Parapneumonic Empyema Research Articles

Beyond diagnosis: maximizing the role of medical thoracoscopy in pleural disease treatment.

Medical thoracoscopy has been extensively utilized in the diagnosis of pleural disease, yet its potential therapeutic applications remain underutilized. This article presents a comprehensive overview of the various uses of medical thoracoscopy in managing pleural diseases. It has been employed to facilitate thoracic drainage and reduce hospitalization duration of patients with complicated parapneumonic effusions and empyema. Additionally, medical thoracoscopic occlusion therapy can be used for bronchoscopic closure and refractory pneumothorax. However, there is currently a lack of standardized protocols for utilizing medical thoracoscopy to reduce the volume of giant emphysematous bullae. Furthermore, medical thoracoscopy allows for pleurodesis or photodynamic therapy in patients with malignant pleural effusion. Nevertheless, further high-quality clinical research is needed to validate these findings.

Decortication with uniport video-assisted thoracoscopic surgery for empyema due to postoperative esophageal leakage: a report of two pediatric cases

BackgroundVideo-assisted thoracoscopic surgery (VATS) is considered useful for the treatment of parapneumonic empyema in children. However, thoracoscopic management of empyema due to esophageal leakage as an operative complication has not been well described in the literature.Case presentationWe successfully decorticated severe empyema using uniport VATS in 2 children (a 2-year-old boy who suffered esophageal perforation after laparoscopic anti-reflux surgery, and a 7-month-old girl who had anastomotic leakage after thoracoscopic repair of esophageal atresia). In these patients, we noticed that pleural effusion rapidly progressed to empyema and caused respiratory insufficiency due to wide-range coverage by fibrotic pleural rind that was successfully decorticated under video-assisted vision from a mini-thoracotomy, followed by spontaneous healing of the leakage.ConclusionsWe did not attempt to closely approach or try to repair the esophageal leakage. We believe that this is an important tip for these situations.

More isn't always better: antibiotic duration after surgical decortication in pleural empyema.

While ample high-level evidence supports the limited use of antibiotics post-source control in intraabdominal infections, there is a paucity of available data in guiding antibiotic duration for intrathoracic infections. This study aims to analyze patient outcomes among those who have undergone surgical decortication for parapneumonic pleural empyema, comparing cases managed with infectious disease (ID) specialists against those without, and to identify predictive factors influencing antibiotic duration post-source control. We hypothesized that antibiotic duration would vary depending on the involvement of ID specialists. A retrospective chart review was completed on patients with parapneumonic pleural empyemas who underwent surgical decortication at a single tertiary center from January 2011 to March 2021. Differences in patient characteristics and outcomes for those whose antibiotics were managed by ID or not were compared with Wilcoxon two-sample tests and Fisher's exact tests. Linear regression was used to evaluate for significant factors predictive of antibiotic duration. A total of 116 patients underwent surgical decortication for pleural empyema of parapneumonic etiology. ID specialists were involved with antibiotic management in 62 (53.4%) cases, while the remaining cases were not managed by ID. Demographics and patient comorbidities were similar between both groups. Growth of preoperative fluid cultures was higher in patients managed by ID (40.3% vs. 20.4%, P=0.03). Postoperatively, patients managed by ID had longer durations of antibiotics (28.7 vs. 20.9 days, P<0.001) and were more likely to be on IV antibiotics than patients not managed by ID (59.7% vs. 38.9%, P=0.04). However, postoperative outcomes were similar, including rates of disease recurrence, readmission, and 30-day mortality. Linear regression revealed length of antibiotics was significantly dependent on preoperative ventilator status [estimate: 16.346; 95% confidence interval (CI): 6.365-26.326; P=0.002], growth of preoperative pleural fluid cultures (estimate: 10.203; 95% CI: 2.502-17.904; P=0.01), and ID involvement (estimate: 8.097; 95% CI: 1.003-15.191; P=0.03). Antibiotic duration for pleural empyema managed with surgical decortication is significantly dependent on ID involvement, preoperative growth of cultures, and preoperative ventilator status. However, outcomes, including disease recurrence and 30-day mortality, were similar between patients regardless of ID involvement and longer length of antibiotics, raising the question of what the adequate duration of antibiotics is for patients who receive appropriate source control for pleural empyema. Further study with randomized control trials should be conducted to provide high-level evidence regarding length of antibiotics in this patient population.

Therapy of parapneumonic empyema in children: a protocol for a scoping review of the literature.

