Pleural Effusions at First ED Encounter Predict Worse Clinical Outcomes in Patients With Pneumonia

Clinical characteristics of community-acquired primary pleural infection compared to postpneumonic pleural infection: a retrospective study

BACKGROUND

Data on the clinical features and treatment outcomes in patients with primary pleural infection (PI) are limited. This study aimed to investigate the clinical characteristics of these patients.

PATIENTS AND METHODS

In this retrospective study, patients with community-acquired PI, diagnosed based on pleural fluid analysis, were classified into postpneumonic and primary PI groups according to computed tomography (CT) findings. Clinical variables, microbiological data, and CT findings were compared between the two groups.

RESULTS

Approximately 28 % of patients with community-acquired PI presented as primary PI. Treatment success rates and in-hospital or 30-day mortality were comparable between the two groups. However, compared to the postpneumonic PI group, the primary PI group was significantly younger and had lower proportions of patients with Pneumonia Severity Index classes 4-5 and RAPID (Renal, Age, Purulence, Infection source, and Dietary factors) score >3. On CT scans, subpleural abscesses were present in less than half of the patients in the primary PI group, compared to most patients in the postpneumonic PI group. Pleural enhancement and extrapleural fat proliferation were more frequently observed in patients with primary PI than in those with postpneumonic PI. In the primary PI group, Streptococcus anginosus group was the most common pathogen, accounting for nearly half of the causative organisms.

CONCLUSIONS

Patients with primary PI had similar treatment outcomes compared to those with postpneumonic PI. However, different causative pathogens and radiologic findings of primary PI suggest a distinct pathogenesis of PI independent of pneumonia.

A retrospective review of concurrent versus sequential administration of intrapleural tissue plasminogen activator and dornase alfa for empyemas

BACKGROUND

Intrapleural tissue plasminogen activator (tPA) and dornase alfa (DNase) administered sequentially, separated by a one to 2 h interval, is a mainstay of pleural infection treatment. Recent literature supports similar efficacy and safety of concurrent therapy (administered immediately after one another). Insufficient evidence are available to utilize concurrent therapy routinely.

OBJECTIVE

The primary objective of this study was to assess the safety and effectiveness of concurrent versus sequential intrapleural tPA and DNase in pleural infections.

METHODS

This was a single-center, retrospective study of patients ≥18 years old admitted to the inpatient setting who received either concurrent or sequential intrapleural tPA or DNase between July 1, 2014, and January 1, 2023. The primary outcome was treatment failure, a composite of 30-day mortality and requirement for a video-assisted thoracoscopic surgery (VATS). Secondary outcomes included cumulative pleural fluid drainage, bleeding adverse events, and pain requiring analgesia dose escalation.

RESULTS

A total of 184 patients were included: 158 patients in the concurrent group and 26 patients in the sequential group. Treatment failure was similar between groups (18.4 % vs 19.2 %, P > 0.99). Increased pleural fluid drainage occurred in the concurrent versus sequential therapy group (1453 mL vs 836 mL, P = 0.05) with no differences in bleeding (23.4 % vs 19.2 %, P = 0.64) or analgesia dose escalation between groups (41.1 % vs 23.1 %, P = 0.09).

CONCLUSION AND RELEVANCE

Concurrent intrapleural fibrinolytics have similar effectiveness and safety compared to sequential administration however, further investigation into the compatibility and stability of the medications is warranted to optimize future pleural infection management.

Pleural Infection: Diagnosis, Management, and Future Directions

Pleural infection represents a significant and ongoing challenge for patients, clinicians, and healthcare providers given the morbidity and mortality associated with this condition. Whilst our understanding of how pleural infection develops and how it should be treated has improved considerably over the past couple of decades, this has yet to translate into a meaningful positive impact on key outcomes. Making the diagnosis of pleural infection is not always straightforward, and the long-standing belief that it always occurs as a complication of lung parenchymal infection is being increasingly recognised as incorrect. Identifying the causative organism(s) is equally uncertain, with almost half of cases of pleural infection proving to be culture negative using traditional methods. Whilst we are now able to determine which patients are more likely to have a poor outcome from their pleural infection at the time of diagnosis, how this should affect their treatment pathway-including the role of more invasive strategies such as surgery or intrapleural enzyme therapy-is not yet known. This review article aims to summarise the existing evidence base and best clinical practice for the non-specialist, whilst highlighting recent research which has or will change the way we manage pleural infection, as well as those areas where further studies are still needed.

Parapneumonic effusion is a risk factor for VTE in hospitalized patients with community-acquired pneumonia: a retrospective cohort study

BACKGROUND

Venous thromboembolism (VTE) is a major, frequent, and potentially fatal health issue worldwide. Community-acquired pneumonia (CAP) is one of the leading causes of hospitalization and parapneumonic pleural effusion (PPE) is a relatively common complication of pneumonia. Whether PPE is a risk factor for VTE in hospitalized patients with CAP has not been studied before.

METHODS

We retrospectively reviewed all patients diagnosed with CAP admitted to our center from 1 January to 31 August in 2019. The clinical and laboratory data were collected from medical records. Univariate and multivariable logistic regression analysis were used to assess the VTE related risk factors. Subgroup analysis was conducted to investigate the potential correlation between PPE and VTE among distinct subsets of hospitalized patients diagnosed with CAP.

RESULTS

This retrospective cohort study included 703 inpatients and 73 patients were confirmed VTE. In multivariable logistic regression analysis, PPE, age, sex, gender, D-dimer, and pneumonia severity index score, were significantly correlated with VTE. Several laboratory parameters within the PPE group demonstrated significant elevated levels compared to the non-PPE cohort, encompassing inflammatory markers such as neutrophils, C reaction protein, D-dimer, as well as some coagulation indicators including platelets, and prothrombin time.

CONCLUSION

PPE is an independent risk factor for hospitalized CAP patients. The patients with PPE have a higher level of inflammation response. Medical clinicians should pay more attention to VTE and improve its prevention and therapeutic strategies among hospitalized CAP patients.

Clinical outcome of urgent thoracoscopic surgery on complicated parapneumonic infection with short-term preoperative antibiotic usage

Background

Prompt initiation of antibiotics and drainage of infection source is essential in the management of pleural cavity infection. Although surgical drainage is considered a gold standard of treatment for unresolved parapneumonic infection, optimal timing for surgical intervention is still under debate. Thus, we seek to analyze the clinical outcomes of urgent thoracoscopic surgery for complicated parapneumonic effusion regarding the duration of preoperative antibiotic usage.

Methods

Medical records were retrospectively reviewed for patients who received thoracoscopic surgery for complicated parapneumonic effusion or empyema. Patients were grouped according to the preoperative antibiotic durations and compared. Group A consists of the patients with less than 3 days of preoperative antibiotics usage and Group B consists of those with more than 3 days of preoperative antibiotic coverage. Basic demographics, preoperative chest computed tomography (CT) findings, antibiotics usage, duration until surgery and treatment outcomes were evaluated.

