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Correspondence |

Pleural Infections in Intensive Care FREE TO VIEW

Edward T.H. Fysh, MBBS, PhD; Arthee Yogendran, MBBS; Andrew Rosenstengel, MD; Brigit Roberts, RN; Anna-Marie Palermo, RN; Ian Kay, PhD; Edward Litton, MBChB, MSc; Kwok-Ming Ho, MPH, PhD; Y. C. Gary Lee, MBChB, PhD, FCCP
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: E. T. H. F. and K.-M. H. received research fellowship funding from the Raine Medical Research Foundation and the Western Australian Department of Health; Y. C. G. L. received research fellowship funding from the National Health and Medical Research Council of Australia. Y. C. G. L. was co-investigator in the TIME-2 trial, for which Rocket Ltd provided pleural catheters without charge. Y. C. G. L. has served on the advisory board of CareFusion Ltd and Sequana Medical. None declared (A. Y., A. R., B. R., A.-M. P., I. K., E. L.)

aIntensive Care Unit, Sir Charles Gairdner Hospital, Perth, Australia

bDepartment of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia

cPleural Medicine Unit, Institute of Respiratory Health, Perth, Australia

dSchool of Medicine and Pharmacology, University of Western Australia, Perth, Australia

eIntensive Care Unit, Fremantle Hospital, Perth, Australia

fIntensive Care Unit, Fiona Stanley Hospital, Perth, Australia

gPathWest, Queen Elizabeth II Medical Centre, Perth, Australia

hIntensive Care Unit, Royal Perth Hospital, Perth, Australia

CORRESPONDENCE TO: Edward T. H. Fysh, MBBS, PhD, Respiratory and Intensive Care Departments, Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, WA 6009, Australia


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(6):1419-1420. doi:10.1016/j.chest.2016.09.032
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Published online

Few studies of pleural infection in ICUs exist, yet they suggest variable etiology and substantial associated mortality.,,,, None of these studies have examined long-term outcomes, and most were published more than a decade ago. The current incidence, microbiology, and long-term outcomes for these patients remain unclear, hindering treatment advances.

We screened our statewide microbiology database for all culture-positive pleural fluid specimens from all three tertiary ICUs in Western Australia between January 1, 2006 and December 31, 2011. Clinical data were retrospectively obtained from patients’ records to determine the (1) incidence, (2) microbiology, and (3) clinical outcomes 5 years after culture-positive pleural infection was confirmed. Cases were included if there was documented clinical suspicion of pleural infections and the patients were treated with intravenous antibiotics and pleural fluid drainage. The Sir Charles Gairdner Group Research Ethics Committee approved the study (reference 2012-038).

A total of 22,274 patients were admitted to three ICUs over 6 years. Sixty of 69 patients (0.3%) with positive pleural fluid results had confirmed culture-positive pleural infection while in the ICU; a total of 83 isolates were cultured (Fig 1). Staphylococci were the commonest isolates (38 of 83; 46%), and 19 of the 60 patients (31.7%) produced mixed-organism cultures. The antibiotic regimen most commonly prescribed was piperacillin-tazobactam and vancomycin (46 of 60; 76.7%). The median (interquartile range) ICU stay was longer for patients with pleural infection compared with patients without pleural infection: 19 (7-30) vs 2 (1-5) days, respectively (P < .001; Mann-Whitney). Fifteen patients (25.0%) died before hospital discharge and 30 of 59 patients (50.8%) died within 5 years. Resistance to piperacillin-tazobactam and vancomycin in combination (n = 9) was associated with significantly increased mortality (66.7%; OR, 9.3; 95% CI, 2.1-37.1; P < .01) (Table 1).

Figure Jump LinkFigure 1 A, Numbers of different microbial isolates showing mixed or single pathogens. B, Pie chart depicting the proportion infections caused according to type of isolate and single or mixed infection. Coag -ve Staph = coagulase-negative staphylococci; E. coli = Escherichia coli; neg = negative; S. aureus = Staphylococcus aureus.Grahic Jump Location

Table Graphic Jump Location
Table 1 Patient Outcomes According to Microbial Class, Antibiotic Resistance, and Admitting Specialty

NS = not significant; P/T+V = piperacillin-tazobactam and vancomycin.