Empyema (the presence of pus in the pleural space) is a severe complication of community-acquired pneumonia and significant cause of morbidity, but, fortunately, not mortality in children. Between 0.6 and 2% of pneumonias are complicated by empyema and the three main pathogens involved are Streptococcus pneumoniae, Staphylococcus aureus and group A Streptococcus 1,2,3,4. Optimal management in children, especially the choice of antibiotics, method of administration and duration of therapy, pleural dranage or surgery, are still a matter of debate and currently, lack of strong specific recommendations. This paper displays the study protocol for a scoping review that aims to summarize the available literature on the microbiological epidemiology, the medical and surgical treatment options, and the outcomes of pleural empyema in pediatric population. Comprehensive research combining the terms pediatric (children aged 0 to 18 years) and pleural empyema will be performed on PubMed and SCOPUS to identify all eligible studies. At first, two reviewers will screen the abstract and then their full text to determine the articles that meet the inclusion criteria. This work will be carried out independently, everyone on a different Excel spreadsheet and each researcher will be blinded to the decision of the other researcher. When the process is completed, in case of discordance, any disagreement will be identified and resolved through discussion or with help of a third author. The findings of this review will be published in a peer-reviewed journal.

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.

Diagnostic and prognostic implications of bacteremia in patients with complicated pleural infection.

The clinical significance of bacteremia in patients with complicated pleural infection is still uncertain. We aimed to examine the incidence and clinical significance of bacteremia in patients with complicated pleural infection. This retrospective study comprised of consecutive patients who received pleural drainage due to complicated parapneumonic effusion or empyema. The clinical, laboratory, and radiologic data and clinical outcome were compared between patients with and without bacteremia. Additionally, the factors associated with overall mortality were evaluated in these patients. Of 341 patients included in the analysis, 25 (7 %) had a positive blood culture. Blood culture testing added 2 % identification of causative pathogen compared to pleural fluid culture alone. By multivariable analysis, radiologic features ofcavitary lesion, a RAPID score≥5, and a positive microbial culture in pleural fluid were independently associated with bacteremia. Despite these clinical distinctions, there was ultimately no significant difference in in-hospital mortality between patients with and without bacteremia (3 vs. 4 %, p=1.0). The only factor significantly associated with overall mortality among patients with complicated pleural infections was a higher RAPID score [HR=1.96 (95 % CI=1.35-2.84)]. The rate of bacteremia in patients with complicated pleural infection was 7 %. Blood culture testing demonstrated limited diagnostic yield and had minimal impact on clinical outcomes compared to pleural fluid culture. Therefore, it seems that blood culture testing is more advantageous for specific patients with suspected pleural infection who have cavitary lesions or a RAPID score≥5.

Intra-Empyema Antibiotic Administration: A Case Report

Background: Untreated empyema has a great morbidity and is potentially lethal. The usual approach for treatment is intravenous antibiotics together with chest tube insertion or thoracoscopic/ surgical interventions. &#x0D; Case presentation: The patient was a 32-year-old man with spinal muscular atrophy and severe intercostal muscular weakness presented with localized pleuritic chest pain and fever. The cause was diagnosed to be parapneumonic empyema. In this case, invasive approaches would potentially exacerbated chest musculature weakness. Other non-invasive managements CT-guided needle drainage and intravenous antibiotic therapy were tried and proved to be ineffective for the patient and the next invasive step would pose considerable risk to the patient. Intra-empyemic antibiotic administration through a small tube catheter was successfully effective without any recurrence. This method was non-invasive with no significant risk to the patient, had a low cost and was accepted by the patient. It was shown to be effective without any complication and saved the patient from performing an invasive procedure.&#x0D; Conclusion: This non-invasive approach may be used in those patients who are of high risk for invasive procedures. Also, potentially it may be used as one of the first line approaches before performing more invasive modalities.

Clinical presentations and complications of parapneumonic effusion and pleural empyema in children presenting in a tertiary care setup.