Results

From February 2008 to November 2018, a total of 180 patients underwent video-assisted thoracoscopic surgery (VATS) for pleural drainage or decortication of lung. Group A patients had higher C-reactive protein value (240 vs. 192 mg/L, P=0.003) and were given significantly shorter duration of total antibiotics (9 vs. 14 days, P<0.001). The median duration of postoperative chest tube indwelling time (5 vs. 5 days, P=0.38), postoperative hospital stays (8 vs. 8 days, P=0.56), operation time (105 vs. 105 min, P=0.88) showed no significant difference between the groups. CT images of Group A patients showed a significantly higher rate of multi-loculation (83 vs. 59, P=0.008) and interlobar effusions (64 vs. 42, P=0.02). There were two postoperative mortalities and four recurrences.

Conclusions

Faster and relatively safe and successful clinical outcomes can be achieved with urgent thoracoscopic surgery on patients with complicated parapneumonic effusion despite limited duration of antibiotics coverage.

Risk factors for pleural effusion in children with plastic bronchitis caused by pneumonia

Objective

We aimed to investigate the clinical features of children with plastic bronchitis caused by pneumonia, and assess the risk factors for pleural effusion (PE) in plastic bronchitis.

Methods

A retrospective study was conducted on children with plastic bronchitis and hospitalized in Xiamen Children's Hospital from January 2017 to April 2023. Participants were categorized based on the presence of PE. Their clinical manifestations and laboratory findings were analyzed.

Results

Sixty-nine children with plastic bronchitis were enrolled: 34 cases (49.27%) in the non-PE group and 35 cases (50.72%) in the PE group. No significant differences were found in sex, age, and etiology between the two groups. Significant differences were found in fever duration, C-reactive protein (CRP), albumin and lactate dehydrogenase (LDH) ( p < 0.05 ). A receiver operating characteristic (ROC) curve analysis showed that the cut-off values for higher risk of PE were CRP > 31.66  mg/L or LDH > 551  U/L. The prediction of PE was performed with the combination of CRP > 31.66  mg/L and LDH > 551  U/L, using multivariate logistic regression analysis. The area under the curve (AUC) for logistic regression was 0.797. Elevated CRP increased the risk of PE (odds ratio [OR] 8.358, 95% confidence interval [CI] 2.179-42.900, p = 0.0042 ), elevated LDH increased the risk of PE (OR 5.851 [95% CI 1.950-19.350], p = 0.0023 ).

Conclusion

The combined detection of CRP and LDH helps predict the risk of PE in children with plastic bronchitis caused by pneumonia.

Ultrasound and Intrapleural Enzymatic Therapy for Complicated Pleural Effusion: A Case Series with a Literature Review

Pleural effusion is the most common manifestation of pleural disease, and chest ultrasound is crucial for diagnostic workup and post-treatment monitoring. Ultrasound helps distinguish the various types of pleural effusion and enables the detection of typical manifestations of empyema, which presents as a complicated, septated effusion. This may benefit from drainage and the use of intrapleural enzyme therapy or may require more invasive approaches, such as medical or surgical thoracoscopy. The mechanism of action of intrapleural enzymatic therapy (IPET) is the activation of plasminogen to plasmin, which breaks down fibrin clots that form septa or the loculation of effusions and promotes their removal. In addition, IPET has anti-inflammatory properties and can modulate the immune response in the pleural space, resulting in reduced pleural inflammation and improved fluid reabsorption. In this article, we briefly review the literature on the efficacy of IPET and describe a case series in which most practical applications of IPET are demonstrated, i.e., as a curative treatment but also as an alternative, propaedeutic, or subsequent treatment to surgery.

Front-door thoracic ultrasound in patients with community-acquired pneumonia to diagnose and predict pleural infection: a prospective study

The incidence of parapneumonic effusions is higher than previously estimated when thoracic ultrasound is used as a diagnostic tool. TUS may have a role in prognostication and prediction of pleural infection, and this requires further evaluation. https://bit.ly/3UkV7nQ.

ICU Utilization After Implementation of Minor Severe Pneumonia Criteria in Real-Time Electronic Clinical Decision Support

OBJECTIVES

To determine if the implementation of automated clinical decision support (CDS) with embedded minor severe community-acquired pneumonia (sCAP) criteria was associated with improved ICU utilization among emergency department (ED) patients with pneumonia who did not require vasopressors or positive pressure ventilation at admission.

DESIGN

Planned secondary analysis of a stepped-wedge, cluster-controlled CDS implementation trial.

SETTING

Sixteen hospitals in six geographic clusters from Intermountain Health; a large, integrated, nonprofit health system in Utah and Idaho.

PATIENTS

Adults admitted to the hospital from the ED with pneumonia identified by: 1) discharge International Classification of Diseases , 10th Revision codes for pneumonia or sepsis/respiratory failure and 2) ED chest imaging consistent with pneumonia, who did not require vasopressors or positive pressure ventilation at admission.

INTERVENTIONS

After implementation, patients were exposed to automated, open-loop, comprehensive CDS that aided disposition decision (ward vs. ICU), based on objective severity scores (sCAP).

MEASUREMENTS AND MAIN RESULTS

The analysis included 2747 patients, 1814 before and 933 after implementation. The median age was 71, median Elixhauser index was 17, 48% were female, and 95% were Caucasian. A mixed-effects regression model with cluster as the random effect estimated that implementation of CDS utilizing sCAP increased 30-day ICU-free days by 1.04 days (95% CI, 0.48-1.59; p < 0.001). Among secondary outcomes, the odds of being admitted to the ward, transferring to the ICU within 72 hours, and receiving a critical therapy decreased by 57% (odds ratio [OR], 0.43; 95% CI, 0.26-0.68; p < 0.001) post-implementation; mortality within 72 hours of admission was unchanged (OR, 1.08; 95% CI, 0.56-2.01; p = 0.82) while 30-day all-cause mortality was lower post-implementation (OR, 0.71; 95% CI, 0.52-0.96; p = 0.03).

CONCLUSIONS

Implementation of electronic CDS using minor sCAP criteria to guide disposition of patients with pneumonia from the ED was associated with safe reduction in ICU utilization.

Pleural macrophages translocate to the lung during infection to promote improved influenza outcomes

Seasonal influenza results in 3 to 5 million cases of severe disease and 250,000 to 500,000 deaths annually. Macrophages have been implicated in both the resolution and progression of the disease, but the drivers of these outcomes are poorly understood. We probed mouse lung transcriptomic datasets using the Digital Cell Quantifier algorithm to predict immune cell subsets that correlated with mild or severe influenza A virus (IAV) infection outcomes. We identified a unique lung macrophage population that transcriptionally resembled small serosal cavity macrophages and whose presence correlated with mild disease. Until now, the study of serosal macrophage translocation in the context of viral infections has been neglected. Here, we show that pleural macrophages (PMs) migrate from the pleural cavity to the lung after infection with IAV. We found that the depletion of PMs increased morbidity and pulmonary inflammation. There were increased proinflammatory cytokines in the pleural cavity and an influx of neutrophils within the lung. Our results show that PMs are recruited to the lung during IAV infection and contribute to recovery from influenza. This study expands our knowledge of PM plasticity and identifies a source of lung macrophages independent of monocyte recruitment and local proliferation.

