Recent Insights into the Management of Pleural Infection

Chest ultrasound is better than CT in identifying septated effusion of patients with pleural disease

Septated pleural effusion is very common. The presence of septations in pleural effusion determines the local treatment strategy for such patients. Therefore, there is a pressing need for imaging techniques to assess the presence of septations. The objective of this research was to assess the diagnostic efficacy of computed tomography (CT) and chest ultrasound in identifying septated pleural effusion. We delineated the ultrasound and enhanced chest CT manifestations for diagnosing septated pleural effusions, and subsequently, we conducted a comparative analysis to assess the diagnostic efficacy of enhanced chest CT and ultrasound in identifying septated pleural effusions. Medical thoracoscopy served as the gold standard for confirming the diagnosis of septated pleural effusions. Ultrasound demonstrated a sensitivity of 82.6% (95% CI 73.3-89.7%) and a specificity of 100.0% (95% CI 98.1-NaN) for diagnosing septated pleural effusion. In comparison, enhanced chest CT exhibited a sensitivity of 59.8% (95% CI 49.0-69.9%) and a specificity of 87.0% (95% CI 81.5-91.4%). The positive predictive value for ultrasound was 100.0% (95% CI 95.3-100.0%), while for enhanced chest CT, it was 68.8% (95% CI 59.0-77.4%). Ultrasound yielded a negative predictive value of 92.3% (95% CI 87.5-NaN), and enhanced chest CT had a negative predictive value of 82.0% (95% CI 74.6-87.8%) in diagnosing septated pleural effusion. Thoracic ultrasound exhibits superior sensitivity and specificity compared to enhanced chest CT in diagnosing septated pleural effusions. Therefore, chest ultrasound is highly recommended as an adjunct for determining septated pleural effusion.

Infective Pleural Effusions-A Comprehensive Narrative Review Article

Infective pleural effusions are mainly represented by parapneumonic effusions and empyema. These conditions are a spectrum of pleural diseases that are commonly encountered and carry significant mortality and morbidity rates reaching upwards of 50%. The causative etiology is usually an underlying bacterial pneumonia with the subsequent seeding of the infectious culprit and inflammatory agents to the pleural space leading to an inflammatory response and fibrin deposition. Radiographical evaluation through a CT scan or ultrasound yields high specificity and sensitivity, with features such as septations or pleural thickening indicating worse outcomes. Although microbiological yields from pleural studies are around 56% only, fluid analysis assists in both diagnosis and prognosis by evaluating pH, glucose, and other biomarkers such as lactate dehydrogenase. Management centers around antibiotic therapy for 2-6 weeks and the drainage of the infected pleural space when the effusion is complicated through tube thoracostomies or surgical intervention. Intrapleural enzymatic therapy, used to increase drainage, significantly decreases treatment failure rates, length of hospital stay, and surgical referrals but carries a risk of pleural hemorrhage. This comprehensive review article aims to define and delineate the progression of parapneumonic effusions and empyema as well as discuss pathophysiology, diagnostic, and treatment modalities with aims of broadening the generalist's understanding of such complex disease by reviewing the most recent and relevant high-quality evidence.

Causes, management and treatment of empyema

Infections in the pleural space have been a significant problem since ancient times and continue to be so today, with an incidence of 52% in patients with post-pneumonia syndrome. Typically, these effusions require a combination of medical treatment and surgical drainage, including debridement and decortication. Researchers have been studying the use of intrapleural fibrinolytics in managing complicated pleural effusions and empyema, but there is still ongoing debate and controversy among clinicians. Empyema has traditionally been considered a surgical disease, with antibiotics and chest tube drainage being the initial treatment modality. However, with advances in minimally invasive procedures such as video-assisted thoracoscopic surgery (VATS) and the use of intrapleural fibrinolytics, medical management is now preferred over surgery for many cases of empyema. Surgical options, such as open thoracotomy, are reserved for patients who fail conservative management and have complicated or chronic empyema. This comprehensive review aims to explore the evolution of various management strategies for pleural space infections from ancient times to the present day and how the shift from treating empyema as a surgical condition to a medical disease continues.

