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Background: Pleural empyema after pneumonectomy still poses a serious postoperative complication. A broncho-pleural fistula is often detected. Despite various therapeutic options developed over the last five decades it remains a major surgical challenge., Materials and Methods: A literature search in MEDLINE database was carried out (accessed through PubMed), by using a combination of the following key-words and MeSH terms: pneumonectomy, postoperative, complications, broncho-pleural fistula, empyema, prevention. The following areas of intervention were identified: epidemiology, etiology, prevention., Results: Pleural empyema in a post-pneumonectomy cavity occurs in up to 16% of patients with a mortality of more than 10%. It is associated with broncho-pleural fistula in up to 80% of them, usually in the early postoperative months. Operative mortality could reach 50% in case of broncho-pleural fistula. Unfavourable prognostic factors are: benign disease, COPD, right-sided surgery, neoadjuvant and adjuvant therapy, time of chest tube removal, long bronchial stump and mechanical ventilation. Bronchial stump protection with vascularised flaps is of utmost importance in the prevention of complications., Conclusion: Postpneumonectomy pleural empyema is a common complication with high mortality. The existing evidence confirms the role of bronchopleural fistula prevention in the prevention of life-threatening complications., (This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Etiology and serotyping of parapneumonic effusion (PPE) and the impact of vaccination was evaluated over a 12-year period, before and after the PCV13 introduction (2011) for Italian children From 0 to 16 years of age. Five hundred and two children were evaluated; 226 blood and 356 pleural fluid samples were obtained and tested using Realtime-PCR and culture. In the pre-PCV13 era S. pneumoniae was the most frequent pathogen identified (64/90; 71.1%) with a large predominance of serotypes 1 (42.4%), 3 (23.7%), 7F (5.1%) and 19A (11.9%). The impact of vaccination, calculated on children 0-8 years of age, demonstrated a significant reduction of PPE: with an incidence rate of 2.82 (95%CL 2.32-3.41) in the pre-PCV13 era and an age-standardized rate (ASR) of 0.66 (95% CL 0.37-1.99) in the post-PCV13 era, p < 0.0001. No increase in non-PCV13 serotypes was recorded. S. pneumoniae remained the most frequent pathogen identified in the post-PCV13 era in unvaccinated children with an unchanged serotype distribution: respectively 26/66 (39.4%), 25/66 (37.9%), 5/66 (7.6%), and 4/66 (6.1%) for 1, 3, 7F and 19A. On the other hand 7F and 19A disappeared in vaccinated children and serotype 1 and 3 decreased by 91.8% and 31.5%, respectively. Realtime PCR was significantly more sensitive than culture both in pleural fluid (79.7% vs 12.5%) and in blood (17.8% vs 7.4%). In conclusion, our findings indicate that routine immunization with PCV13 has significantly reduced the burden of childhood PPE in vaccinated children, without increasing PPE due to other bacteria and without serotype shift. Moreover, the impact of PCV13 may be underestimated due to the increase in pneumococcal surveillance in Italy. Data has also shown that Real-time PCR is an essential tool to better define the etiology of PPE and to monitor vaccination plans. Longer studies will be necessary to evaluate the role of herd protection in PPE prevention., (Copyright © 2019. Published by Elsevier Ltd.)

Development of postpneumonectomy empyema with bronchopleural fistula is a life-threatening condition that requires prompt action. Although measures should be taken to prevent bronchopleural fistula at time of pneumonectomy, many patients experience this complication. Management focuses on drainage of the pleural space, control of the pleural infection including repair of the bronchopleural fistula, and obliteration of the residual pleural cavity. Multiple techniques and procedures have been developed over time to achieve these goals. Knowledge of the diverse therapeutic options is important to select the optimal treatment for these complex patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: In January 2012, Argentina included universal pneumococcal vaccination in the routine childhood vaccination program using a 13-valent pneumococcal conjugate vaccine (PCV13). A 2 + 1 schedule (2 doses in the first year of life and a booster dose at 12 months of age) in children aged <2 years and 2-dose catch-up immunization in children aged 13 to 24 months was administered during the first year of vaccine introduction. The purpose of this study was to assess the burdens of invasive pneumococcal disease (IPD) and/or community-acquired pneumonia (CAP) in hospitalized children younger than 5 years during the first 2 years of the program compared to those in the prevaccination period in our setting., Methods: This was a multicenter, prospective, and descriptive study. Rates of hospitalization resulting from IPD and/or CAP in 5 pediatric reference centers across the country were analyzed (every 10 000 admissions). Clinical, epidemiologic, and microbiological data were recorded. Statistical analysis using Stata 8.0 was performed., Results: A comparison of rates of hospitalization resulting from global IPD and/or CAP in the prevaccine (2009-2011) and postvaccine (2012-2013) periods revealed significant decreases of 50% (P = .003) and 51% (P < .0001), respectively. Significant decreases were also observed in number of hospitalizations resulting from empyema (39%; P = .03) and pneumococcal empyema (67.8%; P = .007); the reduction was not statistically significant for pneumococcal CAP (58%; P = .18). Hospital stays for IPD and/or CAP decreased by 56%., Conclusion: Rapid and significant decreases in the rates of hospitalization resulting from IPD and/or CAP during the first 2 years after PCV13 introduction were observed. A longer surveillance period is required to confirm these results and the effectiveness of the vaccination program., (© Crown copyright 2017)