Diagnosis and management of pleural infection

Pleural infection remains a medical challenge. Although closed tube drainage revolutionised treatment in the 19th century, pleural infection still poses a significant health burden with increasing incidence. Diagnosis presents challenges due to non-specific clinical presenting features. Imaging techniques such as chest radiographs, thoracic ultrasound and computed tomography scans aid diagnosis. Pleural fluid analysis, the gold standard, involves assessing gross appearance, biochemical markers and microbiology. Novel biomarkers such as suPAR (soluble urokinase plasminogen activator receptor) and PAI-1 (plasminogen activator inhibitor-1) show promise in diagnosis and prognosis, and microbiology demonstrates complex microbial diversity and is associated with outcomes. The management of pleural infection involves antibiotic therapy, chest drain insertion, intrapleural fibrinolytic therapy and surgery. Antibiotic therapy relies on empirical broad-spectrum antibiotics based on local policies, infection setting and resistance patterns. Chest drain insertion is the mainstay of management, and use of intrapleural fibrinolytics facilitates effective drainage. Surgical interventions such as video-assisted thoracoscopic surgery and decortication are considered in cases not responding to medical therapy. Risk stratification tools such as the RAPID (renal, age, purulence, infection source and dietary factors) score may help guide tailored management. The roles of other modalities such as local anaesthetic medical thoracoscopy and intrapleural antibiotics are debated. Ongoing research aims to improve outcomes by matching interventions with risk profile and to better understand the development of disease.

Associating a standardized reporting tool for chest radiographs with clinical complications in pediatric acute chest syndrome

BACKGROUND

Acute chest syndrome (ACS) is an important cause of morbidity in sickle cell disease (SCD). A standardized tool for reporting chest radiographs in pediatric SCD patients did not previously exist.

OBJECTIVE

To analyze the interobserver agreement among pediatric radiologists' interpretations for pediatric ACS chest radiographs utilizing a standardized reporting tool. We also explored the association of radiographic findings with ACS complications.

METHODS

This was a retrospective cohort study of pediatric ACS admissions from a single institution in 2019. ICD-10 codes identified 127 ACS admissions. Two radiologists independently interpreted the chest radiographs utilizing a standardized reporting tool, a third radiologist adjudicated discrepancies, and κ analysis assessed interobserver agreement. Clinical outcomes were correlated with chest radiograph findings utilizing Pearsons' χ2 , t tests, and Mann-Whitney U tests. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated.

RESULTS

Interobserver agreement was moderate to near-perfect across variables, with κ analysis showing near-perfect agreement for opacity reported in the right upper lobe (0.84), substantial agreement for right lower lobe (0.63), and vertebral bony changes (0.72), with moderate agreement for all other reported variables. On the initial chest radiograph, an opacity located in the left lower lobe (LLL) correlated with pediatric intensive care unit transfer (p = .03). Pleural effusion on the initial chest radiograph had a 3.98 OR (95% CI: 1.35-11.74) of requiring blood products and a 10.67 OR (95% CI: 3.62-31.39) for noninvasive ventilation.

CONCLUSION

The standardized reporting tool showed moderate to near-perfect agreement between radiologists. LLL opacity, and pleural effusion were associated with increased risk of ACS complications.

A Deep Learning Model Using Chest Radiographs for Prediction of 30-Day Mortality in Patients With Community-Acquired Pneumonia: Development and External Validation

BACKGROUND. Chest radiography is an essential tool for diagnosing community-acquired pneumonia (CAP), but it has an uncertain prognostic role in the care of patients with CAP. OBJECTIVE. The purpose of this study was to develop a deep learning (DL) model to predict 30-day mortality from diagnosis among patients with CAP by use of chest radiographs to validate the performance model in patients from different time periods and institutions. METHODS. In this retrospective study, a DL model was developed from data on 7105 patients from one institution from March 2013 to December 2019 (3:1:1 allocation to training, validation, and internal test sets) to predict the risk of all-cause mortality within 30 days after CAP diagnosis by use of patients' initial chest radiographs. The DL model was evaluated in a cohort of patients diagnosed with CAP during emergency department visits at the same institution from January 2020 to March 2020 (temporal test cohort [n = 947]) and in two additional cohorts from different institutions (external test cohort A [n = 467], January 2020 to December 2020; external test cohort B [n = 381], March 2019 to October 2021). AUCs were compared between the DL model and an established risk prediction tool based on the presence of confusion, blood urea nitrogen level, respiratory rate, blood pressure, and age 65 years or older (CURB-65 score). The combination of CURB-65 score and DL model was evaluated with a logistic regression model. RESULTS. The AUC for predicting 30-day mortality was significantly larger (p < .001) for the DL model than for CURB-65 score in the temporal test set (0.77 vs 0.67). The larger AUC for the DL model than for CURB-65 score was not significant (p > .05) in external test cohort A (0.80 vs 0.73) or external test cohort B (0.80 vs 0.72). In the three cohorts, the DL model, in comparison with CURB-65 score, had higher (p < .001) specificity (range, 61-69% vs 44-58%) at the sensitivity of CURB-65 score. The combination of DL model and CURB-65 score, in comparison with CURB-65 score, yielded a significant increase in AUC in the temporal test cohort (0.77, p < .001) and external test cohort B (0.80, p = .04) and a nonsignificant increase in AUC in external test cohort A (0.80, p = .16). CONCLUSION. A DL-based model consisting of initial chest radiographs was predictive of 30-day mortality among patients with CAP with improved performance over CURB-65 score. CLINICAL IMPACT. The DL-based model may guide clinical decision-making in the care of patients with CAP.

Empyema necessitans in a pediatric patient: A case study

INTRODUCTION AND IMPORTANCE

Empyema necessitans is a rare and severe complication of pleural effusion characterized by the extension of purulent material from the pleural cavity into the surrounding soft tissues, resulting in the formation of a subcutaneous abscess.

CASE PRESENTATION

A one-year-old boy presented with symptoms that were in line with empyema necessitans, and Escherichia coli was shown to be the causative organism. A successful outcome required early detection, rapid diagnosis, and proper management, which included targeted antibiotic medication and drainage of the pleural collection. When a young patient exhibits a growing chest wall swelling, empyema necessitans should be considered in the differential diagnosis.

CLINICAL DISCUSSION

The best care for individuals with empyema necessitans requires a multidisciplinary approach comprising pediatricians, thoracic surgeons, infectious disease experts, and interventional radiologists. Escherichia coli infection requires a comprehensive approach involving antibiotic therapy and surgical intervention if necessary.

CONCLUSION

Empyema necessitans in pediatric patients, caused by Escherichia coli, is an infrequent disease that requires more investigation to enhance our understanding of the associated risk factors, optimal treatment modalities, and potential long-term consequences.

Analysis of clinical characteristics and risk factors of community-acquired pneumonia complicated by parapneumonic pleural effusion in elderly patients

BACKGROUND

Community-acquired pneumonia (CAP) patients usually present with parapneumonic pleural effusion (PPE), which complicates the treatment of pneumonia. This study aims to investigate the clinical characteristics and risk factors of elderly CAP patients hospitalised with PPE.