Successful Interventional Treatment of Pyopneumothorax Caused by Streptococcus constellatus Associated with Hashimoto's Thyroiditis: A Case Report and Literature Review

Background

Streptococcus constellatus rarely causes pyopneumothorax, which is a serious state and requires a surgery. However, not every patient can tolerate surgery and individualized solutions are needed. Furthermore, many known situations are risk factors of S. constellatus infection, but S. constellatus pyopneumothorax associated with Hashimoto's thyroiditis has not been reported.

Case Presentation

We present the case of a 74-year-old male with multiple encapsulated pyopneumothorax caused by S. constellatus. Given his respiratory failure, we provided two-stage percutaneous right empyema radiography for catheter drainage in the radiology interventional department instead of surgery. Moreover, an occult Hashimoto's thyroiditis was discovered in the patient, which was possibly associated with S. constellatus pyopneumothorax. Levothyroxine was administered to improve his situation.

Conclusion

To our knowledge, it is the first case described in this context. We provided an alternative treatment for S. constellatus encapsulated pyopneumothorax in patient who might not tolerate surgery. We also revealed the possible relationship between S. constellatus pyopneumothorax and Hashimoto's thyroiditis.

Unraveling the Predictive Potential of Rapid Scoring in Pleural Infection: A Critical Review

Pleural infection, or pleural empyema, is a severe medical condition associated with high morbidity and mortality rates. Timely and accurate prognostication is crucial for optimizing patient outcomes and resource allocation. Rapid scoring systems have emerged as promising tools in pleural infection prognostication, integrating various clinical and laboratory parameters to assess disease severity and quantitatively predict short-term and long-term outcomes. This review article critically evaluates existing rapid scoring systems, including CURB-65 (confusion, uremia, respiratory rate, blood pressure, age ≥ 65 years), A-DROP (age (male >70 years, female >75 years), dehydration, respiratory failure, orientation disturbance, and low blood pressure), and APACHE II (acute physiology and chronic health evaluation II), assessing their predictive accuracy and limitations. Our analysis highlights the potential clinical implications of rapid scoring, including risk stratification, treatment tailoring, and follow-up planning. We discuss practical considerations and challenges in implementing rapid scoring such as data accessibility and potential sources of bias. Furthermore, we emphasize the importance of validation, transparency, and multidisciplinary collaboration to refine and enhance the clinical applicability of these scoring systems. The prospects for rapid scoring in pleural infection management are promising, with ongoing research and data science advances offering improvement opportunities. Ultimately, the successful integration of rapid scoring into clinical practice can potentially improve patient care and outcomes in pleural infection management.

Pleural Space Infections

Pleural space infections have been a well-recognized clinical syndrome for over 4000 years and continue to cause significant morbidity and mortality worldwide. However, our collective understanding of the causative pathophysiology has greatly expanded over the last few decades, as have our treatment options. The aim of this paper is to review recent updates in our understanding of this troublesome disease and to provide updates on established and emerging treatment modalities for patients suffering from pleural space infections. With that, we present a review and discussion synthesizing the recent pertinent literature surrounding the history, epidemiology, pathophysiology, diagnosis, and management of these challenging infections.

Intrapleural Instillation of Sodium Bicarbonate versus Urokinase in Management of Complicated Pleural Effusion: A Comparative Cohort Study

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.

Analysis of antibiotic use and clinical outcomes in adults with known and suspected pleural empyema

Background

There is not a prevailing consensus on appropriate antibiotic choice, route, and duration in the treatment of bacterial pleural empyema after appropriate source control. Professional society guidelines note the lack of comparative trials with which to guide recommendations. We assessed clinical outcomes in the treatment of known and suspected empyema based upon three aspects of antibiotic use: (1) total duration, (2) duration of intravenous (IV) antibiotics, and (3) duration of anti-anaerobic antibiotics.

