Pleural Space Infection Research Articles

A-116 Pleural Fluid pH - Are We Collecting and Measuring It Correctly?

Abstract Background Pleural fluid pH has diagnostic, therapeutic, and prognostic implications in the management of pleural space infections and malignancy. Pleural fluid sample collection, transportation and processing are known for source of pre-analytical error which contribute to inaccuracy of measured pH with clinical implication to patient care. Some clinical practices observed locally include pleural fluid collection in sterile container for ease of other biochemistry analytes measurement in addition to pH. This study aimed to compare the differences in pleural fluid pH and other commonly ordered biochemistry analytes collected using sterile container against heparinized blood gas syringe. Methods Total 20 Pleural fluid samples were collected from patient using a procedure called thoracentesis from, with approximately 2 to 3ml of fluid directly transferred into heparinized blood gas syringe as well as in a sterile container. Both samples were then transported to Clinical Biochemistry Laboratory within an hour. Both samples were analyzed on 3 analytical systems; 1) pH on Roche COBAS b221 blood gas analyzer, 2) Glucose, Total Protein, LDH on Beckman AU System and 3) Specific Gravity on Reflectometer. Statistical analysis was performed using Analyze-It software. Results pH fluid collected in sterile container demonstrates significant high bias (absolute of 0.4 units or 5%) as compared to sample collected in heparinizes blood gas syringe. Other commonly ordered tests in fluid profile (Glucose, Total Protein, LDH and SG) demonstrate good correlation (Altman-Bland Difference Plot <5%) for pleural fluid collected in sterile container as compared to heparinized syringe. Conclusions This positive bias observed is likely attributed to air exposure in pleural fluid collection in sterile container as compared to heparinized syringe. The accuracy of measured pleural pH is critically dependent on the method of sample collection. This study highlights the need for a standardized protocol for pleural pH collection for accurate measurement.

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.

Neutrophil-mediated Inflammatory Plasminogen Degradation, Rather Than High Plasminogen-Activator Inhibitor-1, May Underly Failures and Inefficiencies of Intrapleural Fibrinolysis

Complex pleural space infections often require treatment with multiple doses of intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease, with treatment failure frequently necessitating surgery. Pleural infections are rich in neutrophils, and neutrophil elastase degrades plasminogen, the target substrate of tPA, that is required to generate fibrinolysis. We hypothesized that pleural fluid from patients with pleural space infection would show high elastase activity, evidence of inflammatory plasminogen degradation, and low fibrinolytic potential in response to tPA that could be rescued with plasminogen supplementation. Does neutrophil elastase degradation of plasminogen contribute to intrapleural fibrinolytic failure? We obtained infected pleural fluid and circulating plasma from hospitalized adults (n= 10) with institutional review board approval from a randomized trial evaluating intrapleural fibrinolytics vssurgery for initial management of pleural space infection. Samples were collected before the intervention and on days 1, 2, and 3 after the intervention. Activity assays, enzyme-linked immunosorbent assays, and Western blot analysis were performed, and turbidimetric measurements of fibrinolysis were obtained from pleural fluid with and without exogenous plasminogen supplementation. Results are reported as median (interquartile range) or number (percentage) as appropriate, with an α value of .05. Pleural fluid elastase activity was more than fourfold higher (P= .02) and plasminogen antigen levels were more than threefold lower (P= .04) than their corresponding plasma values. Pleural fluid Western blot analysis demonstrated abundant plasminogen degradation fragments consistent with elastase degradation patterns. We found that plasminogen activator inhibitor 1 (PAI-1), the native tPA inhibitor, showed high antigen levels before the intervention, but the overwhelming majority of this PAI-1 (82%) was not active (P= .003), and all PAI-1 activity was lost by day 2 after the intervention in patients receiving intrapleural tPA and deoxyribonuclease. Finally, using turbidity clot lysis assays, we found that the pleural fluid of 9 of 10 patients was unable to generate a significant fibrinolytic response when challenged with tPA and that plasminogen supplementation rescued fibrinolysis in all patients. Our findings suggest that inflammatory plasminogen deficiency, not high PAI-1 activity, is a significant contributor to intrapleural fibrinolytic failure. ClinicalTrials.gov; No.: NCT03583931; URL: www. gov.

