1
|
Kommedal Ø, Eagan TM, Fløtten Ø, Leegaard TM, Siljan W, Fardal H, Bø B, Grøvan F, Larssen KW, Kildahl-Andersen A, Hjetland R, Tilseth R, Hareide SKØ, Tellevik M, Dyrhovden R. Microbiological diagnosis of pleural infections: a comparative evaluation of a novel syndromic real-time PCR panel. Microbiol Spectr 2024; 12:e0351023. [PMID: 38656204 DOI: 10.1128/spectrum.03510-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/19/2024] [Indexed: 04/26/2024] Open
Abstract
Current microbial diagnostics for pleural infections are insufficient. Studies using 16S targeted next-generation sequencing report that only 10%-16% of bacteria present are cultured and that 50%-78% of pleural fluids containing relevant microbial DNA remain culture negative. As a rapid diagnostic alternative suitable for clinical laboratories, we wanted to explore a PCR-based approach. Based on the identification of key pathogens, we developed a syndromic PCR panel for community-acquired pleural infections (CAPIs). This was a pragmatic PCR panel, meaning that it was not designed for detecting all possibly involved bacterial species but for confirming the diagnosis of CAPI, and for detecting bacteria that might influence choice of antimicrobial treatment. We evaluated the PCR panel on 109 confirmed CAPIs previously characterized using culture and 16S targeted next-generation sequencing. The PCR secured the diagnosis of CAPI in 107/109 (98.2%) and detected all present pathogens in 69/109 (63.3%). Culture secured the diagnosis in 54/109 (49.5%) and detected all pathogens in 31/109 (28.4%). Corresponding results for 16S targeted next-generation sequencing were 109/109 (100%) and 98/109 (89.9%). For bacterial species included in the PCR panel, PCR had a sensitivity of 99.5% (184/185), culture of 21.6% (40/185), and 16S targeted next-generation sequencing of 92.4% (171/185). None of the bacterial species present not covered by the PCR panel were judged to impact antimicrobial therapy. A syndromic PCR panel represents a rapid and sensitive alternative to current diagnostic approaches for the microbiological diagnosis of CAPI.IMPORTANCEPleural empyema is a severe infection with high mortality and increasing incidence. Long hospital admissions and long courses of antimicrobial treatment drive healthcare and ecological costs. Current methods for microbiological diagnostics of pleural infections are inadequate. Recent studies using 16S targeted next-generation sequencing as a reference standard find culture to recover only 10%-16% of bacteria present and that 50%-78% of samples containing relevant bacterial DNA remain culture negative. To confirm the diagnosis of pleural infection and define optimal antimicrobial therapy while limiting unnecessary use of broad-spectrum antibiotics, there is a need for rapid and sensitive diagnostic approaches. PCR is a rapid method well suited for clinical laboratories. In this paper we show that a novel syndromic PCR panel can secure the diagnosis of pleural infection and detect all bacteria relevant for choice of antimicrobial treatment with a high sensitivity.
Collapse
Affiliation(s)
- Øyvind Kommedal
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | - Tomas Mikal Eagan
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Øystein Fløtten
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | - Truls Michael Leegaard
- Division of Medicine and Laboratory Sciences, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Microbiology and Infection Control, Akershus University Hospital, Lørenskog, Akershus, Norway
| | - William Siljan
- Department of Pulmonary Medicine, Akershus University Hospital, Lorenskog, Akershus, Norway
| | - Hilde Fardal
- Department of Microbiology, Stavanger University Hospital, Stavanger, Norway
| | - Bjørnar Bø
- Department of Pulmonary Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Fredrik Grøvan
- Department of Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Kjersti Wik Larssen
- Department of Medical Microbiology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Arne Kildahl-Andersen
- Department of Thoracic Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Reidar Hjetland
- Department of Microbiology, Førde Central Hospital, Førde, Norway
| | - Rune Tilseth
- Department of Medicine, Førde Central Hospital, Førde, Norway
| | | | - Marit Tellevik
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | - Ruben Dyrhovden
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
2
|
Fitzgerald DB, Polverino E, Waterer GW. Expert Review on Nonsurgical Management of Parapneumonic Effusion: Advances, Controversies, and New Directions. Semin Respir Crit Care Med 2023; 44:468-476. [PMID: 37429296 DOI: 10.1055/s-0043-1769095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
Parapneumonic effusion and empyema are rising in incidence worldwide, particularly in association with comorbidities in an aging population. Also driving this change is the widespread uptake of pneumococcal vaccines, leading to the emergence of nonvaccine-type pneumococci and other bacteria. Early treatment with systemic antibiotics is essential but should be guided by local microbial guidelines and antimicrobial resistance patterns due to significant geographical variation. Thoracic ultrasound has emerged as a leading imaging technique in parapneumonic effusion, enabling physicians to characterize effusions, assess the underlying parenchyma, and safely guide pleural procedures. Drainage decisions remain based on longstanding criteria including the size of the effusion and fluid gram stain and biochemistry results. Small-bore chest drains appear to be as effective as large bore and are adequate for the delivery of intrapleural enzyme therapy (IET), which is now supported by a large body of evidence. The IET dosing regimen used in the UK Multicenter Sepsis Trial -2 has the most evidence available but data surrounding alternative dosing, concurrent and once-daily instillations, and novel fibrinolytic agents are promising. Prognostic scores used in pneumonia (e.g., CURB-65) tend to underestimate mortality in parapneumonic effusion/empyema. Scores specifically based on pleural infection have been developed but require validation in prospective cohorts.