Background: Persistent postoperative pleural effusion can occur after thoracic surgery and might lead to progressive dyspnea with a subsequent complicated and prolonged hospital stay., Objectives: The etiology, prevention and therapy of persistent pleural effusion after thoracic surgical interventions are presented., Material and Methods: A selective literature search was carried out in Medline (pleural effusion, pleural empyema and chylothorax)., Results: Persistent pleural effusions were observed especially after lung resection due to disorders in the pleural fluid balance and reduced postoperative lung expansion. An adequate chest tube management and postoperative physical therapy can reduce the incidence of postoperative pleural effusion. Relevant postoperative bleeding causes a hemothorax. An infection of the pleural effusion is defined as pleural empyema. These patients suffer from a significantly higher postoperative morbidity and require an adjusted multimodal treatment. Intraoperative injury of the thoracic duct can result in a postoperative chylothorax, which should be diagnosed early with specific laboratory investigations of the milky fluid. Interventional radiological procedures have now taken their place alongside conservative measures and surgical procedures in the therapy of chylothorax., Conclusion: Persistent postoperative pleural effusion after thoracic surgical interventions warrant early diagnosis and an adjusted treatment in order to avoid further complications and to shorten the postoperative hospital stay.

Background: Antibiotic use in injured patients requiring tube thoracostomy (TT) to reduce the incidence of empyema and pneumonia remains a controversial practice. In 1998, the Eastern Association for the Surgery of Trauma (EAST) developed and published practice management guidelines for the use of presumptive antibiotics in TT for patients who sustained a traumatic hemopneumothorax. The Practice Management Guidelines Committee of EAST has updated the 1998 guidelines to reflect current literature and practice., Methods: A systematic literature review was performed to include prospective and retrospective studies from 1997 to 2011, excluding those studies published in the previous guideline. Case reports, letters to the editor, and review articles were excluded. Ten acute care surgeons and one statistician/epidemiologist reviewed the articles under consideration, and the EAST primer was used to grade the evidence., Results: Of the 98 articles identified, seven were selected as meeting criteria for review. Two questions regarding presumptive antibiotic use in TT for traumatic hemopneumothorax were addressed: (1) Do presumptive antibiotics reduce the incidence of empyema or pneumonia? And if true, (2) What is the optimal duration of antibiotic prophylaxis?, Conclusion: Routine presumptive antibiotic use to reduce the incidence of empyema and pneumonia in TT for traumatic hemopneumothorax is controversial; however, there is insufficient published evidence to support any recommendation either for or against this practice.

Unlabelled: The aim of the paper is to observe the effectiveness of prophylactic administration of antibacterials against empyema and pneumonia after tube thoracostomy for traumatic collections., Material and Methods: Observational retrospective study over a ten years period (2002-2011), at the Oradea County Emergency Hospital on 939 patients with chest tube drainage for traumatic haemo/pneumothoraces. The morbidity by intrathoracic infections was 5,5% in the curative antibiotic group., Results: The median number of risk factors for surgical infections and case severity were not statistically different (p=0.9653 and p=0,6601) between cases with antibioprophylaxis and curative treatment, but the incidence of intrathoracic infection in the prophylaxis group (n=86) was half (2,3%). Antibioprophylaxis was effective in over 95% of the cases and it associated in-hospital length of stay, length of stay in the ICU and costs of care significantly (p<0.0001, p<0.0001, p=0.0046) lesser than of those patients treated with curative regimen. The overall mortality was 8.6% within the curative regimen group with an attributable mortality to infections of 17.39%; but it was only 2.3% and respectively 0 within the prophylaxis group., Conclusions: Antibiotic prophylaxis for intrathoracic infections after tube thoracostomy for traumatic collections was justified by case severity and risk factors and was effective and cost-efficient, but it should be administered selectively.

In order to achieve respectable postoperative outcomes after lung resection it is essential to understand the mechanism of bronchus healing. The bronchus seal should be air-tight and consist of monofilament suture or staples. The bronchus suture should be covered with vital tissue (lung, mediastinum, muscle flap). A complication in the process of bronchus healing should be diagnosed as early as possible in order to stop the destructive effect of the infection as rapidly as possible., (© Georg Thieme Verlag KG Stuttgart · New York.)

Pleural space problems can create formidable treatment dilemmas for thoracic surgeons. Most arise as iatrogenic sequelae of lung resections, although some occur as late consequences of infection, hemothorax, or systemic inflammatory disease. Regardless of etiology, a central theme in the development and perpetuation of chronic pleural space problems is that there has been a loss of parietal-visceral pleural apposition, and this has allowed for development of an obligate space. A variety of surgical strategies aimed at reestablishment of pleural apposition and obliteration of pleural space are reviewed., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: During the past two decades, the incidence of paediatric empyema has increased in many countries., Purpose: The aim of this retrospective hospital chart review was to evaluate the incidence, aetiology and clinical and laboratory characteristics of parapneumonic empyema in children., Subjects and Methods: Twenty-one patients were admitted to a university hospital from the area with a population of 84,000 children in 1991-2009., Results: The annual incidence of parapneumonic empyema was 1.6/100,000 children in 1991-1998, 0.2/100,000 children in 1999-2005 and 2.7/100,000 children in 2006-2009. Bacterial aetiology was identified in 52% of the cases, and pneumococcus caused 45% of the cases with bacterial aetiology detected. The clinical and laboratory findings in children with and without pleural effusion on admission were surprisingly similar. The development of empyema in hospital during antibiotic therapy was associated with persistent fever and serum C-reactive protein (CRP) >200 mg/L for 48 h after admission., Conclusion: The incidence of parapneumonic empyema in children fluctuated but in the long run, increased in 1991-2009. Pneumococcus caused half of the cases with bacterial diagnosis available. Since 2010, pneumococcal vaccination has belonged to the general vaccination programme, and the effect on the incidence of empyema remains to be seen., (© 2011 The Author(s)/Acta Paediatrica © 2011 Foundation Acta Paediatrica.)

