Pleural empyema

It is used for severe bacterial infections peritonitis, sepsis, meningitis, osteomyelitis, endocarditis, pneumonia, pleural empyema, pulmonary abscess, purulent skin infections and soft tissue infections, and infections of the urinary tract caused by microorganisms that are sensitive to the drug. Synonyms of this drug are nebicine, obracine, and others. 

The spectrum of respiratory tract infections (RTI) can vary from the common cold to acute or chronic bronchitis to community-acquired pneumonia to nosocomial pneumonia and aspiration pneumonia to ventilator-associated pneumonia to chronic pneumonia (in cystic fibrosis, histoplasmosis, tuberculosis, etc.). Important complications are lung abscess and pleural empyema that will often need drainage and prolonged antimicrobial treatment (>6 weeks). 

Pleural empyema. Accumulation of a liquid inflammation product made up of leukocytes (pus) in a cavity of the lungs. Pleurisy. Inflammation of the pleura, with exudation into its cavity and on its surface. Pneumonia. Inflammation of the lungs with consolidation. 

CT can further demonstrate complications of airway obstruction like postobstructive pneumonia, pulmonary abscess formation, pleural effusion, pleural empyema, lobar and pulmonary atelectasis, and lymph node involvement. 

Empyema. While blind surgical drainage may often result in a placement of the chest tube within the pleural space outside a pleural empyema, CT guidance is especially preferable for drainage of loculated empyemas (Fig. 37.14). For optimal access, the patient is placed in... 

Respiratory Cocaine use is associated with various pulmonary complications. Pneumothorax, lung cavitation, and pleural empyema have been reported [27 ]. 

Solini L, Gourgiotis S, Salemis NS, Koukis I. Bilateral pneumothorax, lung cavitations, and pleural empyema in a cocaine addict. Gen Thorac Cardiovasc Surg 2008 56 610-2. 

Empyema Pus in the pleural cavity, usually secondary to infection in the lung. 

Signs and Symptoms Pneumonia with or without bacteremia. Pulmonary abscesses, fluid (pleural effusion) and pus (empyema) in the chest cavity may occur. In acute cases pus is discharged from the nose. There are ulcers in the mucous membranes of the nose and possibly the pharynx. 

Empyema-like eosinophilic pleural effusion following the use of smoked crack cocaine has been reported (114). 

Spontaneous bacterial empyema is found in 1-2% of patients with cirrhosis and ascites. The diagnosis is based on a positive bacterial test in the pleural fluid and a WBC count in excess of 250/mm (or a negative bacterial culture with a cell count exceeding 500/mm ) - which is analogous to spontaneous bacterial peritonitis. (105) (s. p. 302)... 

Of 51 patients with malignant pleural effusions, 14 underwent slurry talc pleurodesis via a chest tube, 14 had talc poudrage during Video-Assisted Thoracoscopic exploration of the pleural cavity for suspected malignant effusion, and 24 underwent chemical pleurodesis with bleomycin via a chest tube (16). The most common adverse effects were chest pain and fever. The duration of adverse effects after talc pleurodesis was longer (2-3 days) than after bleomycin. There was chest pain in 15 of the 28 patients who received talc, with a duration of 18-52 (median 31) hours. There was fever in 22 of those who received talc, with a duration of 5-34 (median 12.5) hours. Complications were more common in those who received talc, such as thoracic empyema n — 1), wound infection n — 2), and respiratory distress n — 5). 

Bouros D, Schiza S, Panagou P, Drositis J, Siafakas N. Role of streptokinase in the treatment of acute loculated parapneumonic pleural effusions and empyema. Thorax 1994 49(9) 852-5. 

Radiographic findings generally are more impressive than the patient s physical findings and include patchy or interstitial infiltrates, which are seen most commonly in the lower lobes. Small unilateral, transient pleural effusions are common, but large effusions and empyema are rare. Roentgenographic abnormalities resolve slowly, and 4 to 6 weeks may be required for complete resolution. 

Parapneumonic effusions occur in up to 40% of patients with bacterial pneumonia (11). Parapneumonic effusions may remain uncomplicated without the presence of bacteria in the pleural space and resolve with antibiotic therapy alone. However, a signiflcant proportion of them may go on to develop into complicated parapneumonic effusions (empyema) with the presence of multiple loculations, bacteria in the pleural space, and a low pleural fluid pH (6,7,9). The interaction of bacteria with the pleural mesothelium initiates a cascade of events that include movement of phagocytic cells from the vascular compartment into the pleural space mediated via the release of mesothelial cell-derived chemokines (12-15). 

ENA-78(CXCL5), another neutrophil chemokine, has been demonstrated to be the predominant chemokine in pleural fluids from patients with uncomplicated parapneumonic effusions. Neutrophil counts correlate with ENA-78 in these patients however, in patients with empyema where the disease has been present for a certain period of time and is associated with bacteria in the pleural space, IL-8 was the predominant chemokine and correlated with the level of neutrophils in empyema fluid (17). In comparison, patients with congestive heart failure have minimal, barely measurable quantities of IL-8 in their pleural fluids (16). Though malignant pleural effusions and those secondary to tuberculosis have mild chemotactic activity for neutrophils present in the pleural fluid, the quantity of IL-8 is significantly lower (0.56 0.5 ng/mL for malignant effusions to 0.28 0 ng/mL in patients with tuberculosis) (16). 

In an animal model of endotoxin pleurisy, IL-8 was found to be an important contributor to the chemotactic activity in the acute inflammatory liquids formed in response to endotoxin (14). Neutralization of IL-8 antibody inhibited the endotoxin-induced neutrophil influx by 77%. Pleural fluid from patients with paraneumonic effusions also contained significant quantities of macrophage inflammatory protein-la (MIP-la CCL-3) MIP-la antibody inhibited up to 43% of the bioactivity for mononuclear cells in pleural fluids of patients with parapneumonic effusions (18). In an animal model of Staphylococcus aureus-induc i experimal empyema, neutrophil chemokine levels of murine KC (KC) and macrophage inflammatory protein-2 (MIP-2) were found to be significantly lower in CD4 knockout mice than in CD4 wild-type mice (19,20). 

On immunohistochemistry (Fig. 1), the pleura is seen to stain avidly for MIP-2. Importantly, the CD4-deficient mice had poorer bacterial clearance than the CD4 wild-type mice. IL-10 levels were increased in CD4 knockout mice, whereas interferon gamma levels were increased in CD4 wild-type mice. It appears that CD4 T cell depletion resulted in decreased neutrophil influx into the pleural space and impaired bacterial clearance in empyema. It is probable that this was in part related to the higher IL-10 levels noted in pleural fluids of CD4 knockout mice. Thus, it appears that CD4 T cells plays a critical role in the control of chemokine presence in empyema. 

Broaddus VC, Hebert CA, Vitangcol RV, Hoeffel JM, Bernstein MS, Boylan AM. Interleukin-8 is a major neutrophil chemotactic factor in pleural hquid of patients with empyema. Am Rev Respir Dis 1992 146 825-830. 

Mohammed KA, Nasreen N, Ward MJ, Antony VB. Induction of acute pleural inflammation by Staphylococcus aureus. I. CD4+ T cells play a critical role in experimental empyema. J Infect Dis 2000 181 1693-1699. 

Postoperative pleural complications occur in up to 22%. The most frequent complications are pneumothorax and empyema (Herridge et al. 1995). During post-transplant follow-up, the majority of surviving patients have residual pleural alterations detectable with CT. These alterations do not seem to worsen the progress of these patients, although they may be an inconvenience should re-transplantation be required. 

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