ENTEROCOCCUS FAECALIS EMPYEMA AS A RARE COMPLICATION OF INDWELLING PLEURAL CATHETER USED IN THE MANAGEMENT OF CHRONIC NONMALIGNANT PLEURAL EFFUSION

Abstract

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Indwelling pleural catheters (IPCs) are increasingly utilized in the symptomatic management of chronic benign and malignant pleural effusions. While they offer notable advantages in terms of improving quality of life and potentially achieving pleurodesis, IPCs have been seldom associated with the development of pleural infection. In fact, a large multicenter review evaluating 1021 patients across 11 different centers reported an infection rate of only 4.8%. Etiology is thought to be related to bacterial "colonization" of the pleural catheter; however, to date, there has been no published literature discussing the incidence or significance of bacterial colonization in IPC-treated patients. Furthermore, most bacterial species isolated from IPC-related empyemas include Staphylococcus, Pseudomonas, and Enterobacteriaceae. Herein lies the first reported case of IPC-related empyema due to Enterococcus faecalis infection. CASE PRESENTATION: An 84-year-old man with a past medical history of end-stage renal disease (ESRD) on hemodialysis, chronic heart failure with preserved ejection fraction (HFpEF), chronic respiratory failure related to poorly controlled obstructive sleep apnea (OSA) requiring 5 liters of supplemental oxygen was admitted to the medical intensive care unit for septic shock due to Enterococcus faecalis bacteremia. Patient recently had A left-sided IPC placed two weeks prior to presentation for chronic left-sided non-malignant pleural effusion. Further evaluation revealed the presence of a new, left-sided, multiloculated pleural effusion. Drainage from the IPC was purulent in nature, and fluid cultures grew Enterococcus faecalis. After allowing continued drainage from the IPC and starting appropriate antibiotic therapy, the patient improved significantly. DISCUSSION: A recent systematic review of nineteen studies evaluated 1168 patients with IPCs and determined the incidence of empyema to be only 2.8%. Despite the rarity of this complication, there are no formal guidelines for management. Several proposed therapeutic options in addition to standard antibiotic therapy have been utilized by clinicians, including instillation of intrapleural fibrinolytics or antibiotics, surgical evacuation, and removal of the IPC. Clinicians should be aware of this seldom reported manifestation, as prompt recognition and diagnosis can assist with developing an appropriate multidisciplinary approach to treatment. CONCLUSIONS: Indwelling pleural catheters (IPCs) are increasingly utilized in the symptomatic management of chronic benign and malignant pleural effusions. Although they offer several benefits in terms of increasing patient quality of life and improving symptoms, clinicians should be aware of the rare potential complications, particularly infection. Several management options are available and should be tailored to patient specific factors. REFERENCE #1: Lui MM, Thomas R, Lee YC. Complications of indwelling pleural catheter use and their management. BMJ Open Respir Res. 2016 Feb 5;3(1):e000123. doi: 10.1136/bmjresp-2015-000123. PMID: 26870384; PMCID: PMC4746457. REFERENCE #2: Van Meter ME, McKee KY, Kohlwes RJ. Efficacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: a systematic review. J Gen Intern Med. 2011 Jan;26(1):70-6. doi: 10.1007/s11606-010-1472-0. Epub 2010 Aug 10. PMID: 20697963; PMCID: PMC3024099. REFERENCE #3: Kniese C, Diab K, Ghabril M, Bosslet G. Indwelling Pleural Catheters in Hepatic Hydrothorax: A Single-Center Series of Outcomes and Complications. Chest. 2019 Feb;155(2):307-314. doi: 10.1016/j.chest.2018.07.001. Epub 2018 Jul 7. PMID: 29990479; PMCID: PMC6363815. DISCLOSURES: No relevant relationships by Mansur Assaad, source=Web Response No relevant relationships by Rajamurugan Meenakshisundaram, source=Web Response No relevant relationships by FARAZ Siddiqui, source=Web Response