Background: Childhood bacterial pneumonia and empyema rates have reportedly increased in recent years in Europe. In September 2006 the seven-valent pneumococcal conjugate vaccination (PCV7) was introduced to the childhood national immunisation programme in England following a successful PCV7 campaign in the USA. The aim of this study was to report national time trends in hospital admissions for childhood bacterial pneumonia and empyema in England before and after the introduction of PCV7., Methods: A population-based time-trend analysis of Hospital Episode Statistics data of children aged <15 years admitted to all NHS hospitals in England, with a primary diagnosis of bacterial pneumonia and empyema from 1997 to 2008 was performed. Annual crude and age-sex standardised hospital admission rates for bacterial pneumonia and empyema were calculated., Results: Admission rates for bacterial pneumonia and empyema increased from 1997 to 2006, then declined to 2008. Bacterial pneumonia rates decreased to 1079 (95% CI 1059 to 1099) per million children and empyema rates decreased to 14 (95% CI 11 to 16) per million children. The RR for bacterial pneumonia admissions was 1.19 (95% CI 1.16 to 1.22) in 2006 compared with 2004 and 0.81 (95% CI 0.79 to 0.83) in 2008 compared with 2006. For empyema, the corresponding RRs were 1.77 (95% CI 1.38 to 2.28) in 2006 compared with 2004 and 0.78 (95% CI 0.62 to 0.98) in 2008 compared with 2006., Conclusion: Childhood bacterial pneumonia and empyema admission rates were increasing prior to 2006 and decreased by 19% and 22% respectively between 2006 and 2008, following the introduction of the PCV7 pneumococcal conjugate vaccination to the national childhood immunisation programme.

Aims: To investigate the change in incidence of childhood empyema and pneumonia in Australia, and ascertain the management trends in all hospitals caring for children with empyema., Methods: The incidences of empyema and pneumonia were calculated for each year between 1993/1994 and 2004/2005 using retrospective primary diagnostic coding from ICD-9 and 10 comprising the Australian National Hospital Morbidity Database for five age groups in patients less than 20 years of age. Hospitals with allocated paediatric beds were surveyed on referral pattern and treatment preferences., Results: In this study, 145 562 patients with pneumonia were admitted with a mean (range) incidence of 2306 (1846-2652) per million. The trend towards an overall increase was not statistically significant. Only the 1-4 years old age group demonstrated a significant increase (P < 0.01, r2 = 0.61). A total of 469 cases of empyema were identified with a mean incidence of 7.35 (4-10.2) per million. There was an overall increase in incidence (P < 0.05, r2 = 0.51) reflecting an increase in the 1- to 4-year-olds (P < 0.005, r2 = 0.60) and 15- to 19-year-olds (P < 0.05, r2 = 0.37). The overall percentage of empyema as a proportion of pneumonia increased from 0.27 to 0.70% (0.48% (0.27-0.70%), P < 0.05, r2 = 0.38). The survey response rate was 75%. Ninety-nine of 121 (82%) hospitals referred children with empyema to a more appropriate centre with wide variations in treatments provided., Conclusions: The rise in incidence of empyema reflects that seen in other countries. Furthermore, there are diverse management practices suggesting a clear need for national guidelines.

Empyema is apparently becoming more common, with pneumococcus being the most common pathogen detected in Europe and the USA. However, group A streptococcus and S. aureus pneumonia are individually more likely to progress to empyema. Serotype 1 pneumococcus is frequently implicated and the reasons for an apparent increase in incidence remain unclear. Management requires antibiotics and removal of pus either by fibrinolysis or primary drainage.

An increased occurrence of complicated parapneumonic effusions in children has been reported from the UK and USA. Data from mainland Europe are scarce. We investigated the incidence of complicated parapneumonic effusion and empyaema in children admitted to the University Hospital of Leuven between 1993 and 2005, an era when pneumococcal conjugated vaccination had not yet been implemented. Sixty-eight cases were identified. The incidence increased from 20-55/100,000 hospital admissions to 120-130/100,000 hospital admissions in 2005, with 50% of the cases occurring from 2003 onwards (late cohort). This increase occurred later than that reported in the UK and US, but is of similar magnitude. The median patient age was 3.6 years (range 0.5-17 years). The median duration of symptoms before admission was 4 days (quartile values 3-7 days). The median white blood cell (WBC) count was 15,450 WBC/mm3 (quartile values 11,300-21,200 WBC/mm3) and the median C-reactive protein (CRP) level was 242 mg/L (quartile values 143-344 mg/L). Patients in the late cohort seemed to have worse disease compared to early cohort patients; significantly higher pleural lactate dehydrogenase (LDH) level (P = 0,02), higher pleural WBC, lower pleural glucose level and significantly longer duration of hospitalisation in the later cohort (P < 0,05), possibly reflecting more severe disease. In both cohorts, Streptococcus pneumoniae was the most frequently isolated pathogen, with serogroup 1 prevailing. The occurrence of complicated parapneumonic effusion increased in Belgian children before pneumococcal vaccination was added to routine childhood immunisations. This increase is pronounced from 2003 onwards (late cohort) and, thus, occurred later than that reported in the UK and USA; several parameters point towards the occurrence of more serious disease in the late cohort patients.

