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Expert Review of Respiratory Medicine Apr 2019Pleural infection is a condition that continues to pose a significant challenge to respiratory physicians. We hypothesize that the main barriers to progress include... (Review)
Review
Pleural infection is a condition that continues to pose a significant challenge to respiratory physicians. We hypothesize that the main barriers to progress include limited understanding of the etiopathogenesis, microbiology,and role of antibiotics in the pleural space. Areas covered: PubMed was searched for articles related to adult pleural infection using the terms 'pleural infection', 'empyema' and 'parapneumonic'. The search focused on relevant literature within the last 10 years, with any older citations used only to display context or lack of progress. Tuberculous pleural infection was excluded. We chose to give specific attention to the etiopathogenesis of pleural infection, including recent advances in diagnostics and biomarkers. We discuss our understanding of the pleural microbiome and rationalize the current use of antibiotics in treating this condition. Expert commentary: Understanding of key events in the development of this condition remains limited. The microbiology is unique compared to the lung, and highly variable. Higher culture yields from pleural biopsy may add new insights into the etiopathogenesis. There is little evidence into achievable effective antibiotic concentration within the pleura. Research into issues including the relevance of biofilm formation and significance of pleural thickening is necessary for treatment progress.
Topics: Anti-Bacterial Agents; Communicable Diseases; Humans; Pleura; Pleural Diseases
PubMed: 30707629
DOI: 10.1080/17476348.2019.1578212 -
The New England Journal of Medicine Feb 2018
Review
Topics: Diagnosis, Differential; Empyema, Pleural; Exudates and Transudates; Humans; Pleura; Pleural Effusion; Pleural Effusion, Malignant; Pneumothorax
PubMed: 29466146
DOI: 10.1056/NEJMra1403503 -
Current Opinion in Pulmonary Medicine Jul 2012Pleural infection remains a common and difficult problem to manage in the 21st century. Despite advances in modern healthcare, the rising incidence and mortality of... (Review)
Review
PURPOSE OF REVIEW
Pleural infection remains a common and difficult problem to manage in the 21st century. Despite advances in modern healthcare, the rising incidence and mortality of empyema highlights a need for better understanding of the disease and more effective strategies in its diagnosis and treatment.
RECENT FINDINGS
Recent studies have progressed our knowledge and understanding of the bacteriology and pathophysiology of pleural infection. However, rather than providing firm conclusions, examination of current literature provokes several unanswered questions on most aspects of the disease.
SUMMARY
This review aims to challenge traditional current concepts and approaches to clinical practice in pleural infection, to stimulate debate and research into potential novel future therapies.
Topics: Empyema, Pleural; Humans; Incidence; Pleura; Pneumonia; Streptococcal Infections
PubMed: 22450303
DOI: 10.1097/MCP.0b013e328352c673 -
The Clinical Respiratory Journal Aug 2018Pleural infection is a condition commonly encountered by the respiratory physician. This review aims to provide the reader with an update on the most recent data... (Review)
Review
OBJECTIVES
Pleural infection is a condition commonly encountered by the respiratory physician. This review aims to provide the reader with an update on the most recent data regarding the epidemiology, microbiology, and the management of pleural infection.
DATA SOURCE
Medline was searched for articles related to pleural infection using the terms "pleural infection," "empyema," and "parapneumonic." The search was limited to the years 1997-2017. Only human studies and reports in English were included.
RESULTS
A rise in the incidence of pleural infection is seen worldwide. Despite the improvement in healthcare practices, the mortality from pleural infection remains high. The role of oral microflora in the etiology of pleural infection is firmly established. A concise review of the recent insights on the pathogenesis of pleural infections is presented. A particular focus is made on the role of tPA, DNAse and similar substances and their interaction with inflammatory cells and how this affects the pathogenesis and treatment of pleural infection.
CONCLUSION
Pleural infection is a common disease with significant morbidity and mortality, as well as a considerable economic burden. The role of medical management is expanding thanks to the widespread use of newer treatments.
