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      Thoracic Empyema: A 12-Year Study from a UK Tertiary Cardiothoracic Referral Centre

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          Abstract

          Background

          Empyema is an increasingly frequent clinical problem worldwide, and has substantial morbidity and mortality. Our objectives were to identify the clinical, surgical and microbiological features, and management outcomes, of empyema.

          Methods

          A retrospective observational study over 12 years (1999–2010) was carried out at The Heart Hospital, London, United Kingdom. Patients with empyema were identified by screening the hospital electronic ‘Clinical Data Repository’. Demographics, clinical and microbiological characteristics, underlying risk factors, peri-operative blood tests, treatment and outcomes were identified. Univariable and multivariable statistical analyses were performed.

          Results

          Patients (n = 406) were predominantly male (74.1%); median age = 53 years (IQR = 37–69). Most empyema were community-acquired (87.4%) and right-sided (57.4%). Microbiological diagnosis was obtained in 229 (56.4%) patients, and included streptococci (16.3%), staphylococci (15.5%), Gram-negative organisms (8.9%), anaerobes (5.7%), pseudomonads (4.4%) and mycobacteria (9.1%); 8.4% were polymicrobial. Most (68%) cases were managed by open thoracotomy and decortication. Video-assisted thoracoscopic surgery (VATS) reduced hospitalisation from 10 to seven days ( P = 0.0005). All-cause complication rate was 25.1%, and 28 day mortality 5.7%. Predictors of early mortality included: older age ( P = 0.006), major co-morbidity ( P = 0.01), malnutrition ( P = 0.001), elevated red cell distribution width (RDW, P<0.001) and serum alkaline phosphatase ( P = 0.004), and reduced serum albumin ( P = 0.01) and haemoglobin ( P = 0.04).

          Conclusions

          Empyema remains an important cause of morbidity and hospital admissions. Microbiological diagnosis was only achieved in just over 50% of cases, and tuberculosis is a notable causative organism. Treatment of empyema with VATS may reduce duration of hospital stay. Raised RDW appears to associate with early mortality.

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          Rapid molecular detection of tuberculosis and rifampin resistance.

          Catharina C. Boehme, Pamela Nabeta, Doris Hillemann … (2010)
          Global control of tuberculosis is hampered by slow, insensitive diagnostic methods, particularly for the detection of drug-resistant forms and in patients with human immunodeficiency virus infection. Early detection is essential to reduce the death rate and interrupt transmission, but the complexity and infrastructure needs of sensitive methods limit their accessibility and effect. We assessed the performance of Xpert MTB/RIF, an automated molecular test for Mycobacterium tuberculosis (MTB) and resistance to rifampin (RIF), with fully integrated sample processing in 1730 patients with suspected drug-sensitive or multidrug-resistant pulmonary tuberculosis. Eligible patients in Peru, Azerbaijan, South Africa, and India provided three sputum specimens each. Two specimens were processed with N-acetyl-L-cysteine and sodium hydroxide before microscopy, solid and liquid culture, and the MTB/RIF test, and one specimen was used for direct testing with microscopy and the MTB/RIF test. Among culture-positive patients, a single, direct MTB/RIF test identified 551 of 561 patients with smear-positive tuberculosis (98.2%) and 124 of 171 with smear-negative tuberculosis (72.5%). The test was specific in 604 of 609 patients without tuberculosis (99.2%). Among patients with smear-negative, culture-positive tuberculosis, the addition of a second MTB/RIF test increased sensitivity by 12.6 percentage points and a third by 5.1 percentage points, to a total of 90.2%. As compared with phenotypic drug-susceptibility testing, MTB/RIF testing correctly identified 200 of 205 patients (97.6%) with rifampin-resistant bacteria and 504 of 514 (98.1%) with rifampin-sensitive bacteria. Sequencing resolved all but two cases in favor of the MTB/RIF assay. The MTB/RIF test provided sensitive detection of tuberculosis and rifampin resistance directly from untreated sputum in less than 2 hours with minimal hands-on time. (Funded by the Foundation for Innovative New Diagnostics.)
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            Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010.

            , Abigail H. Davies, Robert Davies (2010)
            Article 0 comments Cited 135 times – based on 0 reviews     Review now
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              U.K. Controlled trial of intrapleural streptokinase for pleural infection.