Bronchopleural fistula and empyema are serious complications after thoracic surgical procedures, and their prevention is paramount. Herein, we review our experience with routine prophylactic use of the pedicled ipsilateral latissimus dorsi muscle flap. From January 2004 through February 2006, 10 surgically high-risk patients underwent intrathoracic transposition of this muscle flap for reinforcement of bronchial-stump closure or obliteration of empyema cavities. Seven of the patients were chronically immunosuppressed, 5 were severely malnourished (median preoperative serum albumin level, 2.4 g/dL), and 5 had severe underlying obstructive pulmonary disease (median forced expiratory volume in 1 second, 44% of predicted level). Three upper lobectomies and 1 completion pneumonectomy were performed in order to treat massive hemoptysis that was secondary to complex aspergilloma. One patient underwent left pneumonectomy due to ruptured-cavitary primary lung lymphoma. One upper lobectomy was performed because of necrotizing, localized Mycobacterium avium-intracellulare infection. One patient underwent right upper lobectomy and main-stem bronchoplasty for carcinoma after chemoradiation therapy. In 3 patients, the pedicled latissimus dorsi muscle was used to obliterate chronic empyema cavities and to buttress the closure of underlying bronchopleural fistulas. No operative deaths or recurrent empyemas resulted. Two patients retained peri-flap air that required no surgical intervention. We conclude that the use of transposed pedicled latissimus dorsi muscle flap effectively and reliably prevents clinically overt bronchopleural fistula and recurrent empyema. We advocate its routine use in first-time and selected reoperative thoracotomies in patients who are undergoing high-risk lung resection or reparative procedures.

Objective: Postpneumonectomy empyema remains a clinical challenge. We proposed an accelerated therapy without an open chest window 5 years ago. This concept was evaluated on a larger scale in 2 centers in 2 different countries., Methods: Between July 1995 and October 2005, 75 consecutive patients with postpneumonectomy empyema were treated in Szczecin, Poland (n = 35), and Zurich, Switzerland (n = 40). The therapy consisted of repeated open surgical debridement of the pleural cavity after achievement of general anesthesia, a negative pressure wound therapy of the temporarily closed chest cavity filled with povidone-iodine-soaked towels, and continuous suction and systemic antimicrobial therapy. If present, bronchopleural fistulae were closed and reinforced either with a muscle flap or the omentum. Finally, the pleural space was filled with an antibiotic solution and definitively closed., Results: Of 75 patients (63 men; median age, 59 years; age range, 19-82 years), postpneumonectomy empyema was present on the right in 46 patients (32 with bronchopleural fistula) and in 29 patients (12 with bronchopleural fistula) on the left. Median time between pneumonectomy and postpneumonectomy empyema was 131 days (range, 7-7200 days). Bronchopleural fistulae have been closed and additionally reinforced by means of different methods (omentum, 18; muscle, 11; pericardial fat, 5; azygos vein, 1). The chest was definitively closed within 8 days in 94.6% of patients. The median hospitalization time was 18 days (range, 9-134 days). Postpneumonectomy empyema was successfully treated in 97.3% of patients, including 10 (13%) patients who needed a second treatment cycle. Three (4%) patients died within 90 days. The median follow-up time was 29.5 moths (range, 3-107 months)., Conclusions: Treatment of postpneumonectomy empyema with the accelerated treatment is effective and safe. Our results are superior compared with those in reported series using a (temporary) chest fenestration. Patients appreciate the physical integrity of the chest.

Wound infection and empyema complicating pulmonary resection is considered surgical site infection (SSI). Wound infection after pulmonary resection rarely occurs when preventative measures against SSI are taken. Empyema complicating pulmonary resection is organ/space SSI, and one of the most devastating complications after pulmonary resection. Postresectional empyema is often associated with bronchopleural fistula, which makes the management of empyema difficult and needs expertise. The initial treatment of postresectional empyema should include prompt surgical drainage by closed tube thoracostomy and institution of appropriate antibiotics. Definitive treatment of empyema includes complete obliteration of empyema space and secure closure of bronchopleural fistula if applicable. "Prevention is better than cure" does apply to SSI.

Although there are a wide range of complications following thoracic trauma, respiratory failure, pneumonia, and pleural sepsis are the most common potentially preventable problems. Respiratory failure and pneumonia are directly related to the severity of the injury and the age and condition of the patient. A program aimed at aggressive pain control, mobilization, and pulmonary care can reduce the risk of respiratory failure, pneumonia, and death in these patients. Pleural sepsis develops in the face of a retained hemothorax, which becomes contaminated with bacteria. The most common source for this contamination is not pneumonia, but external contamination from the wound itself or at the time of placement of the tube thoracostomy. Measures that reduce the volume of retained pleural blood and reduce or eliminate any bacterial contamination are likely to reduce the incidence of pleural sepsis. The authors review these complications and describe a plan to reduce these complications.

A strategy providing for solution of a number of tactical and technical problems involved in prognosis, prevention and management of postoperative bronchopleural complication after pneumonectomy for lung cancer was suggested. It was followed by a significant decrease in the frequency of bronchopleural fistula, postoperative empyema and lethality from purulent bronchopleural complications.