Collapse
Affiliation(s)
- Deirdre B Fitzgerald
- Department of Respiratory Medicine, Tallaght University Hospital, Dublin, Ireland
- Medical School, University of Western Australia, Australia
| | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; CIBER de enfermedades respiratorias
| | - Grant W Waterer
- Medical School, University of Western Australia, Australia
- Royal Perth Hospital, Perth, WA, Australia
| |
Collapse
|
3
|
Budnick IM, Oliver SF, Barros AJ, Sturek JM. Pleural Fluid Analysis in Neutropenia. Ann Am Thorac Soc 2022; 19:1946-1948. [PMID: 35960258 PMCID: PMC9667807 DOI: 10.1513/annalsats.202204-331rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
| | - Samuel F. Oliver
- University of Virginia School of MedicineCharlottesville, Virginia
| | - Andrew J. Barros
- University of Virginia School of MedicineCharlottesville, Virginia
| | | |
Collapse
|
4
|
Evaluation and management of pleural sepsis. Respir Med 2021; 187:106553. [PMID: 34340174 DOI: 10.1016/j.rmed.2021.106553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 11/21/2022]
Abstract
Pleural sepsis stems from an infection within the pleural space typically from an underlying bacterial pneumonia leading to development of a parapneumonic effusion. This effusion is traditionally divided into uncomplicated, complicated, and empyema. Poor clinical outcomes and increased mortality can be associated with the development of parapneumonic effusions, reinforcing the importance of early recognition and diagnosis. Management necessitates a multimodal therapeutic strategy consisting of antimicrobials, catheter/tube thoracostomy, and at times, video-assisted thoracoscopic surgery.
Collapse
|
5
|
CT appearances of pleural infection: analysis of the Second Multi-centre Intra-pleural Sepsis Trial (MIST 2) cohort. Clin Radiol 2021; 76:436-442. [PMID: 33820639 DOI: 10.1016/j.crad.2020.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 12/24/2020] [Indexed: 11/20/2022]
Abstract
AIM To determine the prevalence of pleural abnormalities and describe the computed tomography (CT) features observed in a well-characterised population of patients with pleural infection. MATERIALS AND METHODS A retrospective study of a subgroup of patients from the Second Multi-centre Intra-pleural Sepsis Trial (MIST 2) trial was carried out. Patients were diagnosed with pleural infection on robust clinical criteria. CT examinations were assessed by three observers independently for the presence of predefined features. Planned subgroup comparisons of patients with and without evidence of parenchymal infection were performed. RESULTS Eighty-one patients were included. Parietal pleural thickening and enhancement were seen in 98.7% of patients. Visceral pleural changes were observed in most, including several previously undescribed features. Consolidation was observed in 61.7% of patients and there was a significant association of parenchymal consolidation with CT evidence of small airways infection (p<0.001) and visceral pleural thickening and enhancement (p<0.05). Features of parenchymal infection were absent in one third of patients. CONCLUSION This study provides a comprehensive account of the parietal pleural, visceral pleural, and parenchymal changes of pleural infection on CT. Parenchymal infection is absent in a significant proportion of patients with pleural infection, suggesting that a pneumonic process may not be necessary for the development of pleural infection.
Collapse
|
6
|
Bailey M, Eapen G, Ost D, Casal RF, Jimenez C, Datar S, Molina S, Bashoura L, Faiz SA, Balachandran DD, Shannon VR, Sheshadri A, Grosu HB. Routine Microbiologic Studies of Pleural Fluid Specimens in Cancer Patients. Am J Med 2020; 133:240-244. [PMID: 31401163 PMCID: PMC6983947 DOI: 10.1016/j.amjmed.2019.07.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 06/26/2019] [Accepted: 07/03/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients who have pleural effusions typically undergo thoracentesis with examination of pleural fluid in their initial assessment. However, limited data are available on the diagnostic yield of pleural fluid bacterial cultures and fungal and acid-fast bacilli (AFB) smear and cultures in patients with cancer. METHODS We performed a retrospective cohort study of consecutive patients who had new onset pleural effusions and underwent an initial thoracentesis. The primary outcome was diagnostic yield of pleural fluid bacterial cultures and fungal and AFB smear and cultures. RESULTS Of 1637 patients, 1547 (94%) had evidence of active malignancy and 1359 (83%) had evidence of metastatic disease. Of the 1637 patients, 542 (33%) had high clinical suspicion of pneumonia within 14 days prior to thoracentesis. Only 14 patients (1.1%) had positive pleural fluid bacterial cultures, and only 6 of these positive cultures met the criteria for true pleural space infection. CONCLUSIONS The incidence of positive results from pleural fluid bacterial, fungal, and AFB in cancer populations is very low. Unless there is a suspicion for infection, microbiological analysis should be ordered selectively.
