PURPOSE: Complicated parapneumonic effusion (CPE) and empyema thoracis are significant complications of pneumonia. There is ongoing debate regarding the best strategy to manage CPE and empyema thoracis, particularly regarding the role of intrapleural fibrinolysis and surgical intervention. Guideline on the management of complicated parapneumonic effusion have been published by the American College of Chest Physicians (ACCP), but it is not certain whether adherence to management guidelines will improve the outcomes of CPE and empyema thoracis.
METHODS: A retrospective review was conducted on 63 patients with diagnoses of CPE or empyema thoracis admitted from January 2003 to June 2005. The clinical presentation and outcomes of this group of patients were analyzed. Potential risk factors associated with adverse outcomes, including non-adherence to ACCP guideline, were explored.
RESULTS: The mean age of recruited patients was 64 ± 16 year with a male to female ratio of 45:18. The pleural fluid culture positivity rate was 68.3%. There were 13 deaths (20.6%) during the index admission. Adherence to ACCP guideline was more frequent among pulmonologists (p<0.001). Adherence to ACCP guideline was independently associated with lower mortality (p=0.005), and discordant initial antibiotic use with higher mortality (p=0.002). Discordant initial antibiotic use was also independently associated with lower surgery-free survival (p<0.001). Subgroup analysis showed that early intrapleural fibrinolytic (≤ 4 days of diagnosis) was associated with a decrease in mortality (p<0.001), an increase in surgery-free survival (p=0.005) and shorter length of hospital stay (p=0.039).
CONCLUSION: Adherence to ACCP guideline, early concordant antibiotics treatment and input from pulmonologist appear to be associated with improved outcomes in patient with CPE and empyema thoracis. Early intrapleural fibrinolytic use was associated with better outcomes when compared with late use.
CLINICAL IMPLICATIONS: A randomized controlled study of early intrapleural fibrinolytics (≤ 4 days of diagnosis) is warranted.
DISCLOSURE: Wah Shing Leung, None.