Elsevier

The Annals of Thoracic Surgery

Volume 66, Issue 5, November 1998, Pages 1782-1786
The Annals of Thoracic Surgery

Original Articles
Outcome of primary empyema thoracis: therapeutic and microbiologic aspects

https://doi.org/10.1016/S0003-4975(98)00601-8Get rights and content

Abstract

Background. This study was undertaken to determine whether all adult patients with primary empyema thoracis need decortication.

Methods. A management algorithm was developed and analyzed in a prospective, longitudinal, nonblinded study of 179 consecutive adult patients. The treatment options included thoracentesis, closed (tube) thoracostomy, image-guided catheter drainage, and decortication. We reviewed the outcomes of these procedures as they related to the pleural fluid cultures isolated and the antibiotic regimens used.

Results. Of the 179 patients, 20 had thoracentesis as the primary procedure, and 18 (90%) were cured. Ninety patients underwent closed thoracostomy as the primary procedure with a cure rate of 62% (56 patients) and a mortality rate of 11% (10 patients), and 24 patients required a secondary procedure. Seventy-six patients underwent decortication as either the primary or the secondary procedure with a cure rate of 88% (67 patients) and a mortality rate of 1.3% (1 patient); 8 patients required conversion to open thoracostomy. Hospital stay for decortication was 14 ± 1 days and for closed thoracostomy, 17 ± 1 days (p < 0.05). Decortication was necessary in 55% of patients with anaerobic infections and in 50% with aerobic infections. Clindamycin in combination with gentamicin sulfate was the most efficacious regimen with a success rate of 82% (51 of 62 patients); only 33% (17 of 52) were cured with penicillin. The overall mortality rate in this study was 6.7% (12 of 179 patients).

Conclusions. Forty-two percent of patients with primary empyema thoracis ultimately require decortication. Decortication is more frequently necessary for anaerobic, tuberculous, staphylococcal, and pneumococcal infections. Although the overall mortality in this study was low, mortality remains high in elderly patients and patients with comorbid disease.

Section snippets

Patients and methods

This prospective, longitudinal, nonblinded study involves 179 consecutive adult patients seen with a diagnosis of primary bacterial thoracic empyema from July 1973 to July 1997. There were 141 men and 38 women aged 19 to 82 years (mean age, 40 ± 1 years [± standard error of the mean]). There were 131 black patients (73%), 43 Latino patients (24%), and 5 patients of other races (3%). From 1987 when the test for human immunodeficiency virus infection became widely used, 81 consecutive patients

Surgical outcomes

As summarized in Figure 1, 179 patients underwent 214 therapeutic procedures. Of the 20 patients who had thoracentesis, 18 (90%) were cured, and 2 (10%) subsequently required decortication as a secondary procedure. Nine patients were treated by image-guided catheter drainage with a success rate of 89% (8 of 9). The patient in whom this method failed required secondary decortication.

As shown in Figure 1, most of the patients (n = 90) were treated initially with closed thoracostomy. Fifty-six

Comment

The suppurative process in the pleural space can be diffuse or localized. The pathologic stages are exudative, fibrinopurulent, and organizing and correlate well with the clinical phases—acute, transitional, and chronic. Thus, the choice of drainage procedure should be based on the pathologic and clinical phases of the suppurative processes 6, 7, not on the biochemical variables. During the acute (exudative) phase, thin fluid can be aspirated, and this may be adequate as both a diagnostic and a

Acknowledgements

We thank Ms Charvette Pilchier for her patience and for processing the manuscript, and Ms Mina R. Mandal for her assistance in our literature search.

References (19)

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