METHODS

The clinical data of 132 elderly patients with CAP were retrospectively analysed. A total of 54 patients with PPE (PPE group) and 78 patients without PPE (NPPE group) were included in this study. Clinical data, laboratory examinations, treatments and other relevant indicators were collected. Univariate analysis and multivariate logistic regression analysis will be used to explore the possible risk factors for PPE.

RESULTS

The proportion of PPE in elderly patients with CAP was 40.9%. PPE patients were significantly more likely to be older, have comorbid neurological diseases, experience chest tightness, and have a lasting fever (P < 0.05). In contrast to NPPE patients, the total number of lymphocytes, serum albumin and blood sodium levels in the PPE group were significantly lower (P < 0.05). The blood D-dimer, C-reactive protein and CURB-65 score of PPE patients were significantly higher (P < 0.05) than those of NPPE patients. Multivariate logistic regression identified chest tightness (OR = 3.964, 95% CI: 1.254-12.537, P = 0.019), long duration of fever (OR = 1.108, 95%CI: 1.009-1.217, P = 0.03), low serum albumin (OR = 0.876, 95%CI: 0.790- 0.971, P = 0.012) or low blood sodium (OR = 0.896, 95%CI: 0.828-0.969, P = 0.006) as independently associated with the development of parapneumonic pleural effusion in the elderly.

CONCLUSION

This study has identified several clinical factors, such as chest tightness, long duration of fever, low serum albumin, and low blood sodium, as risk factors for the development of pleural effusion in elderly patients with CAP. Early identification and prompt management of these patients can prevent inappropriate treatment and reduce morbidity and mortality.

Associations of physical activity and quality of life in parapneumonic effusion patients

Introduction

Little is known about activity behaviours and quality of life (QoL) of patients with parapneumonic pleural effusions (PPE) after hospital discharge. This study is a secondary analysis of a randomised trial (dexamethasone versus placebo) for hospitalised patients with PPE. We: 1) described the patients' activity behaviour patterns and QoL measured at discharge and at 30 days post-discharge; and 2) examined the association between activity behaviours and QoL scores.

Methods

Activity behaviour (7-day accelerometry; Actigraph GT3X+) and QoL (Medical Outcomes Study Short-Form 36) were assessed. Repeated measures analysis of covariance controlling for baseline values and a series of linear regression models were undertaken.

Results

36 out of 53 eligible participants completed accelerometry assessments. Despite modest increases in light physical activity (+7.5%) and some domains of QoL (>2 points) from discharge to 30 days post-discharge, patients had persistently high levels of sedentary behaviour (>65% of waking wear time) and poor QoL (≤50 out of 100 points) irrespective of treatment group (p=0.135-0.903). Increasing moderate-to-vigorous physical activity was associated with higher scores on most QoL domains (p=0.006-0.037). Linear regression indicates that a clinically important difference of 5 points in physical composite QoL score can be achieved by reallocating 16.1 min·day-1 of sedentary time to moderate-to-vigorous physical activity.

Conclusion

Patients with PPE had low levels of physical activity and QoL at discharge and 30 days post-discharge irrespective of treatment. Moderate-to-vigorous physical activity participation was associated with higher QoL scores. Increasing moderate-to-vigorous physical activity following discharge from the hospital may be associated with improvements in QoL.

Expert Review on Nonsurgical Management of Parapneumonic Effusion: Advances, Controversies, and New Directions

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.

Phenotyping empyema by pleural fluid culture results and macroscopic appearance: an 8-year retrospective study

Background

The clinical impact of phenotyping empyema is poorly described. This study was designed to evaluate clinical characteristics and outcomes based on the two readily available parameters, pleural fluid culture status and macroscopic fluid appearance.

Methods

A retrospective study was conducted on patients with empyema hospitalised between 2013 and 2020. Empyema was classified into culture-positive empyema (CPE) or culture-negative empyema (CNE) and pus-appearing empyema (PAE) or non-pus-appearing empyema (non-PAE) based on the pleural fluid culture status and macroscopic fluid appearance, respectively.

Results

Altogether, 212 patients had confirmed empyema (CPE: n=188, CNE: n=24; PAE: n=118, non-PAE: n=94). The cohort was predominantly male (n=163, 76.9%) with a mean age of 65.0±13.6 years. Most patients (n=180, 84.9%) had at least one comorbidity. Patients with CPE had higher rates of in-hospital mortality (19.1% versus 0.0%, p=0.017) and 90-day mortality (18.6% versus 0.0%, p=0.017) and more extrapulmonary sources of infection (29.8% versus 8.3%, p=0.026) when compared with patients with CNE. No significant difference in mortality rate was found between PAE and non-PAE during the in-hospital stay and at 30 days and 90 days. Patients with PAE had less extrapulmonary sources of infection (20.3% versus 36.2%, p=0.010) and more anaerobic infection (40.9% versus 24.5%, p=0.017) than those with non-PAE. The median RAPID (renal, age, purulence, infection source, and dietary factors) scores were higher in the CPE and non-PAE groups. After adjusting for covariates, culture positivity was not independently associated with mortality on multivariable analysis.

Conclusion

Empyema is a heterogeneous disease with different clinical characteristics. Phenotyping empyema into different subclasses based on pleural fluid microbiological results and macroscopic fluid appearance provides insight into the underlying bacteriology, source of infection and subsequent clinical outcomes.

ERS/ESTS statement on the management of pleural infection in adults

Pleural infection is a common condition encountered by respiratory physicians and thoracic surgeons alike. The European Respiratory Society (ERS) and European Society of Thoracic Surgeons (ESTS) established a multidisciplinary collaboration of clinicians with expertise in managing pleural infection with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified: 1) epidemiology of pleural infection, 2) optimal antibiotic strategy, 3) diagnostic parameters for chest tube drainage, 4) status of intrapleural therapies, 5) role of surgery and 6) current place of outcome prediction in management. The literature revealed that recently updated epidemiological data continue to show an overall upwards trend in incidence, but there is an urgent need for a more comprehensive characterisation of the burden of pleural infection in specific populations such as immunocompromised hosts. There is a sparsity of regular analyses and documentation of microbiological patterns at a local level to inform geographical variation, and ongoing research efforts are needed to improve antibiotic stewardship. The evidence remains in favour of a small-bore chest tube optimally placed under image guidance as an appropriate initial intervention for most cases of pleural infection. With a growing body of data suggesting delays to treatment are key contributors to poor outcomes, this suggests that earlier consideration of combination intrapleural enzyme therapy (IET) with concurrent surgical consultation should remain a priority. Since publication of the MIST-2 study, there has been considerable data supporting safety and efficacy of IET, but further studies are needed to optimise dosing using individualised biomarkers of treatment failure. Pending further prospective evaluation, the MIST-2 regimen remains the most evidence based. Several studies have externally validated the RAPID score, but it requires incorporating into prospective intervention studies prior to adopting into clinical practice.

