Comparison of medical and/or surgical management of 23 cats with intracranial empyema or abscessation.

OBJECTIVES: Feline intracranial abscessation or empyema is infrequently reported in the veterinary literature. To date, the largest study is based on a population of 19 cats with otogenic infection. The aim of this study was to review a larger population of cats with intracranial empyema from multiple aetiologies and document their signalment, imaging findings, treatment protocols (including medical and/or surgical management) and to compare outcomes. METHODS: Cases presenting to a single referral centre over a 10 year period with compatible history, neurological signs and imaging findings consistent with intracranial abscessation and empyema were reviewed retrospectively. RESULTS: Twenty-three cats met the inclusion criteria. Advanced imaging (CT and/or MRI) was performed in 22/23 cats; one case was diagnosed via ultrasound. Ten cases underwent medical and surgical management combined, 10 underwent solely medical management and three were euthanased at the time of diagnosis. Short-term outcome showed that 90% of surgically managed and 80% of medically managed cats were alive at 48 h post-diagnosis. Long-term survival showed that surgically managed cases and medically managed cases had a median survival time of 730 days (range 1-3802 days) and 183 days (range 1-1216 days), respectively. No statistical significance in short- or long-term survival ( P >0.05) was found between medically and surgically managed groups. CONCLUSIONS AND RELEVANCE: Feline intracranial abscessation and empyema are uncommon conditions that have historically been treated with combined surgical and medical management. This study documents that, in some cases, intracranial abscessation and empyema can also be successfully treated with medical management alone.

Video-Assisted Thoracoscopic Surgery of Parapneumonic Empyema - a 10-year Single-Centre Experience.

OBJECTIVES: Evaluation of a standardised management for the treatment of patients with parapneumonic empyema. METHODS: A retrospective 10-year single-centre analysis of all patients with parapneumonic empyema undergoing a standardised thoracoscopic treatment approach. We describe referral and age patterns, microbiological results, overall and stage-dependent success rates, conversion rates, 30-day and in-hospital mortality. RESULTS: From May 2003 to April 2013, 248 patients with parapneumonic empyemas were treated in our centre. Most patients were referred at weekends, and younger patients had advanced stages. The cure rate in stage I was 97.6 % and reached 80.3 % in stage II and 63.1 % in stage III. 6 patients (2.4 %) (all stage III) needed conversion to an open procedure. A revision was required in 19.7 % of cases in stage II and 27.7 % in stage III. 30-day mortality was 4.8 %, in-hospital mortality was 8.1 %. CONCLUSION: A standardised approach, including VATS, is associated with a high cure, low revision and moderate conversion rates. In view of a still considerable mortality, a higher index of suspicion and detection of advanced stages, especially in younger patients, is required to improve outcomes.

Influence of postoperative infectious complications on long-term survival of lung cancer patients: a population-based cohort study.

INTRODUCTION: Surgery is essential to any curative plan for lung cancer, but is associated with a high complication rate. We sought to determine the impact of complications on long-term survival after a curative surgery for lung cancer, independent of the effect on early postoperative mortality. METHODS: We studied a population-based cohort of patients with lung cancer who underwent curative-intent surgery in the province of Quebec, Canada, from 2000 to 2005. Kaplan-Meier survival analysis was used to compare unadjusted overall survival (OS) beyond postoperative day 90 for patients with and without complications. Cox regression was used to determine the prognostic impact of 30-day postoperative complications on the OS after adjusting for several confounders. RESULTS: The overall 30-day postoperative complication rate was 58.2% among 4033 eligible patients. A major infectious complication (pneumonia, empyema, or mediastinitis) occurred in 378 patients. The 5-year OS was lower for those with any postoperative complication (62.8%) than those without (73.8%; p < 0.001). Those with major infectious complications had the lowest OS (56.3%; p < 0.001). Postoperative complication was an independent prognostic factor after adjusting for several patient and treatment factors (hazard ratio = 1.37; 95% confidence interval, 1.21-1.54). Adjusted hazard ratio for major infectious complications was 1.67 (95% confidence interval, 1.39-2.01). CONCLUSIONS: Postoperative complications, particularly of a major infectious type, are strong negative predictors of long-term survival in lung cancer patients. The strong association between major infectious complications and survival may also open the door to investigational therapies targeting bacterial antigens in the perioperative period in patients who undergo lung cancer surgery.

Impact of multidrug resistance on experimental empyema by Pseudomonas aeruginosa.