Background: Use of antibiotics in patients with isolated chest trauma is controversial. Available studies offer contradictory results because of small sample sizes. However, information provided by recent randomized controlled trials (RCT) included in a systematic review and meta-analysis could help solve the controversy. We performed a systematic review using high-quality information related to the use of antibiotics in patients with a chest tube., Methods: We developed a systematic review to evaluate the effectiveness of prophylactic antibiotics in chest-trauma patients. Studies included were class I RCT comparing prophylactic antibiotics versus placebo in patients with isolated chest trauma. Main outcomes were posttraumatic empyema and pneumonia., Results: Five Class I studies were selected. There were statistically significant differences regarding the frequency of posttraumatic empyema (RR 0.19) and pneumonia (RR 0.44) in favor of the use of prophylactic antibiotics when compared with placebo., Conclusions: The use of prophylactic antibiotics in patients with chest trauma decreases the incidence of posttraumatic empyema and pneumonia.

During 2003-2004, locally presenting pleural empyema cases in children increased 3-fold. Antigen analysis of empyema fluid identified Streptococcus pneumoniae in 27 of 29 cases for whom samples were available and capsular polysaccharide type 1 in 18 of these. Use of a conjugate vaccine without serotype 1 antigen would have had limited impact on this morbidity in our region.

The efficacy of local instillation of fusidic acid in the prevention of post-surgical microbial complications during various types of lung resection was studied. Four hundred ninety two consecutive patients who underwent 504 thoracotomies for non-small cell lung carcinoma during April 1998-May 2004 were reviewed. The 290 patients of the first period who underwent 298 thoracotomies received a chemoprophylactic regimen of intravenous cefuroxime while the 202 patients of the second period who underwent 206 thoracotomies were additionally treated with fusidic acid, irrigated with local instillation into the pleural space, for the prevention of postoperative septic complications. Patients were followed postoperatively for development of septic complications (empyema and bronchopleural fistula) as well as of pneumonia and wound infection. Seventeen patients (5.7%) of the first period developed empyema and 13 fistula (4.4%), whereas only 2 patients (1.0%) of the second period developed empyema and fistula (OR = 5.876; 95% CI, 1.343- 25.716; P = 0.008 and OR = 4.193; 95% CI, 1.003-20.130; P = 0.034, respectively). Cases of pneumonia decreased, but not significantly, from 21 (7.0%) during the first period to 9 (4.4%) during the second period (OR = 1.613; 95% CI, 0.724-3.593; P = 0.257) while cases of wound infection decreased significantly from 19 (6.4%) to 2 (1.0%) (OR = 6.567; 95% CI, 1.513-28.510; P = 0.003). During the first period 23 pathogens were found from cases of empyema and 73 pathogens from cases of pneumonia and wound infection, whereas during the second period 3 and 18 pathogens were respectively found (OR = 5.3; 95% CI, 1.570-17.888; P = 0.003, and OR = 2.804; 95% CI, 1.628-4.838; P <0.001, respectively). These results indicate that local instillation of fusidic acid in the pleural space prior to lung resection seems effective in reducing the rate of septic complications as well as of wound infections.

Background: Pediatric pneumococcal parapneumonic empyema (PPE) has become increasingly common. In the last decade, Utah has had one of the highest rates of PPE in the United States, 14/100,000 children, attributed primarily to Streptococcus pneumoniae serotype 1. Our objective was to describe the temporal trends in PPE in Utah before and after the availability of the 7-valent pneumococcal conjugate vaccine (PCV-7)., Methods: The Intermountain Health Care (IHC) data warehouse was queried for all cases of empyema in children younger than 18 years, defined as International Classification of Diseases, 9th revision, Clinical Modification code 510.9, for the study period March 1996-June 2005. We also retrieved and serotyped all blood and pleural fluid isolates of S. pneumoniae from children younger than 18 years with a diagnosis of PPE at Primary Children's Medical Center (PCMC) between March 1996 and June 2005. The pre-PCV-7 period (PRE) included 57 months (March 1996-December 2000) and the post-PCV-7 period (POST) included 54 months (January 2001-June 2005)., Results: We identified 776 cases of pediatric empyema in the IHC system, and 478 (62%) were managed at PCMC. In the years 1996-2000, we managed a mean of 38 cases of empyema per year compared with 71.5 cases per year between 2001 and 2004 (P = 0.006). At PCMC, there were 295 cases of invasive pneumococcal disease (IPD), and 74 (25%) were PPE. During the PRE period, PPE represented 24 of 137 (17.5%) cases of IPD compared with 50 of 158 (32%) in the POST period (P = 0.008). One-half of the children with PPE required intensive care and 4 died. During the PRE and POST periods, PPE was most often caused by serotype 1 (46 and 34%, respectively), but in the POST period serogroups 3 (20%), and 19A (14%) were also prevalent. PPE in PCV-7-immunized children was caused exclusively by nonvaccine serotypes., Conclusions: PPE in the post-PCV-7 era is more common, representing one-third of the IPD in children in UT. PPE is associated with significant morbidity and mortality. Serotype 1 remains the most common cause of PPE, but serotypes 3 and 19A are emerging.

Background/purpose: Tube thoracostomy is a standard method of treating pediatric parapneumonic collections. Despite recent work denoting thoracoscopy as a superior method of treatment, few studies have looked at factors predictive of tube thoracostomy failure. We reviewed parapneumonic collections initially treated with tube thoracostomy to identify such factors., Methods: Nontuberculous parapneumonic collections treated initially with tube thoracostomy over a 10-year period were reviewed. A "failed primary tube thoracostomy" was defined as the presence of worsening clinicoradiological signs requiring a further chest procedure (ie, thoracoscopy, thoracotomy, or second thoracostomy)., Results: Fifty-eight patients were identified. Forty-three percent failed primary tube thoracostomy. Within group F (failure group), 32% of patients had a concomitant medical condition (P < .001). Sixty percent of group F patients had duration of symptoms for more than 1 week compared with only 24% of group S (successful group) (P < .001)., Conclusions: Our results suggest that primary treatment of parapneumonic collections with tube thoracostomy is likely to be unsuccessful in patients who are symptomatic for more than a week or who have a concomitant medical condition. A more aggressive primary surgical intervention is suggested for this group.