Collapse
Affiliation(s)
- Marshall Bailey
- Divisions of Critical Care, Pulmonary, and Sleep Medicine, McGovern Medical School at UT Health, Houston, Tex
| | - Georgie Eapen
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - David Ost
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Roberto F Casal
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Carlos Jimenez
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Saumil Datar
- McGovern Medical School at UT Health, Houston, Tex
| | - Sofia Molina
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | - Lara Bashoura
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Saadia A Faiz
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Diwakar D Balachandran
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Vickie R Shannon
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Ajay Sheshadri
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex
| | - Horiana B Grosu
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.
| |
Collapse
|
7
|
Abstract
PURPOSE OF REVIEW Pleural infection remains an important pulmonary disease, causing significant morbidity and mortality. There is a resurgence of disease burden despite introduction of antibiotics and pneumococcal vaccines. A revisit of the pathogenesis and update on intervention may improve the care of pleural infection. RECENT FINDINGS Recent studies have uncovered the prognostic implication of the presence of a pleural effusion in patients with pneumonia. Identifying where the bacteria lives may have diagnostic and therapeutic implications. Over-exaggerated pleural inflammation may underlie development of parapneumonic effusion as indirect evidence and a randomized study in children raised a role of corticosteroids in parapneumonic pleural effusions, but data are lacking for adults. Optimization of the delivery regimen of intrapleural fibrinolytic and deoxyribonuclease therapy is ongoing. SUMMARY The review aims to review the current practice and explore new directions of treatment on pleural infection.
Collapse
|
8
|
Abstract
Effusion cytology plays multiple roles in the management of benign and malignant disease, from primary diagnosis to tissue allocation for ancillary diagnostic studies and biomarker testing of therapeutic targets. This article summarizes recent advances in pleural effusion cytology, with a focus on the practical application of immunohistochemical markers, cytogenetic techniques, flow cytometry, and molecular techniques for the diagnosis and management of primary and secondary neoplasms of the pleura.
Collapse
Affiliation(s)
- Christin M Lepus
- Department of Pathology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Marina Vivero
- Department of Pathology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
| |
Collapse
|
9
|
She RC, Romney MG, Jang W, Walker T, Karichu JK, Richter SS. Performance of the BacT/Alert Virtuo Microbial Detection System for the culture of sterile body fluids: prospective multicentre study. Clin Microbiol Infect 2017; 24:992-996. [PMID: 29274462 DOI: 10.1016/j.cmi.2017.12.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 12/11/2017] [Accepted: 12/12/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Continuous monitoring blood culture systems are commonly used for sterile body fluid cultures. In this multicentre study, we evaluated the performance of the new-generation BacT/Alert Virtuo system compared to the BacT/Alert 3D and conventional culture for the recovery of microorganisms from sterile body fluids. METHODS Peritoneal, cerebrospinal, pericardial, pleural and synovial fluids from adult patients submitted for culture were collected from three different centres. Specimens were inoculated into two bottles of the same bottle type (SA, SN, FA Plus or FN Plus) in equal volumes for simultaneous incubation in the Virtuo and 3D instruments. Each specimen was also Gram stained and seeded to solid media. RESULTS A total of 811 specimens were inoculated to 1257 bottle pairs. The Virtuo and 3D showed equivalent recovery of clinically significant microorganisms (127/155, 81.9%, vs. 126/155, 81.3%, respectively). Solid media cultures recovered fewer pathogens than either continuous monitoring system (95/155, 61.3%, p <0.001), including significantly fewer Enterobacteriaceae and enterococci. The Virtuo was significantly faster than the 3D in median time to detection of isolates from the same specimen (12.5 (range, 2.8-101.5) hours vs. 15.5 (range, 4.3-78.5) hours, p <0.001). Direct specimen Gram stain detected the eventual pathogen in 30 (26.1%) of 115 significant positive specimens. CONCLUSIONS The BacT/Alert Virtuo system was equivalent to the 3D system in organism recovery from sterile body fluid culture but showed faster detection of growth as a result of design enhancements.
Collapse
Affiliation(s)
- R C She
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
| | - M G Romney
- St Paul's Hospital, Providence Health Care, University of British Columbia, Vancouver, British Columbia, Canada; Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - W Jang
- St Paul's Hospital, Providence Health Care, University of British Columbia, Vancouver, British Columbia, Canada
| | - T Walker
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - J K Karichu
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - S S Richter
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
10
|
The American Association for Thoracic Surgery consensus guidelines for the management of empyema. J Thorac Cardiovasc Surg 2017; 153:e129-e146. [PMID: 28274565 DOI: 10.1016/j.jtcvs.2017.01.030] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 12/24/2016] [Accepted: 01/08/2017] [Indexed: 11/24/2022]
|
11
|
Hassan K, Turker T, Zangeneh T. Disseminated sporotrichosis in an immunocompetent patient. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2016; 3:44-7. [PMID: 27583270 PMCID: PMC4996056 DOI: 10.3109/23320885.2016.1168703] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 03/17/2016] [Indexed: 11/13/2022]
Abstract
Sporothrix schenckii, the causative agent of sporotrichosis, is a relatively rare infection. Local infection usually occurs through direct inoculation of the organism through the skin; disseminated disease is rarely seen. This article describes a case of disseminated sporotrichosis in a middle-aged man without the commonly seen risk factors for dissemination.