              John F. Gleeson, T. Peto, Jeffrey Rees … (2005)
              Intrapleural fibrinolytic agents are used in the drainage of infected pleural-fluid collections. This use is based on small trials that did not have the statistical power to evaluate accurately important clinical outcomes, including safety. We conducted a trial to clarify the therapeutic role of intrapleural streptokinase. In this double-blind trial, 454 patients with pleural infection (defined by the presence of purulent pleural fluid or pleural fluid with a pH below 7.2 with signs of infection or by proven bacterial invasion of the pleural space) were randomly assigned to receive either intrapleural streptokinase (250,000 IU twice daily for three days) or placebo. Patients received antibiotics and underwent chest-tube drainage, surgery, and other treatment as part of routine care. The number of patients in the two groups who had died or needed surgical drainage at three months was compared (the primary end point); secondary end points were the rates of death and of surgery (analyzed separately), the radiographic outcome, and the length of the hospital stay. The groups were well matched at baseline. Among the 427 patients who received streptokinase or placebo, there was no significant difference between the groups in the proportion of patients who died or needed surgery (with streptokinase: 64 of 206 patients [31 percent]; with placebo: 60 of 221 [27 percent]; relative risk, 1.14 [95 percent confidence interval, 0.85 to 1.54; P=0.43), a result that excluded a clinically significant benefit of streptokinase. There was no benefit to streptokinase in terms of mortality, rate of surgery, radiographic outcomes, or length of the hospital stay. Serious adverse events (chest pain, fever, or allergy) were more common with streptokinase (7 percent, vs. 3 percent with placebo; relative risk, 2.49 [95 percent confidence interval, 0.98 to 6.36]; P=0.08). The intrapleural administration of streptokinase does not improve mortality, the rate of surgery, or the length of the hospital stay among patients with pleural infection. Copyright 2005 Massachusetts Medical Society.
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                Author and article information

                Contributors
                : Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2012
                Publication date (Electronic): 20 January 2012
                Volume: 7
                Issue: 1
                Electronic Location Identifier: e30074
                Affiliations
                [1 ]Department of Cardiology, The Heart Hospital, University College London Hospitals NHS Foundation Trust, London, United Kingdom
                [2 ]Department of Medicine, University College London, London, United Kingdom
                [3 ]Research Department of Infection and Population Health, University College London Medical School, University College London, London, United Kingdom
                [4 ]Division of Infection and Immunity, Institute of Molecular and Cellular Biology, Porto, Portugal
                [5 ]Department of Cardiothoracic Surgery, The Heart Hospital, University College London Hospitals NHS Foundation Trust, London, United Kingdom
                [6 ]Department of Clinical Microbiology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
                [7 ]Centre for Respiratory Research, University College London, London, United Kingdom
                [8 ]Department of Infection, University College London Medical School, University College London, London, United Kingdom
                Institute of Infectious Diseases and Molecular Medicine, South Africa
                Author notes

                Conceived and designed the experiments: AIZ DJBM SFL MBM RFM PAPW. Performed the experiments: AIZ DJBM DL SFL MMF CYK LFP RFM. Analyzed the data: MGP DJBM SFL MBM RFM JSB. Contributed reagents/materials/analysis tools: MGP DJBM. Wrote the paper: DJBM MMF CYK MGP LFP SFL DL MBM PAPW JSB RFM AIZ. Study leads: AIZ DJBM RFM.

                Article
                Publisher ID: PONE-D-11-19583
                DOI: 10.1371/journal.pone.0030074
                PMC ID: 3262802
                PubMed ID: 22276145
                SO-VID: 91358263-5ef0-4e11-a05f-d610fa279dec
                Copyright © Marks et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                History
                Date received : 3 October 2011
                Date accepted : 13 December 2011
                Page count
                Pages: 8
                Categories
                Subject: Research Article
                Subject: Biology
                Subject: Microbiology
                Subject: Bacterial Pathogens
                Subject: Medicine
                Subject: Critical Care and Emergency Medicine
                Subject: Diagnostic Medicine
                Subject: Infectious Diseases
                Subject: Pulmonology

                ScienceOpen disciplines: Uncategorized
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                ScienceOpen disciplines: Uncategorized

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