Our study revealed important findings regarding the significance of pleural infection in the ICU and some potential pitfalls for physicians treating these patients. Culture-positive pleural infection is associated with significant morbidity and mortality, with 10 times longer ICU stays and a 5-year mortality rate of 50%. Mortality is increased further with antimicrobial resistance, highlighting the importance of microbial culture results and determination of sensitivity at diagnosis, and appropriate and frequent review of antibiotic choice. Unlike among patients with community-acquired pleural infection, staphylococci were the pathogens most commonly found, and polymicrobial infections occurred in almost one-third of patients.

Intensivists are encouraged, therefore, to send fluid for microbiological testing as soon as pleural infection is suspected and to be aware of the importance of broad-spectrum antibiotic coverage and monitoring for resistance. Further prospective studies are necessary and some are already underway.

References

Azoulay E. . Pleural effusions in the intensive care unit. Curr Opin Pulm Med. 2003;9:291-297 [PubMed]journal. [CrossRef] [PubMed]
 
Walden A. .Jones Q. .Matsa R. .Wise M. . Pleural effusions on the intensive care unit: hidden morbidity with therapeutic potential. Respirology. 2013;18:246-254 [PubMed]journal. [CrossRef] [PubMed]
 
Mattison L.E. .Coppage L. .Alderman D.F. .Herlong J.O. .Sahn S.A. . Pleural effusions in the medical ICU: prevalence, causes, and clinical implications. Chest. 1997;111:1018-1023 [PubMed]journal. [CrossRef] [PubMed]
 
Fartoukh M. .Azoulay E. .Galliot R. .et al Clinically documented pleural effusions in medical ICU patients: how useful is routine thoracentesis? Chest. 2002;121:178-184 [PubMed]journal. [CrossRef] [PubMed]
 
Tu C.-Y. .Hsu W.-H. .Hsia T.-C. .et al The changing pathogens of complicated parapneumonic effusions or empyemas in a medical intensive care unit. Intensive Care Med. 2006;32:570-576 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 A, Numbers of different microbial isolates showing mixed or single pathogens. B, Pie chart depicting the proportion infections caused according to type of isolate and single or mixed infection. Coag -ve Staph = coagulase-negative staphylococci; E. coli = Escherichia coli; neg = negative; S. aureus = Staphylococcus aureus.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 Patient Outcomes According to Microbial Class, Antibiotic Resistance, and Admitting Specialty

NS = not significant; P/T+V = piperacillin-tazobactam and vancomycin.

References

Azoulay E. . Pleural effusions in the intensive care unit. Curr Opin Pulm Med. 2003;9:291-297 [PubMed]journal. [CrossRef] [PubMed]
 
Walden A. .Jones Q. .Matsa R. .Wise M. . Pleural effusions on the intensive care unit: hidden morbidity with therapeutic potential. Respirology. 2013;18:246-254 [PubMed]journal. [CrossRef] [PubMed]
 
Mattison L.E. .Coppage L. .Alderman D.F. .Herlong J.O. .Sahn S.A. . Pleural effusions in the medical ICU: prevalence, causes, and clinical implications. Chest. 1997;111:1018-1023 [PubMed]journal. [CrossRef] [PubMed]
 
Fartoukh M. .Azoulay E. .Galliot R. .et al Clinically documented pleural effusions in medical ICU patients: how useful is routine thoracentesis? Chest. 2002;121:178-184 [PubMed]journal. [CrossRef] [PubMed]
 
Tu C.-Y. .Hsu W.-H. .Hsia T.-C. .et al The changing pathogens of complicated parapneumonic effusions or empyemas in a medical intensive care unit. Intensive Care Med. 2006;32:570-576 [PubMed]journal. [CrossRef] [PubMed]
 
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