Methods

We performed a hypothesis-generating retrospective chart review analysis of 355 adult inpatients who had pleural drainage, via either chest tube or surgical intervention, for known or suspected empyema. The primary outcome variable was clinician assessment of resolution or lack thereof. The secondary outcomes were death within 90 days, hospital readmission within 30 days for empyema, and all-cause hospital readmission within 30 days. Mann-Whitney U test was used to compare outcomes with regard to these variables.

Results

None of the independent variables was significantly associated with a difference in clinical resolution rate despite trends for total antibiotic duration and anti-anaerobic antibiotic duration. None of the independent variables was associated with mortality. Longer total antibiotic duration was associated with lower readmission rate for empyema (median 17 [interquartile range 11–28] antibiotic days in non-readmission group vs. 13 [6-15] days in readmission group), with a non-significant trend for all-cause readmission rate (17 [11–28] days vs. 14 [9–21] days). IV antibiotic duration was not associated with a difference in any of the defined outcomes. Longer duration of anti-anaerobic antibiotics was associated with both lower all-cause readmission (8.5 [0–17] vs. 2 [0–11]) and lower readmission rate for empyema (8 [0–17] vs. 2 [0–3]).

Conclusion

Our data support the premise that routine use of anti-anaerobic antibiotics is indicated in the treatment of pleural empyema. However, our study casts doubt on the benefits of extended IV rather than oral antibiotics in the treatment of empyema. This represents a target for future investigation that could potentially limit complications associated with the excessive use of IV antibiotics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07759-8.

Pleural Infections: Antimicrobial Susceptibility Patterns of Bacterial Isolates and Associated Factors in Suspected Hospitalized Patients at Arba Minch General Hospital, Southern Ethiopia

Background:

Pleural infection remains a clinical problem with high morbidity and mortality all over the world. Antimicrobial options are uncertain due to the lack of understanding of the bacteriology of pleural infection. Thus, the goal of this study was to determine bacteriological profiles, antimicrobial susceptibility patterns, and factors associated with pleural infection.

Methods:

An institution-based cross-sectional study was undertaken in Arba Minch General Hospital from 1st January to 30th November 2020. Socio-demographic, clinical, and behavioral data were collected using a pre-tested, structured questionnaire. Adducted amounts of pleural fluid samples were collected aseptically with sterile test tubes. Standard procedures were utilized for bacterial identification, and antimicrobial susceptibility testing was done using Kirby–Disk Bauer's diffusion method. Version 25 of the Statistical Package for the Social Sciences (SPSS) was used to analyze the data. The p-value of 0.05 was considered statistically significant.

Results:

A total of 152 hospitalized patients were enrolled in this study. The overall magnitude of bacterial pleural infection was 27.6%. The predominant bacteria isolated were Staphylococcus aureus with 34.9%, followed by Escherichia coli with 11.6%. Multidrug-resistant (MDR) isolates account for around 48.8% of all isolates, with Gram-positive bacterial isolates accounting for 71.4%. Methicillin-resistant was found in 26.7% and 33.3% of isolated Staphylococcus aureus (MRSA) and coagulase-negative staphylococci (CoNS), respectively. One isolate of Enterococcus spp. was found to be vancomycin-resistant. All isolated Streptococcus pneumoniae and Streptococcus pyogenes were susceptible to penicillin, erythromycin, cotrimoxazole, and vancomycin. Likewise, isolated Pseudomonas aeruginosa was susceptible to piperacillin. The pleural infection showed a statistically significant association with age group less than or equal to 25 years old (p<0.001), hospital admission for more than seven days (p<0.007), chest tube drainage (p<0.021), previous history of pneumonia (p<0.029) and habit of alcohol drinking (p<0.029).

Conclusion:

The overall rate of culture-confirmed pleural infection was high, and a considerable percentage of bacteria isolates showed increased resistant to routinely used antibiotics, indicating that more attention is needed to follow the spread and emergence of drug-resistant bacterial agents.

Nonmalignant Pleural Effusions

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.

