Surgical Infections III - Thoracic Empyema


This Review is part of a series dealing with Surgery and infection. Future reviews in this series will discuss Surgery and AIDS, wound infection, etc.

Introduction  
Pleural Effusion – Classification  
Empyema – Infected Effusions  
  Microbiology  
  Imaging  
Post-pneumonic Empyema  
  Children  
  Adults  
  Tuberculous pleurisy and empyema  
  HIV-positive patients  
Post-Traumatic Empyema  
Treatment  
  Antibiotics  
  Nutritional support  
  Drainage  
    Thoracocentesis  
    Thoracostomy  
    Fibrinolysis  
Surgery  
  Open thoracostomy, rib resection and Eloesser flap  
  VATS  
  Open thoracotomy with or without decortication  
  Thoracoplasty  
  Pneumonectomy  
Recommendations  
References
Questions


Introduction
Both in Africa and in the West, surgeons are often asked by our medical colleagues to drain pleural effusions through the insertion of chest tubes. In Africa, the most common reason for such a request is the post-pneumonic infected effusion or empyema. In the majority of cases the primary care is left to the medical service. While chest tubes are often sufficient to manage this problem, in certain cases the infection may require more sophisticated therapy. Therefore, it is incumbent on the surgeon to understand, in detail, the classification, pathophysiology, diagnostic and therapeutic approaches to pleural space infections (PSI).
This review will concentrate on the post-pneumonic empyema including those associated with tuberculosis and HIV disease. It will deal briefly with post-traumatic pleural infections but not with those occurring after thoracic resection. For these the reader is referred to the following Reviews. (1 ; 2) It will review the clinical presentations and range of infectious agents as well as discuss the new therapeutic approaches of video-assisted thoracic surgery (VATS) and fibrinolysis, which have impacted the modern approach to loculated and chronic empyemas. Finally it will discuss the role of various surgical modalities in the treatment of complex empyemas.


Pleural Effusions – Classification
Three very good reviews outline the classification and approach to the patient with a pleural effusion. (3 - 5) Although pleural effusions can be diagnosed through physical examination (dullness to percussion, decreased breath sounds and vocal fremitus, shift of the trachea), they are most commonly found on chest xrays. A standard upright posteroanterior chest xray can detect 150 ml of fluid and the costophrenic angle is blunted with up to 500 ml. The lateral decubitus chest ray is particularly sensitive; if there is layering of fluid 1 cm in thickness the effusion is accessible via thoracentesis - the standard diagnostic test.
Pleural effusions are first classified as transudates or exudates. Transudates, commonly a result of congestive heart failure, nephrotic syndrome or cirrhosis, are generally clear and straw coloured. Exudates occur with parapneumonic effusions, malignancy, tuberculous pleurisy, pulmonary embolism, collagen vascular disease, pancreatitis and other conditions. Transudates and exudates are distinguished on the basis of their protein content. An exudate is characterized by a protein content > 3.0 g/dL and LDH >200, but pleural/serum ratios are more accurate: protein >0.5; LDH > 0.6.(6) Sadly these tests are not available in every African hospital. Measurement of cell count, pH and glucose level and culture of the fluid are particularly important in infectious effusions (see below). Cytologic examination is important in the diagnosis of malignant effusions. Pleural biopsy may play a role. (7) Porcel (8) examined the characteristics of large or massive effusions in 153 patients and found that most were secondary to infections or malignancy.

Empyema – Infected Effusions
Para-pneumonic exudative effusions occur in up to 50% of pneumonias. Pleural space infections – empyemas need to be distinguished from these by the presence of an infectious agent, (although culture may be negative in up to 30% of PSIs), their ability to cause morbidity and their need for specific treatment. A number of excellent recent reviews discuss the nature and management of thoracic empyema. (9 - 13) The majority, 40-60%, are post-pneumonic. Infections after thoracic surgery and trauma make up the rest, with about 10% being idiopathic. A rare cause is the pyothorax associated lymphoma arising in chests treated with chronic pneumothorax. (14)
Empyemas have been divided into three stages: 1st or exudative, 2nd or fibrinopurulent and 3rd consolidative or chronic stage. Complex empyemas are multi-loculated. In the exudative stage drainage may not be necessary. However if frank pus is present or culture or gram stain is positive; if pH < 7.2, glucose < 35mg/dL, or LDH >1000 IU/L, then drainage is mandatory and should not be delayed. Azoulay et al (15) used reagent sticks to measure pH, protein content and leukocyte esterase levels and found good correlations with standard laboratory methods and ability to distinguish infectious exudates. This study is particularly relevant to the African context where laboratory facilities are practically non-existent. Where tests such as these may not be available it is better to err on the side of drainage.
Drainage is the sine qua non of empyema treatment. In the early stages before fibrinous deposits have fixed the lung to the underlying chest wall, drainage to an underwater seal must be maintained. In later stages open drainage with rib resection has traditionally been used. Undrained, delayed or inadequately drained pus results in pleural scarring and fibrosis, persistence of the lung collapse and maintenance of the infection. (16) A chronic empyema, which begins about 6 weeks after infection, requires surgical intervention aimed at obliterating the cavity either by VATS or thoracotomy with decortication of the lung and removal of the pleural peel, plus or minus lung resection, or with thoracoplasty bringing the chest wall down to the lung. Bronchopleural fistula complicates the decision process.
Microbiology
A wide range of infectious agents have been shown to cause PSI. While culture of pleural fluid must always be done, blood cultures should also be taken in febrile patients. Streptococcus pneumoniae (17) and staphylococcus aureus (18) are generally the most common pathogens in children, but anaerobes (19) and gram negative aerobes such as Klebsiella (20) may predominate in adults. Unusual organisms like Salmonella (21), Yersinia (22), Gemella (21) and fungal disease (24) may cause empyemas; hydatid cysts of the liver may rupture into the pleural space (25); even trichomonas (26) has been isolated. Tuberculous pleurisy is an important entity that will be discussed below.
Imaging
While the PA chest xray is the standard tool in the diagnosis of pleural effusion and empyema, other imaging techniques play an important role. (27) One of the major problems in the treatment of empyema is its failure to resolve with tube thoracostomy. (see below) This may occur as a result of the formation of septae and loculations in the pleural space resulting in multiple, non-communicating cavities. Ultrasound plays an important role in the diagnosis of this septation and can predict the success of simple thoracostomy and the need for alternative measures. (28) Image guided drainage can also be carried out.(29 ; 30) CT scan identification of a pleural peel accurately predicts the need for surgery. (31)