Collapse
Affiliation(s)
- Kareem Hassan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago , Chicago , IL , USA
| | - Tolga Turker
- Department of Orthopaedic Surgery, The University of Arizona , Tucson , AZ , USA
| | - Tirdad Zangeneh
- Division of Infectious Diseases, Department of Medicine , Tucson , AZ , USA
| |
Collapse
|
12
|
Charoentunyarak S, Kananuraks S, Chindaprasirt J, Limpawattana P, Sawanyawisuth K. Blood Culture Bottle and Standard Culture Bottle Methods for Detection of Bacterial Pathogens in Parapneumonic Pleural Effusion. Jundishapur J Microbiol 2015; 8:e24893. [PMID: 26587217 PMCID: PMC4644317 DOI: 10.5812/jjm.24893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 02/01/2015] [Accepted: 03/17/2015] [Indexed: 11/20/2022] Open
Abstract
Background: Bacterial parapneumonic pleural effusions (PPEs) have high morbidity. The accurate identification of pathogens is vital for initiating the appropriate treatment. A previous study suggested that the use of blood culture bottles might improve the bacterial yield in PPEs. Objectives: The aim of this study was to compare the culture positivity rate by the blood culture bottles and the standard culture bottles in bacterial PPEs. Patients and Methods: Patients diagnosed with PPEs at the Khon Kaen Hospital, Khon Kaen, Thailand, which is an endemic area of melioidosis, were enrolled consecutively and prospectively. The study period was from June first, 2012 to December 31st, 2013. The inclusion criteria were adult patients aged > 18 years, with exudative, neutrophilic parapneumonic effusion. Of the pleural fluid samples, 5 mL from all the eligible patients were collected in both blood culture bottles and the standard culture bottles. Patient baseline characteristics, laboratory results, and culture results were collected and analyzed. Results: During the study period, 129 patients met the study criteria. The bacteria-positive rate of pleural fluid culture using the standard culture bottle was 14.0%, whereas the positive rate using blood culture bottles was 24.0% (P < 0.001). Conclusions: The blood culture bottle method is more effective than the standard culture bottle method for the detection of bacterial pathogens in PPE.
Collapse
Affiliation(s)
| | | | - Jarin Chindaprasirt
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Panita Limpawattana
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Kittisak Sawanyawisuth
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
- Research Center in Back, Neck Other Joint Pain and Human Performance (BNOJPH), Khon Kaen University, Khon Kaen, Thailand
- Corresponding author: Kittisak Sawanyawisuth, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. Tel: +66-43363664, Fax: +66-43348399, E-mail:
| |
Collapse
|
13
|
Kim J, Park JS, Cho YJ, Yoon HI, Lee JH, Lee CT, Lim HJ, Kim DK. Predictors of prolonged stay in patients with community-acquired pneumonia and complicated parapneumonic effusion. Respirology 2015; 21:164-71. [PMID: 26510382 DOI: 10.1111/resp.12658] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 06/03/2015] [Accepted: 07/20/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Development of CPE in CAP is associated with prolonged hospital stay and it may increase the morbidity and mortality. We aimed to identify microbiological and clinical factors that predicate a prolonged hospital admission in patients treated with a tube thoracostomy to control CPE. METHODS This retrospective cohort included patients with CPE requiring chest tube drainage in a tertiary referral Korean hospital from 1 January 2004 to 30 July 2012. After dichotomous grouping according to the mean duration of hospital stay, clinical, laboratory and microbiological parameters were compared. RESULTS The final analysis included 158 patients with CPE. The majority were male (130, 85.0%), and the mean age was 62.8 years. The mean duration of hospital stay was 17.7 (±10.2) days. The mean duration of chest tube drainage was 9.6 (±6.7) days. Streptococcus viridans (48.4%) was the most common pathogen. Intrapleural fibrinolysis was performed in 85 (53.8%); additional tube insertion was needed in 40 (25.3%) patients. In the multivariate analysis after adjusting for covariates, a prolonged hospital stay was associated with fever (aOR: 3.42, P = 0.02), lower PaO2 (aOR: 4.89, P = 0.007) and haemoglobin (aOR: 4.90, P = 0.003) levels, and an increased blood neutrophil fraction (aOR: 3.83, P = 0.01) on admission as well as the identification of microbes in CPE (aOR: 4.14, P = 0.03), and ineffective pleural drainage (aOR: 3.28, P = 0.03). CONCLUSIONS This study suggests that physicians should note the clinical symptoms and laboratory findings of severe infection and effectiveness of pleural drainage to predicate which patients with a CAP needing thoracostomy for CPE will have a prolonged hospital stay.
Collapse
Affiliation(s)
- Junghyun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jong Sun Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Ho Il Yoon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Jae Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Choon-Taek Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Hyo-Jeong Lim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Deog Kyeom Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, South Korea
| |
Collapse
|
14
|
Madani A, Ferri L, Seely A. Pleural Disorders. POCKET MANUAL OF GENERAL THORACIC SURGERY 2015. [PMCID: PMC7123486 DOI: 10.1007/978-3-319-17497-6_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
This chapter provides an overview of both benign and malignant pleural disorders, starting with the relevant anatomy and physiology. The focus is on the management of pneumothoraces and pleural effusions—conditions that are commonly encountered on a general thoracic surgery service. The pleural cavity is lined by parietal and visceral pleura, which are smooth membranes that are continuous with one another at the hilum and pulmonary ligaments.
Parietal Pleura: innermost chest wall layer, divided into cervical, costal, mediastinal and diaphragmatic pleura.