Bone Plug in the Bronchoscopic Management of Postoperative Bronchopleural Fistulas

BackgroundBronchopleural fistula (BPF) is a rare and often difficult postoperative complication to manage. This case series describes a bronchoscopic technique using a bone plug for closure of BPFs. MethodsSix patients at Henry Ford Hospital from 2014 to 2021, who had a postoperative BPF after lung resection with curative intent for non-small cell lung cancer, underwent bronchoscopic placement of a customized bone plug. ResultsAll 6 patients experienced initial resolution of the BPF after bone plug placement. Four of the 6 (66.7%) patients were inpatients, with severe pleural space infections requiring chest tube drainage; all patients clinically improved with resolution of persistent air leaks resulting in chest tube removal. Two of the 6 (33.3%) patients had BPF recurrence within 2 months, and 2 of the /6 (33.3%) patients also eventually required additional surgical repair. ConclusionsEndobronchial placement of a customized bone plug is an option for the management of postoperative BPF.

Outcomes of Pleural Space Infections in Patients With Indwelling Pleural Catheters for Active Malignancies.

Pleural infections related to indwelling pleural catheters (IPCs) are an uncommon clinical problem. However, management decisions can be complex for patients with active malignancies due to their comorbidities and limited life expectancies. There are limited studies on the management of IPC-related infections, including whether to remove the IPC or use intrapleural fibrinolytics. We conducted a retrospective cohort study of patients with active malignancies and IPC-related empyemas at our institution between January 1, 2005 and May 31, 2021. The primary outcome was to evaluate clinical outcomes in patients with malignant pleural effusions and IPC-related empyemas treated with intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) compared with those treated with tPA alone or no intrapleural fibrinolytic therapy. The secondary outcome evaluated was the incidence of bleeding complications. We identified 69 patients with a malignant pleural effusion and an IPC-related empyema. Twenty patients received tPA/DNase, 9 received tPA alone, and 40 were managed without fibrinolytics. Those treated with fibrinolytics were more likely to have their IPCs removed as part of the initial management strategy ( P =0.004). The rate of surgical intervention and mortality attributable to the empyema were not significantly different between treatment groups. There were no bleeding events in any group. In patients with IPC-related empyemas, we did not find significant differences in the rates of surgical intervention, empyema-related mortality, or bleeding complications in those treated with intrapleural tPA/DNase, tPA alone, or no fibrinolytics. More patients who received intrapleural fibrinolytics had their IPCs removed, which may have been due to selection bias.

Treatment of pleural space infections

Pleural space infections occur in approximately 10% of patients hospitalized for pneumonia and their incidence is increasing with an aging population. Pulmonary ultrasound is a good bedside diagnostic tool able to reduce complications associated with thoracocentesis and drainage. The RAPID score is being increasingly validated as a predictor for mortality but has not yet been proven useful to guide the treatment strategy and needs incorporation into prospective studies. Awaiting studies on outcome prediction and the comparison of an early surgical strategy versus drainage with intrapleural enzyme therapy, this article presents a summary of current knowledge of this complication.

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.

Pleural procedures: an audit of practice and complications in a regional Australian teaching hospital.