Post-Pneumonic Empyema (32)
Interest has focused on which patients develop PSI. (33) Multiple factors including underlying patient health, bacterial virulence and promptness of drainage determine clinical outcome in PSI. (34 ;35) In one retrospective study delaying drainage for 3 days after recognition was associated with an increase in mortality rate from 3% to 16%. Cell mediated immunity is depressed in empyema patients. (36) Treatment failure has also been associated with the presence of antibiotic resistant organisms (37) and with delay in diagnosis and referral.
Children
In the last 10 years, only two reports in English are available from Africa on the treatment of post-pneumonic PSI in children.(38 ;39) In both the mean patient age was five. Fever, cough, dyspnea were the standard presentations with radiologic evidence of pleural effusion. Pneumococci or staphylococci were the most common organisms isolated. No patient in the Ethiopian study and one in the Nigerian study received thoracotomy and decortication. This may indicate lack of or inadequate utilization of surgical services. The mortality rate ranged from 7-16%. In a recent study of 265 children with empyema from India (40), staphylococcus was the most common organism. Tube thoracostomy failed in 21% of cases classified as fibrinopurulent. Decortication was required in 25% of all thoracotomies, particularly when surgery was delayed. Eastham et al (17) present their experience with 47 children from north England. In 75% of cases an infectious agent was identified of which 86% were pneumococcci, although this diagnosis could only be made through the isolation of bacterial DNA. The prior prescription of antibiotics in 96% of cases may have played a role in the lack of positive pleural cultures. PSI complicates 2-8% of pneumonias in children in the US. Schultz et al (41) report on 230 children in Texas over a 10 year period. 32% of pleural cultures were positive. The development and use of pneumococcal vaccine resulted in staphylococci being the most common organism isolated in the later period. Antibiotic resistance was a developing feature.
Adults
Nadeem et al (42) reported on 105 consecutive patients older than 10 years presenting to a Thoracic Surgical Unit in Peshawar, India. The mean duration of symptoms was 6 weeks with 38% having had an unsuccessful drainage prior to admission. The majority of patients required open surgery with a mortality rate of 7%. Cheng (43) reported on 72 patients from California treated with a non aggressive protocol with a mortality rate of 6%. Tsai et al (44) compared empyema in Tawainese adults older than 65 years with younger patients. The older patients had similar mortality rates, but higher morbidity, rates of fungal infection and an increased risk of associated malignancy.
Tuberculous pleurisy and empyema
Tuberculous pleurisy and empyema are discrete clinical entities requiring specific approaches. Pleural effusions may complicate up to 30% of cases of tuberculosis in Africa. (11 ;12) The association between AIDS and TB is well known. In tuberculous pleurisy the effusion occurs as part of the primary infection. The duration of symptoms is usually long with a mean of 4 months. Chest xray may or may not show typical findings of TB. Early on the pleural fluid shows a typical exudative character, later lymphocytes may predominate. Pleural levels of adenosine deaminase (ADA) are increased. Sputum may be positive for AFB in about 50% of cases. Mycobacteria are cultured in less than 50% of samples of pleural fluid; the yield is improved with histology and culture of pleural biopsies. While tuberculous pleurisy may resolve spontaneously over several months, ATB therapy is indicated.
Tuberculous empyema is a much more serious condition with massive contamination of the pleural cavity as a complication of pulmonary tuberculosis. The pleural fluid is purulent and AFB are more commonly identified. A bronchopleural fistula may be present. Al Kattan et al (45) report on 26 patients from Saudi Arabia. The empyemas were classified using pleural aspirates and CT scan findings. Aspiration and tube thoracostomy were adequate for exudative collections alone, but more advanced stages required other interventions. Decortication, pulmonary resections and open thoracostomies are important treatment modalities. Olgac et al (46) recommended decortication alone in patients with prolonged lung collapse and pleural infection secondary to tuberculosis.
HIV-positive patients
It is uncertain whether PSI is more common in HIV-positive patients but it is more serious. Borge et al (47) reported on 23 HIV-positive patients who were all intra-venous drug users. Most empyemas were secondary to community-acquired pneumonia with staph aureus and gram negative bacilli being the most common organism. Closed thoracostomies and fibrinolytic therapy was used. Patients with AIDS had higher risk of bronchopleural fistula and prolonged hospital stay. Khwaja (48) found that AIDS patients with CD4 counts < 200 had more complex empyemas requiring open drainage and decortication.