Clinical relevance of molecular testing methods in the diagnosis and guidance of therapy in patients with staphylococcal empyema: a systematic review and meta-analysis

Background

Efficient detection tools for determining staphylococcal pleural infection are critical for its eradication. The objective of this meta-analysis was to assess the diagnostic utility of nucleic acid amplification tests (NAAT) in suspected empyema cases to identify staphylococcal strains and avoid unnecessary empiric methicillin-resistant Staphylococcus aureus (MRSA) therapy.

Methods

From inception to July 24, 2021, relevant records were retrieved from PubMed, Embase, Scopus, Web of Science, and the Cochrane Library. The quality of studies was determined using the QUADAS-2 tool. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and hierarchical summary receiver operating characteristic (HSROC) curve for NAAT’s diagnostic performance were evaluated using an HSROC model.

Results

Eight studies comprising 424 samples evaluated NAAT accuracy for Staphylococcus aureus (SA) identification, while four studies comprising 317 samples evaluated methicillin-resistant Staphylococcus aureus (MRSA) identification. The pooled NAAT summary estimates for detection of both SA (sensitivity: 0.35 (95% CI 0.19–0.55), specificity: 0.95 (95% CI 0.92–0.97), PLR: 7.92 (95% CI 4.98–12.59), NLR: 0.44 (95% CI 0.14–1.46), and DOR: 24.0 (95% CI 6.59–87.61) ) and MRSA (sensitivity: 0.45 (95% CI 0.15–0.78), specificity: 0.93 (95% CI 0.89–0.95), PLR: 10.06 (95% CI 1.49–67.69), NLR: 0.69 (95% CI 0.41–1.15), and DOR: 27.18 (95% CI 2.97–248.6) ) were comparable. The I2 statistical scores for MRSA and SA identification sensitivity were 13.7% and 74.9%, respectively, indicating mild to substantial heterogeneity. PCR was frequently used among NAA tests, and its diagnostic accuracy coincided well with the overall summary estimates. A meta-regression and subgroup analysis of country, setting, study design, patient selection, and sample condition could not explain the heterogeneity (meta-regression P = 0.66, P = 0.46, P = 0.98, P = 0.68, and P = 0.79, respectively) in diagnostic effectiveness.

Conclusions

Our study suggested that the diagnostic accuracy of NAA tests is currently inadequate to substitute culture as a principal screening test. NAAT could be used in conjunction with microbiological culture due to the advantage of faster results and in situations where culture tests are not doable.

Imaging Approach to Disease of the Pleura

Diseases of pleura are not only common but also have a significant impact on patients' outcomes. While early detection and treatment are imperative in reducing this burden, many pleural entities present similarly, thus posing a diagnostic dilemma for radiologists requiring critical further workup. While chest radiography, CT, and image-guided thoracentesis are primarily utilized as the initial imaging techniques for the workup of pleural diseases, MRI, and FDG-PET/CT are also frequently employed to investigate the root cause of pleural abnormalities. By elucidating the common imaging features of neoplastic, inflammatory, and infectious pleural pathologies, clinicians can quickly and easily differentiate the various pleural diseases, rapidly reach the correct diagnosis, and ultimately improve patient outcomes.

Ceftazidime-avibactam and intrapleural amikacin therapy for extensively drug-resistant Pseudomonas aeruginosa thoracic empyema: A case report

INTRODUCTION

Thoracic empyema and concomitant bronchopleural fistula are serious complications of pneumonia. The treatment of empyema caused by extensively drug-resistant Pseudomonas aeruginosa (XDR-PA) has become increasingly challenging.

PATIENTS CONCERNS AND IMPORTANT CLINICAL FINDINGS

A 57-year-old woman with controlled schizophrenia developed hospital-associated bacterial pneumonia secondary to P. aeruginosa on day 13 of hospitalization for brain meningioma surgery.

DIAGNOSIS

Chest radiography and computed tomography revealed right-sided necrotizing pneumonia with pneumothorax, a focal soft tissue defect over the right lower chest wall, and a mild right-sided encapsulated pleural effusion with consolidation. XDR-PA was isolated on empyema cultures.

INTERVENTIONS

The patient was treated with intrapleural amikacin as a bridge to video-assisted thoracoscopic surgery, followed by novel ceftazidime-avibactam therapy.