Pleural procedures are essential for the investigation and management of pleural disease and can be associated with significant morbidity and mortality. There is a lack of pleural procedure complication data in the Australian and New Zealand region. To review pleural procedure practices at Wollongong Hospital with an emphasis on the assessmentof complications, use of thoracic ultrasound (TUS), pathology results and comparison of findings with international data. Retrospective analysis of medical records was performed on pleural procedures identified through respiratory specialist trainee logbooks at Wollongong Hospital from January 2018 to December 2021. Comparison of complication rates was made to the British Thoracic Society 2011 a national pleural audit. One hundred and twenty-one pleural procedures were identified. There were 71 chest drains, 49 thoracocentesis and one indwelling pleural catheter (IPC) insertion. Ninety-seven per cent of procedures were performed for pleural effusions and 3% for pneumothorax. This audit demonstrated a complication rate (excluding pain) of 16.9% for chest drains and 4.1% for thoracocentesis. This gave an overall complication event rate of 10.8% (excluding pain) for pleural procedures. There was no major bleeding, organ puncture, pleural space infection or death. Bedside TUS was used in 99% of procedures. Complication rates for pleural procedures performed by respiratory specialist trainees at Wollongong Hospital are comparable with international outcomes. This audit provides data for comparison on pleural procedure complication rates in Australia. Future studies are required to determine complication rates with IPCs.

A Large Lung Abscess in an Electronic Cigarette User: To Drain or Not to Drain

A lung abscess is a walled necrotizing infection involving the lung parenchyma, characterized by a cavitary lesion filled with fluid. It is usually caused by microbial infection with aspiration of oropharyngeal contents being the most common mechanism for primary lung abscesses. Secondary lung abscesses occur in the presence of predisposing lung conditions like bronchial obstruction, vascular or septic emboli or impaired host defenses. Lung abscesses caused by electronic cigarette use have gained relevance in the recent years since the outbreak of EVALI, that is, e-cigarette or vaping product use-associated lung injury, in 2019. First-line therapy involves prompt initiation of antibiotics given their success rate in the treatment of lung abscess in the current potent antibiotic era. Percutaneous aspiration and catheter drainage is considered a second line approach due to concerns for potential complications including catheter blockage necessitating repeat procedures, pneumothorax, hemothorax, hemoptysis, need for surgical intervention, infection of pleural space and bronchopleural fistula. We describe a case of a 21-year-old female with a history of electronic cigarette use presenting with a large left upper lobe lung abscess (14.5 x 8.5 x 13.3 cm) treated successfully with broad-spectrum antibiotics alone resulting in clinical and radiologic improvement.

Autologous blood patch pleurodesis for persistent air leak in the setting of chronic non-invasive ventilation: case report

Background: Persistent air leaks (PAL) are associated with significant morbidity and mortality, including prolonged length of hospital stays, increased re-admission rates and increased incidences of pneumonia and pleural space infections. Autologous blood patch pleurodesis (ABPP) may be used in the management of PAL, however it is unclear whether this treatment option can be used in patients requiring chronic non-invasive ventilation.

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.

Empyema necessitans: After recent thoracostomy in an immunocompromised patient.

This paper consists of a clinical image of an unexpected complication of a pleural space infection that dissects through the pleura into the soft tissues of the chest in an immunocompromised patient.

Management of bronchopleural fistula using Amplatzer duct occluder device.

Management of bronchopleural fistula using Amplatzer duct occluder device.

RIB FRACTURE AS A RARE AND UNDER-REPORTED ETIOLOGY OF PLEURAL SPACE INFECTION: CASE REPORT AND REVIEW OF LITERATURE

RIB FRACTURE AS A RARE AND UNDER-REPORTED ETIOLOGY OF PLEURAL SPACE INFECTION: CASE REPORT AND REVIEW OF LITERATURE

DRAMATIC IMPROVEMENT OF ADULT PATIENTS WITH POST-TB PULMONARY PNEUMATOCELE AND BAD PULMONARY FUNCTION AFTER SURGICAL INTERVENTION