Topics: Cost of Illness; Empyema, Pleural; Gastrointestinal Microbiome; Humans; Incidence; Pleura; Pleural Effusion; Thoracoscopy; Thrombolytic Therapy; Tomography, X-Ray Computed
PubMed: 30005142
DOI: 10.1111/crj.12941 -
Annals of the American Thoracic Society Sep 2020
Topics: Humans; Infections; Pleura; Pleural Diseases; Thoracoscopy; Thrombolytic Therapy
PubMed: 32667210
DOI: 10.1513/AnnalsATS.202006-658LE -
American Journal of Respiratory and... Mar 2023Sonographic septations are assumed to be important clinical predictors of outcome in pleural infection, but the evidence for this is sparse. The inflammatory and... (Observational Study)
Observational Study
Sonographic septations are assumed to be important clinical predictors of outcome in pleural infection, but the evidence for this is sparse. The inflammatory and fibrinolysis-associated intrapleural pathway(s) leading to septation formation have not been studied in a large cohort of pleural fluid (PF) samples with confirmed pleural infection matched with ultrasound and clinical outcome data. To assess the presence and severity of septations against baseline PF PAI-1 (Plasminogen-Activator Inhibitor-1) and other inflammatory and fibrinolysis-associated proteins as well as to correlate these with clinically important outcomes. We analyzed 214 pleural fluid samples from PILOT (Pleural Infection Longitudinal Outcome Study), a prospective observational pleural infection study, for inflammatory and fibrinolysis-associated proteins using the Luminex platform. Multivariate regression analyses were used to assess the association of pleural biological markers with septation presence and severity (on ultrasound) and clinical outcomes. PF PAI-1 was the only protein independently associated with septation presence ( < 0.001) and septation severity ( = 0.003). PF PAI-1 concentrations were associated with increased length of stay ( = 0.048) and increased 12-month mortality ( = 0.003). Sonographic septations alone had no relation to clinical outcomes. In a large and well-characterized cohort, this is the first study to associate pleural biological parameters with a validated sonographic septation outcome in pleural infection. PF PAI-1 is the first biomarker to demonstrate an independent association with mortality. Although PF PAI-1 plays an integral role in driving septation formation, septations themselves are not associated with clinically important outcomes. These novel findings now require prospective validation.
Topics: Humans; Fibrinolysis; Infections; Plasminogen Activator Inhibitor 1; Pleura; Pleural Diseases; Pleural Effusion; Prospective Studies; Tissue Plasminogen Activator; Ultrasonography
PubMed: 36191254
DOI: 10.1164/rccm.202206-1084OC -
Annals of the American Thoracic Society Sep 2020
Topics: Humans; Infections; Pleura; Pleural Diseases; Thoracoscopy; Thrombolytic Therapy
PubMed: 32667224
DOI: 10.1513/AnnalsATS.202007-780LE -
PloS One 2013Heat shock protein 70 (HSP70) has been implicated in infection-related processes and has been found in body fluids during infection. This study aimed to determine...
Heat shock protein 70 (HSP70) has been implicated in infection-related processes and has been found in body fluids during infection. This study aimed to determine whether pleural mesothelial cells release HSP70 in response to bacterial infection in vitro and in mouse models of serosal infection. In addition, the in vitro cytokine effects of the HSP70 isoform, Hsp72, on mesothelial cells were examined. Further, Hsp72 was measured in human pleural effusions and levels compared between non-infectious and infectious patients to determine the diagnostic accuracy of pleural fluid Hsp72 compared to traditional pleural fluid parameters. We showed that mesothelial release of Hsp72 was significantly raised when cells were treated with live and heat-killed Streptococcus pneumoniae. In mice, intraperitoneal injection of S. pneumoniae stimulated a 2-fold increase in Hsp72 levels in peritoneal lavage (p<0.01). Extracellular Hsp72 did not induce or inhibit mediator release from cultured mesothelial cells. Hsp72 levels were significantly higher in effusions of infectious origin compared to non-infectious effusions (p<0.05). The data establish that pleural mesothelial cells can release Hsp72 in response to bacterial infection and levels are raised in infectious pleural effusions. The biological role of HSP70 in pleural infection warrants exploration.
