Spontaneous Bacterial Empyema Research Articles

Diagnosis and Management of Hepatic Hydrothorax.

Hepatic hydrothorax is a pleural effusion (typically ≥500 mL) that develops in patients with cirrhosis and/or portal hypertension in the absence of other causes. In most cases, hepatic hydrothorax is seen in patients with ascites. However, ascites is not always found at diagnosis and is not clinically detected in 20% of patients with hepatic hydrothorax. Some patients have no symptoms and incidental findings on radiologic examination lead to the diagnosis of the condition. In the majority of cases, the patients present with symptoms such as dyspnea at rest, cough, nausea, and pleuritic chest pain. The diagnosis of hepatic hydrothorax is based on clinical manifestations, radiological features, and thoracocentesis to exclude other etiologies such as infection (parapneumonic effusion, tuberculosis), malignancy (lymphoma, adenocarcinoma) and chylothorax. The management strategy involves a stepwise approach of one or more of the following: Reducing ascitic fluid production, preventing fluid transfer to the pleural space, fluid drainage from the pleural cavity, pleurodesis (obliteration of the pleural cavity), and liver transplantation. The complications of hepatic hydrothorax are associated with significant morbidity and mortality. The complication that causes the highest morbidity and mortality is spontaneous bacterial empyema (also called spontaneous bacterial pleuritis).

Hepatic hydrothorax.

Hepatic hydrothorax (HH) refers to the presence of a pleural effusion that develops in the context of underlying liver cirrhosis and portal hypertension. It carries a high risk of morbidity and mortality, with a median survival of 8-12 months. Diagnosis is usually confirmed by pleural aspiration, demonstrating typical features of a transudative effusion in the absence of co-existent cardio-pulmonary or renal pathology. The clinical presentation is quite variable, with some patients remaining relatively asymptomatic in the presence of small or incidental effusions, while others present with frank respiratory failure requiring pleural intervention. The development of spontaneous bacterial empyema (SBEM) is a significant and not infrequent complication, requiring prompt recognition and treatment. While the mainstay of management is focused on optimising fluid balance through dietary salt restriction and diuretic therapy, liver transplantation remains the definitive treatment option. As such, it is crucial to adopt a multi-disciplinary approach-involving pulmonologists, hepatologists, dieticians, and palliative care physicians-in order to optimise care for this often complex group of patients. This review will discuss the basic pathophysiology of HH, its clinical presentation and diagnosis, as well as the approach to management of HH in clinical practice, focussing on both interventional and non-interventional treatment modalities.

Lung Abnormalities in Liver Cirrhosis

Regardless of preexisting lung illness, patients suffering from liver cirrhosis, especially decompensated liver cirrhosis can develop distinct pulmonary complications. Liver cirrhosis patients should be assessed for hepatopulmonary syndrome (HPS), portopulmonary hypertension (PoPH), hepatic hydrothorax (HH) and spontaneous bacterial empyema (SBEM) which are the most clinically significant pulmonary consequences, in particular when dyspnea develops in conjunction with hepatic cirrhosis. These entities differ in terms of pathophysiology, clinical characteristics, diagnosis and suitable treatment options. This emphasize the need of specific diagnostic algorithm in liver cirrhosis patients presenting with dyspnea or other pulmonary symptoms. These pulmonary complications might be rare in patients with liver cirrhosis and portal hypertension but these complications might carry significant morbidity and mortality risks and, therefore, strong clinical suspicion is required to make an early accurate diagnosis. There are several medical therapies available for each condition in the multiple studies but most of the treatments and proceures doesn’t have significant benefit or have short lived benefit. The only treatment that changes the clinical prognosis of decompensated cirrhosis effectively in long term is liver transplantation. However liver transplantation also needs careful considerations as on some cases it might increase the risk of morbidity and mortality.
 
 Keywords: Cirrhosis Hepatis, Hepatopulmonary Syndrome, Portopulmonary Hypertension, Hepatic Hydrothorax, Spontaneous Bacterial Empyema

The clinician's dilemma with spontaneous bacterial empyema.

The clinician's dilemma with spontaneous bacterial empyema.

