parapneumonic effusion (pleural empyema)
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Introduction
Empyema is the presence of pus in an anatomic cavity or 'potential space' i.e. pleural space, or for clinical purposes, bacteria in the pleural space.
Classification
- uncomplicated
- < 10 mm on lateral decubitus, free flowing
- pleural fluid glucose > 60 mg/dL
- pleural fluid pH > 7.2
- complicated
- loculated or thickened pleura
- pleural fluid glucose < 60 mg/dL
- pleural fluid pH < 7.2
- empyema
- bacteria seen on gram stain
- aspiration of pus
- - pleural fluid pH < 7.0[3]
Etiology
- bacterial infection
- pneumonia (50%)
- bacteremia (< 10%)
- organisms
- Staphylococcus aureus (25-35%)
- anaerobes (15-35%)
- cultures positive in 1/3 of cases
- gram-negative bacilli (15-30%)
- Streptococci (12-15%)
- cultures positive in < 5% of cases
- Actinomyces israelii
- Aggregatibacter actinomycetemcomitans[5]
- immunocompromised host (< 10%)
- trauma (5-15%)
- thoracic surgery (10-25%)
- esophageal perforation
- lung abscess
- infarction
Epidemiology
- 40-60% of hospitalized patients with bacterial pneumonia
Laboratory
- thoracentesis & pleural fluid analysis: (also see pleural effusion, thoracentesis)
- exudative effusion
- pleural fluid leukocyte count of > 10,000/mm3
- predominance of neutrophils
- pleural fluid pH < 7.20*
- pleural fluid glucose < 40 mg/dL; < 60 mg/dL*[3]; pleural fluid glucose/serum glucose < 0.5
- pleural fluid LDH > 1000 U/L; > 3.6 x upper end of reference interval
- positive gram stain or culture
* thoracostomy indicated[3]
Management
- antibiotic therapy
- include anaerobic coverage for empyema[3]
- community-acquired empyema
- 2nd or 3rd generation cephalosporin plus metronidazole or aminopenicillin with beta-lactamase inhibitor[7]
- hospital or procedure-acquired empyema
- include coverage for MRSA & Pseudomonas aeruginosa[7]
- thoracostomy
- pleural fluid pH < 7.20 or pleural fluid glucose < 60 mg/dL[3]
- small bore pleural drain is adequate[3][6]
- intrapleural injection to promote drainage
- tissue plasminogen activator treatment of choice (MKSAP18)[3][9]
- streptokinase no better than saline[3]
- video assisted thoracoscopic surgery[7]
- poor prognostic indicators
- older age
- multiple bacterial isolates
- gram-negative bacilli
- hospital-acquired
- concurrent serious illness
More general terms
Additional terms
References
- ↑ Manual of Medical Therapeutics, 28th edition, Ewald & McKenzie (eds) Little, Brown & Co, 1995, pg 259
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 773
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Colice GL, Curtis A, Deslauriers J et al Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline. Chest. 2000 Oct;118(4):1158-71. PMID: https://www.ncbi.nlm.nih.gov/pubmed/11035692
- ↑ 5.0 5.1 Cabot RC et al Case 25-2015 - An 8-Year-Old Girl with a Chest-Wall Mass and a Pleural Effusion. N Engl J Med 2015; 373:657-667. August 13, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21158661 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMcpc1400836
- ↑ 6.0 6.1 Rahman NM, Maskell NA, Davies CW et al The relationship between chest tube size and clinical outcome in pleural infection. Chest. 2010 Mar;137(3):536-43. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19820073
- ↑ 7.0 7.1 7.2 7.3 Shen KR, Bribriesco A, Crabtree T et al The American Association for Thoracic Surgery consensus guidelines for the management of empyema. J Thorac Cardiovasc Surg. 2017 Feb 4 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28274565 <Internet> http://www.jtcvsonline.org/article/S0022-5223(17)30152-6/abstract
- ↑ McCauley L, Dean N. Pneumonia and empyema: causal, casual or unknown. J Thorac Dis. 2015 Jun;7(6):992-8. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26150912 Free PMC Article
- ↑ 9.0 9.1 Rahman NM, Maskell NA, West A et al Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011 Aug 11;365(6):518-26. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21830966 Free Article