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Clinical Microbiology and Infection :... Aug 2019The view of pleural empyema as a complication of bacterial pneumonia is changing because many patients lack evidence of underlying pneumonia. To further our... (Comparative Study)
Comparative Study
OBJECTIVES
The view of pleural empyema as a complication of bacterial pneumonia is changing because many patients lack evidence of underlying pneumonia. To further our understanding of pathophysiological mechanisms, we conducted in-depth microbiological characterization of empyemas in clinically well-characterized patients and investigated observed microbial parallels between pleural empyemas and brain abscesses.
METHODS
Culture-positive and/or 16S rRNA gene PCR-positive pleural fluids were analysed using massive parallel sequencing of the 16S rRNA and rpoB genes. Clinical details were evaluated by medical record review. Comparative analysis with brain abscesses was performed using metagenomic data from a national Norwegian study.
RESULTS
Sixty-four individuals with empyema were included. Thirty-seven had a well-defined microbial aetiology, while 27, all of whom had community-acquired infections, did not. In the latter subset, Fusobacterium nucleatum and/or Streptococcus intermedius was detected in 26 patients, of which 18 had additional facultative and/or anaerobic species in various combinations. For this group, there was 65.5% species overlap with brain abscesses; predisposing factors included dental infection, minor chest trauma, chronic obstructive pulmonary disease, drug abuse, alcoholism and diabetes mellitus. Altogether, massive parallel sequencing yielded 385 bacterial detections, whereas culture detected 38 (10%) and 16S rRNA gene PCR/Sanger-based sequencing detected 87 (23%).
CONCLUSIONS
A subgroup of pleural empyema appears to be caused by a set of bacteria not normally considered to be involved in pneumonia. Such empyemas appear to have a similar microbial profile to oral/sinus-derived brain abscesses, supporting spread from the oral cavity, potentially haematogenously. We suggest reserving the term 'primary empyema' for these infections.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Bacteria; Bacterial Proteins; Brain Abscess; Community-Acquired Infections; Empyema, Pleural; Female; High-Throughput Nucleotide Sequencing; Humans; Male; Metagenomics; Middle Aged; Mouth; Norway; Pleural Effusion; Pneumonia, Bacterial; RNA, Ribosomal, 16S; Retrospective Studies; Risk Factors; Young Adult
PubMed: 30580031
DOI: 10.1016/j.cmi.2018.11.030 -
Thoracic Surgery Clinics Nov 2021Empyema may occur in the pleural space after pulmonary resection. Subsequent bacterial contamination results in infection and development of frank empyema.... (Review)
Review
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.
Topics: Bronchial Fistula; Empyema, Pleural; Humans; Lung Diseases; Pleural Diseases; Pneumonectomy; Sepsis
PubMed: 34696853
DOI: 10.1016/j.thorsurg.2021.08.001 -
Surgical Innovation Oct 2023Pleural empyemas carry a high morbidity and mortality. Some can be managed with medical treatment but most require some form of surgery with the goals to remove the...
BACKGROUND/NEED
Pleural empyemas carry a high morbidity and mortality. Some can be managed with medical treatment but most require some form of surgery with the goals to remove the infected material from the pleural space and to help re-expand the collapsed lung. Keyhole surgery by Video Assisted Thoracoscopy Surgery (VATS) is rapidly becoming a common approach to deal with early stage empyemas to avoid larger, more painful thoracotomies that hinder recovery. However, the ability to achieve those aforementioned goals is often hindered by VATS surgery due to the instruments available.
METHODOLOGY AND DEVICE DESCRIPTION
We have developed a simple instrument called the "VATS Pleural Debrider" to achieve those goals in empyema surgery that can be used in keyhole surgery.
PRELIMINARY RESULTS
We have used this device in over 90 patients with no peri-operative mortality and a low re-operation rate.
CURRENT STATUS
Used in routine urgent/emergency pleural empyema surgery across 2 cardiothoracic surgery centres.