BACKGROUND: Pseudomonas aeruginosa is a cause of infections of the lower respiratory tract among patients with chronic lung disorders. It is questionable whether virulence of this species may be influenced by multidrug resistance (MDR). OBJECTIVES: To define the impact of MDR in experimental lung infection. METHODS: Experimental empyema was induced in rabbits by MDR (group A, n = 16) and by susceptible isolates (group B, n = 10). Pleural fluid was sampled for quantitative culture and estimation of cell apoptosis and of tumor necrosis factor-alpha (TNFα) and malondialdehyde (MDA). Survival was recorded. Cytokine production was stimulated in U937 monocytes by samples of pleural fluid. Whole blood of rabbits was incubated with the isolates; induction of apoptosis was assessed. RESULTS: Survival of group A was prolonged compared to group B. This was accompanied by lower bacterial counts of the inoculated pathogens in pleural fluid and in the lungs of group A compared with group B. Early apoptosis of neutrophils of pleural fluid of group A was lower compared with group B. Pleural fluid concentrations of TNFα and MDA did not differ between the groups. Cytokine production by U937 monocytes after stimulation with pleural fluid was greater in group B than in group A. The susceptible isolate induced apoptosis of neutrophils in vitro at a greater rate than the MDR isolate. CONCLUSIONS: Experimental empyema by susceptible P. aeruginosa is accompanied by greater mortality compared with MDR P. aeruginosa. This phenomenon may be attributed to the different growth pattern of the pathogens or to their interaction with the innate immune system.

Costo-efectividad de la vacunación universal antineumocócica en Uruguay / Cost-effectiveness of universal pneumococcal vaccination in Uruguay

OBJETIVO: Evaluar la relación costo-efectividad del programa de vacunación universal con la vacuna antineumocócica conjugada heptavalente (VCN7) en niños menores de 5 años en Uruguay. MÉTODOS: Se desarrolló un modelo Markov simulando una cohorte de 48 000 niños nacidos en 2007 y su evolución hasta los 76 años de edad. El caso base usó un esquema de tres dosis con una duración estimada de protección de cinco años. La presunción de eficacia y efectividad de la vacuna se realizó acorde con estudios realizados en Estados Unidos con ajuste a la prevalencia-incidencia de serotipos en Uruguay. Los resultados se expresaron como costo incremental por año de vida ganado (AVG) y por año de vida [ganado] ajustado por calidad (AVAC). RESULTADOS: Para el caso base, el costo incremental fue de US$ 7 334,6 por AVG y US$ 4 655,8 por AVAC, previniéndose 8 muertes y 4 882 casos de otitis, 56 bacteriemias-sepsis, 429 neumonías y 7 meningitis. El modelo muestra sensibilidad a variaciones en eficacia, costo de la vacuna y tasa de mortalidad por neumonía. CONCLUSIONES: El programa de vacunación universal con VCN7 en Uruguay es altamente costo-efectivo y, en consecuencia, recomendable para otros países con carga de enfermedad neumocócica y cobertura de serotipos similares a Uruguay.

OBJECTIVE: Evaluate the cost-effectiveness ratio of the program for universal vaccination with heptavalent pneumococcal conjugate vaccine (PCV7) in children under 5 years of age in Uruguay. METHODS: A Markov model was developed that simulated a cohort of 48 000 children born in 2007 and their progress to age 76. The baseline case used a regimen of three doses with estimated protection for five years. The presumption of vaccine efficacy and effectiveness was based on studies conducted in the United States with adjustment for serotype prevalence-incidence in Uruguay. The results were expressed as the incremental cost per life year gained (LYG) and quality-adjusted life year (QALY) [gained]. RESULTS: For the baseline case, the incremental cost was US $7334.60 for each LYG and US $4655.80 for each QALY. Eight deaths and 4 882 cases of otitis, 56 cases of bacteremia-sepsis, 429 cases of pneumonia, and 7 cases of meningitis were prevented. The model shows sensitivity to variations in vaccine cost, efficacy, and pneumonia-related mortality. CONCLUSIONS: The universal vaccination program with PCV7 in Uruguay is highly cost-effective. Therefore, it is recommended for other countries with burden of pneumococcal disease and serotype coverage similar to those of Uruguay.

[Spinal epidural empyema. Limited surgical treatment combined with continuous irrigation and drainage]. / Spinales epidurales Empyem. Limitierte operative Behandlung kombiniert mit kontinuierlicher Spüldrainage.