Topics: Adult; Aged; Aged, 80 and over; Animals; Cell Line; Cytokines; Epithelial Cells; Epithelium; Extracellular Space; Female; HSP72 Heat-Shock Proteins; Humans; Male; Mice; Mice, Inbred BALB C; Mice, Inbred C57BL; Middle Aged; Peritoneal Lavage; Pleura; Pleural Effusion; Streptococcal Infections; Streptococcus pneumoniae
PubMed: 23704948
DOI: 10.1371/journal.pone.0063873 -
Chest Oct 2018Pleural infection is a common complication of pneumonia associated with high mortality and poor clinical outcome. Treatment of pleural infection relies on the use of... (Clinical Trial)
Clinical Trial
BACKGROUND
Pleural infection is a common complication of pneumonia associated with high mortality and poor clinical outcome. Treatment of pleural infection relies on the use of broad-spectrum antibiotics because reliable pathogen identification occurs infrequently. We performed a feasibility interventional clinical study assessing the safety and significance of ultrasound (US)-guided pleural biopsy culture to increase microbiological yield. In an exploratory investigation, the 16S ribosomal RNA technique was applied to assess its utility on increasing speed and accuracy vs standard microbiological diagnosis.
METHODS
Twenty patients with clinically established pleural infection were recruited. Participants underwent a detailed US scan and US-guided pleural biopsies before chest drain insertion, alongside standard clinical management. Pleural biopsies and routine clinical samples (pleural fluid and blood) were submitted for microbiological analysis.
RESULTS
US-guided pleural biopsies were safe with no adverse events. US-guided pleural biopsies increased microbiological yield by 25% in addition to pleural fluid and blood samples. The technique provided a substantially higher microbiological yield compared with pleural fluid and blood culture samples (45% compared with 20% and 10%, respectively). The 16S ribosomal RNA technique was successfully applied to pleural biopsy samples, demonstrating high sensitivity (93%) and specificity (89.5%).
CONCLUSIONS
Our findings demonstrate the safety of US-guided pleural biopsies in patients with pleural infection and a substantial increase in microbiological diagnosis, suggesting potential niche of infection in this disease. Quantitative polymerase chain reaction primer assessment of pleural fluid and biopsy appears to have excellent sensitivity and specificity.
Topics: Bacterial Infections; Feasibility Studies; Female; Humans; Image-Guided Biopsy; Male; Middle Aged; Pilot Projects; Pleura; Pleural Diseases; Respiratory Tract Infections; Ultrasonography, Interventional
PubMed: 29524388
DOI: 10.1016/j.chest.2018.02.031 -
Acta Tropica 2007Although, pleural (PT) and disseminated tuberculosis (DT) have been considered as extreme endpoints of the Th1-Th2 immunological spectrum of the Mycobacterium... (Review)
Review
Although, pleural (PT) and disseminated tuberculosis (DT) have been considered as extreme endpoints of the Th1-Th2 immunological spectrum of the Mycobacterium tuberculosis infection, these conditions can occur together. The presence of PT and DT could be explained by (1) PT as primary condition, with progression of HIV infection possibly leading to dissemination of bacilli located in the pleura; (2) preexisting PT, with reinfection at lower LTCD4+ count explaining the DT form; (3) simultaneous acute PT and DT, considering immune compartmentalization phenomena in pleura. There are several important aspects of the immune response and its compartmentalization in co-infected patients with tuberculosis and HIV. PT and DT should not be always considered as extremes of the immunological response against M. tuberculosis, both diseases together may be explained after the understanding of compartmentalization of immune response. Associations between these entities are not so rare, while they remain incompletely explained. This brief review discusses several points of this contradictory association.
Topics: Acquired Immunodeficiency Syndrome; CD4 Lymphocyte Count; HIV Infections; Humans; Pleura; Tuberculosis
PubMed: 17825240
DOI: 10.1016/j.actatropica.2007.07.009