Optimal Duration of Antibiotics Therapy After Video-assisted Thoracoscopic Surgery in Thoracic Empyema and Complicated Parapneumonic Effusion

BackgroundThere is no evidential report about the optimal duration of antibiotic use following video-assisted thoracoscopic surgery debridement (VATS-D) in thoracic empyema (TE) or complicated parapneumonic effusion (PPE). The purpose of this study was to determine the optimal duration of antibiotic therapy after VATS-D for TE /PPE.MethodsBetween January 2011 and December 2019, total thirty-three patients (28 men, 5 women; median age 63 years) corresponding to ACCP category 3 or 4 receiving VATS-D were included in the study. Time until the body temperature (BT) was to be less than 37.5 ºC and 37.0 ºC, WBC count to be less than 10,000/μl and segmented neutrophil (seg) count to be less than 80% were retrospectively analyzed.ResultsThe median time from the onset of TE/PPE to the operation was 13 days. Pre and postoperative antibiotic had median values of 5 and 7 days, respectively. There were no hospital deaths within 30 days of the operation. Major complications occurred in 4 cases (3 respiratory failures and one celebral infarction). Median postoperative hospital stay was 14 days. Success rate in TE/PPE treatment was 88%. The median number of days until the conditions met were BT>37.5 ºC for 3 days, BT>37.0 ºC for 6 days, WBC<10,000 for 4 days and seg<80% for 7 days.ConclusionThe optimal antibiotic duration of antibiotic use after VATS-D for TE/PPE is approximately 5 days. Urgent VATS-D will shorten the total antibiotic duration.

The use of fibrinolytic therapy for parapneumonic effusion in pregnancy: a case report and a review

The use of intrapleural fibrinolytics for complicated parapneumonic effusion has been shown to be an effective and safe alternative to surgery. However, there is limited evidence about its use during pregnancy. We present a case and a review of the literature of pregnant women who had successful treatment of their complicated parapneumonic effusion with intrapleural fibrinolytics. To our knowledge this is the first review of cases of pregnant women with parapneumonic effusion managed with intrapleural fibrinolytic.

Sonographic septation: a useful diagnostic predictor of complicated parapneumonic effusion

Sonographic septation is associated with prolonged hospitalization and increased mortality in patients diagnosed with empyema. However, it is unknown whether sonographic septation is associated with complicated parapneumonic effusion (CPPE) or the need for invasive procedures among patients with pneumonia. In this retrospective study, we included 180 patients with non-purulent neutrophilic exudative pleural effusion secondary to pulmonary infections such as pneumonia and lung abscess. We performed univariate and multivariate logistic regression analyses, including baseline clinical characteristics, values from blood samples, and sonographic echogenicity, to identify variables correlated with CPPE and the need for invasive procedures. Seventy of the 180 included patients (38.89%) displayed sonographic septation. Multivariate logistic regression analysis identified that sonographic septation (adjusted OR (AOR)=3.38 (95% CI 1.64 to 6.98), p=0.001) and younger age (AOR=2.63 (95% CI 1.24 to 5.58), p=0.012) were independently associated with CPPE. With regard to treatment strategy, sonographic septation (AOR 9.06 (95% CI 3.71 to 22.11), p<0.001) and total serum protein level (AOR=1.80 (95% CI 1.13 to 2.86), p=0.013) were independently associated with the need for subsequent invasive procedures in patients with CPPE using multivariate logistic regression analysis. Sonographic septation is a useful predictor of CPPE and may imply the need for early invasive procedures.

Legionella pulmonary abscess and pleural space infection in an immunocompetent patient

A 34-year-old woman is admitted to the hospital with dyspnoea, dry cough and left-sided flank pain. Her Legionella urinary test was positive and CT imaging demonstrated multifocal pneumonia with pulmonary abscesses. Although she had initial clinical improvement on appropriate antibiotic therapy, her hospital course was complicated by worsening flank pain, hypoxemia and leucocytosis, prompting clinical re-evaluation and assessment for development of complications involving the pleural space. CT imaging revealed interval development of a loculated complicated parapneumonic effusion. Successful treatment required chest tube drainage assisted by fibrinolytic therapy. This case highlights the importance of considering Legionella in patients with pulmonary abscess, demonstrates an approach to a patient with a non-resolving pneumonia and illustrates the management of parapneumonic effusions.

Diagnostic Value of C-Reactive Protein in Discrimination between Uncomplicated and Complicated Parapneumonic Effusion

Objectives: The role of serum C-reactive protein (CRPs) and pleural fluid CRP (CRPpf) in discriminating uncomplicated parapneumonic effusion (UCPPE) from complicated parapneumonic effusion (CPPE) is yet to be validated since most of the previous studies were on small cohorts and with variable results. The role of CRPs and CRPpf gradient (CRPg) and of their ratio (CRPr) in this discrimination has not been previously reported. The study aims to assess the diagnostic efficacy of CRPs, CRPpf, CRPr, and CRPg in discriminating UCPPE from CPPE in a relatively large cohort. Methods: The study population included 146 patients with PPE, 86 with UCPPE and 60 with CPPE. Levels of CRPs and CRPpf were measured, and the CRPg and CRPr were calculated. The values are presented as mean ± SD. Results: Mean levels of CRPs, CRPpf, CRPg, and CRPr of the UCPPE group were 145.3 ± 67.6 mg/L, 58.5 ± 38.5 mg/L, 86.8 ± 37.3 mg/L, and 0.39 ± 0.11, respectively, and for the CPPE group were 302.2 ± 75.6 mg/L, 112 ± 65 mg/L, 188.3 ± 62.3 mg/L, and 0.36 ± 0.19, respectively. Levels of CRPs, CRPpf, and CRPg were significantly higher in the CPPE than in the UCPPE group (p < 0.0001). No significant difference was found between the two groups for levels of CRPr (p = 0.26). The best cut-off value calculated by the receiver operating characteristic (ROC) analysis for discriminating UCPPE from CPPE was for CRPs, 211.5 mg/L with area under the curve (AUC) = 94% and p < 0.0001, for CRPpf, 90.5 mg/L with AUC = 76.3% and p < 0.0001, and for CRPg, 142 mg/L with AUC = 91% and p < 0.0001. Conclusions: CRPs, CRPpf, and CRPg are strong markers for discrimination between UCPPE and CPPE, while CRPr has no role in this discrimination.