Objective: To evaluate the clinical presentations and complications of parapneumonic effusion (PPE) and pleural empyema (PE) in children presenting in a tertiary care setup in Karachi. Study Design: Cross-sectional study. Setting: Medical Units of National Institute of Child Health, Karachi, Pakistan. Period: July 2022 to June 2023. Material &amp; Methods: Hospitalized children of either gender, aged between 1 month and 12 years diagnosed with PPE or PE on the basis of radiological findings were analyzed. Baseline laboratory investigations were done. Complications of PPE/PE were noted. Outcome was observed in the form of discharged, referred or mortality. Results: In a total of 86 with PPE/PE, 61.6% were boys while the overall mean age was 4.35±3.17 years. Common clinical symptoms included fever (100%), decreased air entry (86%), cough (75.6%), and respiratory difficulty (74.4%). Blood cultures revealed bacterial infections in 10.5% of cases, while most common isolates were Staphylococcus aureus and Pseudomonas. Positive pleural fluid cultures noted in 39.5% of cases while pseudomonas and staphylococcus aureus were the most common bacterial isolates. Most commonly used antimicrobials were Vancomycin, Ceftriaxone, Tazobactum+Piperacillin, and Linezolid. Tube thoracostomy was performed in 96.5% of patients. Most frequent complications of PPE/PE included residual organized empyema (36%), pneumothorax (9.3%), and sepsis (9.1%). Overall, the mortality was noted in 5.8% cases. Conclusion: Most frequent clinical presentations of PPE/PE include fever, cough, respiratory difficulty, and abdominal pain, with fever being universal. Staphylococcus aureus and Pseudomonas were the most common bacterial isolates. The most common complications were residual organized empyema, pneumothorax, and sepsis.

Benefit of intrapleural fibrinolytic therapy in the treatment of complicated parapneumonic effusion and empyema.

Our study aimed to assess the benefit of intrapleural fibrinolysis before resorting to surgery to treat complicated parapneumonic effusion and empyema. We conducted a retrospective and descriptive study, including all patients hospitalized in the intensive care unit (ICU) of the Abderhaman Mami hospital, Tunisia for empyema treated with instillation of intrapleural fibrinolytic therapy between the 1st January 2000 and 31st December 2016. In all patients, empyema was diagnosed on clinical features, imaging findings (chest X-ray, thoracic echography and/or computed tomography (CT), and microbiological data. The fibrinolytic agent used was streptokinase. The efficiency of intrapleural fibrinolytic therapy was judged on clinical and paraclinical results. Among 103 cases of complicated parapneumonic effusion and empyema, 34 patients were included. The mean age was 34 years [15-81] with a male predominance (sex ratio at 2.77). Median APACH II score was 9. Fifty (50%) of the patients (n=17) had no past medical history; addictive behavior was described in 17 patients (50%). All patients were admitted for acute respiratory failure and one patient for septic shock. Pleural effusion was bilateral in 7 patients. Bacteria isolated were Streptococcus pneumonia (6 cases), Staphylococcus aureus (3 cases, including one which methicillin-resistant), Staphylococcus epidermidis (1 case), anaerobes (5 cases), and Klebsiella pneumoniae (1 case). First-line antimicrobial drug therapy was amoxicillin-clavulanate in 20 patients. A chest drain was placed in all cases in the first 38 hours of ICU admission. The median number of fibrinolysis sessions was 4 [2-9] and the median term of drainage was 7 days [3-16]. No side effects were observed. Video-assisted thoracoscopic surgery was proposed in 5 patients. The median length of hospitalization stay was 15 days [6-31]. One patient died due to multi-organ failure.

Therapy of parapneumonic empyema in children: a protocol for a scoping review of the literature

Background: Empyema (the presence of pus in the pleural space) is a severe complication of community-acquired pneumonia and significant cause of morbidity, but, fortunately, not mortality in children. Between 0.6 and 2% of pneumonias are complicated by empyema and the three main pathogens involved are Streptococcus pneumoniae, Staphylococcus aureus and group A Streptococcus 1,2,3,4. Optimal management in children, especially the choice of antibiotics, method of administration and duration of therapy, are still matter of debate and currently, lack of strong specific recommendations. This paper displays the study protocol for a scoping review that aims to summarize the available literature on the microbiological epidemiology, the treatment options, and the outcomes of pleural empyema in pediatric population. Methods: Comprehensive research combining the terms pediatric (children aged 0 to 18 years) and pleural empyema will be performed on PubMed and SCOPUS to identify all eligible studies. At first, two reviewers will screen their abstract and then their full text to detecting the articles that meet the inclusion criteria. This work will be carried out independently, everyone on a different Excel spreadsheet and each researcher will be blinded to the decision of the other researcher. When the process will be completed, in case of discordance, any disagreement will be identified and resolved through discussion or with the help, when needed, of a third author. Dissemination: The findings of this review will be published in a peer-reviewed journal.

Rapid detection of S. pyogenes and S. pneumoniae in pleural fluid for diagnosis of parapneumonic empyema.