Topics: Humans; Thoracic Surgery, Video-Assisted; Empyema, Pleural; Pneumothorax; Thoracotomy; Pleural Cavity; Retrospective Studies
PubMed: 36796368
DOI: 10.1177/15533506231157170 -
Respiration; International Review of... 2021The detection of foreign bodies in the pleural cavity is rare and mostly consequent to iatrogenic or traumatic events. The migration of an inhaled foreign body from the...
The detection of foreign bodies in the pleural cavity is rare and mostly consequent to iatrogenic or traumatic events. The migration of an inhaled foreign body from the airways to the pleural space through a bronchopleural fistula is an exceptional event. We report a case of a pleural empyema consequent to an inhaled wooden skewer. CT scan and bronchoscopy were unable to identify the foreign body, due to its migration in the peripheral airways. The thin and pointed foreign body perforated the visceral pleural surface emerging in the pleural cavity.
Topics: Bronchial Fistula; Empyema, Pleural; Foreign Bodies; Humans; Pleura; Pleural Diseases
PubMed: 34134111
DOI: 10.1159/000516507 -
Current Opinion in Pulmonary Medicine Jan 2022Pleural 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... (Review)
Review
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.
Topics: Empyema, Pleural; Humans; Pleura; Pleural Diseases; Pleural Effusion; Pulmonary Medicine; Thoracoscopy
PubMed: 34698676
DOI: 10.1097/MCP.0000000000000841 -
Journal of the College of Physicians... Mar 2020To analyse the outcome and morbidity associated with decortication in empyema thoracis.
OBJECTIVE
To analyse the outcome and morbidity associated with decortication in empyema thoracis.
STUDY DESIGN
A case series.
PLACE AND DURATION OF STUDY
Departments of Surgery, Combined Military Hospitals (CMH) of Rawalpindi, Quetta and Lahore, from January 2006 to March 2018.
METHODOLOGY
This is a retrospective study of 812 cases of open and VATS (video-assisted thoracic surgery) decortication for empyema thoracis, operated by the same consultants. Only patients with established empyema were included. Those who were unfit for one-lung ventilation, undergoing local anesthesia procedures like rib resection, clagget window or tube windows, with clotted hemothorax and malignant pathology were excluded. Posterolateral serratus sparing thoracotomy was used in open decortications. Multiportal or uniport VATS was employed for video-assisted thoracoscopic decortications (VATD). Histopathology and microbiological sampling was also done in all cases.
RESULTS
There were 537 (66.1%) males and 275 (33.9%) females. Age ranged from 1 to 80 years with a mean of 37 years. Open decortication was done in 650 (80%), standard decortication with posterolateral thoracotomy in 458 (56.4%), minithoracotomy was done in 69 (8.4%) patients with loculated empyema, thoracotomy and open decortication with conventional thoracoplasty was done in 21 patients. Twenty-two patients required open decortications with tailored thoracoplasty and muscle flap. Open decortication with intercostal muscle (ICM) flap or primary closure of bronchopleural fistula was performed in 55 patients. VATD was done in 162 cases, out of which 120 were early empyema, and 42 were of chronic empyema; of which 22 required a further utility thoracotomy. Decortication with lung resection and muscle flap reinforcement to bronchial stump was done in 25 patients. Blood transfusion was required in 331 (40.7%). Twenty-six (3.4%) patients developed residual space and collection requiring intervention; and 384 (47.3%) patients had a histopathology diagnostic for tuberculosis. There were 11 (1.3%) deaths.
CONCLUSION
Open decortication is still one of the preferred procedures in developing countries. VATD is also increasingly utilised for empyema.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Child, Preschool; Empyema, Pleural; Female; Humans; Infant; Lung; Male; Middle Aged; Pakistan; Retrospective Studies; Thoracic Surgery, Video-Assisted; Thoracotomy; Treatment Outcome; Young Adult
PubMed: 32169143
DOI: 10.29271/jcpsp.2020.03.313 -
Chest Nov 2023The optimal treatment for community-acquired childhood pneumonia complicated by empyema remains unclear.
BACKGROUND
The optimal treatment for community-acquired childhood pneumonia complicated by empyema remains unclear.