Epidural empyema of the spinal column is a rare, but in some cases devastating, disease. Surgery can be excessive or very limited. We want to report our results of combined therapy of limited surgical treatment and continuous irrigation with antibiotic solution and drainage. In the last 5 years we have operated on 12 patients (7 female, 5 male, median age: 61.5 years, range: 22-89 years) with spinal epidural empyema. All surviving patients were evaluated after 3 months including MRI. Six infections were caused by injections, two by spontaneous discitis, two by chronic systemic infections, and in two patients the cause remained unknown. In every case we implanted two catheters, one for irrigation with antibiotic solution and one for drainage. On average the catheters were used for 3 days. For evacuation in seven patients interlaminar fenestration in one, two, or three levels was enough. Only in one patient was a laminectomy performed. Five patients recovered totally, three partially, one did not recover at all, and three died. The autopsy of two dead patients showed complete healing of the operated area; they died because of lethal infections in other parts of their body. In only one case did a reoperation have to be done. The cause was an additional subdural empyema. In spite of the limited surgical procedure without relevant operative morbidity the reported method is an effective and safe therapy.

Effect of cotrimoxazole on causes of death, hospital admissions and antibiotic use in HIV-infected children.

BACKGROUND: Cotrimoxazole prophylaxis reduces morbidity and mortality in HIV-1-infected children, but mechanisms for these benefits are unclear. METHODS: CHAP was a randomized trial comparing cotrimoxazole prophylaxis with placebo in HIV-infected children in Zambia where background bacterial resistance to cotrimoxazole is high. We compared causes of mortality and hospital admissions, and antibiotic use between randomized groups. RESULTS: Of 534 children (median age, 4.4 years; 32% 1-2 years), 186 died and 166 had one or more hospital admissions not ending in death. Cotrimoxazole prophylaxis was associated with lower mortality, both outside hospital (P = 0.01) and following hospital admission (P = 0.005). The largest excess of hospital deaths in the placebo group was from respiratory infections [22/56 (39%) placebo versus 10/35 (29%) cotrimoxazole]. By 2 years, the cumulative probability of dying in hospital from a serious bacterial infection (predominantly pneumonia) was 7% on cotrimoxazole and 12% on placebo (P = 0.08). There was a trend towards lower admission rates for serious bacterial infections in the cotrimoxazole group (19.1 per 100 child-years at risk versus 28.5 in the placebo group, P = 0.09). Despite less total follow-up due to higher mortality, more antibiotics (particularly penicillin) were prescribed in the placebo group in year one [6083 compared to 4972 days in the cotrimoxazole group (P = 0.05)]. CONCLUSIONS: Cotrimoxazole prophylaxis appears to mainly reduce death and hospital admissions from respiratory infections, supported further by lower rates of antibiotic prescribing. As such infections occur at high CD4 cell counts and are common in Africa, the role of continuing cotrimoxazole prophylaxis after starting antiretroviral therapy requires investigation.

Management of empyema after lung resections (pneumonectomy/lobectomy).

Empyemas that complicate lung resection are an uncommon but morbid and too-often deadly sequela, particularly after pneumonectomy. Knowledge of the conditions that place patients at high risk for this complication and of the well-established principles of bronchial stump closure are crucial to preventing empyemas. One should be familiar with the various options of stump reinforcement and should use them aggressively, particularly in high-risk situations. Prompt recognition of this complication demands immediate intervention and drainage of the empyema space to minimize the risks of aspiration to the remaining lung. The principles that guide the management of these empyemas are those established by Clagett and Geraci 40 years ago [37]. Modern variations of these guidelines have allowed improved results and a more timely recovery and should be considered in low-risk patients.

Unsuspected Toxoplasma gondii empyema in a bone marrow transplant recipient.

Toxoplasma gondii is an opportunistic parasite that can cause severe disease in immunosuppressed individuals. We report a case of unsuspected T. gondii empyema in a bone marrow transplant recipient that was diagnosed by the visualization of numerous intracellular and extracellular tachyzoites in Giemsa- and Gram-stained smears. The patient was treated with pyrimethamine, sulfadiazine, clindamycin, and atovaquone, and she survived 110 days after diagnosis, despite having a large parasite burden.