Post-Traumatic Empyema
Tube thoracostomy is appropriate and necessary treatment for traumatic pneumothorax and hemothorax. (49) Empyema and pleural fibrosis are significant risks in undrained hemothoraces. Bailey (50) reviewed complications of tube thoracostomy. Empyema occurs in about 2%. Maxwell et al (51) found that post-traumatic empyemas were related to the degree of underlying (particularly penetrating) lung injury and duration of tube placement. Concurrent antibiotics did not appear to be preventative.

Treatment

Antibiotics
Antibiotic therapy, active against the common pathogens causing PSI, should be initiated parenterally in all cases of empyema, before culture reports are available. Since these include pneumococcus, staph aureus, anaerobes and gram negatives, a broad spectrum penicillin with beta-lactamase resistance along with an anaerobic agent is a good choice. Amoxicillin/clavulinate or cefuroxime plus metronidazole are reasonable combinations. Palacios et al (52) found that cefuroxime was as effective as dicloxacillin/chloramphenicol in children. Teixeira et al (53) found significant differences in pleural antibiotic levels among various agents. Aminoglycosides, which are inactivated in pus and low pH, should probably be avoided. Paganini et al (54) found that PSI from penicillin resistant organisms was no more virulent. Surgeons should be aware of local antibiotic resistance.

Nutritional support
Empyema patients are often nutritionally depleted. Nutritional assessment and support is vital to the resolution of the underlying infection.

Drainage
In 2000 the American College of Chest Physicians published a Consensus Statement on the treatment of parapneumonic effusions. (55) They divided patients into 4 groups, on the basis of risk of poor outcome and used quantity of fluid, presence or absence of loculation, fluid culture reports, and pH of pleural fluid, to develop recommendations regarding the necessity of drainage. Basically if the effusion is small and free flowing, the culture negative and the pH>7.2 drainage is unnecessary (groups 1 & 2). If the effusion is greater than ½ hemothorax OR loculated OR culture positive OR pH<7.2 drainage is recommended (groups 3 & 4).
The main cause of treatment failure, morbidity and mortality in empyema is the development of loculated, undrained pus resulting in pleural scarring, fibrosis and chronicity of infection requiring surgical intervention. The objective of treatment is not only to resolve the infection but prevent this progression to chronicity. To succeed prompt and complete evacuation of infected fluid must be achieved.
A number of treatment modalities are available. These include:

Thoracocentesis – Repeated ultrasound guided thoracocentesis has been compared to closed thoracostomy in a small study. (54) Excluding patients with massive empyema resulting in mediastinal shift, both modalities had similar number of treatment failures. Intra-pleural fibrinolysis was used as deemed necessary in both groups. I believe that this modality should only be used in the earliest and most responsive cases and mandates extreme vigilance.

Closed thoracostomy – Closed chest tube drainage has been the standard first line therapy for empyema throughout the last century. Large bore tubes have historically been inserted to underwater seal and suction applied. Used with antibiotics alone, these have a significant failure rate of up to 50%. Repeated chest xrays must be taken to ensure prompt evacuation of all fluid. Chest tubes should not normally be clamped. If drainage ceases a chest xray should be taken to assess if there is kinking or if residual fluid remains. The tube can be irrigated. If the tube is malfunctioning or drainage less than 100 in 24 hours, it should be removed. A simple suture for closing thoracostomy incisions has been described. (55) If significant fluid remains the next level of intervention should be undertaken.
Huang et al (56) determined that pleural fluid WBC<6400/uL and loculation were independent predictors of failure of tube thoracostomy. Pierrepoint et al published a study using historical controls which showed pigtail catheters to be superior to standard chest tubes in preventing the need for surgical intervention.(30)