Objective: To determine whether presumptive antibiotics reduce the risk of empyema or pneumonia following tube thoracostomy for traumatic hemopneumothorax., Methods: A prospective, randomized, double-blind trial was performed comparing the use of cefazolin for duration of tube thoracostomy placement (Group A) versus 24 hours (Group B) versus placebo (Group C)., Results: A total of 224 patients received 229 tube thoracostomies. Logistic regression analysis revealed that duration of tube placement and thoracic acute injury score were predictive of empyema (p <0.05). Empyema tended to occur more frequently in patients with penetrating injuries (p=0.09). chi analysis showed pneumonia occurred significantly more frequently in blunt than penetrating injuries (p <0.05). Presumptive antibiotic use did not significantly effect the incidence of empyema or pneumonia, although no empyemas occurred in Group A., Conclusions: The incidence of empyema was low and the use of presumptive antibiotics did not appear to reduce the risk of empyema or pneumonia.

Objectives: Pneumonectomy in chronic pulmonary infection with empyema is associated with a high mortality rate and an increased risk of recurrent empyema. The surgical resection is technically demanding, and successful management continues to be a challenge., Methods: We evaluated a concept which combines (pleuro-)pneumonectomy or completion pneumonectomy with surgical debridement of the pleural cavity and packing with povidine-iodine soaked dressings. The debridement and packing is repeated in the operating theater after 48 h until the chest cavity is macroscopically clean. Finally, the pleural space is obliterated with antibiotic solution., Results: Between February 1997 and October 2000, 11 patients (average age of 59 years, ranging from 25 to 84) with destroyed lung caused by tuberculosis (six), aspergilloma (two), bronchiectasis (one), esophago-pleural fistula (one) or broncho-pleural fistula after lobectomy for bronchial carcinoma (one) and ongoing chronic infection with acute empyema (ten) (25-2500 days between first and definitive therapy) were treated. Pleural culture findings showed Aspergillus in four, Mycobacterium in two, Enterococcus in two, Candida in one and Staphylococcus in one, respectively. The mean number of interventions was 2.9 (2-4). The chest was definitively closed in all patients within 1 week. The mean hospitalization time was 19 days (9-31 days). In the follow-up (10-54 months), there was no recurrence of empyema. One patient (84 years) died at day 31, due to sepsis., Conclusions: Pneumonectomy combined with repeated surgical debridement and antimicrobial therapy enables the successful treatment of chronic pulmonary infection with empyema within a short time period.

An apparatus for automatic lung straightening may be used in medical technologies employed in thoracic (lung) surgery in the postoperative rehabilitation of a patient. This apparatus may automatically (without a physician's or a nurse observance) maintain tension relief in the pleural cavity in the patient on an individual basis, which is required for complete lung strengthening. Its use greatly reduces the number of postoperative complications in the lung, such as residual cavities, edema, and empyema of the pleura. This apparatus is to go into quantity production as a cheap, expendable device to prevent AIDS and hepatitis.

Background and Objectives: Postpneumonectomy empyema is a dreaded complication of pneumonectomy. The effectiveness of prophylactic intracavitary antibiotic instillation is not known. We conducted a retrospective review to assess the effect of pneumonectomy space antibiotic instillation on septic complications (empyema and bronchial fistula) of pneumonectomy., Methods: Ninety-three consecutive patients underwent pneumonectomy at our institution over a three-year period. Their charts were reviewed retrospectively and data was collected on age, gender, diagnosis, intravenous antibiotics, intracavitary (pneumonectomy space) antibiotics, empyemas, bronchial fistulas, length of hospital stay, and operative mortality., Results: All 93 patients received 3 perioperative doses of prophylactic intravenous antibiotics. One group (n=47) of patients also received intraoperative intracavitary instillation of an antibiotic solution (penicillin G: 5 million units, bacitracin: 50,000 units, gentamicin: 60 mg, in 1 litre of saline) while the other group (n=46) did not. Age, gender, diagnosis, and length of stay were not significantly different in the two groups. There were no empyemas or bronchial fistulas in the intracavitary antibiotic group. Postpneumonectomy empyemas occurred in 6 (13%) patients (empyema with bronchial fistula: 5, empyema alone: 1) that had not received intracavitary antibiotics (p=0.012). There were 4 deaths (9%) in each group (p=0.63)., Conclusions: Prophylactic intraoperative intracavitary antibiotic instillation may reduce the incidence of empyemas after pneumonectomy. However, a randomized trial would be needed to prove the effectiveness of this form of prophylactic antibiotic strategy.

Results of surgical treatment of 20 patients with malignant lung tumors operated in N.N. Burdenko faculty surgical clinic were analyzed. The authors have developed the method of prophylaxis of acute postoperative pleural empyemas patented in Russian Federation. This method is: after main stage of operation (lob- or pneumonectomy) pleural cavity in filled with antiseptic solutions (furacillin 1:5000, 0.02% chlorgexidin). 5 ml of photosense (sulfured ftalocyanin of aluminium) were injected in pleural cavity, after it pleural cavity is treated by low-frequency ultrasound. After it the antiseptic is removed and pleural cavity is irradiated by red light with use of KAMIN-VIDEO lamp. In all the 20 operated patients who had undergone sanation of pleural cavity by low-frequency ultrasound and it irradiation by KAMIN-VIDEO lamp the postoperative period was uncomplicated.

