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Elsheikh A, Bhatnagar M, Rahman NM. Diagnosis and management of pleural infection. Breathe (Sheff) 2023; 19:230146. [PMID: 38229682 PMCID: PMC10790177 DOI: 10.1183/20734735.0146-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/07/2023] [Indexed: 01/18/2024] Open
Abstract
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.
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Affiliation(s)
- Alguili Elsheikh
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Both authors contributed equally
| | - Malvika Bhatnagar
- Cardiothoracic Unit, Freeman Hospital, Newcastle upon Tyne, UK
- Both authors contributed equally
| | - Najib M. Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
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Luque-Paz D, Verdier MC, Lefèvre CR, Chauvin P, Goter T, Armange L, Bayeh B, Lalanne S, Tattevin P, Jouneau S. Pleural penetration of amoxicillin and metronidazole during pleural infection: An ambispective cohort study. Int J Antimicrob Agents 2023; 62:107004. [PMID: 37839716 DOI: 10.1016/j.ijantimicag.2023.107004] [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: 06/08/2023] [Revised: 09/06/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVES The pharmacokinetics of antibiotics in pleural fluid during pleural infections has been poorly described. This study aimed to explore amoxicillin and metronidazole diffusion into the pleural space. METHODS This was an ambispective, single-centre study that included patients with complicated parapneumonic effusion or pleural empyema managed with repeated therapeutic thoracentesis as first-line treatment between 2014 and 2022. Pleural steady-state or trough concentrations of amoxicillin and metronidazole were measured, with a lower limit of quantification of 5 mg/L. RESULTS Seventy paired blood and pleural samples were analysed from 40 patients. The median (interquartile range) patient age was 55 years (45-67 years) and 88% were male. The median patient weight was 65.8 kg (57.3-82 kg) and median plasma albumin concentration was 29.7 g/L (23.7-33.9 g/L). Median creatinine clearance was 106 mL/min (95-117 mL/min). Median amoxicillin pleural concentrations in patients treated with oral, bolus and continuous intravenous administrations (6 g/day) were, respectively, 5.2 (<5-6.4), 9.4 (8-13.1) and 10.8 (7.1-13.1) mg/L. Pleural concentrations were <5 mg/L in 5/11 samples (45%) with oral treatment and 6/59 (10%) with intravenous treatment. Median metronidazole pleural concentrations were 18.4 (15.7-22.8) mg/L, with all patients being treated orally (1.5 g/day). CONCLUSIONS Oral metronidazole (1.5 g/day) and intravenous amoxicillin (6 g/day) achieved therapeutic targets in pleural fluid in most cases, but oral amoxicillin did not.
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Affiliation(s)
- David Luque-Paz
- Department of Respiratory Diseases, Rennes University Hospital, Rennes, France; Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France; University of Rennes, Inserm, BRM (Bacterial Regulatory RNAs and Medicine), UMR 1230, Rennes, France.
| | - Marie-Clémence Verdier
- Clinical Pharmacology Department, CHU Rennes, Rennes, France; University of Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000, Rennes, France
| | - Charles R Lefèvre
- Biochemistry Laboratory, Pontchaillou Hospital CHU Rennes, Rennes, France
| | - Pierre Chauvin
- Department of Respiratory Diseases, Rennes University Hospital, Rennes, France
| | - Thomas Goter
- Department of Respiratory Diseases, Rennes University Hospital, Rennes, France
| | - Lucas Armange
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | | | | | - Pierre Tattevin
- Department of Respiratory Diseases, Rennes University Hospital, Rennes, France; University of Rennes, Inserm, BRM (Bacterial Regulatory RNAs and Medicine), UMR 1230, Rennes, France
| | - Stéphane Jouneau
- Department of Respiratory Diseases, Rennes University Hospital, Rennes, France; University of Rennes, CHU Rennes, Inserm, EHESP, IRSET (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
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3
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Bedawi EO, Ricciardi S, Hassan M, Gooseman MR, Asciak R, Castro-Añón O, Armbruster K, Bonifazi M, Poole S, Harris EK, Elia S, Krenke R, Mariani A, Maskell NA, Polverino E, Porcel JM, Yarmus L, Belcher EP, Opitz I, Rahman NM. ERS/ESTS statement on the management of pleural infection in adults. Eur Respir J 2023; 61:2201062. [PMID: 36229045 DOI: 10.1183/13993003.01062-2022] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/22/2022] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Eihab O Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Sara Ricciardi
- Unit of Thoracic Surgery, San Camillo Forlanini Hospital, Rome, Italy
- PhD Program Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Maged Hassan
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Michael R Gooseman
- Department of Thoracic Surgery, Hull University Teaching Hospitals NHS Trust, Hull York Medical School, University of Hull, Hull, UK
| | - Rachelle Asciak
- Department of Respiratory Medicine, Queen Alexandra Hospital, Portsmouth, UK
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - Olalla Castro-Añón
- Department of Respiratory Medicine, Lucus Augusti University Hospital, EOXI Lugo, Cervo y Monforte de Lemos, Lugo, Spain
- C039 Biodiscovery Research Group HULA-USC, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Karin Armbruster
- Department of Medicine, Section of Pulmonary Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Martina Bonifazi
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