Diagnostic value of soluble biomarkers for parapneumonic pleural effusion

Parapneumonic pleural effusion (PPE) is a common complication in patients with pneumonia. Timely and accurate diagnosis of PPE is of great value for its management. Measurement of biomarkers in circulating and pleural fluid have the advantages of easy accessibility, short turn-around time, objectiveness and low cost and thus have utility for PPE diagnosis and stratification. To date, many biomarkers have been reported to be of value for the management of PPE. Here, we review the values of pleural fluid and circulating biomarkers for the diagnosis and stratification PPE. The biomarkers discussed are C-reactive protein, procalcitonin, presepsin, soluble triggering receptor expressed on myeloid cells 1, lipopolysaccharide-binding protein, inflammatory markers, serum amyloid A, soluble urokinase plasminogen activator receptor, matrix metalloproteinases, pentraxin-3 and cell-free DNA. We found that none of the available biomarkers has adequate performance for diagnosing and stratifying PPE. Therefore, further work is needed to identify and validate novel biomarkers, and their combinations, for the management of PPE.

Which Surgery for Stage II-III Empyema Patients? Observational Single-Center Cohort Study of 719 Consecutive Patients

OBJECTIVE

Recent guidelines support the use of thoracoscopic surgery in stage II-III empyema; however, there is still debate regarding the best surgical approach. The aim of our study is to compare postoperative outcomes of VATS and open surgical approaches for the treatment of post-pneumonic empyema.

METHODS

Observational cohort study on prospectively collected cases of post-pneumonic empyema surgically treated in a single center (2000-2020). Patients were divided into an open group (OT, posterolateral muscle sparing thoracotomy) and VATS group (VT, 2 or 3 port ± utility incision). The primary outcome of the study was empyema resolution, assessed by the recurrence rate. Secondary outcomes were mortality, complications, pain and return to daily life. All patients were followed up at 1, 3 and 6 months after surgery in the outpatient clinic with a chest radiograph/CT scan.

RESULTS

In total, 719 consecutive patients were surgically treated for stage II-III empyema, with 644 belonging to the VT group and 75 to the OT group. All patients had a clinical history of pneumonia lasting no more than 6 months before surgery, and 553 (76.9%) had stage II empyema. Operative time was 92.7 ± 6.8 min for the OT group and 112.2 ± 7.4 for the VT group. The conversion rate was 8.4% (46/545) for stage II and 19.2% (19/99) for stage III. Twelve patients (1.86%) in the VT group and four patients (5.3%) in the OT group underwent additional surgery for bleeding. Postoperative mortality was 1.25% (9/719): 5.3% (4/75) in OT and 0.77% (5/644) in VT. Postoperative stay was 10 ± 6.5 days in OT and 8 ± 2.4 in VT. Overall morbidity was 14.7% (106/719): 21.3% (16/75) in OT and 13.9% (90/644) in VT. In VT, six patients (0.93%) showed recurrent empyema: five were treated with chest drainage and one with additional open surgery.

CONCLUSIONS

Our findings suggest that the VATS approach, showing a 99% success rate, shorter length of stay and lower postoperative morbidity, should be considered the treatment of choice for thoracic empyema.

Significance of pleural effusion detected by metagenomic next-generation sequencing in the diagnosis of aspiration pneumonia

Objective

Using metagenomic next-generation sequencing (mNGS) to profile the bacterial pathogen of pleural infection in aspiration pneumonia for therapeutic decision-making.

Methods

Collection and analysis of the clinical and laboratory data of aspiration pneumonia patients who underwent mNGS detection of pleural effusion at the Second Hospital of Jilin University from November 2020 and March 2022.

Results

Nine males and one female were included, aged 33 to 69 years. All patients had chest pain, fever, cough, and hypoxemia symptoms; 90% had expectoration. The laboratory tests revealed that all patients had elevated white blood cell, neutrophil, and C-reactive protein (CRP) levels. Furthermore, erythrocyte sedimentation rate (ESR) increased in 8 patients, and procalcitonin increased in only one patient. Chest CT indicated different degrees of lobar pneumonia and pleural effusion in all patients, and biochemical results implied exudative effusion according to Light criteria. Most routine culture results were negative. Among bacteria identified by mNGS, Fusobacterium nucleatum (n=9) was the most common, followed by Parvimonas micra (n=7) and Filifactor alocis (n=6). Three patients underwent surgical treatment after applying targeted antibiotics, thoracic puncture and drainage, and fibrinolytic septum treatment. After the adjusted treatment, the number of white blood cells, neutrophils, and lymphocytes decreased significantly, indicating the eradication of the infection.

Conclusions

Improving the vigilance of atypical people suffering from aspiration pneumonia is essential. The mNGS detection of pleural effusion clarified the microbial spectrum of aspiration pneumonia, allowing targeted antibiotic administration.

Steroid Therapy and Outcome of Parapneumonic Pleural Effusions (STOPPE): A Pilot Randomized Clinical Trial

Rationale: Pleural effusion commonly complicates community-acquired pneumonia and is associated with intense pleural inflammation. Whether antiinflammatory treatment with corticosteroids improves outcomes is unknown. Objectives: To assess the effects of corticosteroids in an adult population with pneumonia-related pleural effusion. Methods: The STOPPE (Steroid Therapy and Outcome of Parapneumonic Pleural Effusions) trial was a pilot, multicenter, double-blinded, placebo-controlled, randomized trial involving six Australian centers. Patients with community-acquired pneumonia and pleural effusion were randomized (2:1) to intravenous dexamethasone (4 mg twice daily for 48 h) or placebo and followed for 30 days. Given the diverse effects of corticosteroids, a comprehensive range of clinical, serological, and imaging outcomes were assessed in this pilot trial (ACTRN12618000947202). Measurements and Main Results: Eighty patients were randomized (one withdrawn before treatment) and received dexamethasone (n = 51) or placebo (n = 28). This pilot trial found no preliminary evidence of benefits of dexamethasone in improving time to sustained (>12 h) normalization of vital signs (temperature, oxygen saturations, blood pressure, heart, and respiratory rates): median, 41.0 (95% confidence interval, 32.3-54.5) versus 27.8 (15.4-49.5) hours in the placebo arm (hazard ratio, 0.729 [95% confidence interval, 0.453-1.173]; P = 0.193). Similarly, no differences in C-reactive protein or leukocyte counts were observed, except for a higher leukocyte count in the dexamethasone group at Day 3. Pleural drainage procedures were performed in 49.0% of dexamethasone-treated and 42.9% of placebo-treated patients (P = 0.60). Radiographic pleural opacification decreased over time with no consistent intergroup differences. Mean duration of antibiotic therapy (22.4 [SD, 15.4] vs. 20.4 [SD, 13.8] d) and median hospitalization (6.0 [interquartile range, 5.0-10.0] vs. 5.5 [interquartile range, 5.0-8.0] d) were similar between the dexamethasone and placebo groups. Serious adverse events occurred in 25.5% of dexamethasone-treated and 21.4% of placebo-treated patients. Transient hyperglycemia more commonly affected the dexamethasone group (15.6% vs. 7.1%). Conclusions: Systemic corticosteroids showed no preliminary benefits in adults with parapneumonic effusions. Clinical trial registered with www.anzctr.org.au (ACTRN12618000947202).