International survey among hepatologists and pulmonologists on the hepatic hydrothorax: plea for recommendations

BackgroundThe Hepatic hydrothorax is a pleural effusion related to portal hypertension; its diagnosis and therapeutic management may be difficult. The aims of this article are which follows: To gather the practices of hepatogastroenterologists or pulmonologists practitioners regarding the diagnosis and management of the hepatic hydrothorax.MethodsPractitioners from 13 French- speaking countries were invited to answer an online questionnaire on the hepatic hydrothorax diagnosis and its management.ResultsFive hundred twenty-eight practitioners (80% from France) responded to this survey. 75% were hepatogastroenterologists, 20% pulmonologists and the remaining 5% belonged to other specialities. The Hepatic hydrothorax can be located on the left lung for 64% of the responders (66% hepatogastroenterologists vs 57% pulmonologists; p = 0.25); The Hepatic hydrothorax can exist in the absence of clinical ascites for 91% of the responders (93% hepatogastroenterologists vs 88% pulmonologists; p = 0.27). An Ultrasound pleural scanning was systematically performed before a puncture for 43% of the responders (36% hepatogastroenterologists vs 70% pulmonologists; p < 0.001). A chest X-ray was performed before a puncture for 73% of the respondeurs (79% hepatogastroenterologists vs 54% pulmonologists; p < 0.001). In case of a spontaneous bacterial empyema, an albumin infusion was used by 73% hepatogastroenterologists and 20% pulmonologists (p < 0.001). A drain was used by 37% of the responders (37% hepatogastroenterologists vs 31% pulmonologists; p = 0.26).An Indwelling pleural catheter was used by 50% pulmonologists and 22% hepatogastroenterologists (p < 0.01). TIPS was recommended by 78% of the responders (85% hepatogastroenterologists vs 52% pulmonologists; p < 0.001) and a liver transplantation, by 76% of the responders (86% hepatogastroenterologists vs 44% pulmonologists; p < 0.001).ConclusionsThe results of this large study provide important data on practices of French speaking hepatogastroenterologists and pulmonologists; it appears that recommendations are warranted.

Lung Abnormalities in Liver Cirrhosis

Regardless of preexisting lung illness, patients suffering from liver cirrhosis, especially decompensated liver cirrhosis, can develop distinct pulmonary complications. Liver cirrhosis patients should be assessed for hepatopulmonary syndrome (HPS), portopulmonary hypertension (PoPH), hepatic hydrothorax (HH) and spontaneous bacterial empyema (SBEM) which are the most clinically significant pulmonary consequences, in particular when dyspnea develops in conjunction with hepatic cirrhosis. These entities differ in terms of pathophysiology, clinical characteristics, diagnosis and suitable treatment options. This emphasize the need of specific diagnostic algorithm in liver cirrhosis patients presenting with dyspnea or other pulmonary symptoms. These pulmonary complications might be rare in patients with liver cirrhosis and portal hypertension, but these complications might carry significant morbidity and mortality risks and, therefore, strong clinical suspicion is required to make an early accurate diagnosis. There are several medical therapies available for each condition in the multiple studies but most of the treatments and procedures does not have significant benefit or have short lived benefit. The only treatment that changes the clinical prognosis of decompensated cirrhosis effectively in long term is liver transplantation. However, liver transplantation also needs careful considerations as on some cases it might increase the risk of morbidity and mortality.

Tapped Twice: A Case of a Rapidly Re-accumulating Hepatic Hydrothorax in a Patient with Spontaneous Bacterial Empyema

Tapped Twice: A Case of a Rapidly Re-accumulating Hepatic Hydrothorax in a Patient with Spontaneous Bacterial Empyema

471 - An infected chylothorax- an unusual case of spontaneous bacterial empyema

471 - An infected chylothorax- an unusual case of spontaneous bacterial empyema

An Unusual Case of Spontaneous Bacterial Empyema Caused by Aeromonas hydrophila

An Unusual Case of Spontaneous Bacterial Empyema Caused by Aeromonas hydrophila

S1340 Spontaneous Bacterial Empyema Is Associated With Increased Mortality and Liver Transplant Has Survival Benefit: A Systemic Review and Meta-Analysis