- Respiratory Diseases Unit, Azienda Ospedaliero-Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Sarah Poole
- Department of Pharmacy and Medicines Management, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Elinor K Harris
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Stefano Elia
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
- Thoracic Surgical Oncology Programme, Policlinico Tor Vergata, Rome, Italy
| | - Rafal Krenke
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Alessandro Mariani
- Thoracic Surgery Department, Heart Institute (InCor) do Hospital das Clnicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Jose M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, Lleida, Spain
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth P Belcher
- Department of Thoracic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Chinese Academy of Medical Health Sciences, University of Oxford, Oxford, UK
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4
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Klausen MB, Laursen C, Bendixen M, Naidu B, Bedawi EO, Rahman NM, Christensen TD. Does the time to diagnosis and treatment influence outcome in adults with pleural infections. Eur Clin Respir J 2023; 10:2174645. [PMID: 36743828 PMCID: PMC9897775 DOI: 10.1080/20018525.2023.2174645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Objective To investigate the effect of early diagnosis and intervention in adult patients with complicated parapneumonic pleural effusion or pleural empyema and the impact on outcomes. Methods A systematic review based on a literature search of the PubMed database was performed. Results Eleven eligible studies were included; nine observational studies and two randomised controlled trials totalling a study population of 10,717 patients. The studies were conducted from 1992 to 2018, all in Europe and Northern America except one. Results varied between studies, but a trend towards better outcome in patients with shorter duration of symptoms and quicker initiation of treatment was found. We found that duration of symptoms before treatment may affect length of hospital stay, rate of conversion to open surgery, and frequency of complications. Conclusion We found that an earlier intervention in adults suffering from complicated parapneumonic pleural effusion and pleural empyema may potentially improve the outcome of patients in terms of length of stay, conversion to open surgery, and general complications following treatment, but not regarding mortality. Further studies are required to specify the timing of each intervention, and direct comparison in early management of interventions.
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Affiliation(s)
- Mads Brögger Klausen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark.,Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Morten Bendixen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Babu Naidu
- Department of Thoracic Surgery, Queen Elizabeth Hospital Birmingham, UK & Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Eihab O Bedawi
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Najib M Rahman
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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Zayed NE, El Fakharany K, Mehriz Naguib Abozaid M. Intrapleural Instillation of Sodium Bicarbonate versus Urokinase in Management of Complicated Pleural Effusion: A Comparative Cohort Study. Int J Gen Med 2022; 15:8705-8713. [PMID: 36575733 PMCID: PMC9790168 DOI: 10.2147/ijgm.s388488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Aim The main target is evacuation; however, with evidence about the value of intrapleural instillation of different fibrinolytic agents still under evaluation, our aim was comparing the effectiveness and safety of intrapleural instillation of sodium bicarbonate (NaHCO3) in comparison with urokinase in patients with infected pleural effusion. Methods Our prospective cohort study included 40 patients with complicated empyema; the diagnosis was based on analysis of aspirated fluid in association with radiological and bacteriological culture. The patients were subjected to instillation of two different fibrinolytic agents; the first one was NaHCO3, the second was urokinase. Results The commonest underlying chest infection that was visualized by CT was pneumonia 70%. Nearly half of cases had community-acquired infection (45%), and more than half of them (55%) had anaerobic infection, and only five cases had TB pleural effusion based on ADA-positive, tuberculin skin test in addition to Abram's needles closed biopsy. The rate of repeated therapeutic thoracentesis success in each group was 85%; 80% in NaHCO3 group, and 90% in urokinase group, both of them was significantly equal, P=0.37. Moreover, the frequency of complications in all patients was less than 13%, hence hemothorax and iatrogenic pneumothorax was 12.5%, and only 10% of cases were admitted in ICU after the maneuver, with insignificant difference in between the groups. However, looking at the smaller rate of RTT failure of NaHCO3 or urokinase, the logistic regression model showed that RTT-NaHCO3 was insignificantly related to failure in both unadjusted and adjusted models, P=0.37 and 0.32, respectively, and only smoking habits increase the likelihood of failure 9-fold (OR=8.9, P=0.04) with respect to age, sex, and treatment methods. Conclusion The efficacy of repeated therapeutic thoracentesis (RTT) with intrapleural instillation of NaHCO3 was effective and safe, the same as urokinase, with consideration that NaHCO3 was much more available and affordable than urokinase.
