Suppurative diseases of the lungs. Pleurae and pericardium

Pyogenic lung abscess in an infectious disease unit: a 20-year retrospective study

Background:

Pyogenic lung abscesses are rare and poorly described infections. This study aimed to describe their prognostic factors.

Methods:

We retrospectively included all patients hospitalized between 1 January 1998 and 1 June 2018, with an International Classification of Diseases, version 10 (IDC-10) diagnosis of pyogenic lung abscess, from the Diamm based medical records (Micro6, Nancy, France). Parasitic, fungal, or mycobacterial lung abscesses were excluded.

Results:

A total of 64 patients were included. Abscesses were associated with immunosuppression in 28 patients, including HIV infection and immunosuppressive therapy for eight and 12 patients, respectively. Bacterial identification was obtained for 36 patients. Nine patients (14%) developed lung abscesses after hematogenous dissemination. They differed from bronchogenic abscesses by their younger age (p = 0.03), the absence of smoking or emphysema (p = 0.05), Staphylococcus aureus (p = 0.001) or Streptococcus spp. (p = 0.05) isolation, and the smaller size of their abscess (p = 0.02). Overall, evolution was marked by radiological sequelae (46.9%), relapse (12.5%), and death (4.8%). Radiological sequelae occurred more frequently during the course of bronchogenic abscesses (p = 0.02), particularly when they spontaneously discharged (p = 0.04). Relapses were more frequent in patients with emphysema (p = 0.04) and when Haemophilus influenzae was isolated (p = 0.04). In multivariate analysis, poor outcomes, including death, sequelae, and relapse occurred more frequently in patients who had bronchogenic abscess (p = 0.02), and in those who received antibiotics during less than 6 weeks (p = 0.05).

Conclusion:

A duration of antibiotic treatment of less than 6 weeks and bronchogenic presentation were globally associated with poor outcome of pyogenic lung abscesses. These data should be considered when proposing guidelines for the care of pyogenic lung abscesses.

The reviews of this paper are available via the supplemental material section.

Efficacy and safety of percutaneous tube drainage in lung abscess: a systematic review and meta-analysis

Objectives: Lung abscess is an infectious lung disease. The main objective of this review was to assess the efficacy and safety of percutaneous tube drainage (PTD) in patients with lung abscess by systematic review and meta-analysis of published data. Methods: We searched all literature published between 1 January 2010, and 6 August 2019, in the PubMed, Cochrane Central Library, EMBASE, Wanfang, Chinese National Knowledge Infrastructure, and Chinese Biomedical Literature databases for relevant reports. The data from these studies were pooled for statistical analysis, and sensitivity analysis and risk-of-bias analysis was performed. Results: Meta-analysis revealed that percutaneous tube drainage (PTD) was superior to conservative treatment in terms of the total effectivity rate (P < 0.01). Moreover, length of hospital stay and number of fever days were reduced for the PTD group than for the group receiving conservative treatment (P < 0.01). There was no significant difference between PTD and conservative treatment in terms of complication rate (P = 0.43). Conclusion: Lung abscess drainage is a safe and effective method for treating lung abscesses. Based on the principle that as much drainage as possible should be performed as treatment of abscess diseases, drainage should be promoted as treatment for lung abscess.

Pleural empyema: 24-year experience

BACKGROUND

Despite the widespread use of antibiotics, empyema remains a common and serious problem, and its treatment is controversial.

METHODS

Our experience in 380 patients with empyema was retrospectively reviewed.

RESULTS

The causes of empyema were as follows: pneumonia (n = 308), late complication of tuberculosis (n = 24), trauma (n = 15), pulmonary gangrene (n = 3), retained foreign body (n = 1), and undetermined (n = 29). An exudative state was diagnosed in 273 patients, a fibrinopurulent state in 55, and an organizing state in 52. Pleuroscopy was performed in 107 patients resistant to treatment, and this revealed an expansible lung in 49 patients, a nonexpansible lung in 51, and exceptional findings (foreign body, necrotizing pneumonitis, and perforated esophageal cancer) in 7. Treatment was modified accordingly. Five patients died (mortality, 1.3%).

CONCLUSIONS

Pleuroscopy is very helpful in disclosing factors responsible for resistance to treatment and in carrying out thorough pleural toilet. The use of talc in selected patients causes pleurodesis and prevents the reaccumulation of pus. Decortication is the ideal treatment in the organizing stage, enabling complete lung expansion. Fenestration is lifesaving in moribund patients who cannot tolerate decortication.

Streptococcal sepsis and death caused by empyema

A case is presented of a young man who complained of pain in the pectoral area secondary to empyema, which was not recognized. The patient subsequently died of Streptococcal sepsis. Empyema of the thorax is a well known suppurative disease of the chest. The incidence of empyema has declined dramatically since the advent of antibiotics. It is rarely encountered in the modern emergency department.