Collapse
Affiliation(s)
| | | | - Andrew Seely
- The Ottawa Hospital – General Campus, University of Ottawa, Ottawa, Ontario Canada
| |
Collapse
|
15
|
Bhatnagar R, Maskell NA. Treatment of complicated pleural effusions in 2013. Clin Chest Med 2013; 34:47-62. [PMID: 23411056 DOI: 10.1016/j.ccm.2012.11.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The incidence of pleural infection seems to be increasing worldwide. Despite continued advances in the management of this condition, morbidity and mortality have essentially remained static over the past decade. This article summarizes the current evidence and opinions on the epidemiology, etiology, and management of complicated pleural effusions caused by infection, including empyema. Although many parallels may be drawn between children and adults in such cases, most trials, guidelines, and series regard pediatric patient groups and those more than 18 years of age as separate entities. This review focuses mainly on the treatment of adult disease.
Collapse
Affiliation(s)
- Rahul Bhatnagar
- Respiratory Research Unit, Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol BS10 5NB, UK
| | | |
Collapse
|
16
|
Makhlouf HA, Morsy KH, Makhlouf NA, Eldin EN, Khairy M. Spontaneous bacterial empyema in patients with liver cirrhosis in Upper Egypt: prevalence and causative organisms. Hepatol Int 2012. [DOI: 10.1007/s12072-012-9372-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
17
|
|
18
|
Insa R, Marín M, Martín A, Martín-Rabadán P, Alcalá L, Cercenado E, Calatayud L, Liñares J, Bouza E. Systematic use of universal 16S rRNA gene polymerase chain reaction (PCR) and sequencing for processing pleural effusions improves conventional culture techniques. Medicine (Baltimore) 2012; 91:103-110. [PMID: 22391472 DOI: 10.1097/md.0b013e31824dfdb0] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Conventional culture of pleural fluid samples frequently provides false-negative results. Universal polymerase chain reaction (PCR) of the 16S ribosomal ribonucleic acid (rRNA) gene (16S PCR) has proven useful in the diagnosis of various bacterial infections. We conducted a prospective study to assess the value of 16S PCR in the etiologic diagnosis of pleural effusion. All pleural fluid samples received for culture were also studied using 16S PCR. Positive samples were sequenced for identification. Clinical records and conventional culture results were analyzed to classify pleural fluid samples as infected or not infected. We studied 723 samples. We excluded 188 samples because they were obtained from a long-term chest tube, there was a diagnosis of mycobacterial infection, or there were insufficient data to classify the episode. Finally, 535 pleural fluid samples were analyzed. According to our criteria, 82 (15.3%) were infected and 453 (84.7%) were not infected. In the infected samples, 16S PCR was positive in 67 samples (81.7%) while conventional culture was positive in 45 (54.9%). There were 4 false positives with 16S PCR (0.9%) and 12 with culture (2.6%). The values for the etiologic diagnosis of bacterial pleural effusion of conventional culture compared with 16S PCR were as follows: sensitivity, 54.9%/81.7%; specificity, 97.4%/99.1%; positive predictive value, 76.3%/94.4%; negative predictive value, 92.6%/96.8%; and accuracy, 90.8%/96.5%.When compared with conventional culture, 16S PCR plus sequencing substantially improves the etiologic diagnosis of infectious pleural effusion. In our opinion, this technique should be added to the routine diagnostic armamentarium of clinical microbiology laboratories.
Collapse
Affiliation(s)
- Rosario Insa
- From the Clinical Microbiology and Infectious Diseases Department (RI, MM, AM, PMR, LA, EC, EB), Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid; CIBER de Enfermedades Respiratorias (CIBERES) (MM, PMR, LA, EC, LC, JL, EB), Palma de Mallorca; Red Española de Investigación en Patología Infecciosa (REIPI) (MM, PMR, LA, EC, JL, EB); and Hospital Universitario de Bellvitge (LC, JL), Barcelona, Spain
| | | | | | | | | | | | | | | | | |
Collapse
|
19
|
|
20
|
Bewick T, Lim WS. Diagnosis of community-acquired pneumonia in adults. Expert Rev Respir Med 2010; 3:153-64. [PMID: 20477309 DOI: 10.1586/ers.09.3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Community-acquired pneumonia (CAP) is a common presentation to both primary and secondary care, representing approximately 5% of the acute medical intake in the UK. Treatment is often based on an empirical approach, using broad-spectrum antibiotic regimens, with which the majority of patients will achieve clinical cure. However, in cases of severe CAP, initial treatment failure or severe comorbidity, a more rigorous diagnostic approach is required. This review assesses the evidence base behind the common diagnostic methods for CAP, and presents the case for a rapid and accurate microbiological and radiological diagnosis in improving management and outcomes of this common condition.
Collapse
Affiliation(s)
- Thomas Bewick
- Nottingham University Hospitals NHS Trust, David Evans Building, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK.
| | | |
Collapse
|
21
|
McGrath EE, Blades Z, Needham J, Anderson PB. A systematic approach to the investigation and diagnosis of a unilateral pleural effusion. Int J Clin Pract 2009; 63:1653-9. [PMID: 19765100 DOI: 10.1111/j.1742-1241.2009.02068.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Fluid in the pleural space is a common sequela of a wide range of diseases which may be pulmonary, pleural or extrapulmonary. As the differential diagnosis is wide, a systematic approach to investigation and diagnosis is recommended. This review highlights the important features and recommendations for the investigation of a unilateral pleural effusion, a common condition encountered by the general physician. The aim of this study was to assist with a speedy diagnosis of the underlying pathology, using appropriate investigative techniques, while minimising the use of invasive procedures.