TYPE: Late Breaking Case Report TOPIC: Cardiothoracic Surgery INTRODUCTION: Pulmonary pneumatoceles (PCs) are thin walled air-filled cysts that develop within pulmonary parenchyma. PCs are developed after infection,or trauma. PCs caused as a complication of Staphylococcus pneumonia, and are more frequently in infants and children. Adult tuberculous pulmonary pneumatoceles are seldom [1]. PCs are asymptomatic. Large PCs may compress adjacent lung with mediastinal shift causing cardiopulmonary symptoms [2]. Surgical intervention is indicated when PCs cause cardiopulmonary compromise or rupture into the pleural space or unresolved infection [3]. CASE PRESENTATION: 60-years female patient presented by dry cough and shortness of breath (SOB). She was on corticosteroid therapy as treatment of bronchial asthma. She had history of resolved pulmonary TB. Clinical examination revealed diminished air entry . CXR showed translucent zone. CT with contrast showed large PC occupying >2/3 of hemithorax with mediastinal shift. During operation, rupture of PC by diathermy to avoid its over-inflation during ventilation , and wedge resection with fistula site repair through uniportal VATS.Closure of thoracotomy was performed as a routine with two ICT. Postoperative CXR revealed full inflated lung . They discharged with smooth postoperative course. DISCUSSION: PC in adult can occur during or after anti-TB treatment [3]. there was a history of resolved TB. Urgent surgery indicated in complicated PC (infection, tension, rupture). [6]. VATS procedure performed to PC excision and repair. CONCLUSIONS: Surgical excision of symptomatic complicated pulmonary pneumatocele with mini approach after well preparation gives marvelous improvement of respiratory condition. DISCLOSURE: Nothing to declare. KEYWORD: Pulmonary Pneumatocele, Pulmonary Tuberculosis, Fungal Ball, Cardiopulmonary Compromise.

Risks and Outcomes Associated with Pleural Space Infections After Lung Transplantation

<h3>Purpose</h3> Pleural space infections (PSI) are a serious complication after lung transplantation (LT) however there is limited data on the associated risk factors and outcomes of PSI. We examined: 1) risk factors associated with PSI after LT; 2) effect of PSI on LT outcomes. <h3>Methods</h3> This is a retrospective single center cohort study of 74 consecutive LT recipients (1/2018- 6/2020). Patients were divided into infected and non-infected groups, where PSI were defined as post-LT pleural effusions with pathogen(s) isolated from pleural fluid. Data were collected and compared between two groups with two-sample t-test or Fisher-exact. Multivariable logit model was performed with estimations of odds ratio (OR) and its confidence interval [CI]. <h3>Results</h3> Among 74 LT recipients, 38 (51%) developed pleural effusions requiring drainage; of them 16 (42%) had PSI. Baseline demographics were similar in patients with and without PSI (Table). Notably, 88% of PSI group received steroids pre-LT compared to 55% in the non-infected group (p<0.05); 88% of the PSI group had an underlying diagnosis of interstitial lung disease versus 45% of the non-infected group (p<0.01). Overall post-operative complications occurred more frequently in the PSI group vs. non-infected group 77% vs. 25% (p<0.01) and airway complications in 86% vs. 44% (p<0.01). Hospital length of stay was longer in the PSI group with the median of 78 versus 31 days in the non-infected group (p<0.01). Results of logistical modeling showed high risk of PSI with presence of post-LT airway complications (OR =10.8 95% CI 1.7- 72.5) and presence of post operative complications (OR=10.6, 95% CI 1.8-63.5). There was no difference in the incidence of readmissions, acute cellular rejection or 1 year mortality between the two cohorts. <h3>Conclusion</h3> PSI remain a prevalent yet under-studied complication. Airway or post-operative complications after LT were associated with PSI. One-year outcomes were similar in LT recipients with and without PSI.

Pleural Effusions and Pericarditis: A Retrospective Cohort Study of Patients Undergoing Cardiac Magnetic Resonance Imaging.

