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pleural empyema
Pleural empyema, also known as pyothorax or purulent pleuritis, is empyema (an accumulation of pus) in the pleural cavity that can develop when bacteria invade the pleural space, usually in the context of a pneumonia. It is one of various kinds of pleural effusion. There are three stages: exudative, when there is an increase in pleural fluid with or without the presence of pus; fibrinopurulent, when fibrous septa form localized pus pockets; and the final organizing stage, when there is scarring of the pleura membranes with possible inability of the lung to expand. Simple pleural effusions occur in up to 40% of bacterial pneumonias. They are usually small and resolve with appropriate antibiotic therapy. If however an empyema develops additional intervention is required.
== Epidemiology ==
The incidence of pleural empyema and the prevalence of specific causative microorganisms varies depending on the source of infection (community acquired vs. hospital acquired pneumonia), the age of the patient and host immune status. Risk factors include alcoholism, drug use, HIV infection, neoplasm and pre-existent pulmonary disease.〔Alfageme I, Munoz F, Pena N, Umbria S. "Empyema of the thorax in adults. Etiology, microbiologic findings, and management". Chest 1993; 103(3):839-43〕 Pleural empyema was found in 0.7% of 3675 patients needing hospitalization for a community acquired pneumonia in a recent Canadian single-center prospective study.〔Ahmed R, Marri T, Huang J. "Thoracic empyema in patients with community-acquired pneumonia". American Journal of Medicine 2006; 119(10):877-83〕 A multi-center study from the UK including 430 adult patients with community acquired pleural empyema found negative pleural-fluid cultures in 54% of patients, Streptococcus milleri group in 16%, Staphylococcus aureus in 12%, Streptococcus pneumoniae in 8%, other Streptococci in 7% and anaerobic bacteria in 8%.〔Maskell NA, Davies CWH, Nunn AJ, Hedley EL, Gleeson FV, Miller R, Gabe R, Rees GL, Peto TEA, Woodhead MA, Lane DJ, Darbyshire JH, Davies RJO. "U.K. controlled trial of intrapleural streptokinase for pleural infection". New England Journal of Medicine 2005; 352(9):865-74〕 Given the difficulties in culturing anaerobic bacteria the frequency of the latter (including mixed infections) might be underestimated.
The risk of empyema in children seems to be comparable to adults. Using the United States Kids’ Inpatient Database the incidence is calculated to be around 1.5% in children hospitalized for community acquired pneumonia,〔Li S, Tancredi D. "Empyema hospitalizations increased in US children despite pneumococcal conjugate vaccine". Pediatrics 2010; 125(1):26-33〕 although percentages up to 30% have been reported in individual hospitals,〔Byington CL, Spencer LY, Johnson TA, Pavia AT, Allen D, Mason EO, Kaplan S, Carroll KC, Daly JA, Christenson JC, Samore MH. "An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: risk factors and microbiological associations". Clinical Infectious Diseases 2002; 34(4):434-40〕 a difference which may be explained by an transient endemic of highly invasive serotype or overdiagnosis of small parapneumonic effusions. The distribution of causative organisms does differ greatly from that in adults: in an analysis of 78 children with community acquired pleural empyema, no micro-organism was found in 27% of patients, Streptococcus pneumoniae in 51%, Streptococcus pyogenes in 9% and Staphylococcus aureus in 8%.〔Le Monnier A, Carbonnelle E, Zahar JR, Le Bourgeois M, Abachin E, Quesne G, Varon E, Descamps P, De Blic J, Scheinmann P, Berche P, Ferroni A. "Microbiological diagnosis of empyema in children: comparative evaluations by culture, polymerase chain reaction, and pneumococcal antigen detection in pleural fluids". Clinical Infectious Diseases 2006; 42(8):1135-40〕
Although pneumococcal vaccination dramatically decreased the incidence of pneumonia in children, it did not have this effect on the incidence of complicated pneumonia. It has been shown that the incidence of empyema in children was already on the rise at the end of the 20th century, and that the widespread use of pneumococcal vaccination did not slow down this trend.〔Grijalva CG, Nuorti JP, Zhu Y, Griffin MR. "Increasing incidence of empyema complicating childhood community-acquired pneumonia in the United States". Clinical Infectious Diseases 2010; 50(6):805-13〕 This might in part be explained by a change in prevalence of (more invasive) pneumococcal serotypes, some of which are not covered by the vaccine, as well a rise in incidence of pneumonia caused by other streptococci and staphylococci.〔Obando I, Camacho-Lovillo MS, Porras A, Gandía-González MA, Molinos A, Vazquez-Barba I, Morillo-Gutierrez B, Neth OW, Tarrago D. "Sustained high prevalence of pneumococcal serotype 1 in paediatric parapneumonic empyema in southern Spain from 2005 to 2009". Clinical Microbiology and Infection 2012; 18(8):763-8〕 The incidence of empyema seems to be rising in the adult population as well, albeit at a slower rate.
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