Collapse
Affiliation(s)
- E E McGrath
- Department of Respiratory Medicine, Northern General Hospital, Sheffield S5 7AU, UK.
| | | | | | | |
Collapse
|
22
|
Kuboi S, Nomura H. Clinical background of cases showing a positive culture of pleural effusion at Shin-Kokura Hospital over a period of 5 years. J Infect Chemother 2006; 12:264-8. [PMID: 17109089 DOI: 10.1007/s10156-006-0459-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2006] [Accepted: 06/27/2006] [Indexed: 10/23/2022]
Abstract
We investigated the clinical background of patients at Shin-Kokura Hospital who showed a positive culture of pleural effusion during the period from January 1998 through December 2002. Microorganism cultures of the pleural effusions of 127 patients were performed in this 5-year period. Seventeen patients showed a positive microorganism culture from a pleural effusion, and 12 of these patients (70.6%) were 60 years old or more. Ten patients were diagnosed with thoracic empyema. Thirteen patients had an underlying disease such as malignancy (5 cases), diabetes mellitus (4 cases), etc. A purulent effusion and a high concentration of lactic dehydrogenase (LDH) in the pleural fluid were more frequently recognized in the positive-culture group. A total of 21 strains of microorganism were isolated from the 17 patients, including 10 strains of Gram-positive cocci, 6 strains of Gram-negative bacilli, 3 strains of anaerobes, 1 strain of mycobacterium (Mycobacterium tuberculosis), and 1 strain of fungus. Susceptibility to antimicrobial agents was generally good for most of the microorganisms isolated. Of the 17 patients, chest-tube drainage was performed in 13, and 6 needed a surgical operation. Twelve patients improved, but 5 died. In this study, thoracic empyema accounted for 58.8% of the 17 cases with a positive culture of pleural effusion. Of the 10 thoracic empyema patients, 5 patients needed surgical treatment in spite of adequate antimicrobial treatment and chest-tube drainage. Our data indicate that thoracic empyema is still difficult to treat, and thus adequate and rapid treatment is needed for any pleural infection.
Collapse
Affiliation(s)
- Satoshi Kuboi
- Department of Internal Medicine, Shin-Kokura Hospital, 1-3-1 Kanada, Kokurakita-ku, Kitakyushu, 803-8505, Japan.
| | | |
Collapse
|
23
|
Abstract
Parapneumonic effusion is a common clinical problem, and those that go on to develop pleural infection have high morbidity and mortality. The process of pleural infection evolution involves changes in pleural physiology that are increasingly being elucidated and understood. The microbiology of pleural infection has changed over recent years, with clear differences emerging between hospital- and community-acquired infections. Using biochemical surrogates of infection, chest drainage can be undertaken rationally for those who do not respond to antibiotics alone. Recent data suggest that fibrinolytics do not influence outcomes in pleural infection. The optimal type and timing of surgery remain controversial.
Collapse
Affiliation(s)
- Najib M Rahman
- Oxford Pleural Diseases Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital Site, Oxford Radcliffe Hospital, Headington, Oxford OX3 7LJ, UK.
| | | | | |
Collapse
|
24
|
Jiménez D, Díaz G, García-Rull S, Vidal R, Sueiro A, Light RW. Routine use of pleural fluid cultures. Are they indicated? Limited yield, minimal impact on treatment decisions. Respir Med 2006; 100:2048-52. [PMID: 16584878 DOI: 10.1016/j.rmed.2006.02.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2005] [Revised: 01/13/2006] [Accepted: 02/10/2006] [Indexed: 11/19/2022]
Abstract
In pleural infection, it has been recommended that Gram stain and cultures should be obtained on a routine basis. However, this recommendation has not been tested prospectively. We evaluated the yield of microbiological studies in 259 patients with parapneumonic pleural effusion. Microbiological studies were positive on the pleural fluid of 50 patients (19.3%). In 48 of the 50 patients with positive microbiological results (96%), the need for pleural drainage was correctly predicted by pleural fluid parameters. There were no differences in hospital stay (9.5+/-2.5 days versus 9.9+/-3.2 days, P=0.68) or in mortality (2 deaths in each group, P=0.58) between the group of patients in which antibiotic treatment was changed according to microbiological results and the group of patients in which it is not. In conclusion, this study demonstrates that, at least in our institution, routine microbial investigation of pleural fluid adds very little to the standard management of parapneumonic effusions.
Collapse
Affiliation(s)
- D Jiménez
- Respiratory Department, Hospital Ramón y Cajal, Madrid, Spain.
| | | | | | | | | | | |
Collapse
|
25
|
Abstract
Pleural infection remains a common illness, with a high morbidity and mortality. The development of frank empyema from a simple exudative pleural effusion is a result of biochemical changes within the pleural space in response to bacterial invasion. These changes can be used in the diagnosis of pleural infection and used to predict which patients will require intercostal drainage for resolution of infection. Recent large trials in empyema have further advanced our knowledge of microbiologic patterns, informing important decisions about empiric antibacterial therapy. Diagnosis of pleural infection relies on high clinical suspicion in association with clinical features, radiology, and pleural fluid characteristics. Treatment of pleural infection is based upon accurate and often empiric choice of antibacterial agents, intercostal drainage in certain contexts, and appropriate surgical referral. Intrapleural thrombolytic therapy is not currently recommended for the treatment of pleural infection, on the basis of evidence from the largest randomized trial in empyema to date.