Etiología del empiema infantil / Pleural empyema etiologiies in our environment

Se realizó un estudio retro-prospectivo en el Hospital Pediátrico Dr. Francisco de Ycaza Bustamante (Hospital del Niño), con un universo de 120 niños, con edades que estaban comprendidas entre cero y trece años, de ambos sexos, los cuales presentaban clínica y radiológicamente signos y síntomas de neumonía con derrame pleural. Se estudiaron las etiologías infecciosas más frecuentes comprobadas mediante cultivos. Pudo comprobarse que durante la primera semana de su estancia intrahospitalaria los cultivos revelan un evidente predominio de estafilococos, pero los cultivod hechos después de ésta, y sobre todo los realizados cuando el paciente lleva cuatro o más semanas en el hospital muestran con mucha más frecuencia pseudomonas, lo cual hace pensar en un elevado índice de sobreinfecciones hospitalarias.

Pleural complications in lung transplant recipients.

Pleural complications occurred in 30 (22%) of 138 patients after 53 single and 91 double lung transplants between September 1986 and February 1993. These were defined for the purpose of this study as pneumothorax persisting beyond the first 14 postoperative days, recurrent pneumothorax, or any other pleural process that necessitated diagnostic or therapeutic intervention. Overall, a higher pleural complication rate was seen in double lung transplantation (25 of 30) than in single lung transplantation (5 of 30) with no differences noted in the frequency among preoperative diagnostic groups (p > 0.05). Pneumothorax was the most frequent complication, affecting 14 of 30 patients, with 6 of 14 cases occurring after transbronchial biopsy. All pneumothoraces in single (n = 4) and double lung transplantation (n = 10) resolved spontaneously or with chest tube thoracostomy. One patient required placement of a Clagett window after open lung biopsy and another required thoracotomy and pleural abrasion after transbronchial biopsy. Parapneumonic effusion was observed in 4 of 30 double lung transplantations with spontaneous resolution in all cases. Empyema affected 7 of 30 patients and occurred exclusively in the double lung transplant group. Sepsis developed in three of the patients with this complication and they subsequently died. The risk of empyema was independent of preoperative diagnosis (p > 0.05). Of interest, all patients with cystic fibrosis (n = 3) with complicating empyema had Pseudomonas cepacia in the pleural fluid. Other miscellaneous complications included subpleural hematoma, chylothorax, and hemothorax. The latter two necessitated thoracic duct and bronchial artery ligation, respectively. In summary, a significant proportion of lung transplant recipients will have pleural space complications. The vast majority of these will resolve spontaneously or with conservative procedures. These complications were not related to preoperative diagnosis nor associated with a significant prolongation of hospital stay (p > 0.05). Empyema is the only pleural space complication associated with increased patient mortality and, as such, is an important clinical marker for those at risk for sepsis and death.

Empyema thoracis: 14-year experience in a teaching center.

One hundred two patients with empyema thoracis were managed at the Royal Melbourne Hospital between 1976 and 1989. Fifty-five cases of empyema thoracis were postpneumonic, 8 followed esophageal rupture, and 5 were associated with thoracic trauma. Some form of systemic illness was a major contributing factor in the presentation of 29 patients. A single causal organism was found in 53 patients (the most common being Staphylococcus aureus), multiple organisms in 36, and no growth in 13. During the years 1983 to 1989 there was an increased incidence of empyemas caused by multiple or antibiotic-resistant organisms. Operative drainage was required in 90 patients and 12 were managed by thoracentesis or intercostal tube drainage alone. The in-hospital mortality rate for patients managed nonoperatively was 58% (7 of 12 patients); it was 16% (14 of 90 patients) for those receiving operative drainage. There were seven late deaths, four empyema related and three nonrelated. Early adequate operative drainage is recommended for patients with empyema thoracis.

[Life expectancy and disability following pleural empyema]. / Lebenserwartung und Invalidität nach Pleuraempyem.

The pleural empyema, e.g. postpneumonial or postoperative, has, in an acute state of being, to be treated before all by an aimed intensive puncture, irrigation, and drainage therapy. Removing the cause of the empyema you can expect a cure as a rule, but in certain cases an operative intervention is still necessary. The chronic empyema often needs a decortication for an operative correction. The trials of medical treatment being often conservative and the chronic intoxication most often cause a strong impairment of the general condition. A lot of other organic affections or damages reduce the chances of cure and increase lethality. The chronic empyema not available for an operative correction has, as a whole, a bad long-term prognosis with a high morbidality and lethality. The qualities of living of these patients are often reduced a lot.

Empyema thoracis in Nigerians: experience with a policy of conservative operative management.