Introduction: Spontaneous bacterial empyema (SBE) is an infection of a pre-existing hepatic hydrothorax in patients with cirrhosis. It is rarely reported in the literature and the prognostic significance of SBE is not clearly illustrated. Liver Transplant (LT) has been suggested to have a survival benefit in patients with SBE, however, this has been limited by very small sample sizes. The aim of this study was to perform a systematic review and meta-analysis to evaluate the effect of SBE on mortality and the survival benefit that LT may provide. Methods: A comprehensive search of several databases from each database’s inception to December 2021 was conducted. Studies included in the systematic review met the following inclusion criteria: adult patients, age >18 years, with a diagnosis of SBE. Manuscripts with < 5 patients were excluded from the study. The databases included Ovid MEDLINE®, Ovid EMBASE, and Google Scholar. Outcomes of interest were mortality and LT. Data synthesis was obtained using random-effects metanalysis and reported as risk ratio (RR) with 95 % confidence intervals (CIs). Heterogeneity was assessed using I2 statistics. Results: After excluding duplicates, 257 unique titles were screened, ultimately including 3 retrospective cohort studies (Fig A). Study characteristics are shown in Table. Two studies reported mortality as an outcome, with a total of 34 patients with SBE compared to 909 patients without SBE. A total of 943 patients with liver cirrhosis were included. Of which, 34 (3.61%) patients had SBE. SBE is significantly associated with increased mortality (RR 1.66, 95% CI 1.06-2.59, I2=6%) (Fig B). All studies included reported outcomes of LT. 50 patients with SBE were included, of which 12 (24%) patients received a LT – none of which had died at last follow up. LT was significantly associated with reduced mortality (RR 0.13, 95% CI 0.03-0.58, I2=0%) (Fig C). Conclusion: Patients who develop SBE have a higher risk of mortality. LT may provide a survival benefit in patients with SBE. More studies with larger sample sizes are needed to validate our findings.Figure 1.: (A) Flowchart of the literature review. (B) Forest plot showing that SBE was associated with increased mortality. (C) Forest plot showing that LT was associated with lower mortality among patients with SBE Table 1. - Characteristics of patients with SBE in the literature Study (year); Location Age Females Etiology of Cirrhosis; Alcohol/Viral/Other MELD Score MELD-Na Score CTP classification: A/B/C (n) CTP score Osman (2022); United States of America 53.42 ± 10.11 3 (25.00%) 5/4/3 27.00 ± 5.75 28.92 ± 6.23 0/4/8 11.17 ± 1.85 Jiménez-Gutiérrez (2021); Mexico 58.00 (52.00– 64.00) 11 (50.00%) 3/5/14 16.00 (12.20–17.80) 21.50 (17.20– 26.00) 0/10/12 0.00 (8.00– 11.00) Xiol (1996); Spain NR NR NR NR NR NR 11 (10.00– 11.25) Abbreviations: n, number; SBE, Spontaneous bacterial empyema; MELD-Na, Model for end-stage liver disease-Sodium; CTP, Child-Turcotte-Pugh; NR, not reported.

S2911 The Spectrum of Spontaneous Bacterial Empyema: An Elusive Disease

S2911 The Spectrum of Spontaneous Bacterial Empyema: An Elusive Disease

Early thoracentesis correlated with survival benefit in patients with spontaneous bacterial empyema.

Spontaneous bacterial empyema (SBEM) is a rare complication of hepatic hydrothorax characterized by hydrothorax infection in the absence of pneumonia. We conducted this study to compare clinical outcomes in SBEM patients who underwent early thoracentesis (ET) (≤ 24h from presentation) versus those who underwent delayed thoracentesis (DT). All patients diagnosed with SBEM at Mayo Clinic Rochester, Minnesota from January 1st 1999 to December 31st 2020 were reviewed. Demographics, pleural fluid studies, laboratory results and clinical outcomes were analyzed. A total of 54 SBEM patients (27 ET and 27 DT) were identified with 38 (70.4%) of patients presenting with right-sided effusions. Both groups had similar baseline characteristics. The rate of ICU admission was significantly higher in the DT group (15 (55.6%) vs. 7 (25.9%) patients, P=0.027). Patients with DT had similar rate of AKI (11 (40.7%) vs. 6 (22.2%) patients, P=0.074). In-hospital mortality (11 (40.7%) vs. 2 (7.4%) patients, P=0.004), 3-month mortality (16 (59.3%) vs. 2 (7.4%) patients, P<0.001) and 1-year mortality rate (21 (77.8%) vs. 6 (22.2%) patients, P<0.001) were higher in the DT group. Patients with SBEM who underwent thoracentesis after 24h from presentation (DT) had higher rates of mortality and ICU admission compared to patients who received early thoracentesis. Thoracentesis should be performed early in patients with suspected SBEM since it may improve survival.