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Affiliation(s)
- Niveen E Zayed
- Department of Chest Disease, Faculty of Medicine, Zagazig University, Zagazig City, Egypt,Correspondence: Niveen E Zayed, Chest Department, Zagazig University, Faculty of Medicine, Sharkia Government, Zagazig City, 44519, Egypt, Tel +201024831444, Email ;
| | - Karim El Fakharany
- Department of Cardiothoracic Surgery, Faculty of Medicine, Zagazig University, Zagazig City, Egypt
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Arnold DT, Tucker E, Morley A, Milne A, Stadon L, Patole S, Nava GW, Walker SP, Maskell NA. A feasibility randomised trial comparing therapeutic thoracentesis to chest tube insertion for the management of pleural infection: results from the ACTion trial. BMC Pulm Med 2022; 22:330. [PMID: 36042460 PMCID: PMC9425800 DOI: 10.1186/s12890-022-02126-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pleural infection is a complex condition with a considerable healthcare burden. The average hospital stay for pleural infection is 14 days. Current standard of care defaults to chest tube insertion and intravenous antibiotics. There have been no randomised trials on the use of therapeutic thoracentesis (TT) for pleural fluid drainage in pleural infection. AIMS AND OBJECTIVES To assess the feasibility of a full-scale trial of chest tube vs TT for pleural infection in a single UK centre. The primary outcome was defined as the acceptability of randomisation to patients. METHODS Adult patients admitted with a pleural effusion felt to be related to infection and meeting criteria for drainage (based on international guidelines) were eligible for randomisation. Participants were randomised (1:1) to chest tube insertion or TT with daily review assessing need for further drainages or other therapies. Neither participant nor clinician were blinded to treatment allocation. Patients were followed up at 90 days post-randomisation. RESULTS From September 2019 to June 2021, 51 patients were diagnosed with pleural infection (complex parapneumonic effusion/empyema). Eleven patients met the inclusion criteria for trial and 10 patients were randomised (91%). The COVID-19 pandemic had a substantial impact on recruitment. Data completeness was high in both groups with no protocol deviations. Patients randomised to TT had a significantly shorter overall mean hospital stay (5.4 days, SD 5.1) compared to the chest tube control group (13 days, SD 6.0), p = 0.04. Total number of pleural procedures required per patient were similar, 1.2 in chest tube group and 1.4 in TT group. No patient required a surgical referral. Adverse events were similar between the groups with no readmissions related to pleural infection. CONCLUSIONS The ACTion trial met its pre-specified feasibility criteria for patient acceptability but other issues around feasibility of a full-scale trial remain. From the results available the hypothesis that TT can reduce length of stay in pleural infection should be explored further. TRIAL REGISTRATION ISRCTN: 84674413.
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Affiliation(s)
- David T Arnold
- Academic Respiratory Unit, University of Bristol, Level 2, Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK. .,North Bristol NHS Trust, Bristol, UK.
| | | | | | | | | | | | - George W Nava
- Academic Respiratory Unit, University of Bristol, Level 2, Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.,North Bristol NHS Trust, Bristol, UK
| | - Steven P Walker
- Academic Respiratory Unit, University of Bristol, Level 2, Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.,North Bristol NHS Trust, Bristol, UK
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Level 2, Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.,North Bristol NHS Trust, Bristol, UK
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Porcel JM. Nonmalignant Pleural Effusions. Semin Respir Crit Care Med 2022; 43:570-582. [PMID: 36104027 DOI: 10.1055/s-0042-1748186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Although the potential causes of nonmalignant pleural effusions are many, the management of a few, including complicated pleural infections and refractory heart failure and hepatic hydrothoraces, can be challenging and requires the assistance of interventional pulmonologists. A pragmatic approach to complicated parapneumonic effusions or empyemas is the insertion of a small-bore chest tube (e.g., 14-16 Fr) through which fibrinolytics (e.g., urokinase and alteplase) and DNase are administered in combination. Therapeutic thoracenteses are usually reserved for small to moderate effusions that are expected to be completely aspirated at a single time, whereas video-assisted thoracic surgery should be considered after failure of intrapleural enzyme therapy. Refractory cardiac and liver-induced pleural effusions portend a poor prognosis. In cases of heart failure-related effusions, therapeutic thoracentesis is the first-line palliative therapy. However, if it is frequently needed, an indwelling pleural catheter (IPC) is recommended. In patients with hepatic hydrothorax, repeated therapeutic thoracenteses are commonly performed while a multidisciplinary decision on the most appropriate definitive management is taken. The percutaneous creation of a portosystemic shunt may be used as a bridge to liver transplantation or as a potential definitive therapy in nontransplant candidates. In general, an IPC should be avoided because of the high risk of complications, particularly infections, that may jeopardize candidacy for liver transplantation. Even so, in noncandidates for liver transplant or surgical correction of diaphragmatic defects, IPC is a therapeutic option as valid as serial thoracenteses.
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Affiliation(s)
- José M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain
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