RESEARCH QUESTION
In children with parapneumonic effusion or empyema, do hospital length of stay and other key clinical outcomes differ according to the treatment modality used?
STUDY DESIGN AND METHODS
A living systematic review of randomized controlled trials (RCTs) was conducted by searching the Cochrane Central Register of Controlled Trials, Embase, Latin American and Caribbean Health Sciences Literature, Ovid MEDLINE, and Web of Science Core Collection databases. Eligible RCTs included patients aged < 18 years and compared two of the following treatment modalities: antibiotics alone, chest tube insertion with or without fibrinolytics, video-assisted thoracoscopic surgery (VATS), and decortication via thoracotomy. A network meta-analysis was performed to evaluate treatment effects on hospital length of stay (LOS), the primary outcome.
RESULTS
Eleven trials including a total of 590 patients were selected for the network meta-analysis. Compared with a chest tube alone, a chest tube with fibrinolytics, thoracotomy, and VATS were all associated with shorter LOS, with a mean difference of 5.05 days (95% CI, 2.46-7.64), 6.33 days (95% CI, 3.17-9.50), and 5.86 days (95% CI, 3.38-8.35), respectively. No substantial differences in LOS were observed between the latter three interventions. None of the 11 RCTs compared antibiotics alone vs other types of treatment. Most trials reported peri-procedural complications and the need for reintervention, but the descriptions differed significantly between trials, preventing meta-analysis. In trials reporting health care-associated costs, fibrinolytics had cost advantages compared with VATS. Short- and long-term morbidity and mortality were very low, regardless of the treatment modality.
INTERPRETATION
The results of this network meta-analysis showed that a chest tube alone was associated with a longer LOS compared with other treatment modalities. The lower cost associated with a chest tube plus fibrinolytics warrants consideration when choosing between treatment options, given similar LOS and clinical outcomes compared with the other modalities.
Topics: Child; Humans; Anti-Bacterial Agents; Chest Tubes; Community-Acquired Infections; Drainage; Empyema, Pleural; Network Meta-Analysis; Pleural Effusion; Pneumonia; Thoracic Surgery, Video-Assisted
PubMed: 37463660
DOI: 10.1016/j.chest.2023.06.010 -
Updates in Surgery Apr 2023Common complications of coronavirus disease 2019 (COVID-19) related ARDS and ventilation are barotrauma-induced pneumothorax, pneumatocele and/or empyema. We analysed...
Common complications of coronavirus disease 2019 (COVID-19) related ARDS and ventilation are barotrauma-induced pneumothorax, pneumatocele and/or empyema. We analysed indications and results of video-assisted thoracoscopic surgery (VATS) in complicated COVID-19 patients. This is a retrospective single-institution study analysing a case series of patients treated by VATS for secondary spontaneous pneumothorax (SSP), pneumatocele and empyema complicating COVID-19, not responding to drainage in Lodi Maggiore Hospital between February 2020 and May 2021. Out of 2076 patients hospitalized in Lodi Maggiore Hospital with COVID-19, nine Males (0,43%; mean age 58,1-33-81) were treated by VATS for complications of pneumonia (6 SSP and 3 empyema; 1 case complicated by haemothorax). 7 patients (77%) had CPAP before surgery for 21.3 days mean (4-38). Mean Operative time was 80.9 min (38-154). Conversion rate was 0%. 3 (33%) patients were admitted to ICU before VATS. Treatments were: bullectomy in six patients (66%), drainage of the pleural space in all patients, pleural decortication and fluid aspiration in five cases (55%). two patients (22%) needed surgery interruption and bilateral ventilation to restore adequate oxygenation. Mortality was 1/9 (11%) due to respiratory failure for persistent pneumonia. In one patient (11%) redo surgery was performed for bleeding. Mean postop Length of Stay (LOS) was 37.9 days (10-77). Our report shows that VATS can be considered an extreme, but effective treatment for COVID-19 patients with SSP, pneumatocele or empyema, for patients who can tolerate general anaesthesia. Attention must be paid to the aerosol-generation of infected droplets.