Spontaneous bacterial empyema in cirrhosis: A systematic review and meta-analysis.

BACKGROUNDSpontaneous bacterial empyema (SBE) occurs when a hepatic hydrothorax becomes infected and runs a course similar to spontaneous bacterial peritonitis (SBP). It remains underdiagnosed as patients with cirrhosis do not routinely undergo diagnostic thoracentesis. Current understanding is limited by small cohorts, while studies reporting its association with ascites/SBP are conflicting. AIMTo explore the incidence of SBE, to determine its association with ascites, and to summarize what is known regarding treatment and outcomes for patients with SBE. METHODSMajor databases were searched until June 2021. Outcomes include the incidence of SBE in pleural effusions, SBP in peritoneal fluid, and SBE in patients without ascites within our cohort of patients with cirrhosis. We performed a meta-analysis using a random-effects model with pooled proportions and 95% confidence intervals (CI). We assessed heterogeneity using I2 and classic fail-safe to determine bias.RESULTSEight studies with 8899 cirrhosis patients were included. The median age ranged between 41.2 to 69.7 years. The majority of the patients were Child-Pugh B and C. Mean MELD score was 18.6 ± 8.09. A total of 1334 patients had pleural effusions and the pooled incidence of SBE was 15.6% (CI 12.6-19; I2 50). Amongst patients diagnosed with SBE, the most common locations included right (202), left (64), and bilateral (8). Amongst our cohort, a total of 2636 patients had ascites with a pooled incidence of SBP of 22.2% (CI 9.9-42.7; I2 97.8). The pooled incidence of SBE in patients with cirrhosis but without concomitant ascites was 9.5% (CI 3.6-22.8; I2 82.5).CONCLUSIONSBE frequently occurs with concurrent ascites/SBP; our results suggest high incidence rates of SBE even in the absence of ascites. The pleura can be an unrecognized nidus and our findings support the use of diagnostic thoracentesis in patients with decompensated cirrhosis after exclusion of other causes of pleural effusion. Thoracentesis should be considered particularly in patients without ascites and when there is a high suspicion of infection. The need for diagnostic thoracentesis will continue to be important as rates of multi-drug resistant bacterial infections increase and antibiotic susceptibility information is required for adequate treatment.

Spontaneous bacterial empyema: a tertiary care center experience and a systematic review

ABSTRACT Background Spontaneous bacterial empyema (SBE) is an infection of a preexisting hepatic hydrothorax (HH). We aim to describe the experience in managing SBE in a liver transplant (LT) referral center and assessing the incidence and mortality rates of SBE after conducting a systematic review. Methods 992 patients with cirrhosis were retrospectively reviewed from 2015 to 2020. SBE was diagnosed by (i) positive microbiological culture and polymorphonuclear leukocyte count >250 cells/µL or (ii) negative microbiological culture, compatible clinical course, and polymorphonuclear count >500 cells/µL in pleural fluid. Furthermore, we conducted a comprehensive literature search of MEDLINE, EMBASE, and Google Scholar for studies evaluating SBE. Results Twelve patients (10.4%) had spontaneous bacterial empyema out of 115 patients with HH. Five patients underwent LT, 6 had died, and 1 did not get transplanted and was alive throughout the duration of follow-up. Ten studies were included in the systematic review. Pooled incidence in patients with HH was 19.03%. Only 20.69% of the patients received a LT. Pooled mortality rate was 46.45%, with only 3.45% of the patients dying post-transplant. Conclusion SBE is a severe complication of cirrhosis and HH. LT may provide a survival benefit. Thus, patients should be considered for early transplant.