Pericarditis associated with Hemophilus influenzae type B pneumonia and bacteremia in two adults

Two cases of pericarditis associated with Hemophilus influenzae bacteremia and pneumonia are reported and the literature reviewed. Both patients were treated with antibiotics alone and had resolution of their illnesses without apparent adverse sequelae. Neither patient required pericardial drainage. It is suggested that there is a stage in the development of H influenzae pericarditis at which antibiotic treatment alone can be curative.

Inflammatory constriction following complete pericardiectomy in tuberculous constrictive pericarditis

A 13-year-old boy with active tuberculous constrictive pericarditis underwent complete pericardiectomy together with antituberculous therapy and a short course of steroids. Six weeks following the surgery, he was seen with clinical and hemodynamic findings of recurrent pericardial constriction, presumably due to an inflammatory collection around the heart. Symptoms gradually resolved within six months with resumption of steroid therapy. Repeat hemodynamic study showed normal hemodynamics. The case demonstrates the production of cardiac constriction by nonpericardial inflammatory tissue and the possible benefits of steroid therapy in the treatment of tuberculous constrictive pericarditis.

Timely therapy for empyema: what it constitutes and why

The incidence and treatment of empyema historically have fluctuated with the introduction of new antibiotics. As resistant strains of bacteria emerge, a return to aggressive surgical therapy becomes necessary. Empyemas are most likely to occur in patients with an underlying factor such as alcoholism, bronchitis, asthma, emphysema, diabetes, tuberculosis, carcinoma, heroin addiction, or steroid therapy. The bacteriology is constantly changing. Recently, the importance of anaerobic organisms--which are now involved in three out of four cases of empyema--has been recognized. Diagnosis is established and antibiotics chosen on the basis of Gram staining and culture of pleural fluid. Surgical procedures include thoracentesis, closed chest tube drainage, open drainage plus rib resection, decortication, thoracoplasty, and excision of the empyema sac with an extrapleural dissection.

Lung abscess: back for an encore?

The rise in incidence of lung abscess due to opportunistic organisms has reemphasized the need for early recognition and treatment. Opportunistic organisms can cause lung abscess in immunocompromised hosts. Most lung abscesses are primary, occurring as a result of aspiration of oral contents into the dependent portions of the lung in persons with dysphagia or decreased consciousness. Symptoms of lung abscess include productive cough, fever, leukocytosis, weight loss, and putrid sputum. Among the complications are progression to a chronic stage, empyema, massive hemoptysis, metastatic brain abscess, and bronchopleural fistula. Treatment of lung abscess is primarily medical, consisting of an appropriate antibiotic regimen and chest physical therapy. Surgery is reserved for unresponsive patients or those with complications.

Lung abscess and empyema of the thorax

Empyema is best managed by the physician familiar with the indications and principals of the various procedures used in the treatment of empyema of the thorax. The objective of each modality used to treat empyema is to drain the pleura cavity and to allow full expansion of the lung. If the infected material can be removed and the visceral and parietal pleural approximated, the body will heal the pleural infection. The procedure chosen to treat empyema greatly depends upon the phase of maturation of the empyema when treatment is begun.

Early decortication for anaerobic empyema in children

Nine children underwent early decortication for empyema. Three had posttraumatic empyema and six had postpneumonic empyema. The decision for decortication was made 3-5 days after diagnosis of empyema, when it was judged that conventional treatment by antibiotics and intercostal catheter drainage was failing. Such failure was manifested by: loculated effusions (9), persistent fever (8), persistent respiratory distress (3), pulmonary air leak (3), and worsening parenchymal disease (1). The decortication procedure consisted of a standard posterolateral thoracotomy, removal of the fibrinous peel from the visceral and parietal pleurae, debridement or resection of necrotic lung tissue, irrigation of the pleural space, and drainage by intercostal catheters. In the 9 children who underwent this procedure, there were no deaths and a single complication, suppurative thrombophlebitis. Recovery was rapid in 6 out of 9 children, who were discharged within 10 days of operation. The remaining 3 out of 9 children had associated injuries or illnesses that necessitated a longer hospital stay. Bacteriologic studies confirmed anaerobic bacteria in the infected pleural contents of 5 out of 9 children. Bacteroides and anaerobic streptococci were the commonest isolates. Anaerobic infection of the pleural space cannot be cured without aggressive surgical drainage, in addition to antibiotics. Our experience suggests that early decortication is an efficacious procedure for selected children with empyema. The presence of anaerobic bacteria in the empyema may constitute an unequivocal indication for early decortication.