term survival. I have not found this to be the case and I feel that statistical evidence favors this view.

The relationship between postoperative empyema and long-term survival after pneumonectomy. Results of surgical treatment of bronchogenic carcinoma

In order to present the possible influence of postoperative empyema on the survival rate of patients with bronchogenic carcinoma, who had been treated by pneumonectomy, a retrospective investigation was made upon 207 patients over a 10-year period. In patients with and without a complicating postoperative empyema, a cumulative survival rate of 0.04 and 0.26, respectively, was found. The difference was not significant. However, other retrospective investigations on the influence of postoperative empyema on long-term survival after surgical treatment for bronchogenic carcinoma have shown results that might stimulate prospective studies on the subject. Furthermore, this investigation showed that the probability of long-term survival was highest in patients under 60 years of age, when the bronchogenic carcinoma is a planocellular carcinoma located in the left lung without postoperative empyema. Among pneumonectomized lung cancer patients, the mortality was above expectancy, even 8-10 years after operation compared with the estimated survival rate in the average population.

Management of thoracic amebiasis

The thoracic complications of amebiasis frequently necessitate surgical intervention. Experience with 28 patients is presented. Involvement included the pleura in 19 patients, the lungs in 10, and the pericardium in five. In 25%, more than one site was involved. Treatment consisted of measures designed to obliterate the pleural space or widely drain the pericardial sac, as indicated. Concurrent drainage of the associated amebic liver abscess was done in half the cases. The mortality rate was 36%, generally related to the poor general condition of the patients and their delay in seeking hospitalization.

Influence of postoperative empyema on survival after pulmonary resection for bronchogenic carcinoma

Fifty patients who had developed empyema after pulmonary resection for primary carcinoma of the lung were individually paired with patients who had not suffered this complication. Pairs were matched as far as possible for age, sex, extent of operation, histology of tumour, extent of primary spread, extent of lymphatic spread, and use of postoperative radiotherapy. Analysis of survival times both for the matched pairs and for the two groups of patients showed no significant difference in long-term survival. The results suggest that any immunological suppression of carcinoma cells due to sepsis in the pleural space is ineffective in prolonging survival.

Empyema in children in tropics

Thirty-six cases of empyema were diagnosed in children over a two year period, giving an overall incidence of 0.11% of the total hospital admissions. Many of them had measles bronchopneumonia and most were malnourished. 16 children had penicillin resistant staphylococcal infection. 29 of them were treated with closed tube drainage. Thirteen died during the course of treatment, the majority within three days of admission. The rest were followed up over a period of up to six months and showed good recovery. Six of these patients developed pneumothorax during the course of treatment. Various combinations of Ampicillin, Cloxacillin, Gentamycin and Cotrimoxazole parenterally were used. Supportive treatment with blood transfusion was found to be beneficial.

Duration of hospitalization for acute bacterial empyema at Boston City Hospital during 12 selected years from 1935 to 1972

The duration of hospitalization for acute bacterial empyema of the pleura was determined for all cases at Boston City Hospital during 12 selected years between 1935 and 1972. Patients whose infection was acquired after admission stayed in the hospital longer than those in whom the empyema, or the infection of which the empyema was a complication, was present at the time of admission. The differences were mostly related to serious underlying disease in the hospital-acquired cases. However, the duration of hospitalization after the empyema was bacteriologically confirmed was not much different in the community-acquired and hospital-acquired cases. Hospital stay was further prolonged in patients whose empyema was superinfected with new bacterial species after the original infecting organisms were determined. Hospitalization was shorter in the 10 selected years between 1974 and 1972, when penicillin and other active antibiotics were used, than in two years before penicillin became available, 1935 and 1941.

Changing ecology of acute bacterial empyema: occurrence and mortality at Boston City Hospital during 12 selected years from 1935 to 1972

The occurrence, etiology, and demography of acute bacterial empyema are presented to reflect the widespread use of sulfonamides, penicillin, and other active antibiotics. In community-acquired (C-A) cases Streptococcus pneumoniae, hemolytic streptococci, and Staphylococcus aureus were the most frequent single organisms identified in initial positive cultures of pleural fluid during 1935. S. pneumoniae declined steadily until 1953 but continued to occur frequently in C-A cases. Hemolytic streptococci became infrequent. S. aureus increased and became the most frequent organism in 1955 and declined to original levels after 1965 while gram-negative rods increased. S. aureus, aerobic gram-negative rods, and enterococci were most frequent in originally mixed infections, hospital-acquired cases, and superinfections. Anaerobes with or without aerobes were mostly seen in C-A cases and did not vary in incidence. Mortality increased with age. Overall mortality was greater during the 10 antibiotic years, associated with a marked decrease in the proportion of patients younger than 50 years and increase in those over 60 years old, and was greater in patients with serious underlying diseases subjected to more complicated surgical procedures.

Computerized tomography and surgical treatment in intracranial suppuration. Report of 30 consecutive unselected cases of brain abscess and subdural empyema

The authors report their experience with 30 cases of intracranial suppuration: 23 with brain abscess and seven with subdural empyema. All of the cases were diagnosed by means of computerized tomography and enhancement with intravenous contrast material. Most of the patients were treated by single or repeated aspiration through burr holes.

Brain abscess and subdural empyema. Factors influencing mortality and results of various surgical techniques

The authors review the results of various surgical techniques in relation to mortality and morbidity in 100 consecutive cases of brain abscess and subdural empyema. The mortality rate is the same with total excision and fractional drainage of brain abscesses, although in acute and subacute cases slight differences between both techniques are seen. In terms of morbidity, fractional drainage appears to be more favourable than total excision. The authors believe that factors other than surgical procedure influence mortality in cases of brain abscess and subdural empyema. These factors are defined in detail.