Fibrinolysis – The intra-pleural instillation of fibrinolytic agents has been used to breakdown loculations. Schiza et al (59) reviewed the agents used. Generally 250,000 IU of streptokinase is diluted in 20-100 ml saline and instilled via the chest tube which is clamped for 2-4 hours. Twice daily instillations for three days are routine. This regime is applicable for children as well.(60) Fever and allergic responses have been the most common side effects. Bleeding complications are unusual. The treatment does induce the presence of anti-streptokinase antibodies. (61)
The efficacy of fibrinolytics has been carefully scrutinized. Cameron et al (62) examined the published RCTs for the Cochrane Database and concluded there was insufficient evidence to recommend their use. This lack of evidence has recently been resolved with the publication of the MIST study from the UK. (63) This large, multicenter RCT in adults clearly showed no difference between saline and streptokinase chest tube instillation in terms of treatment failures, need for surgery or mortality. Need for surgery and mortality rate were similar in both groups at 15%. A recent RCT from India showed no difference in short term results between streptokinase and saline (none of their patients failed) but a significant reduction in need for delayed surgery in those with multiloculated empyemas who had received streptokinase. (64) Another RCT from South Africa showed a significant improvement in treatment success and avoidance of surgery in streptokinase treated patients after seven days. (65) A recently published RCT from Greece also showed an improved success rate and lowered mortality rate with fibrinolysis compared to tube drainage alone. (66) While the MIST study certainly casts doubt on the value of fibrinolysis, further RCTs and meta-analyses can be anticipated. Although fibrinolysis may not be useful, agents such as DNase, which actually reduce the viscosity of the pus, may prove to be of value. (67)

Surgery
The unresolved fibrinopurulent or chronic empyema has always been the province of the surgeon. Open thoracostomy with rib resection and Eloesser flap has been the standard method of open and evacuating the cavity. Thoracotomy and decortication with or without pulmonary resection has historically been reserved for chronic empyemas where lung re-expansion is prevented by pleural fibrosis. The development of video-assisted thoracoscopy (VATS) in the 1980s changed that. (68) Now early exploration of the entire pleural cavity under direct vision could be undertaken without the morbidity of a thoracotomy. However, during this same period, the use of fibrinolysis and the proliferation of imaging techniques, with the application of image guided drainage, have in many cases delayed surgical referral with resulting negative consequences.
Avansino et al (69) using a meta-analysis of 23 years of reports on empyema therapy in children has shown that primary operative therapy compares favourably with non-operative therapy. The failure rate is significantly reduced with primary operative therapy as are mortality rates, re-intervention rates, hospital stay, duration of tube and antibiotics. Gates et al (70) focusing on VATS reached similar conclusions. Other individual reports have done the same.(71 - 73) Considering recent doubts cast on the value of fibrinolysis, it is clear that all cases of stage 2 empyema which do not resolve promptly with tube thoracostomy or which have thick, multiloculated fluid should have prompt surgical referral. The same is true for all stage 3 empyemas. The Recommendations of the British Thoracic Society BTS (disregarding the comments on fibrinolysis) would form a good basis for therapeutic approach. (74) In light of this the following recommendations can be made:
Open thoracostomy, rib resection and Eloesser flap
This historical approach to open surgical drainage is indicated when closed drainage is unsuccessful, VATS is unavailable and adhesions have fixed the lung to the overlying pleura. (75) A variable number of ribs can be resected. It is particularly suitable when the patient is not fit for general anaesthesia. BTS2.16 The cavity has historically been treated with sterilizing solutions such as Dakin’s. Maruyama et al (76) describes a slightly different approach.
VATS
Where facilities are available VATS is the procedure of choice for any empyema not promptly (4-8 days) and completely responding to closed thoracostomy. BTS2.15 General anaesthesia and double lumen endotracheal intubation are part of this highly technical, but very effective, modality.(77) Angelillo Mackinlay et al in 1996 favourably compared VATS with open thoracotomy and recommended RCTs to define its role. (78) Sadly only one RCT comparing immediate VATS with fibrinolysis has been published. VATS was deemed to be more effective as a result of a significantly higher treatment success rate, shorter hospital stay and duration of chest drainage. “Medical thoracoscopy”, carried out under local anaesthesia and sedation, has been described.(79)
Open thoracotomy with or without decortication
In settings where VATS is not available but where there is adequate surgical expertise, open thoracotomy and drainage of abscess is indicated in stable patients whose empyemas do not respond promptly (4-8 days) and adequately to closed thoracostomy. (80) BTS2.15 Decortication is added if a thick pleural peel prevents expansion of the lung. (81) Lung resection may be necessary if there is a bronchopleural fistula or severely damaged lung.
Thoracoplasty
In patients with chronic empyema, collapsed lung and pleural fibrosis who are not fit for thoracotomy, a thoracoplasty can be done to collapse the chest wall onto the lung thereby obliterating the cavity.
Pneumonectomy
Extra-pleural pneumonectomy can be carried for serious damaged lungs in the presence of chronic empyema. (82) Most cases are associated with chronic tuberculosis. This is an operation for experts.