OUTCOMES

On the 104th day of admission, the patient underwent chest wall debridement and closure. The patient was discharged on day 111. Twenty-eight days after discharge, there were no observable sequelae of empyema.

CONCLUSION

Although the minimum inhibitory concentration of ceftazidime-avibactam for XDR-PA is relatively high (8 mg/L), this report emphasizes the efficacy of ceftazidime-avibactam treatment for XDR-PA empyema, as well as the importance of source control.

Modified regimen intrapleural alteplase with pulmozyme in pleural infection management: a tertiary teaching hospital experience

Background

Current management of poorly draining complex effusions favours less invasive image-guided placement of smaller tubes and adjunctive intrapleural fibrinolysis therapy (IPFT). In MIST-2 trial, intrapleural 10 mg alteplase (t-PA) with 5 mg of pulmozyme (DNase) twice daily for 72 h were used. We aimed to assess the effectiveness and safety of a modified regimen 16 mg t-PA with 5 mg of DNase administered over 24 h in the management of complex pleural infection.

Methods

This was a single centre, prospective study involving patients with poorly drained pleural infection. Primary outcome was the change of pleural opacity on chest radiograph at day 7 compared to baseline. Secondary outcomes include volume of fluid drained, inflammatory markers improvement, surgical referral, length of hospitalisation, and adverse events.

Results

Thirty patients were recruited. Majority, 27 (90%) patients were successfully treated. Improvement of pleural opacity on chest radiograph was observed from 36.9% [Interquartile range (IQR 21.8–54.9%)] to 18.1% (IQR 8.8–32.7%) of hemithorax (P < 0.05). T-PA/DNase increased fluid drainage from median of 45 mls (IQR 0–100) 24 h prior to intrapleural treatment to 1442 mls (IQR 905–2360) after 72 h; (P < 0.05) and reduction of C-reactive protein (P < 0.05). Pain requiring escalation of analgesia affected 20% patients and 9.9% experienced major adverse events. None required surgical intervention.

Conclusion

This study suggests that a modified regimen 16 mg t-PA with 5 mg DNase can be safe and effective for patients with poorly drained complex pleural infection.

Trial registration The study was registered retrospectively on 07/06/2021 with ClinicalTrials number NCT04915586 (https://clinicaltrials.gov/ct2/show/NCT04915586).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01995-z.

Inflammation of the Pleural Cavity: A Review on Pathogenesis, Diagnosis and Implications in Tumor Pathophysiology

Simple Summary

The pleura is a cavity whose pathology ranges from simple fluid accumulation to tumor development, all inducing important consequences in patents health, and usually having an important association with local inflammation. Understanding the pathophysiology of pleural inflammation helps the development of the correct treatment strategies and opens new windows in pleural research. Thus, the aim of this review is to present the etiologies and the pathophysiological mechanisms of pleural inflammation with a special interest in their role on tumor development and diagnosis.

Abstract

Pleural effusions are a common respiratory condition with many etiologies. Nonmalignant etiologies explain most pleural effusions and despite being nonmalignant, they can be associated with poor survival; thus, it is important to understand their pathophysiology. Furthermore, diagnosing a benign pleural pathology always harbors the uncertainty of a false-negative diagnosis for physicians and pathologists, especially for the group of non-specific pleuritis. This review aims to present the role of the inflammation in the development of benign pleural effusions, with a special interest in their pathophysiology and their association with malignancy.