Advanced stage empyemas in community-acquired pneumonia: how hospital re-organization during the Covid-19 pandemic affected the increase in surgically treated cases

The cause of pleural empyema is bacterial pneumonia and three stages has been described in the evolution of this disease: exudative, fibrino-purulent and organizational phases. The first therapeutic intervention is the antibiotic therapy; where pharmacological therapy alone is not sufficient to eradicate the infection, it is also necessary a surgical treatment. Since the province of Piacenza having been in the epicenter area during the first Sars-Cov 2 pandemic wave in March 2020 and the number of patients with Covid-related pneumonia required invasive and non-invasive respiratory support, had a considerable organizational impact on pulmonology and respiratory unit, hindering an optimal treatment of the bacterial pneumonia both in community as well as in the hospital. Among the many "collateral" damages of the epidemiological wave of the infection with Sars Cov-2, we have been able to observe in our Hospital, also an increase of pulmonary empyemas diagnosed at an advanced stage for what we believe to be organizational and social causes directly related to the pandemic: in order to cope with the emergency the Unit of Pneumology has been since March nearly uninterruptedly dedicated to the exclusive treatment of covid patients so the pneumologist has been removed due to the need from outpatient and residential management of general pneumology.

Diagnosis of parapneumonic pleural effusion with serum and pleural fluid Activin A

OBJECTIVE

The aim is to evaluate the diagnostic value of Activin A levels in serum and pleural fluid on Parapneumonic Pleural Effusion (PPE).

METHODS

The authors collected serum and pleural fluid from 86 PPE and 37 Non-PPE (NPPE) patients. Including Activin A, levels of biomarkers such as Lactate Dehydrogenase (LDH), Procalcitonin (PCT), and C-Reactive Protein (CRP) were measured. All factors were calculated for association with days after admission. The diagnostic potential of biomarkers on PPE was considered by Receiver Operating Characteristic (ROC) curve analysis.

RESULTS

Levels of Activin A in serum and pleural fluid of PPE patients were significantly higher than those of the NPPE patients. Moreover, concentrations of Activin A in pleural fluid showed a more obvious relevant days after admission. ROC curve analysis found that Activin A in pleural fluid had AUCs of 0.899 with 93% sensitivity and 84% specificity for PPE diagnosis.

CONCLUSION

Activin A in pleural fluid correlated with disease severity could act to diagnose PPE.

Nicotinamide phosphoribosyltransferase as a biomarker for the diagnosis of infectious pleural effusions

Nicotinamide phosphoribosyltransferase (NAMPT) has been reported to be involved in infectious diseases, but it is unknown whether it plays a role in infectious pleural effusions (IPEs). We observed the levels of NAMPT in pleural effusions of different etiologies and investigated the clinical value of NAMPT in the differential diagnosis of infectious pleural effusions. A total of 111 patients with pleural effusion were enrolled in the study, including 25 parapneumonic effusions (PPEs) (17 uncomplicated PPEs, 3 complicated PPEs, and 5 empyemas), 30 tuberculous pleural effusions (TPEs), 36 malignant pleural effusions (MPEs), and 20 transudative effusions. Pleural fluid NAMPT levels were highest in the patients with empyemas [575.4 (457.7, 649.3) ng/ml], followed by those with complicated PPEs [113.5 (103.5, 155.29) ng/ml], uncomplicated PPEs [24.9 (20.2, 46.7) ng/ml] and TPEs [88 (19.4, 182.6) ng/ml], and lower in patients with MPEs [11.5 (6.5, 18.4) ng/ml] and transudative effusions [4.3 (2.6, 5.1) ng/ml]. Pleural fluid NAMPT levels were significantly higher in PPEs (P < 0.001) or TPEs (P < 0.001) than in MPEs. Moreover, Pleural fluid NAMPT levels were positively correlated with the neutrophil percentage and lactate dehydrogenase (LDH) levels and inversely correlated with glucose levels in both PPEs and TPEs, indicating that NAMPT was implicated in the neutrophil-associated inflammatory response in infectious pleural effusion. Further, multivariate logistic regression analysis showed pleural fluid NAMPT was a significant predictor distinguishing PPEs from MPEs [odds ratio (OR) 1.180, 95% confidence interval (CI) 1.052-1.324, P = 0.005]. Receiver-operating characteristic (ROC) analysis demonstrated that NAMPT was a promising diagnostic factor for the diagnosis of infectious effusions, with the areas under the curve for pleural fluid NAMPT distinguishing PPEs from MPEs, TPEs from MPEs, and IPEs (PPEs and TPEs) from NIPEs were 0.92, 0.85, and 0.88, respectively. In conclusion, pleural fluid NAMPT could be used as a biomarker for the diagnosis of infectious pleural effusions.

Clinical utility of 16S rRNA PCR in pleural infection

Pleural infections cause major morbidity and mortality, particularly amongst paediatric and elderly populations. The aetiology is broad, but pleural culture fails to yield a causative pathogen in approximately 40 % of cases. Alternative pathogen identification methods are therefore required. The aim of the study was to investigate the yield from and impact on patient care when performing 16S rRNA PCR on culture-negative pleural fluid specimens and to determine whether any individual laboratory parameters were associated with a positive 16S rRNA PCR result. We conducted a study on 90 patients with suspected pleural infection, who had a culture-negative pleural fluid specimen, which underwent 16S rRNA PCR analysis between August 2017 and June 2019. This study was undertaken at a large NHS Trust in London, UK. Thirty-one per cent of culture-negative pleural fluid specimens tested by 16S rRNA PCR yielded a positive PCR result. Our data demonstrated that 16S rRNA PCR detected a significantly higher proportion of Streptococcus pneumoniae (P<0.0001) and fastidious, slow-growing and anaerobic pathogens (P=0.0025) compared with culture-based methods. Of the 25 16S rRNA PCR results that were positive for a causative pathogen, 76 % had a direct impact on clinical management. No single laboratory variable was found to be associated with a positive 16S rRNA PCR result. The findings from our real-world evaluation highlight the importance of 16S rRNA PCR in confirming pleural infection when the aetiology is unknown, and its direct, positive impact on clinical management.

Pleural effusion as an indicator for the poor prognosis of COVID-19 patients

BACKGROUND

Coronavirus Disease 19 (COVID-19) is a global health concern that has become a pandemic over the past few months. This study aims at understanding the clinical manifestations of COVID-19 patients with pleural effusion.

METHODS

COVID-19 patients were retrospectively enrolled from the Union Hospital, Tongji Medical College, Huazhong University of Science and Technology. Pharyngeal swabs from patients were tested using real-time polymerase chain reaction. Patients with COVID-19 were divided into two groups based on their computed tomography (CT) scans for the presence of pleural effusion at admission. We compared the clinical features, laboratory findings, scans and clinical outcomes between the two groups.