Recommendations
1. All undiagnosed pleural effusions should be aspirated and have their protein and LDH content measured and compared with serum levels. Exudates should have cell counts and differentials, pH and glucose determination, gram and acid fast staining and culture. Urine reagent sticks may be used in the absence of formal chemical analysis.
2. Drainage is appropriate for all parapneumonic effusions which are greater than ½ hemothorax OR loculated fluid OR culture or gram stain positive OR pH<7.2. Other criteria such as frank pus, glucose<35mg/dL or LDH>1000IU/L should also be considered.
3. Streptococcus pneumonia and staphylococcus aureus are the major pathogens in childen; gram-negative aerobes and anaerobes predominate in adults.
4. Tuberculous pleurisy needs to be distinguished from TB empyema. The former needs only ATB therapy, the later the full gamut of empyema strategies.
5. Chest tubes are important in traumatic pneumo- and hemothorax, but they should be removed as soon as air and blood drainage cease. Risk of post-traumatic empyema is a reflection of underlying lung injury.
6. Ultrasound examination should be undertaken in all pleural effusions and especially those which do not resolve promptly with tube drainage. The presence of septations is an indication of an increased risk of failure of tube drainage and the need for surgical drainage.
7. Antibiotic protocols should be started before definitive culture reports are available. These include amoxicillin/clavulinic acid or a second generation cephalosporin such as cefuroxime plus an anaerobic agent like metronidazole. In patients with penicillin allergy, a fluoroquinone like ciprofloxacin, a carbapenem like imipenem, or perhaps chloramphenicol may be substituted.
8. Nutritional assessment and support should be offered to all empyema patients.
9. Empyemas should be classified as stage 1 – exudative; stage 2 - fibrinopurulent and stage 3 - chronic.
10. Exudative empyemas (stage 1) which are less than ½ hemothorax, are not loculated, with negative gram stain and culture and with pH>7.2 can be treated without drainage. These should be followed very closely with xray and if necessary repeated thoracentesis to diagnose any progression to stage 2 and ensure resolution.
11. In large or loculated stage 1 and all stage 2 empyemas the first line therapy is prompt and adequate drainage, probably with closed tube thoracostomy. Multiloculated collections have a higher risk of failure with tube drainage.
12. Failure of prompt (4-8 days) radiologic or clinical response after tube drainage mandates surgical consultation.
13. In light of the MIST study, the role of intrapleural fibrinolysis in the management of empyema is in doubt.
14. VATS, if available, is the procedure of choice for the evacuation of refractory empyemas. VATS is probably one of the most useful minimally invasive procedures in the African setting and is recognized in the FCS syllabus of COSECSA.
15. In the absence of VATS, thoracotomy, with or without decortication, is indicated in multiloculated, inadequately drained empyemas.
16. All stage 3 empyemas require surgery as first line therapy. Thoracotomy with decortication is required. Lung resection may be necessary in some cases, particularly if there is a bronchopleural fistula. Some cases can be managed by VATS.
17. Open thoracostomy with rib resection and Eloesser flaps should be used in localized and inadequately drained empyemas, particularly when the patient’s condition is poor or expertise lacking.