The aim of this study was to assess the reliability of rapid antigen detection tests (RADT) for Streptococcus pyogenes (GAS) and Streptococcus pneumoniae on pleural fluid samples for diagnosis of parapneumonic effusion/empyema (PPE) and their potential for improving pathogen identification rates. Sixty-three pleural samples were included from 54 patients on which GAS and S. pneumoniae RADT (BinaxNOW), culture, 16S rRNA PCR, and S. pneumoniae-specific PCR were performed. GAS RADT showed a sensitivity of 95.2% and a specificity of 100%. Pneumococcal RADT showed a sensitivity of 100% and specificity of 88.6%. Both RADT increased the pathogen identification rate in PPE compared to culture.

Pleural penetration of amoxicillin and metronidazole during pleural infection: An ambispective cohort study

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. 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. 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). 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.

Effects of Concurrent Dosing on the Efficacy of Tissue Plasminogen Activator and Deoxyribonuclease in the Treatment of Pleural Infection.

The goal of this study was to evaluate how the administration of concurrent tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) therapy with variable dosing for complicated parapneumonic effusions and empyema affects patient outcomes in an inner-city community hospital. This retrospective analysis was performed at an inner-city hospital located in Raleigh, North Carolina. A list of all patients treated with tPA and DNase between July 1, 2015, and December 31, 2017, was generated and screened. Data were collected through a review of past medical records, including demographics, past medical history, and details about their hospital course. A total of 38 patients were found to have been treated with concurrent tPA and DNase for complicated parapneumonic effusion or empyema. Twenty (52.6%) patients received the full six doses of combined concurrent tPA/DNase. Of the 18 (47.4%) patients who did not receive the full six doses, 11 did not require the full six doses for effusion resolution, and seven had to discontinue therapy due to tube blockage or pain. Only seven (18.4%) patients had complications related to tPA/DNase administration, most commonly pain. Nineteen (50%) patients had complete radiological clearance of effusion, with 13 (34.2%) having partial clearance, and six (15.8%) having no change or worsening of their effusion. Eight (21.1%) patients needed further surgical management of their effusion. The current most common dosing pattern for combined tPA and DNase therapy of twice daily for three days may not be optimal for all patients. The dosing regimen should be individualized depending on clinical response.Concurrent dosing is safe.

Diagnostic Yield of 16S Ribosomal Ribonucleic Acid Gene-Based Targeted Metagenomic Sequencing for Evaluation of Pleural Space Infection: A Prospective Study

ObjectiveTo better understand the microbial profile of complicated parapneumonic effusions and empyema, and to evaluate whether antimicrobial selection would differ if guided by targeted metagenomic sequencing (tMGS) vs conventional cultures (CCs) alone. Patients and MethodsWe analyzed the pleural fluid of a cohort of 47 patients undergoing thoracentesis from January 1, 2017 to August 31, 2019, to characterize their microbial profile. All samples underwent 16S ribosomal ribonucleic acid gene polymerase chain reaction, followed by tMGS. ResultsPleural space infection was deemed clinically present in 20 of the 47 (43%) participants. Of those, n=7 (35%) had positive pleural fluid cultures and n=14 (70%) had positive tMGS results. The organisms identified by tMGS were concordant with CCs; however, tMGS detected additional bacterial species over CCs alone. Streptococcus and Staphylococcus species were the most common organisms identified, with Streptococcus intermedius/constellatus identified in 5 patients. Polymicrobial infections were found in 6 of the 20 patients, with anaerobes being the most common organisms identified in these cases. ConclusionStreptococci and staphylococci were the most common organisms identified in infected pleural fluid. Anaerobes were common in polymicrobial infections. When compared with CCs, tMGS had higher sensitivity than CCs. Targeted metagenomic sequencing identified additional organisms, not identified by CCs, with associated potential management implications.

The mTORC2/SGK1/NDRG1 Signaling Axis Is Critical for the Mesomesenchymal Transition of Pleural Mesothelial Cells and the Progression of Pleural Fibrosis.

