Empyema By

Narthanan Mathiselvan DM Pulmo Resident

Aims

o To evaluate patients with complicated pleural effusion

o To know the current scientific evidence about the treatment of empyema

o To discuss controversial questions in invasive management of empyema

Introduction• Pleural space contains 0.3

mL/kg of fluid

• Pleural fluid circulation- lymphatics deal with several 100 mLs of extra fluid/ 24 hrs

Pathogenesis

Am Rev Respir Dis 1962; 85: 935–936.

PLEURAL EMPYEMA

Complicated paraneumonic effusion

Thoracic empyema

Uncomplicated paraneumonic effusion ►Exudative biochemical

characteristics

►Usually sterile

►Resolution with pneumonia

Paraneumonic pleural effusion

Thoracic empyema

Uncomplicated paraneumonic effusion

Complicated paraneumonic effusion

Anaerobic use of

glucose

pHLysis of

neutrophils

LDH

Rapid bacterial clearing

Cultures negative

Deposition of fibrin

Pleural loculati

on

Paraneumonic pleural effusion

Uncomplicated paraneumonic effusion

Complicated paraneumonic effusion

Thoracic empyema

Paraneumonic pleural effusion

►Bacterial organisms seen on Gram stain and/or aspiration of pus on thoracentesis

DiagnosisThoracentesis

DiagnosisPleural fluid

analysisNeutrophil protease

Cell lysis pH Glucose Proteins

LDH

Pleural fluid analysisOther biomarkers

Diagnosis

►C-reactive protein►Procalcitonin►STREM-1, VEGF, IL-8

Eur Respir J 2009;34:1383-9Clin Biochem 2013;46:1484-8

PCT>0.18: Senst 83%, Spec 81%

Bacteriology

Gram-positive bacteria

Anaerobic bacteria

Mixed etiology

Other etiologies

Bacteriology

Thorax 2010;65(suppl 2):ii41-ii53

Streptococcus spp.

Staphylococcus aureus

Gram-negative aerobes

Anaerobes0%

10%

20%

30%

40%

50%

60%

Community-acquired Hospital-acquired

S. milleriS. pneumoniaeS. intermedius Enterobacteriac

eaeEscherichia coli

Escherichia coliPs. aeruginosaKlebsiella spp.

Fusobacterium sppBacteroides sppPeptostreptococcus spp Mixed

25% MRSA10% MSSA

Bacteriology

Survival according etiology

Am J Respir Crit Care Med 2006;174:817-823

BacteriologyGram-positive, anaerobic, bacteriaStreptococcus milleri: The main etiological agent

Am J Respir Crit Care Med 1997;156:1508-14

► Frenquently associated with comorbidities► Mortality: 20%► Anaerobes associated in 63%

Bacteriology

► Serotypes: 1, 3, 19A, 17 and 7F

► Relevant influence of PCV-7 in children and adults

Clin Infect Dis:2006; 42:1135-40

Gram-positive, aerobic, bacteriaStreptococcus pneumoniae: A common etiological agent

Bacteriology

► Causing empyema in 10-24%

► Older patients

► Underlying comorbities

► Tendency to cavitation► MRSA not only in

hospitalized patients

Gram-positive, aerobic, bacteriaStaphylococcus aureus

Chest 2005;128:2732-8

BacteriologyAnaerobic bacteria

► Etiology in 36-76% of empyemas

► Difficult culture and isolation

► Predominant microorganisms: Fusobacterium nucleatum and Prevotella spp.

BacteriologyMixed etiology

► Animal models suggest that infection with a mixed bacterial flora containing aerobes and anaerobes is more likely to produce an empyema than infection with a single microorganism.

► The common combination is:

anaerobes + microaerophilic or aerobic streptococci

(normal oral flora)

Pleural Infections – Rx general Principles1) Accurate diagnosis 2) Control sepsis: Suitable antibiotic therapy 3) Drainage of infected material :Intercostal tube

drainage 4) Intrapleural adjunctive therapies 5) Surgery

Complications of Empyema

Antibiotic treatment

Treatment

► Antibiotics should be guided by bacterial cultures (when it is possible)

► Use anaerobes coverage in all patients (except culture proven pneumoococcal infection)

► Good pleural space penetration: penicillins, penicillins+beta-lactamase inhibitors, cephalosporines, metronidazol

► Avoid aminoglycosides

► Empirical hospital-acquired empyema treatment should include treatment for MRSA and anaerobic bacteria

Antibiotic treatment

Treatment

Duration of antibiotic therapy depends on: Sensitivity of

the microorganism

Response to initial therapy

Extent of pulmonary and pleural disease

Host immunity status

Cessation of output chest

tube

2-4 weeks following defervescence

Chest drainage indication

Treatment

Frank pus

Presence of organisms in Gram stain or

cultures

pH < 7.20

Glucose <60 mg/dL (3.4 mmol/L)

Does the size (of the chest tube)

matter?

Chest tube drainage

Intercostal Drainage

Fibrinolytic agents

Fibrinolytic agentsTreatment

Respir Med 2012;106,716-723

Alteplase reduces rate of decortication

Fibrinolytic agentsTreatment

Better outcome [Treatment failure (surgical intervention or death)] than placebo

Less duration of hospitalization compared to placebo

Chest 2012; 142(2):401–411

TreatmentThoracoscopy debridement

Ann Thorac Surg 2005;79:1851-6

Conclusion• Pleural infection is increasing • Microbiology is complex and varied • Less pain from smaller drains and seem to work • Potential prediction algorithm (requires validation) • tPA + DNase improves CXR (and maybe more) • Optimal timing and selection for surgery - unknown