Dr. Brian Ostrow
Guelph, Ontario

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Reference List

  1. Miller JI. Postsurgical Empyema. General Thoracic Surgery Vol.1. Lippincott, Williams & Wilkins, 2005. (4082 kb)
  2. Kacprzak G, Marciniak M, Addae-Boateng E, Kolodziej J, Pawelczyk K. Causes and management of postpneumonectomy empyemas: our experience. European Journal of Cardio-Thoracic Surgery 2004; 26(3):498-502. (255 kb)
  3. Andrade RS, Maddaus M. Pleural Effusion. In: Doublas W, editor. ACS Surgery: Principles & Practice. United States of America: WebMD Inc, 2006.
  4. Barnes NP, Hull J, Thomson AH. Medical management of parapneumonic pleural disease. Pediatric Pulmonology 2005; 39(2):127-134. (169 kb)
  5. Yataco JC, Dweik RA. Pleural effusions: evaluation and management. Cleveland Clinic Journal of Medicine 858; 72(10):854-856. (428 kb)
  6. Segura RM. Useful clinical biological markers in diagnosis of pleural effusions in children. Paediatric Respiratory Reviews 2004; 5 Suppl A:S205-S212. (94 kb)
  7. Nusair S, Breuer R, Amir G, Berkman N. Closed pleural needle biopsy: predicting diagnostic yield by examining pleural fluid parameters. Respiratory Medicine 2002; 96(11):890-894. (169 kb)
  8. Porcel JM, Vives M. Etiology and pleural fluid characteristics of large and massive effusions. Chest 2003; 124(3):978-983. (658 kb)
  9. Cohen RG DTLE. The Pleura. Surgery of the Chest Vol. 1. W.B. Saunders Company, 1996: 547-561. (9348 kb)
  10. Katariya K. Disease of the Pleura. Clinics in Chest Medicine 1998; 19(2). (153 kb)
  11. de Hoyos A, Sundaresan S. Thoracic empyema. Surgical Clinics of North America 2002; 82(3):643-671. (3186 kb)
  12. Chapman SJ, Davies RJ. The management of pleural space infections. Respirology 2004; 9(1):4-11. (106 kb)
  13. Heffner JE. Infection of the pleural space. Clinics in Chest Medicine 1999; 20(3):607-622. (483 kb)
  14. Aozasa K, Takakuwa T, Nakatsuka S. Pyothorax-associated lymphoma: a lymphoma developing in chronic inflammation. Advances in Anatomic Pathology 2005; 12(6):324-331. (851 kb)
  15. Azoulay E, Fartoukh M, Galliot R, Baud F, Simonneau G, Le Gall JR et al. Rapid diagnosis of infectious pleural effusions by use of reagent strips. Clinical Infectious Diseases 31(4):914-9, 2000. (120 kb)
  16. Mutsaers SE, Prele CM, Brody AR, Idell S. Pathogenesis of pleural fibrosis. Respirology 2004; 9(4):428-440. (245 kb)
  17. Eastham KM, Freeman R, Kearns AM, Eltringham G, Clark J, Leeming J et al. Clinical features, aetiology and outcome of empyema in children in the north east of England. Thorax 2004; 59(6):522-525. (124 kb)
  18. Goel A, Bamford L, Hanslo D, Hussey G. Primary staphylococcal pneumonia in young children: a review of 100 cases. Journal of Tropical Pediatrics 1999; 45(4):233-236. (114 kb)
  19. Levison ME. Anaerobic pleuropulmonary infection. Current Opinion in Infectious Diseases 2001; 14(2):187-191. (70 kb)
  20. Chen KY, Hsueh PR, Liaw YS, Yang PC, Luh KT. A 10-year experience with bacteriology of acute thoracic empyema: emphasis on Klebsiella pneumoniae in patients with diabetes mellitus. Chest 2000; 117(6):1685-1689. (697 kb)
  21. Crum NF. Non-typhi Salmonella empyema: case report and review of the literature. Scandinavian Journal of Infectious Diseases 2005; 37(11-12):852-857. (61 kb)
  22. Mofredj A, Guerin JM, Leibinger F, Masmoudi R. Spontaneous pleural empyema due to Yersinia enterocolitica. Southern Medical Journal 2003; 96(5):525-527. (63 kb)
  23. Valipour A, Koller H, Setinek U, Burghuber OC. Pleural empyema associated with Gemella morbillorum: report of a case and review of the literature. Scandinavian Journal of Infectious Diseases 2005; 37(5):378-381. (93 kb)
  24. Ko SC, Chen KY, Hsueh PR, Luh KT, Yang PC. Fungal empyema thoracis: an emerging clinical entity. Chest 2000; 117(6):1672-1678. (152 kb)
  25. Keramidas D, Mavridis G, Soutis M, Passalidis A. Medical treatment of pulmonary hydatidosis: complications and surgical management. Pediatric Surgery International 2004; 19(12):774-776. (210 kb)
  26. Lewis KL, Doherty DE, Ribes J, Seabolt JP, Bensadoun ES. Empyema caused by trichomonas. Chest 2003; 123(1):291-292. (404 kb)
  27. Evans AL, Gleeson FV. Radiology in pleural disease: state of the art. [Review] [114 refs]. Respirology 2004; 9(3):300-312. (699 kb)
  28. Chen KY, Liaw YS, Wang HC, Luh KT, Yang PC. Sonographic septation: a useful prognostic indicator of acute thoracic empyema. Journal of Ultrasound in Medicine 2000; 19(12):837-843. (97 kb)
  29. Shankar S, Gulati M, Kang M, Gupta S, Suri S. Image-guided percutaneous drainage of thoracic empyema: can sonography predict the outcome? European Radiology 2000; 10(3):495-499. (590 kb)
  30. Pierrepoint MJ, Evans A, Morris SJ, Harrison SK, Doull IJ. Pigtail catheter drain in the treatment of empyema thoracis. Archives of Disease in Childhood 2002; 87(4):331-332. (100 kb)
  31. de Souza A, Offner PJ, Moore EE, Biffl WL, Haenel JB, Franciose RJ et al. Optimal management of complicated empyema. American Journal of Surgery 2000; 180(6):507-511. (209 kb)