Progressive lung scarring because of persistent pleural organization often results in pleural fibrosis (PF). This process affects patients with complicated parapneumonic pleural effusions, empyema, and other pleural diseases prone to loculation. In PF, pleural mesothelial cells undergo mesomesenchymal transition (MesoMT) to become profibrotic, characterized by increased expression of α-smooth muscle actin and matrix proteins, including collagen-1. In our previous study, we showed that blocking PI3K/Akt signaling inhibits MesoMT induction in human pleural mesothelial cells (HPMCs) (1). However, the downstream signaling pathways leading to MesoMT induction remain obscure. Here, we investigated the role of mTOR complexes (mTORC1/2) in MesoMT induction. Our studies show that activation of the downstream mediator mTORC1/2 complex is, likewise, a critical component of MesoMT. Specific targeting of mTORC1/2 complex using pharmacological inhibitors such as INK128 and AZD8055 significantly inhibited transforming growth factor β (TGF-β)-induced MesoMT markers in HPMCs. We further identified the mTORC2/Rictor complex as the principal contributor to MesoMT progression induced by TGF-β. Knockdown of Rictor, but not Raptor, attenuated TGF-β-induced MesoMT in these cells. In these studies, we further show that concomitant activation of the SGK1/NDRG1 signaling cascade is essential for inducing MesoMT. Targeting SGK1 and NDRG1 with siRNA and small molecular inhibitors attenuated TGF-β-induced MesoMT in HPMCs. Additionally, preclinical studies in our Streptococcus pneumoniae-mediated mouse model of PF showed that inhibition of mTORC1/2 with INK128 significantly attenuated the progression of PF in subacute and chronic injury. In conclusion, our studies demonstrate that mTORC2/Rictor-mediated activation of SGK1/NDRG1 is critical for MesoMT induction and that targeting this pathway could inhibit or even reverse the progression of MesoMT and PF.

Current Management of Pediatric Parapneumonic Pleural Effusions and Pleural Empyema.

Current Management of Pediatric Parapneumonic Pleural Effusions and Pleural Empyema.

Conservative and Surgical Modalities in the Management of Pediatric Parapneumonic Effusion and Empyema: A Living Systematic Review and Network Meta-Analysis

The optimal treatment for community-acquired childhood pneumonia complicated by empyema remains unclear. In children with parapneumonic effusion or empyema, do hospital length of stay and other key clinical outcomes differ according to the treatment modality used? A living systematic review of randomized controlled trials (RCTs) was conducted by searching the Cochrane Central Register of Controlled Trials, Embase, Latin American and Caribbean Health Sciences Literature, Ovid MEDLINE, and Web of Science Core Collection databases. Eligible RCTs included patients aged< 18 years and compared two of the following treatment modalities: antibiotics alone, chest tube insertion with or without fibrinolytics, video-assisted thoracoscopic surgery (VATS), and decortication via thoracotomy. A network meta-analysis was performed to evaluate treatment effects on hospital length of stay (LOS), the primary outcome. Eleven trials including a total of 590 patients were selected for the network meta-analysis. Compared with a chest tube alone, a chest tube with fibrinolytics, thoracotomy, and VATS were all associated with shorter LOS, with a mean difference of 5.05days (95%CI, 2.46-7.64), 6.33days (95%CI, 3.17-9.50), and 5.86days (95%CI, 3.38-8.35), respectively. No substantial differences in LOS were observed between the latter three interventions. None of the 11 RCTs compared antibiotics alone vsother types of treatment. Most trials reported peri-procedural complications and the need for reintervention, but the descriptions differed significantly between trials, preventing meta-analysis. In trials reporting health care-associated costs, fibrinolytics had cost advantages compared with VATS. Short- and long-term morbidity and mortality were very low, regardless of the treatment modality. The results of this network meta-analysis showed that a chest tube alone was associated with a longer LOS compared with other treatment modalities. The lower cost associated with a chest tube plus fibrinolytics warrants consideration when choosing between treatment options, given similar LOS and clinical outcomes compared with the other modalities.

Choice of intrapleural fibrinolytic agents in the treatment of adult complicated parapneumonic effusion and empyema: Network meta-analysis.