Collapse
Affiliation(s)
- Najib M Rahman
- Oxford Centre for Respiratory Medicine, Headington, Oxford, England
| | | | | |
Collapse
|
26
|
Soriano T, Alegre J, Alemán C, Ruiz E, Vázquez A, Carrasco JL, Segura R, Ferrer A, Fernández de Sevilla T. Factors Influencing Length of Hospital Stay in Patients with Bacterial Pleural Effusion. Respiration 2005; 72:587-93. [PMID: 16106111 DOI: 10.1159/000087366] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2004] [Accepted: 12/08/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Factors influencing length of hospital stay have been poorly analyzed in parapneumonic pleural effusions (PPE). OBJECTIVES The aim of this work is to identify the variables that determine increased hospital stay in patients with infectious pleural effusion (PE). PATIENTS AND METHODS We analyzed 112 patients with PE: empyema, complicated parapneumonic and non-complicated parapneumonic. Epidemiologic, biochemical, therapeutic and radiological variables were analyzed. Correlations with hospital stay were studied using the Student's t test, analysis of variance, Mann-Whitney U-test and linear regression model. RESULTS Among the 112 patients studied, there were 32 empyema, 50 complicated and 30 non-complicated parapneumonic cases. The median of length stay for all patients was 17 days. Longer hospitalization was required in patients with empyemic PE (p = 0.015), patients with underlying diseases (p = 0.003), those needing pleural drainage (p = 0.005) or decortication (p = 0.043) and those presenting unfavorable radiological outcome after treatment (p = 0.02). Biochemical parameters associated with longer hospital stay were elevated pleural fluid polymorphonuclear elastase (p = 0.001, r = 0.307) and lactate dehydrogenase (p = 0.001, r = 0.312). After linear regression analysis, only underlying disease, pleural drainage and pleural fluid polymorphonuclear elastase values remained in the model, explaining 23.1% of the variability of days of hospitalization. CONCLUSIONS The patients with PPE and empyema who required longer hospitalization were those with purulent fluid, underlying disease, surgical drainage and/or decortication, with unfavorable radiological outcome and higher pleural fluid levels of lactate dehydrogenase and polymorphonuclear elastase.
Collapse
Affiliation(s)
- T Soriano
- Department of Internal Medicine, Vall d'Hebrón General Teaching Hospital, Mare de Deu dels Angels 50-54, 5o-9a, ES-08035 Barcelona, Spain.
| | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Barnes TW, Olson EJ, Morgenthaler TI, Edson RS, Decker PA, Ryu JH. Low Yield of Microbiologic Studies on Pleural Fluid Specimens. Chest 2005; 127:916-21. [PMID: 15764776 DOI: 10.1378/chest.127.3.916] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND It is generally recommended that pleural fluid samples from pleural effusions of unknown cause be cultured for bacteria, mycobacteria, and fungi. However, the utility of this practice has been not been adequately assessed. DESIGN Retrospective review. SETTING Tertiary care, referral medical center. PATIENTS Five hundred twenty-five patients undergoing diagnostic thoracentesis at Mayo Medical Center, Rochester, MN, over a 12-month period from July 1, 2001, to June 30, 2002. INTERVENTIONS None. MEASUREMENTS AND RESULTS Among 525 patients undergoing diagnostic thoracenteses, 476 patients (91%) had one or more cultures performed on their pleural fluid specimens. Thirty-nine positive results (3.0% of 1,320 cultures) occurred in 35 of these 476 patients (7.4%). After excluding likely contaminants, true pathogens were identified in only 19 of 1,320 pleural fluid cultures (1.4%) belonging to 15 patients (3.2% of those who had cultures performed on their pleural fluid specimen). These positive results included 2.3% of aerobic bacterial, 1.2% of anaerobic bacterial, 1.4% of fungal, and 0% of mycobacterial cultures. Microbiologic smears performed on these pleural fluid samples included 357 Gram stains, 109 fungal smears (potassium hydroxide), and 232 acid-fast smears with positive yields of 2.5%, 0%, and 0%, respectively. These positive findings represented 1.3% of all smears performed. Of the specimens obtained from outpatient thoracenteses, only one had a true-positive result (0.8%). Only 1.1% (four specimens) of the cultures performed on free-flowing effusions demonstrated true pathogens; three of these four specimens grew fungi. CONCLUSIONS The positive yield of microbiologic smears and cultures on pleural fluid specimens is low, particularly in the outpatient setting and in patients with free-flowing effusions. Microbiologic testing of pleural fluid specimens should be ordered more selectively.