  32. McLaughlin JS KM. Parapneumonic Empyema. General Thoracic Surgery Vol.1. Lippincott, Williams & Wilkins, 2005. (723 kb)
  33. Roson B, Carratala J, Fernandez-Sabe N, Tubau F, Manresa F, Gudiol F. Causes and factors associated with early failure in hospitalized patients with community-acquired pneumonia. Archives of Internal Medicine 2004; 164(5):502-508. (101 kb)
  34. Mwandumba HC, Beeching NJ. Pyogenic lung infections: factors for predicting clinical outcome of lung abscess and thoracic empyema. Current Opinion in Pulmonary Medicine 2000; 6(3):234-239. (138 kb)
  35. Chu MW, Dewar LR, Burgess JJ, Busse EG. Empyema thoracis: lack of awareness results in a prolonged clinical course. Canadian Journal of Surgery 2001; 44(4):284-288. (45 kb)
  36. Mishra OP, Varshney K, Usha, Ali Z, Nath G, Pathak VK et al. Immune status with empyema thoracis. Indian Journal of Pediatrics 2004; 71(4):301-305. (127 kb)
  37. Margenthaler JA, Weber TR, Keller MS. Predictors of surgical outcome for complicated pneumonia in children: impact of bacterial virulence. World Journal of Surgery 2004; 28(1):87-91. (118 kb)
  38. Hailu S. Paediatric thoracic empyema in an Ethiopian referral hospital. East African Medical Journal 2000; 77(11):618-621. (12 kb)
  39. Tagbo O, Uchenna O, Anthony H. Childhood parapneumonic pleural effusion in Enugu. Nigerian Postgraduate Medical Journal 2005; 12(1):28-32. (12 kb)
  40. Baranwal AK, Singh M, Marwaha RK, Kumar L. Empyema thoracis: a 10-year comparative review of hospitalised children from south Asia. Archives of Disease in Childhood 2003; 88(11):1009-1014. (316 kb)
  41. Schultz KD, Fan LL, Pinsky J, Ochoa L, Smith EO, Kaplan SL et al. The changing face of pleural empyemas in children: epidemiology and management. Pediatrics 2004; 113(6):1735-1740. (382 kb)
  42. Nadeem A, Bilal A, Shahkar S, Shah A. Presentation and management of empyema thoracis at Lady Reading Hospital Peshawar. Journal of Ayub Medical College, Abbottabad: JAMC 2004; 16(1):14-17. (48 kb)
  43. Cheng G, Vintch JR. A retrospective analysis of the management of parapneumonic empyemas in a county teaching facility from 1992 to 2004. Chest 2005; 128(5):3284-3290. (619 kb)
  44. Tsai TH, Jerng JS, Chen KY, Yu CJ, Yang PC. Community-acquired thoracic empyema in older people. Journal of the American Geriatrics Society 2005; 53(7):1203-1209. (86 kb)
  45. Al Kattan KM. Management of tuberculous empyema. European Journal of Cardio-Thoracic Surgery 2000; 17(3):251-254. (316 kb)
  46. Olgac G, Yilmaz MA, Ortakoylu MG, Kutlu CA. Decision-making for lung resection in patients with empyema and collapsed lung due to tuberculosis. Journal of Thoracic & Cardiovascular Surgery 2005; 130(1):131-135. (218 kb)
  47. Borge Jea. Thoracic Empyema in HIV-infected patients. Chest 1998; 113(3).
  48. Khwaja S, Rosenbaum DH, Paul MC, Bhojani RA, Estrera AS, Wait MA et al. Surgical treatment of thoracic empyema in HIV-infected patients: severity and treatment modality is associated with CD4 count status. Chest 2005; 128(1):246-249. (147 kb)
  49. Molnar TF, Hasse J, Jeyasingham K, Rendeki MS. Changing dogmas: history of development in treatment modalities of traumatic pneumothorax, hemothorax, and posttraumatic empyema thoracis. Annals of Thoracic Surgery 2004; 77(1):372-378. (440 kb)
  50. Bailey RC. Complications of tube thoracostomy in trauma. Journal of Accident & Emergency Medicine 2000; 17(2):111-114. (129 kb)
  51. Maxwell RA, Campbell DJ, Fabian TC, Croce MA, Luchette FA, Kerwin AJ et al. Use of presumptive antibiotics following tube thoracostomy for traumatic hemopneumothorax in the prevention of empyema and pneumonia--a multi-center trial. Journal of Trauma-Injury Infection & Critical Care 2004; 57(4):742-748. (707 kb)
  52. Palacios GC, Gonzalez SN, Perez FL, Cuevas SF, Solorzano SF. Cefuroxime vs a dicloxacillin/chloramphenicol combination for the treatment of parapneumonic pleural effusion and empyema in children. Pulmonary Pharmacology & Therapeutics 2002; 15(1):17-23. (76 kb)
  53. Teixeira LR, Sasse SA, Villarino MA, Nguyen T, Mulligan ME, Light RW. Antibiotic levels in empyemic pleural fluid. Chest 2000; 117(6):1734-1739. (139 kb)
  54. Paganini H, Guinazu JR, Hernandez C, Lopardo H, Gonzalez F, Berberian G. Comparative analysis of outcome and clinical features in children with pleural empyema caused by penicillin-nonsusceptible and penicillin-susceptible Streptococcus pneumoniae. International Journal of Infectious Diseases 2001; 5(2):86-88. (322 kb)
  55. Colice Gea. ACCP Consensus Statement: Medical and Surgical Treatment of Parapneumonic Effusions. Chest 2000; 118(4). (213 kb)
  56. Shoseyov D, Bibi H, Shatzberg G, Klar A, Akerman J, Hurvitz H et al. Short-term course and outcome of treatments of pleural empyema in pediatric patients: repeated ultrasound-guided needle thoracocentesis vs chest tube drainage. Chest 2002; 121(3):836-840. (688 kb)
  57. Vasseur BG. A simplified technique for closing thoracostomy incisions. Annals of Thoracic Surgery 2004; 77(4):1467-1468. (108 kb)