The appropriate use of intrapleural fibrinolytic agents in patients with complicated parapneumonic effusion and empyema remains unclear, especially regarding the choice of fibrinolytic agents. We conducted a network meta-analysis comparing outcomes of intrapleural fibrinolytic agents in patients with complicated parapneumonic effusion and empyema. MEDLINE and EMBASE were searched through April 2022 to identify randomized controlled trials (RCTs) that investigated outcomes in patients with complicated parapneumonic effusion or empyema who were treated with intrapleural fibrinolytic agents. The outcomes of interest were surgical requirements, bleeding, length of hospital stay, and all-cause mortality. Our analysis included 10 RCTs that enrolled 1085 patients treated with intrapleural tissue plasminogen activator (TPA) (n = 138), TPA + deoxyribonuclease (DNase) (n = 52), streptokinase (n = 311), urokinase (n = 75), DNase (n = 51), or placebo (n = 458). The rates of surgical requirement were significantly lower with TPA and TPA + DNase than with placebo (risk ratio [RR]; 95% confidence interval [CI] = 0.36 [0.14-0.97], p = 0.038, RR [95% CI] = 0.25 [0.08-0.78], p = 0.017, respectively). The risk of bleeding was higher with TPA + DNase than with placebo (RR [95% CI] = 10.91 [1.53-77.99], p = 0.017), as well as TPA and TPA + DNase than with urokinase (RR [95% CI] = 17.90 [1.07-299.44], p = 0.044, RR [95% CI] = 89.3 [2.88-2772.49], p = 0.010, respectively). All-cause mortality was similar among the groups. TPA and TPA + DNase reduced the rates of surgical requirement compared with placebo. However, TPA + DNase increased the risk of bleeding compared with placebo. Intrapleural agents for complicated parapneumonic effusion and empyema should be selected with an individual risk assessment.

Clinical Implications of the Controlling Nutritional Status Score on Short-term Outcomes in Patients with Pleural Infection.

Objective Pleural infection is a significant disease that continues to pose severe problems for respiratory physicians. However, prognostic factors of pleural infection remain poorly understood. The controlling nutritional status (CONUT) score represents the immune-nutrition status of patients with chronic infectious diseases. This study investigated its prognostic value in patients with pleural infections. Methods We retrospectively analyzed a collected database of 2,363 patients who underwent thoracentesis and pleural fluid analyses between January 2010 and December 2019. Of these, only 335 patients with complicated parapneumonic effusion and empyema defined as pleural infection were included. They were divided into two groups based on the dichotomized CONUT score (i.e. <6 for low scores and ≥6 for high scores). The primary outcome was all-cause mortality within 90 days from the time of pleural fluid collection. Results Overall mortality was 8.4% at 3 months (28 out of 335). The incidence of 90-day mortality was higher in patients with higher CONUT scores than in those with lower scores [25.3% (21/84) vs. 2.8% (7/251), p<0.001]. In addition, after adjusting for confounders, a high CONUT score was found to be an independent prognostic factor for 90-day mortality (hazard ratio, 9.30; 95% confidence interval, 3.96-21.87; p<0.001). Conclusion Our study indicated that a high CONUT score was associated with an increased risk of 90-day mortality in patients with pleural infection and can be considered for clinical evaluations in practice.

Intrapleural tissue plasminogen activator and deoxyribonuclease administered concurrently and once daily for complex parapneumonic pleural effusion and empyema.

Pleural infection is life-threatening and increasingly prevalent. In addition to usual care, twice-daily, separate administration of tissue plasminogen activator and deoxyribonuclease (tPA-DNase) reduces radiological pleural opacity with lower surgical referral rates. This retrospective cohort study examines the use of once-daily, concurrent administration of tPA-DNase for complex parapneumonic pleural effusion and empyema. Patients with pleural infection who received intrapleural tPA-DNase between October 2014 and July 2020 at Logan Hospital, where it is given concurrently and once-daily as salvage therapy, were retrospectively identified. Radiographic opacification, inflammatory markers, clinical response and complications were examined. Thirty-one patients were identified. Mean age was 48.8 years (standard deviation [SD], 17.2). Median tPA-DNase administration was 3 (interquartile range [IQR], 2-3). Chest x-ray pleural opacity decreased significantly (P = 0.047) from a median of 39.6% (IQR, 28.8-65.7%) to 9.7% (IQR, 2.5-23.2%), a median relative reduction of 75.5% (IQR, 47.7-93.9%). White cell count and C-reactive protein improved significantly (P = 0.002 and P = 0.032, respectively) from a median of 16.3 × 109 /L (IQR, 11.8-20.6 × 109 /L) to 9.9 × 109 /L (IQR, 8.0-12.3 × 109 /L) and 311.0 mg/L (IQR, 218.8-374.0 mg/L) to 69.0 mg/L (IQR, 36.0-118.0 mg/L), respectively. No patients experienced significant bleeding or died. Five patients (16.1%) were referred for surgery. This is pilot evidence that a practical regimen of concurrent, once-daily intrapleural tPA-DNase improved pleural opacification and inflammatory markers without bleeding or mortality. The surgical referral rate was higher than in studies assessing twice-daily administration, though the validity of this outcome as a measure of treatment success is limited, and further studies are needed to assess the optimal dose and frequency of intrapleural therapy and indications for surgical referral.