Abstract
BackgroundEmpyema is an increasingly frequent clinical problem worldwide, and has substantial morbidity and mortality. Our objectives were to identify the clinical, surgical and microbiological features, and management outcomes, of empyema.MethodsA retrospective observational study over 12 years (1999–2010) was carried out at The Heart Hospital, London, United Kingdom. Patients with empyema were identified by screening the hospital electronic ‘Clinical Data Repository’. Demographics, clinical and microbiological characteristics, underlying risk factors, peri-operative blood tests, treatment and outcomes were identified. Univariable and multivariable statistical analyses were performed.ResultsPatients (n = 406) were predominantly male (74.1%); median age = 53 years (IQR = 37–69). Most empyema were community-acquired (87.4%) and right-sided (57.4%). Microbiological diagnosis was obtained in 229 (56.4%) patients, and included streptococci (16.3%), staphylococci (15.5%), Gram-negative organisms (8.9%), anaerobes (5.7%), pseudomonads (4.4%) and mycobacteria (9.1%); 8.4% were polymicrobial. Most (68%) cases were managed by open thoracotomy and decortication. Video-assisted thoracoscopic surgery (VATS) reduced hospitalisation from 10 to seven days (P = 0.0005). All-cause complication rate was 25.1%, and 28 day mortality 5.7%. Predictors of early mortality included: older age (P = 0.006), major co-morbidity (P = 0.01), malnutrition (P = 0.001), elevated red cell distribution width (RDW, P<0.001) and serum alkaline phosphatase (P = 0.004), and reduced serum albumin (P = 0.01) and haemoglobin (P = 0.04).ConclusionsEmpyema remains an important cause of morbidity and hospital admissions. Microbiological diagnosis was only achieved in just over 50% of cases, and tuberculosis is a notable causative organism. Treatment of empyema with VATS may reduce duration of hospital stay. Raised RDW appears to associate with early mortality.
Highlights
Thoracic empyema, defined as pus in the pleural cavity, is associated with considerable morbidity and mortality worldwide
We aimed to identify the clinical characteristics, risk factors, microbial aetiology, operative management and outcomes, and predictors of early mortality of empyema cases presenting to a referral cardiothoracic centre in the UK, to provide informed guidance on developing improved management and cost-effective service delivery
Empyema were principally community-acquired (87.4%, P,0.0001, OR = 6.96, 95%CI = 4.89–9.90) and rightsided (57.4%, P = 0.03, OR = 1.38, 95%CI = 1.04–1.82); four patients had bilateral empyema
Summary
Thoracic empyema, defined as pus in the pleural cavity, is associated with considerable morbidity and mortality worldwide. Thoracic empyema currently affects over 65,000 patients each year in the US and UK, at an estimated cost of $500 million to health services [9,10]. Specific microbiological diagnosis is required to guide choice of antibiotic therapy, and is usually achieved through evaluation of pleural fluid/ exudate and blood cultures. Mycobacterium tuberculosis (TB) is one of the most important causes of pleural infection, often associated with HIV co-infection [1,13,14]. Empyema is an increasingly frequent clinical problem worldwide, and has substantial morbidity and mortality. Our objectives were to identify the clinical, surgical and microbiological features, and management outcomes, of empyema
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