  58. Huang HC, Chang HY, Chen CW, Lee CH, Hsiue TR. Predicting factors for outcome of tube thoracostomy in complicated parapneumonic effusion for empyema. Chest 1999; 115(3):751-756. (693 kb)
  59. Schiza SE, Antoniou KM, Economidou FN, Siafakas NM. Pharmacotherapy in complicated parapneumonic pleural effusions and thoracic empyema. Pulmonary Pharmacology & Therapeutics 2005; 18(6):381-389. (148 kb)
  60. Ulku R, Onen A, Onat S, Kilinc N, Ozcelik C. Intrapleural fibrinolytic treatment of multiloculated pediatric empyemas. Pediatric Surgery International 2004; 20(7):520-524. (1573 kb)
  61. Laisaar T, Pullerits T. Effect of intrapleural streptokinase administration on antistreptokinase antibody level in patients with loculated pleural effusions. Chest 2003; 123(2):432-435. (647 kb)
  62. Cameron R, Davies HR. Intra-pleural fibrinolytic therapy versus conservative management in the treatment of parapneumonic effusions and empyema.[update of Cochrane Database Syst Rev. 2000;(3):CD002312; PMID: 10908554]. [Review] [44 refs]. Cochrane Database of Systematic Reviews 2004;(2):CD002312. (243 kb)
  63. Maskell NA, Davies CW, Nunn AJ, Hedley EL, Gleeson FV, Miller R et al. U.K. Controlled trial of intrapleural streptokinase for pleural infection. [erratum appears in N Engl J Med. 2005 May 19;352(20):2146]. New England Journal of Medicine 2005; 352(9):865-874. (131 kb)
  64. Singh M, Mathew JL, Chandra S, Katariya S, Kumar L. Randomized controlled trial of intrapleural streptokinase in empyema thoracis in children. Acta Paediatrica 2004; 93(11):1443-1445. (50 kb)
  65. Diacon AH, Theron J, Schuurmans MM, Van de Wal BW, Bolliger CT. Intrapleural streptokinase for empyema and complicated parapneumonic effusions.[see comment]. American Journal of Respiratory & Critical Care Medicine 2004; 170(1):49-53. (78 kb)
  66. Misthos P, Sepsas E, Konstantinou M, Athanassiadi K, Skottis I, Lioulias A. Early use of intrapleural fibrinolytics in the management of postpneumonic empyema. A prospective study. European Journal of Cardio-Thoracic Surgery 28(4):599-603, 2005. (84 kb)
  67. Simpson G, Roomes D, Reeves B. Successful treatment of empyema thoracis with human recombinant deoxyribonuclease. Thorax 2003; 58(4):365-366. (109 kb)
  68. Kern JA, Rodgers BM. Thoracoscopy in the management of empyema in children. Journal of Pediatric Surgery 28(9):1128-32, 1993. (554 kb)
  69. Avansino JR, Goldman B, Sawin RS, Flum DR. Primary operative versus nonoperative therapy for pediatric empyema: a meta-analysis. Pediatrics 2005; 115(6):1652-1659. (2471 kb)
  70. Gates RL, Caniano DA, Hayes JR, Arca MJ. Does VATS provide optimal treatment of empyema in children? A systematic review. Journal of Pediatric Surgery 2004; 39(3):381-386. (86 kb)
  71. Shankar KR, Kenny SE, Okoye BO, Carty HM, Lloyd DA, Losty PD. Evolving experience in the management of empyema thoracis. Acta Paediatrica 2000; 89(4):417-420. (40 kb)
  72. Hilliard TN, Henderson AJ, Langton Hewer SC. Management of parapneumonic effusion and empyema. Archives of Disease in Childhood 2003; 88(10):915-917. (140 kb)
  73. Anstadt MP, Guill CK, Ferguson ER, Gordon HS, Soltero ER, Beall AC, Jr. et al. Surgical versus nonsurgical treatment of empyema thoracis: an outcomes analysis. American Journal of the Medical Sciences 2003; 326(1):9-14. (401 kb
  74. )Davies CW, Gleeson FV, Davies RJ, Pleural Diseases Group SoCCBTS. BTS guidelines for the management of pleural infection. Thorax 58 Suppl 2:ii18-28, 2003. (314 kb)
  75. Thourani VH, Lancaster RT, Mansour KA, Miller JI, Jr. Twenty-six years of experience with the modified eloesser flap. Annals of Thoracic Surgery 2003; 76(2):401-405. (373 kb)
  76. Maruyama R, Ondo K, Mikami K, Ueda H, Motohiro A. Clinical course and management of patients undergoing open window thoracostomy for thoracic empyema. Respiration 2001; 68(6):606-610. (403 kb)
  77. Petrakis Iea. Video-assisted Thoracoscopic Surgery for Thoracic Empyema. American Journal of Surgery 2004; 187(4). (139 kb)
  78. Angelillo-Mackinlay D. VATS debridement versus thoracotomy in the treatemtn of loculated postpneumonic empyema. Annals of Thoracic Surgery 1996; 61(6):1626-1630. (91 kb)
  79. Brutsche MH, Tassi GF, Gyorik S, Gokcimen M, Renard C, Marchetti GP et al. Treatment of sonographically stratified multiloculated thoracic empyema by medical thoracoscopy. Chest 2005; 128(5):3303-3309. (886 kb)
  80. Rice TW. Fibrothorax and Decortication of the Lung. General Thoracic Surgery Vol.1. Lippincott, Williams & Wilkins, 2005. (5151 kb)
  81. Alexiou C, Goyal A, Firmin RK, Hickey MS. Is open thoracotomy still a good treatment option for the management of empyema in children? Annals of Thoracic Surgery 2003; 76(6):1854-1858. (159 kb)
  82. Shiraishi Y, Nakajima Y, Koyama A, Takasuna K, Katsuragi N, Yoshida S. Morbidity and mortality after 94 extrapleural pneumonectomies for empyema. Annals of Thoracic Surgery 2000; 70(4):1202-1206. (199 kb)

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