BackgroundPleural effusions can occur due to acute pericarditis and can necessitate intervention. We sought to add to the evidence base by performing a retrospective review of patients presenting to the advanced cardiac imaging unit with pericarditis and pleural effusion to determine laterality, trends in pleural fluid analyses, and the need for pleural intervention. Local ethical (Caldicott) approval was obtained for this study.MethodologyDescriptive statistical methodology was applied with continuous data presented as mean (standard deviation, SD; range) and categorical variables as frequencies or percentages.ResultsIn 60 patients with pericarditis, 24 (39%) had pleural effusions on contemporaneous imaging. The mean age of the study population was 63.3 years (range: 20-83), and 17 patients were males. Diagnoses were viral (five), rheumatological (one), amyloidosis (one), listeria (one), and the rest idiopathic (17). Four effusions were only left-sided, one right-sided, and 20 bilateral. Ten pleural taps were performed, one for a unilateral effusion and nine for one side being bigger than the other. The mean pH was 7.46 (7.33-7.6), mean lactate dehydrogenase was 210 (74-393 U/L), mean fluid protein was 36.1 (19-56 g/L) (four effusions exudative/three transudative), mean glucose was 5.8 (4.8-6.8 mmol/L), and all cytologies were negative. Five patients underwent large volume aspirations for symptom control. Three indwelling pleural catheters (IPC) were placed for treatment refractory effusions. There was one pleural space infection in six months related to an IPC. There were three deaths at 12 months, with none related to pericarditis.ConclusionsPleural effusions associated with pericarditis are usually small, bilateral, and exudative. Treatment refractory cases require pleural intervention, with aspirations, drains, and IPCs being viable options. Further prospective studies are warranted.

The Case for Prolonged ECMO for COVID-19 ARDS as a Bridge to Recovery or Lung Transplantation.

The Case for Prolonged ECMO for COVID-19 ARDS as a Bridge to Recovery or Lung Transplantation.

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.

A Study of Bacteriological Profile of Pleural Fluid and Antibiogram of Isolates at Pandit Dindayal Upadhyay Medical College Andhospital College, Rajkot

Background: The bacteriology of thoracic empyema has been changing since the introduction of antibiotics. Gram stain and culture has for decades been the “gold standard” for the detection of microorganisms in pleural fluid samples. The present retrospective study was designed to review our experience with the microbial causes of empyema and their antibiotic sensitive patterns. The knowledge of likely prevalent strains along with their antimicrobial sensitive pattern helps in the framing of antibiotic policy and better management of patients.&#x0D; Materials and Methods: This descriptive study was including 500 cases suspected of bacteriological infection of pleural fluid in patients admitted in ward of PDU Government Hospital, Rajkot. The performa include serial number, register number, age, sex, ward, clinical features of patients and investigation. All the samples were inoculated into Blood agar and MacConkey agar and Nutrient agar. All the plates were incubated aerobically at 370 C and results were read after 24 hours. If no growth present it is further incubated for next 24 hours. One smear was prepared on clean glass slide, then air dried and was heat fixed. Gram staining was done by standard technique.&#x0D; Results: This study include 500 cases of pleural effusion from January 2015 to July 2016, out of which 87 cases show positive Bacterial culture growth and 232 cases were adenosine deaminase positive. In total 87 positive bacterial cultures, 20(22%) show bacterial pathogens in gram stain. Total positive culture found in 17.4%. Among them; most common Bacteria isolated was Pseudomonas aeruginosa in 40 (45%) patients, this was followed by Klebsiella pneumonaie in 21 (24%), Staphylococcus aureus in 10 (11.49%), Acinetobacter spp. in 4 (4.59%), Proteus spp.in 3 (3.44%) and Providencia in 1 (1.14%).&#x0D; Conclusion: Pleural space infection continues to be prevalent in our country particularly in the lower socioeconomic strata due to the delay in seeking medical care, inappropriate antibiotics and dosages and duration of antibiotic treatment. All gram positive bacteria isolate were 100% sensitivity to Rifampicin, Vancomycin, Linezolid.