Collapse
Affiliation(s)
- Terrance W Barnes
- Division of Pulmonary and Critical Care Medicine, Desk East 18, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | | | | | | | | | | |
Collapse
|
28
|
Abstract
Pleural infection is responsible for significant morbidity and mortality worldwide, and its clinical management is challenging. The diagnosis of empyema and tuberculous pleurisy may be difficult, and these conditions may be confused with other causes of exudative pleural effusions. Complicated parapneumonic effusion or empyema may present with 'atypical' clinical features; delays in diagnosis are common and may contribute to the high mortality of these infections. Pleural aspiration is the key diagnostic step; pleural fluid that is purulent or that has a pH < 7.2, or organisms on Gram stain or culture, is an indication for formal intercostal drainage. In order to achieve a definitive diagnosis of tuberculous pleurisy, Mycobacterium tuberculosis must be isolated in the culture of pleural fluid, pleural tissue or sputum; demonstration of granulomas in pleural tissue is also suggestive of tuberculosis. The use of pleural fluid biochemical markers, such as adenosine deaminase, in the diagnosis of tuberculous pleurisy varies among clinicians; the diagnostic value of such markers is affected by the background prevalence of tuberculosis and the likelihood of an alternative diagnosis. Uncertainties also remain regarding the treatment of pleural infection. Treatment of complicated parapneumonic effusion and empyema involves prolonged courses of antibiotics and attention to the patient's nutritional state. The role of intrapleural fibrinolytics and the optimal timing of surgical intervention are unknown. The lack of clear predictors of clinical outcome in empyema contributes to the difficulty in treating this condition. The pharmacological treatment of tuberculous pleurisy is the same as for pulmonary tuberculosis; the precise role of steroids in the treatment of tuberculous pleurisy remains uncertain.
Collapse
Affiliation(s)
- Stephen J Chapman
- Wellcome Trust Centre for Human Genetics, Oxford University, Oxford, UK.
| | | |
Collapse
|
29
|
Abstract
PURPOSE OF REVIEW Complicated parapneumonic effusion and empyema continue to account for significant morbidity and mortality, and uncertainties remain regarding their optimal management. This review describes recent advances in this field, as well as areas for future research. RECENT FINDINGS Recent advances have addressed the pathogenesis, bacteriology, and treatment of pleural infection. Key areas for research in the development of empyema include the interplay between inflammatory and coagulation cascades and development of fibrosis within the pleural space. The varied bacteriology of empyema has been more clearly defined, and in particular the differences between community- and hospital-acquired infection highlighted. Studies of treatment have focused particularly on the roles of intrapleural fibrinolytics and surgery. SUMMARY Increased understanding of the pathogenesis of empyema may ultimately yield novel therapeutic targets. Comprehensive descriptions of the bacteriology of empyema aids antibiotic choice, and the use of intrapleural DNase shows promise in facilitating drainage of infected pleural fluid. Uncertainties remain, such as the role of intrapleural fibrinolytics and the optimal timing of surgical intervention.
Collapse
Affiliation(s)
- Stephen J Chapman
- Oxford Pleural Diseases Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK.
| | | |
Collapse
|
30
|
Maskell NA, Butland RJA. BTS guidelines for the investigation of a unilateral pleural effusion in adults. Thorax 2003; 58 Suppl 2:ii8-17. [PMID: 12728146 PMCID: PMC1766019 DOI: 10.1136/thorax.58.suppl_2.ii8] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- N A Maskell
- Oxford Centre for Respiratory Medicine, Churchill Hospital Site, Oxford Radcliffe Hospital, Headington, Oxford OX3 7LJ, UK.
| | | |
Collapse
|
31
|
Azoulay E, Fartoukh M, Galliot R, Baud F, Simonneau G, Le Gall JR, Schlemmer B, Chevret S. Rapid diagnosis of infectious pleural effusions by use of reagent strips. Clin Infect Dis 2000; 31:914-9. [PMID: 11049770 DOI: 10.1086/318140] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/1999] [Revised: 02/16/2000] [Indexed: 12/24/2022] Open
Abstract
Reagent strips have not yet been tested for use in the diagnosis of infectious pleural effusions. A reagent strip was used to evaluate 82 patients with pleural effusions: 20 patients had transudative effusions, 35 had infectious exudative effusions (empyema in 14 and parapneumonic effusion in 21), and 27 had noninfectious exudative effusions. Pleural fluid protein, as evaluated by the reagent strip, proved accurate for the detection of exudative effusions (sensitivity, 93.1%; specificity, 50%; positive predictive value, 84.3%; negative predictive value, 71.5%; odds ratio [OR], 6.77; and 95% confidence interval [CI], 1.87-24). The reagent strip leukocyte esterase test effectively detected infectious exudative effusions (sensitivity, 42.8%; specificity, 91.3%; positive predictive value, 88.2%; negative predictive value, 51.2%; OR, 4.46; and 95% CI, 1.2-16.4). Pleural pH was significantly predicted by the reagent strip but was of no assistance in categorization of exudative effusions as infectious or noninfectious. Compared with physical, laboratory, and microbiological data, the reagent strip was as accurate for estimation of percentages of infectious and noninfectious exudative effusions. Thus, reagent strips may be a rapid, easy-to-use, and inexpensive technique for discriminating transudative from exudative pleural effusions and for categorizing exudative pleural effusions as infectious or noninfectious.
Collapse
Affiliation(s)
- E Azoulay
- Medical Intensive Care Unit, Saint Louis Teaching Hospital, Paris 7 University, France.
| | | | | | | | | | | | | | | |
Collapse
|