ABSTRACT
Clinical importance of infection in the pleural space 296 Historical perspective 297 Epidemiology of pleural infection 297 Pathophysiology of pleural infection 298
Development of the initial pleural effusion: “The exudative phase” 298
Evolution of infection: “The fibropurulent phase” 299 Natural healing: “The organizing stage” 299
Correlation of clinicopathological stages in pleural infection 299 Simple parapneumonic effusion 299 Complicated parapneumonic effusion 299 Empyema 300 Microbiology-positive pleural fluid:
“Pleural infection” 300 Bacteriology of pleural infection 301 Diagnosis and clinical assessment of
pleural infection 304 Differential diagnosis 306 Radiology 307 Antibiotic therapy 308
Community-acquired pleural infection 308 Hospital-acquired (nosocomial) pleural infection 309
Chest catheter drainage310 Intrapleural fibrinolytics 311
Streptokinase 311 Direct tissue plasminogen activators and
combination intrapleural therapy 315 Safety profile of intrapleural fibrinolytics 317
Surgery in pleural infection 317 Other interventions in pleural infection 319
Medical thoracoscopy 319 Bronchoscopy 319 Nutritional support 319
Special circumstances in pleural infection 319 The patient with persistent sepsis who is unfit
for general anesthesia319 Pleural infection in patients with human
immunodeficiency virus (HIV) infection 320 Clinical outcome prediction in pleural infection 320 Future directions 321 Acknowledgment 321 References 321
Pleural infection remains an important disease with a signicant clinical impact on respiratory specialists, physicians working in internal medicine, and thoracic surgeons. Diagnosis is oen challenging and a sophisticated multidisciplinary management strategy is required, using input as necessary from physicians, surgeons, radiologists, and microbiologists. Furthermore, the incidence of pleural infection is on the increase in both adult and pediatric populations without clear cause.1-4 Postulated reasons for this rise have included improvements in clinical awareness and diagnostics, a replacement phenomenon with widening use of pneumococcal vaccination,3,5-7 or the consequence of an aging population living with chronic disease. is increasing caseload comes alongside the persistently high morbidity and mortality associated with pleural infection despite continued advances in medical diagnostics and therapeutics over the past three decades. Published studies indicate an overall mortality in the region of 20% from pleural infection,8-13 rising to over 30% in vulnerable populations such as the elderly1,10,11,13 and the immunocompromised.14 is mortality appears to be “disease-associated” in that it occurs over the 6 months aer initial presentation9,10 and by implication should be amenable to reduction with improved clinical care.9,12,13 Patients who survive 6 months aer their episode of pleural infection have a survival similar to normal subjects over the next 4 years (Figure 23.1). In addition to this considerable mortality, up to 20% of patients will fail medical treatment with chest tube drainage and antibiotics alone and require surgical
drainage of their infected pleural collection.10,11 Despite this, there continues to be great variation in the management of patients with pleural infection, with an evidencebased and universally accepted optimal standard of care still to be established despite extensive publication in this eld of practice.15,16-32
Simple parapneumonic eusions will arise in up to 57% of cases of pneumonia,33 and approximately 80,000 new cases of pleural infection will be diagnosed in adults in the United States and United Kingdom each year1,10,11,33,34 at an estimated cost of over $500 million for hospital services per year. Of these 80,000 cases of pleural infection, about 30,000 will either require surgery or die within 6 months of their diagnosis. is chapter describes the current
● e bacteriology of pleural infection is substantially dierent to that of pneumonia and dierent antibiotic regimens are required as a consequence.