Topics: Male; Humans; Thoracic Surgery, Video-Assisted; Retrospective Studies; Empyema, Pleural; COVID-19; Pneumonia; Length of Stay
PubMed: 36385609
DOI: 10.1007/s13304-022-01420-4 -
Pediatric Surgery International Nov 2023Both thoracic drainage and video-assisted thoracic surgery (VATS) are available treatment for pleural empyema in pediatric patients.
BACKGROUND
Both thoracic drainage and video-assisted thoracic surgery (VATS) are available treatment for pleural empyema in pediatric patients.
MATERIALS AND METHODS
This retrospective multicenter study includes pediatric patients affected by pleural empyema treated from 2004 to 2021 at two Italian centers. Patients were divided in G1 (traditional approach) and G2 (VATS). Demographic and recovery data, laboratory tests, imaging, surgical findings, post-operative management and follow-up were analyzed.
RESULTS
70 patients with a mean age of 4.8 years were included; 12 (17.1%) in G1 and 58 (82.9%) in G2. Median surgical time was 45 min in G1, 90 in G2 (p < 0.05). Mean duration of thoracic drainage was 7.3 days in G1, 6.2 in G2 (p > 0.05). Patients became afebrile after a mean of 6.4 days G1, 3.9 in G2 (p < 0.05). Mean duration of antibiotic therapy was 27.8 days in G1, 25 in G2 (p < 0.05). Mean duration of postoperative hospital stay was 16 days in G1, 12.1 in G2 (p < 0.05). There were 4 cases (33.3%) of postoperative complications in G1, 17 (29.3%) in G2 (p > 0.05). 2 (16.7%) patients of G1 needed a redosurgery with VATS, 1 (1.7%) in G2.
CONCLUSIONS
VATS is an effective and safe procedure in treatment of Pleural Empyema in children: it is associated to reduction of chest tube drainage, duration of fever, hospital stay, time of antibiotic therapy and recurrence rate.
Topics: Child; Humans; Child, Preschool; Thoracic Surgery, Video-Assisted; Debridement; Empyema, Pleural; Drainage; Retrospective Studies; Anti-Bacterial Agents
PubMed: 37926703
DOI: 10.1007/s00383-023-05566-z -
BMC Infectious Diseases Jan 2023Fungal empyema is an uncommon disease and is associated with a high mortality rate. Surgical intervention is suggested in stage II and III empyema. However, there were...
BACKGROUND
Fungal empyema is an uncommon disease and is associated with a high mortality rate. Surgical intervention is suggested in stage II and III empyema. However, there were no studies that reported the outcomes of surgery for fungal empyema.
METHODS
This study is a retrospective analysis in a single institute. Patients with empyema thoracis who underwent thoracoscopic decortication between January 2012 and December 2021 were included in the study. We separated the patients into a fungal empyema group and a bacterial empyema group according to culture results. We used 1:3 propensity score matching to reduce selection bias.
RESULTS
There were 1197 empyema patients who received surgery. Of these, 575 patients showed positive culture results and were enrolled. Twenty-eight patients were allocated to the fungal empyema group, and the other 547 patients were placed in the bacterial empyema group. Fungal empyema showed significantly longer intensive care unit stay (16 days vs. 3 days, p = 0.002), longer median ventilator usage duration (20.5 days vs. 3 days, p = 0.002), longer hospital stay duration (40 days vs. 17.5 days, p < 0.001) and a higher 30-day mortality rate (21.4% vs. 5.9%, p < 0.001). Fungal empyema revealed significantly poorer 1-year survival rate than bacterial empyema before matching (p < 0.001) but without significant difference after matching.
CONCLUSIONS
The fungal empyema patients had much worse surgical outcomes than the bacterial empyema patients. Advanced age and high Charlson Comorbidity Index score are independent predictors for poor prognosis. Prompt surgical intervention combined with the use of antifungal agents was the treatment choice for fungal empyema.
Topics: Humans; Retrospective Studies; Treatment Outcome; Thoracic Surgery, Video-Assisted; Empyema, Pleural; Bacteria
PubMed: 36609233
DOI: 10.1186/s12879-022-07978-z