Postpneumonectomy empyema represents a frequently lethal complication. It remains unsolved whether prophylactic antibiotics achieve a bactericidal concentration in the pleural cavity after pneumonectomy. 12 patients undergoing pneumonectomy received ciprofloxacin intravenously (2 x 200 micrograms/d) and orally (2 x 500 micromilligrams/d) during the first and second postoperative week, respectively. 1, 6, 9 and 14 days after the operation the ciprofloxacin concentration was measured in the pleural fluid and serum. Already after 24 hours bactericidal levels (0.56 microgram/ml) were found in the pleural fluid, rising to 1.11 micrograms/ml on day 14 under the higher oral dosage. Thus, it could be demonstrated that during the first two weeks after pneumonectomy high concentrations of an antibiotic similar to the levels in the serum can be achieved in the pleural fluid.

Parapneumonic effusions are common accompaniments of pneumonia that require proper management to prevent progression to empyema. Management decisions require thoughtful individualization of care because of the multiple factors that affect outcome; no one algorithmic approach exists for all patients. Basic principles of care, however, apply to all patients and center on the early detection of infected pleural fluid and the rapid completion of effective pleural drainage and lung re-expansion, when indicated to decrease morbidity and mortality.

The following are essential for prophylaxis and treatment of empyema: antibiotic therapy for pneumonia, based on susceptibility results; early detection of parapneumonic effusions (decubitus radiograph, sonography); immediate diagnostic thoracocentesis if a parapneumonic effusion is large, increasing despite antibiotic therapy, if it is associated with clinical deterioration or if empyema is suspected; assessment of the stage of parapneumonic effusion or empyema (clinical signs, sonography, CT, laboratory parameters); immediate therapeutic thoracocentesis of frank empyema, in loculated empyema fibrinolytic agents may be used; early surgical intervention if conservative management fails; complete thoracoscopic decortication, if necessary open thoracotomy to assure complete reexpansion of the lung.

Bronchoesophageal fistula are commonly caused by a lung or esophageal malignancy eroding into the neighboring structure. Benign forms of bronchoesophageal fistula are less common and may have a congenital nature. Congenital bronchoesophageal fistula usually present in adult life with chronic symptoms of lung suppuration. We present a case of congenital bronchoesophageal fistula in an octogenarian and review the literature on this subject. We also suggest an extrapleural approach to the fistula to lessen the possibility of postoperative empyema.

Fulminant infections of oropharyngeal origin may cause the most lethal form of mediastinitis due to extension of the infection along the neck fascial planes or by lymphatic way: descending necrotizing mediastinitis. Two cases of this rare life-threatening entity of odontogenic and tonsillar origin are reported. A pleural empyema and pericarditis as complications were observed. Bacteriologic etiology, possibilities of the early diagnosis and the aggressive treatment by means of a thoracotomy are discussed.

Parapneumonic effusions are frequent complications of bacterial pneumonia. Depending on the severity of the underlying pneumonia, the promptness of antibiotic therapy, and the virulence of the infecting organism, 5% to 50% of patients will require pleural fluid drainage to prevent progression to an empyema. The decision to drain the pleural space depends on multiple clinical, laboratory, and radiographic factors. Delayed drainage results in pleural loculations, prolonged hospitalizations, and increased mortality. Image-guided percutaneous chest catheters provided an effective method for draining both free-flowing and loculated effusions. Fibrinolytic agents are gaining wider acceptance for promoting drainage of loculated, viscous pleural fluid although randomized studies do not exist. Patients failing a chest tube drainage method should undergo early evaluation for an open surgical procedure.

We performed a case control study to examine protective and risk factors for acute respiratory infections (ARI) in hospitalized children in Kuala Lumpur. Consecutive children between the ages of one month and five years hospitalized for pneumonia (n = 143), acute bronchiolitis (n = 92), acute laryngotracheobronchitis (n = 32) and empyema (n = 4) were included as cases and were compared with 322 children hospitalized during the same 24 hour period for non-respiratory causes. Potential risk and protective factors were initially analysed by univariate analysis. Logistic regression analysis confirmed that several home environmental factors were significantly associated with ARI. The presence of a coughing sibling (OR = 3.76, 95%CI 2.09, 6.77), a household with more than five members (OR = 1.52, 95%CI 1.03, 2.19) and sleeping with three other persons (OR = 1.45, 95%CI 1.00, 2.08) were independent risk factors. Significant host factors were history of allergy (OR = 2.50, 95%CI 1.74, 3.61) and ethnicity (Malay race) (OR = 2.07 95%CI, 1.27, 3.37). Breast feeding for at least one month was confirmed as an independent protective factor (OR = 0.58, 95%CI 0.38, 0.86). However, the study was not able to demonstrate that domestic air pollution had an adverse effect. This study provides further evidence that home environmental factors, particularly those associated with crowding, may predispose to ARI and that breast feeding is an important protective factor.

This study was planned in order to determine the value of antimicrobial prophylaxis in preventing post-operative empyema in patients undergoing lung cancer surgery. Two-hundred consecutive subjects operated upon for lung cancer received teicoplanin and aztreonam, starting at the induction of anesthesia and lasting until removal of the pleural drains. Cultures for aerobic and anaerobic bacteria were taken from: (1) the bronchus at the time of surgical division; (2) the pleural space before closure of the chest; (3) the pleural fluid during the post-operative period; and (4) the tips of chest drains at the time of their removal. In the 200 patients receiving antibiotic prophylaxis, the number of post-operative empyemas (1%) was lower than that (7.5%) found in 53 comparable patients who were previously treated with placebo. In the 'placebo group', empyema was due to gram-positive bacteria, while in the 'prophylaxis group', it was caused by Gram-negative bacteria (Pseudomonas aeruginosa). A significant (P < 0.05) correlation between infected bronchial secretions, pleural space contamination at surgery, contamination of chest fluid and drains during the post-operative period, and empyema development was demonstrated. In conclusion, antibiotic prophylaxis, while being effective in preventing post-operative empyema, may induce the colonization of the respiratory tract with highly resistant gram-negative bacteria.