One-year outcome of patients with cirrhosis who developed spontaneous bacterial empyema: A cohort study.

This study aimed to evaluate outcomes in cirrhotic patients diagnosed with spontaneous bacterial empyema (SBE) compared with those without this complication. We performed a retrospective cohort study of cirrhotic patients from a tertiary care center. The primary outcome was time to death or liver transplantation (LT) within one year after diagnosis of infection. We integrated three groups: patients with SBE (group A), patients with spontaneous bacterial peritonitis (SBP; group B), and cirrhotic patients without SBP or SBE (group C), matched by age, model for end-stage liver disease-sodium (MELD-Na) score and year of infection. Outcomes were analyzed using a Cox regression model adjusted for cardiovascular risk factors and MELD-Na score. Between January 1999 and February 2019, 4829 cirrhotic patients were identified. Among them, 73 (1.5%) had hepatic hydrotorax, of whom 22 (30.1%) were diagnosed with SBE. Median age in group A was 58 years, 50% were men, and median MELD-Na was 21.5. Compared with group C, the hazard ratio of death or LT during the first year after infection was 2.98 (95% confidence interval [CI] 1.43-6.22, P = 0.004) for group A and 1.23 (95% CI 0.65-2.32, P = 0.522) for group B. Our results suggest that patients with SBE have a worse outcome during the first year after infection is diagnosed. Patients who develop SBE should be promptly referred for transplant evaluation. SBE may emerge as new indication that could benefit from MELD exception points.

Empiema bacteriano espontáneo como complicación de la cirrosis hepática: ¿cuándo sospecharlo y cómo tratarlo? Presentación de casos

Spontaneous bacterial empyema is defined as infection of the liver hydrothorax in the cirrhotic patients. It is a rare cause of decompensated cirrhosis, with few bibliographic reports in the region, and its presence marks a turning point of inflection in the evolution of the disease with a poor prognosis in the short term. Two clinical cases of patients with this complication are presented, which were referred to the National Liver Transplant Program of Uruguay. The clinical features, a pathophysiology and a therapeutic approach of this pathology are reviewed. Special emphasis is placed on empirical antibiotic treatment based on the site of acquisition of the infection and local epidemiology, and in the opportunity for the resolution of the underlying hepatic hydrothorax, with a high risk of complications that may be associated with invasive treatments.

Spontaneous Bacterial Peritonitis and Secondary Bacterial Peritonitis—a Comprehensive Review

Spontaneous bacterial peritonitis (SBP) and secondary bacterial peritonitis are life-threatening complications of cirrhosis if not recognized immediately and managed appropriately. SBP occurs in ~ 3.5 to 10% of patients with cirrhosis and ascites, whereas secondary bacterial peritonitis occurs in 5%. Prompt recognition of SBP variants is vital for tailoring therapy to decrease mortality rate from 90 to 20%. Our objective is to provide an update on the recent publications to elucidate the variants of SBP and provide a management algorithm for the potentially life-threatening complications of cirrhosis. The general guidelines for the management of spontaneous bacterial peritonitis are mostly unchanged, but there are newer data regarding trends in bacteriology and pathogens and newer prophylactic strategies. Spontaneous fungal peritonitis, spontaneous bacterial empyema, and secondary bacterial peritonitis can be clinically challenging if not diagnosed promptly. Nutrition is an under-recognized but important aspect of the management of ascites and SBP prevention. Emerging options for the management of diuretic refractory ascites and infection management are discussed in detail. Early diagnosis and treatment of SBP and secondary bacterial peritonitis are usually associated with good outcomes, but mortality remains as high as 40%. There is a higher risk of other decompensating cirrhotic events after the initial episode of SBP or secondary bacterial peritonitis that portends poor prognosis. The emphasis should be to identify the precipitating cause and focus on the modifiable risk factors to improve outcomes and survival. Newer strategies for SBP prophylaxis and ascites management appear promising until liver transplantation. Personalized approach is crucial to improve the morbidity, quality of life, and mortality in every patient with decompensated cirrhosis.

A Real-World Assessment of Clinical Outcomes and Safety of Eravacycline: A Novel Fluorocycline.