From Chest Wall Resection to Medical Management: The Continued Saga of Parapneumonic Effusion Management and Future Directions

Pleural space infections have been described since the time of Hippocrates and to this day remains a significant pathology. Every year in the USA approximately there are one million hospital admissions for pneumonia with 20%-40% associated with some form of pleural space infections leading to pleural effusions with increased morbidity and mortality. Often, management of these effusions mandate combination of medical treatment and surgical drainage with debridement and decortication. There has been a lot of ongoing research regarding the safety and efficacy of intrapleural fibrinolytics in the management of complicated pleural effusions and empyema. Till this day, areas of debate and controversies exist among clinicians treating pleural space infection. Empyema is historically considered a surgical disease. There have been societies and guidelines for the management of infected parapneumonic effusions with antibiotics and chest tube drainage as an initial empiric treatment modality. With the advances in the use of Intrapleural fibrinolytics and minimally invasive procedures such as video-assisted thoracoscopic surgery (VATS), empyema a surgical disease is now more favoring medical management. Surgical option, such as open thoracotomy, is reserved for patients who failed conservative management and chronic empyema. The aim of this comprehensive review is to shed light on the evolution of various management strategies from the era of Hippocrates to current day practice and how there continues to be a paradigm shift in treating empyema as a surgical condition to a medical disease.

Optimizing the management of complicated pleural effusion: From intrapleural agents to surgery

Pleural effusion is a frequent complication of acute pulmonary infection and can affect its morbidity and mortality. The possible evolution of a parapneumonic pleural effusion includes 3 stages: exudative (simple accumulation of pleural fluid), fibropurulent (bacterial invasion of the pleural cavity), and organized stage (scar tissue formation). Such a progression is favored by inadequate treatment or imbalance between microbial virulence and immune defenses. Biochemical features of a fibrinopurulent collection include a low pH (<7.20), low glucose level (<60 mg/dl), and high lactate dehydrogenase (LDH). A parapneumonic effusion in the fibropurulent stage is usually defined "complicated" since antibiotic therapy alone is not enough for its resolution and an invasive procedure (pleural drainage or surgery) is required. Chest ultrasound is one of the most useful imaging tests to assess the presence of a complicated pleural effusion. Simple parapneumonic effusions are usually anechoic, whereas complicated effusions often have a complex appearance (non-anechoic, loculated, or septated). When simple chest tube placement fails and/or patients are not suitable for more invasive techniques (i.e. surgery), intra-pleural instillation of fibrinolytic/enzymatic therapy (IPET) might represent a valuable treatment option to obtain the lysis of fibrin septa. IPET can be used as either initial or subsequent therapy. Further studies are ongoing or are required to help fill some gaps on the optimal management of parapneumonic pleural effusion. These include the duration of antibiotic therapy, the risk/benefit ratio of medical thoracoscopy and surgery, and new intrapleural treatments such as antibiotic-eluting chest tubes and pleural irrigation with antiseptic agents.

16S rRNA is a valuable tool in finding bacterial aetiology of community-acquired pleural empyema-a population-based observational study in South Sweden

BACKGROUND

The incidence of community-acquired pleural empyema is increasing. Knowledge of the bacterial aetiology is important in order to base recommendations on empirical antimicrobial treatment. The primary aim of the present study was to describe the bacterial aetiology of adult patients with culture proven and/or 16S rRNA-positive community-acquired pleural infection.

METHODS

We performed a retrospective, population-based observational cohort study in Skåne County, south of Sweden. We included all patients with pleural samples obtained between 1st of January 2011 to 31st of December 2017 in Skåne, south of Sweden, with a positive culture and/or 16S rRNA result. Exclusion criteria were patients with culture-negative and/or 16S rRNA-negative pleural samples, age < 18 years, pleural empyema caused by trauma or iatrogenesis, pleural infection caused by tuberculosis or fungi, simultaneous lung- or abscess of the abdomen and bacterial species considered to be contaminants.

RESULTS

A total of 291 patients were included in the study, of which 63% were men and the median age was 69 years. The dominating bacterial aetiology was viridans streptococci (36%), followed by Streptococcus pneumoniae (14%) and anaerobic bacteria (12%). 16S rRNA added information of bacterial aetiology in addition to standard culturing methods in 63% of the patients.

CONCLUSION

We found that the aetiology of adult patients with culture proven and/or 16S rRNA-positive community-acquired pleural empyema is dominated by viridans streptococci, S. pneumoniae and anaerobic bacteria. Our study shows that 16S rRNA is a valuable tool in finding the bacterial aetiology of community-acquired pleural empyema.