RESULTS

Pleural effusion was observed in 9.19% of the patients. Patients with pleural effusion were more likely to be severe or critical cases. Moreover, patients with pleural effusion were associated with increased mortality. Of the 799 discharged patients, patients with pleural effusion had longer hospital stays and duration of viral shedding since the onset of symptoms as compared with that for patients without pleural effusion. After discharge, 217 patients visited for a follow-up CT re-examination at the Union Hospital. The CT scans showed that patients with pleural effusion required a longer time to resolve the lung inflammation after the onset of COVID-19 as compared with the time required by patients without pleural effusion.

CONCLUSION

This population of patients requires special attention and pleural effusion may be an indicator of poor prognosis in COVID-19 patients.

Advances in pleural infection and malignancy

Pleural infection and malignancy are among the most common causes of pleural disease and form the mainstay of pleural practice. There has been significant research and increase in scientific understanding in these areas in the past decade. With regard to pleural infection, the rising incidence remains worrying. An increased awareness allowing earlier diagnosis, earlier escalation of therapy and the use of validated risk stratification measures may improve outcomes. In pleural malignancy, research has enabled clinicians to streamline patient pathways with focus on reducing time to diagnosis, definitive management of malignant pleural effusion and achieving these with the minimum number of pleural interventions. Trials comparing treatment modalities of malignant pleural effusion continue to highlight the importance of patient choice in clinical decision-making. This article aims to summarise some of the most recent literature informing current practice in these two areas.

Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia

This clinical policy from the American College of Emergency Physicians is a revision of the 2009 "Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Community-Acquired Pneumonia." A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In the adult emergency department patient diagnosed with community-acquired pneumonia, what clinical decision aids can inform the determination of patient disposition? (2) In the adult emergency department patient with community-acquired pneumonia, what biomarkers can be used to direct initial antimicrobial therapy? (3) In the adult emergency department patient diagnosed with community-acquired pneumonia, does a single dose of parenteral antibiotics in the emergency department followed by oral treatment versus oral treatment alone improve outcomes? Evidence was graded and recommendations were made based on the strength of the available data.

Advances in pleural effusion diagnostics

Introduction: Pleural effusion is a common clinical problem. Yet, in a significant proportion of patients (~20%), the cause of pleural effusion remains unknown. Understanding the diagnostic value of pleural fluid tests is crucial for the development of accurate diagnostic models.Areas covered: This paper provides an overview of latest advances in the diagnosis of pleural effusion based on the best evidence available.Expert opinion: For pleural fluid tests to have a good diagnostic value, it is necessary that data obtained from clinical history, physical examination, and radiological studies are correctly interpreted. Thoracentesis and pleural biopsy should always be performed under image guidance to improve its diagnostic sensitivity and prevent complications. Nucleic acid amplification tests, pleural tissue cultures, and collection of pleural fluid in blood culture bottles improve the diagnostic yield of pleural fluid cultures. Although undiagnosed pleural effusions generally have a favorable prognosis, follow-up is recommended to prevent the development of a malignant pleural effusion.

Steroid therapy and outcome of parapneumonic pleural effusions (STOPPE): Study protocol for a multicenter, double-blinded, placebo-controlled randomized clinical trial

BACKGROUND

Community-acquired pneumonia (CAP) is a major global disease. Parapneumonic effusions often complicate CAP and range from uninfected (simple) to infected (complicated) parapneumonic effusions and empyema (pus). CAP patients who have a pleural effusion at presentation are more likely to require hospitalization, have a longer length of stay and higher mortality than those without an effusion. Conventional management of pleural infection, with antibiotics and chest tube drainage, fails in about 30% of cases. Several randomized controlled trials (RCT) have evaluated the use of corticosteroids in CAP and demonstrated some potential benefits. Importantly, steroid use in pneumonia has an acceptable safety profile with no adverse impact on mortality. A RCT focused on pediatric patients with pneumonia and a parapneumonic effusion demonstrated shorter time to recovery. The effects of corticosteroid use on clinical outcomes in adults with parapneumonic effusions have not been tested. We hypothesize that parapneumonic effusions develop from an exaggerated pleural inflammatory response. Treatment with systemic steroids may dampen the inflammation and lead to improved clinical outcomes. The steroid therapy and outcome of parapneumonic pleural effusions (STOPPE) trial will assess the efficacy and safety of systemic corticosteroid as an adjunct therapy in adult patients with CAP and pleural effusions.

METHODS

STOPPE is a pilot multicenter, double-blinded, placebo-controlled RCT that will randomize 80 patients with parapneumonic effusions (2:1) to intravenous dexamethasone or placebo, administered twice daily for 48 hours. This exploratory study will capture a wide range of clinically relevant endpoints which have been used in clinical trials of pneumonia and/or pleural infection; including, but not limited to: time to clinical stability, inflammatory markers, quality of life, length of hospital stay, proportion of patients requiring escalation of care (thoracostomy or thoracoscopy), and mortality. Safety will be assessed by monitoring for the incidence of adverse events during the study.

DISCUSSION

STOPPE is the first trial to assess the efficacy and safety profile of systemic corticosteroids in adults with CAP and pleural effusions. This will inform future studies on feasibility and appropriate trial endpoints.

TRIAL REGISTRATION

ACTRN12618000947202 PROTOCOL VERSION:: version 3.00/26.07.18.

Emerging concepts in pleural infection

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.

Diagnosis of Parapneumonia Pleural Effusion with Serum and Pleural Fluid Cell-Free DNA

Objective

As cell-free DNA levels in the pleural fluid and serum of parapneumonic pleural effusion (PPE) patients have not been thoroughly explored, we evaluated their diagnostic potential.

Methods

Twenty-two PPE and 16 non-PPE patients were evaluated. Serum and pleural fluids were collected, and cell-free DNA was quantified. All biomarkers were assessed for correlation with days after admission. Receiver operating characteristic (ROC) curve analysis was used to determine diagnostic accuracy and optimal cut-off point.

Results

Nuclear and mitochondrial DNA levels in the pleural fluid and nuclear DNA levels in serum of PPE patients were significantly higher than in those of the non-PPE patients. However, only cell-free DNA levels in pleural fluid correlated with days after admission among PPE patients (r= 0.464, 0.538, respectively). ROC curve analysis showed that nuclear and mitochondrial DNA in pleural fluid had AUCs of 0.945 and 0.889, respectively. With cut-off values of 134.9 and 17.8 ng/ml for nuclear and mitochondrial DNA in pleural fluid, respectively, 96% sensitivity and 81% specificity were observed for PPE diagnosis.

Conclusion

Nuclear and mitochondrial DNA in pleural fluid possess PPE diagnostic potential and correlated with disease severity. Serum nuclear DNA could also be used to distinguish freshly admitted PPE patients (Day 1) from non-PPE patients, but with less accuracy.

Pleural infection: a closer look at the etiopathogenesis, microbiology and role of antibiotics

INTRODUCTION

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.

Diagnosis of infectious pleural effusion using predictive models based on pleural fluid biomarkers

INTRODUCTION:

Diagnosis of pleural infection (PI) may be challenging. The purpose of this paper is to develop and validate a clinical prediction model for the diagnosis of PI based on pleural fluid (PF) biomarkers.

METHODS:

A prospective study was conducted on pleural effusion. Logistic regression was used to estimate the likelihood of having PI. Two models were built using PF biomarkers. The power of discrimination (area under the curve) and calibration of the two models were evaluated.