BackgroundEravacycline is a novel fluorocycline approved for treatment of intraabdominal infections, with a broad spectrum of activity against a range of pathogens including multidrug-resistant species, including ESBL- or KPC-producing isolates. It is approved for twice-daily dosing with no need for adjustment in renal dysfunction. In the concomitant administration with CYP 3A4-inducing drugs, eravacycline dosing should be modified.ObjectiveTo evaluate the efficacy and safety of eravacycline in a range of infections such as intraabdominal infections, pneumonia and diabetic foot infections in seriously ill patients.MethodsA retrospective observational cohort study using electronic patient records of 50 consecutive patients administered eravacycline during inpatient acute care admission or as part of outpatient antibiotic therapy (OPAT).ResultsTherapy of 1.5 mg/kg q24h was initiated in the hospital in most patients, although some of the less sick were managed in the office or OPAT setting. All patients concluded their management outside of the hospital. Of the 50 patients, 47 (94%) achieved clinical resolution of their infection and 3 (6%) clinical failures occurred. Only three (6%) patients did not have comorbidities, three had a single comorbidity (6%), and the majority (88%) of patients had two or more comorbidities. Most common infections were intraabdominal (36%), pneumonia (18%), diabetic foot (12%), spontaneous bacterial peritonitis (8%) and empyema (8%). Almost half of infections had more than one pathogen isolated, and resistant isolates were frequent. The drug was well tolerated with only two reports of nausea, which did not result in treatment discontinuation, and in 30 days of post-eravacycline therapy only one case of Clostridiodes difficile.ConclusionsIn this real-world setting, eravacycline demonstrated a similar high level of clinical efficacy as seen in clinical trials, 94%, in a variety of infections, including against multidrug-resistant bacteria, and was well tolerated.

Pulmonary Complications in Patients with Liver Cirrhosis.

Patients with advanced chronic liver diseases, particularly with decompensated liver cirrhosis, can develop specific pulmonary complications independently of any pre-existing lung disease. Especially when dyspnea occurs in combination with liver cirrhosis, patients should be evaluated for hepato-pulmonary syndrome (HPS), porto-pulmonary hypertension (PPHT), hepatic hydrothorax and spontaneous bacterial empyema, which represent the clinically most relevant pulmonary complications of liver cirrhosis. Importantly, the pathophysiology, clinical features, diagnosis and the corresponding therapeutic options differ between these entities, highlighting the role of specific diagnostics in patients with liver cirrhosis who present with dyspnea. Liver transplantation may offer a curative therapy, including selected cases of HPS and PPHT. In this review article, we summarize the pathogenesis, clinical features, diagnostic algorithms and treatment options of the 4 specific pulmonary complications in patients with liver cirrhosis.

Coexistence of Spontaneous Bacterial Peritonitis and Spontaneous Bacterial Empyema Carries Poor Prognosis in Cirrhotic Patients with Ascites and Hydrothorax

Background and study aim:Patients with decompensated cirrhosis suffer from serious sequelae including infections that may endanger life. The study aimed at determination of the incidence, outcomes and risk factors of spontaneous bacterial empyema (SBEM) among patients with cirrhotic ascites and hydrothorax. Patients and Methods: This study included 50 patients subjected to clinical, imaging and biochemical workup including diagnostic tapping of ascitic and pleural fluid to diagnose spontaneous bacterial peritonitis (SBP) by cellular count and SBEM by cellular count and culture. Results: There The mean age was 57.14 years and 52% were males. SBP was found in 25 cases (50%); alone in 15 and with concomitant SBEM in 10. Only 7 (14%) had positive culture of the pleural fluid including five gram positive bacteria. Patients SBP and SBP/SBEM had significantly higher mean age, higher median TLC, and corrected PMN in pleural fluid compared to patients with no infection. The infection group stayed a significantly more duration in hospital. All the four deaths occurred in the infection group, three with SBP/SBEM and one with SBP. By multivariate logistic regression analysis, pleural fluid TLC and corrected PMN and duration of hospital stay were significant independent predictors of SBEM. Conclusion: SBEM is a common sequel of hydrothorax in patients with cirrhotic ascites and its coexistence with SBP leads to higher morbidity and mortality.