Empyema after lung resection is an uncommon, but serious, complication. Its reported incidence varies from 1% to 5%, and it is frequently associated with a bronchopleural fistula. This article covers the prevention and treatment of empyema. Treatment requires the use of appropriate antibiotics, adequate drainage, obliteration of the pleural space, and closure of the fistula in order to achieve a long-term successful outcome.

Antibiotic prophylaxis is currently recommended in clean-contamined surgery (type II of Altemeier classification). Pulmonary surgery belongs to this type. This prospective randomized and controlled study was designed to compare amoxicillin and cefamandole for prevention of pleural and bronchopulmonary infections after pulmonary resections. It included 256 patients, admitted between October 1st 1989 and July 1st 1991, for elective thoracotomy and probable pulmonary resection. The patients were allocated into two groups, group A (amoxicillin) and group C (cefamandole). The first intravenous antibiotic injection took place immediately after induction of anaesthesia (1 g of amoxicillin or 1.5 g of cefamandole). Postoperative injections were performed every 6 hours during 36 hours (i.e. a total of 6 injections). Infection was defined by the association of general signs including hyperthermia (> 38 degrees C), hyperleucocytosis (> 12,000/mm3), and local signs such as bronchitis (B), pneumonia (P), empyema (E), wound sepsis (W) and non thoracic infection (S). Follow-up included the hospital stay and a period of eight months after surgery for possible rehospitalisation for infection. Respiratory infections (bronchitis n = 35, pneumonia n = 5, empyema n = 2) occurred in 18% of the total population. No difference was seen between the two groups concerning the type of infection and the repartition of infection in relation to the type of pulmonary surgery. The causative bacterial organisms were Haemophilus influenzae (n = 4), Streptococcus pneumoniae (n = 2), Escherichia coli (n = 1), anaerobic bacteria (n = 1). Multiple bacteria were found in one case. The empyema and wound sepsis occurred in the amoxicillin group.(ABSTRACT TRUNCATED AT 250 WORDS)

In our experience, anastomotic leakage occurred in five of 69 patients with intrathoracic anastomosis after resection of carcinoma of the esophagus. In the early period, only an ordinary right thoracic drain was put in place, and when leakage occurred, two patients died because of pyothorax, while one patient was saved by surgical drainage. However, in the recent period, in addition to the ordinary right thoracic drain, another drain has also been placed just distal to the anastomosis through the esophageal hiatus through the abdominal cavity, exiting the abdominal wall. After such procedure, drainage has been adequate without any occurrence of pyothorax, even when anastomotic leakage occurred, as in the two most recent instances. Therefore, unless drainage is inadequate and surgical drainage is indicated, as in instances of necrosis of substitutes, mediastinoabdominal drainage seems to be effective in the treatment of intrathoracic anastomotic leakage.

The most important postoperative infections in general pulmonary surgery are empyema, pneumonia and wound infection. Risk factors are underlying malignant disease and the duration of the operation. The extent of pulmonary resection also appears to be of a certain significance. Five prospective randomized, double-blind, placebo-controlled investigations are available. Together, these investigations demonstrate that prophylactic antibiotic treatment, in which the first dose is administered immediately prior to operation, reduces the frequency of pneumonia (from 27% to 17%) and the frequency of wound infection (from 18% to 4%). Despite antibiotic prophylaxis, empyema occurs with frequency of 3%. Prophylactic antibiotic treatment has also reduced the duration of hospitalization and the postoperative employment of antibiotics. The relatively few comparative investigations have not indicated unanimously that any particular antibiotic was more advantageous than other. At present, we have insufficient knowledge about the pathogenesis of the above mentioned postoperative infections. Such knowledge could increase the possibility of other prophylatic measures.

An analysis of the results of the examination and treatment of 379 patients undergoing transthoracic interventions showed that the use of the target-aimed selective immunomodulation, short-term antibacterial prophylaxis, inhibitors of arachidonic acid metabolites, active elimination of the circulating immune complexes and medium-weight molecular peptides and adequate local analgesia after the interventions providing normalization of the laryngeal reflex and early activation of the patients permitted the incidence of the pulmonary complications to be decreased by 2.5 times, pleural complications by 1.7 times, suppuration of the postoperative wound by 1.8 times and the total expenses by 25.6 per cent.

Most prospective studies recommend antibiotic prophylaxis whilst a thoracostomy tube is in place or even longer. We conducted a randomised study of 188 patients with penetrating chest injuries requiring a chest drain. Of these patients, 95 received a single dose of ampicillin before insertion of the chest tube, the remaining 93 patients received additional antibiotic prophylaxis for as long as the drain was in place. The incidence of intrathoracic sepsis (pneumonia or empyema) was 3.1% and 3.2%, respectively. It is concluded that single-dose prophylaxis in penetrating chest trauma is as effective as prolonged prophylaxis. The importance of chest physiotherapy immediately after the drain insertion and of early removal of the drain is stressed. The role of various possible risk factors in the development of sepsis is discussed.