RESULTS:

The sample was composed of 706 pleural effusion (248 malignant; 28 tuberculous; 177 infectious; 48 miscellaneous exudates; and 212 transudates). Areas under the curve for Model 1 (leukocytes, percentage of neutrophils, and C-reactive protein) and Model 2 (the same markers plus interleukin-6 [IL-6]) were 0.896 and 0.909, respectively (not significant differences). However, both models showed higher capacity of discrimination than their biomarkers when used separately (P < 0.001 for all). Rates of correct classification for Models 1 and 2 were 88.2% (623/706: 160/177 [90.4%] with infectious pleural effusion [IPE] and 463/529 [87.5%] with non-IPE) and 89.2% (630/706: 153/177 [86.4%] of IPE and 477/529 [90.2%] of non-IPE), respectively.

CONCLUSIONS:

The two predictive models developed for IPE showed a good diagnostic performance, superior to that of any of the markers when used separately. Although IL-6 contributes a slight greater capacity of discrimination to the model that includes it, its routine determination does not seem justified.

Risk Stratification in Patients with Complicated Parapneumonic Effusions and Empyema Using the RAPID Score

PURPOSE

Complicated parapneumonic effusions and empyema are a leading cause of morbidity in the United States with over 1 million admissions annually and a mortality rate that remains high in spite of recent advances in diagnosis and treatment. The identification of high risk patients is crucial for improved management and the provision of cost-effective care. The RAPID score is a scoring system comprised of the following variables: renal function, age, purulence, infection source, and dietary factors and has been shown to predict outcomes in patients with pleural space infections.

METHODS

In a single center retrospective study, we evaluated 98 patients with complicated parapneumonic effusions and empyema who had tube thoracostomy (with or without Intrapleural fibrinolytic therapy) and assessed treatment success rates, mortality, length of hospital stay, and direct hospitalization costs stratified by three RAPID score categories: low-risk (0-2), medium risk (3-4), and high-risk (5-7) groups.

RESULTS

Treatment success rate was 71%, and the 90 day mortality rate was 12%. There was a positive-graded association between the low, medium and high RAPID score categories and mortality, (5.3%, 8.3% and 22.6%, respectively), length of hospital stay (10, 21, 19 days, respectively), and direct hospitalization costs ($19,909, $36,317 and $43,384, respectively).

CONCLUSION

Our findings suggest that the RAPID score is a robust tool which could be used to identify patients with complicated parapneumonic effusions and empyema who may be at an increased risk of mortality, prolonged hospitalization, and who may incur a higher cost of treatment. Randomized controlled trials identifying the most effective initial treatment modality for medium- and high-risk patients are needed.

Diagnostic chest ultrasound for acute respiratory failure

Acute respiratory failure (ARF) is a common life-threatening medical condition, with multiple underlying aetiologies. Diagnostic chest ultrasound provides accurate diagnosis of conditions that commonly cause ARF, and may improve overall diagnostic accuracy in critical care settings as compared to standard diagnostic approaches. Respiratory physicians are becoming increasingly familiar with ultrasound as a part of routine clinical practice, although the majority of data to date has focused on the emergency and intensive care settings. This review will examine the evidence for the use of diagnostic chest ultrasound, focusing on different levels of imaging efficacy; specifically ultrasound test attributes, impacts on clinician behaviour and impact on health outcomes. The evidence behind use of multi-modality ultrasound examinations in ARF will be reviewed. It is hoped that readers will become familiar with the advantages and potential issues with chest ultrasound, as well as evidence gaps in the field.

Thoracic Empyema as Rare Complication of an Appendicular Mass: A Case Study and Review of the Literature

Introduction

Thoracic empyema is an infrequent complication of appendicitis that has rarely been reported in the literature.

Case Presentation and Review of the Literature

The case of a 11-year-old boy who was admitted for medical management of an appendicular mass is presented. His clinical course was complicated by the development of an appendicular abscess and an extensive right-sided empyema. A comprehensive review of the literature was conducted including the most representative cases. The data were collected and analyzed by two independent investigators. Ten cases were found. Most patients were young individuals (mean age: 25.1 years; male : female ratio: 0.5). Risk factors for thoracic empyema included pregnancy (10%) and age (60%). The most frequent organisms isolated were Escherichia coli, Bacteroides spp., and Klebsiella spp. The survival rate was 100%.

Conclusion

Thoracic empyema should be considered a potential cause of respiratory distress in patients with appendicitis. Furthermore, the abdomen should be carefully evaluated as a source of infection in patients with thoracic empyema without an underlying lung disease.

Rebounds after discharge from the emergency department for community-acquired pneumonia: focus on the usefulness of severity scoring systems

BACKGROUND

Community-acquired pneumonia (CAP) is common cause of hospital admission and leading cause of morbidity and mortality. Severity scoring systems are used to predict risk profile, outcome and mortality, and to help decisions about management strategies. Aim of the work and Methods: To critically analyze pneumonia "rebound" cases, once discharged from the emergency department (ED) and afterwards admitted. We conducted an observational clinical study in the acute setting of a university teaching hospital, prospectively analyzing, in a 1 year period, demographic, medical, clinical and laboratory data, and the outcome.

RESULTS

249 patients were discharged home with diagnosis of CAP; 80 cases (32.1%) resulted in the high-intermediate risk class according to CURB-65 or CRB-65. Twelve patients (4.8%) presented to the ED twice and were then admitted. At their first visit 5 were in the high-intermediate risk group; just 4 of them were in the non-low risk group at the time of their admission. The rebound cohort showed some peculiar abnormalities in laboratory parameters (coagulation and renal function) and severe chest X-rays characteristics. None died in 30 days.

CONCLUSIONS

The power of CURB-65 to correctly predict mortality for CAP patients discharged home from the ED is not confirmed by our results; careful clinical judgement seems to be irreplaceable in the management process. Many patients with a high-intermediate risk according to CURB-65 can be safely treated as outpatients, according to adequate welfare conditions; we identified a subgroup of cases that should worth a special attention and, therefore, a brief observation period in the ED before the final decision to safely discharge or admit.

Infectious pleural effusion status and treatment progress

Pleural cavity infection continuously seriously threatens human health with continuous medical progress. From the perspective of pathophysiology, it can be divided into three stages: exudative stage, fibrin exudation and pus formation stage, and organization stage. Due to the pathogenic bacteria difference of pleural cavity infection and pulmonary infection, it is very important for disease treatment to analyze the bacteria and biochemical characteristics of the infectious pleural effusion. Most prognoses of patients have been relatively good, while for some patients, the complicated parapneumonic effusion or empyema could be evolved. Antibiotic treatment and sufficient drainage are the foundation for this treatment. No evidence can support the routine use of a fibrin agent. However, it has been reported that the plasminogen activator and deoxyribonuclease can be recommended to be applied in the pleural cavity. In case of failure on conservative medical treatment, operative treatment can be applied such as thoracoscopy and pleural decortication. According to the clinical characteristics of these patients, it is a key to research prognosis, as well as early evaluation and stratification, in the future.