A combined retrospective and prospective review of 150 children and 28 adult Nigerian empyema thoracis patients was conducted between 1978 and 1986. Comorbidity requiring additional treatment was present in 145 patients (82.5%) while 175 patients (98.3%) had no, low or medium family income. In addition to medical management 161 out of 178 patients (90.4%) had tube thoracostomy while eight (4.4%) and seven (3.9%) respectively required additional minor and major thoracic procedures for failure of tube thoracostomy and arrest of, or failure to achieve, progressive pulmonary re-expansion and resolution of concomitant illness. Mean period of in-patient care was 30.5 days +/- 30.3. In spite of limitation of resources and poor clinical condition of most patients reduction of onset-diagnosis and diagnosis-treatment intervals and our overall management significantly reduced the perioperative mortality from 15.1% during the retrospective study period to 4.8% during the prospective period for a 9% overall perioperative mortality rate.

Manejo del empiema pleural postneumonectomía / Management of postneumonectomy pleural empyema

En un perído de 10 años, entre enero de 1974 y diciembre de 1983, fueron tratados 42 empiemas postneumonectomía. Se analiza el resultado operatorio y se describen los diferentes métodos de tratamiento del empiema postneumonectomía. La mortalidad operatoria fue de 9,5% (4/42). La esterilización del espacio infectado postneumonectomía fue entre 1 mes y 4 años, con un promedio de 8 meses

Management of refractory empyema with early decortication.

One hundred consecutive patients underwent surgical procedures for empyema. Sixty-six patient acquired empyema from pneumonia, 16 from trauma, 11 from abdominal sepsis, and 7 from other causes. If tube thoracostomy failed, computerized tomography and ultrasonography were used to demonstrate a loculated empyema. After a median observation period of 11 days, 91 patients underwent thoracotomy and decortication and 9 patients underwent either rib resection, an Eloesser flap procedure, or both. The mortality rate was 6 percent 30 days postoperatively, the in-hospital mortality rate was 9 percent, and the overall morbidity rate was 17 percent. An excellent result was achieved in 85 percent of the patients with a recurrence rate of 4 percent. Gram-positive aerobes were the most common organisms cultured, but several opportunistic infections were encountered. We have concluded that early thoracotomy and decortication of empyema results in eradication of difficult pleural infections with hospital stays of an acceptable length and reasonably low morbidity and mortality rates.

Empyema: analysis of treatment techniques.

Empyema is associated with a high mortality. To study the factors responsible for the failure of treatment, the authors reviewed 90 cases of nontuberculous thoracic empyema seen at the University of Western Ontario in London, between 1970 and 1980. The most common causes of empyema were bronchopulmonary infections (63%), complications of pulmonary surgery (14%) and secondary infections of hydrothoraces or hemothoraces (13%). In 51 patients (57%) the condition was acquired in hospital or was related to previous medical therapy. Nine cases were recognized only at autopsy. The treatment of empyema was assessed in 81 patients, who received an average of 2.2 antibiotics during the course of treatment. Five patients received antibiotics as the only therapy; one died. Seventy-two patients were treated by surgical drainage; 35 (49%) were cured and 18 (25%) subsequently died. Twelve of 18 decortication procedures were successful including 4 performed as a primary procedure and 8 as a secondary procedure. Five of seven patients who underwent thoracoplasty were cured. The overall mortality in the series was 23%. Prevention and early recognition of empyema may reduce the mortality. Patients who do not improve promptly with surgical drainage may benefit from early decortication.

Early thoracotomy and decortication for nontuberculous empyema in adults with and without underlying disease. A twenty-five year review.

The present review deals with 63 adult patients having acute nontuberculous empyema treated by early thoracotomy and decortication, during the period from 1955 through 1979. Group I (38 patients) had postpneumonic empyema, but no underlying disease. Group II (25 patients) had acute empyema and one or more serious associated diseases. Positive cultures were present in 45 of 63 patients (71.4%). Most surgeons have customarily recommended conservative management, especially for patients in Group II, because of the supposedly "high risk" involved in decortication. Consequently, the mortality is extremely high. The empyema must be cured; a "well drained" or "controlled" empyema will not suffice. The severely ill patient can better withstand the ordeal of a major operation than the deleterious effects of a lingering empyema. The critically ill patient is best managed by the primary procedure of open thoracotomy and decortication. The author's experience confirms that such patients can expect an outlook (8% mortality) approaching the zero mortality of Group I patients.

Reevaluation of early evacuation of clotted hemothorax.

During an 181/2 year period, we encountered 14,300 patients with blunt or penetrating thoracic or thoracicoabdominal trauma. In 155 patients, residual clotted hemothorax or empyema developed later. Thirty-nine patients underwent early evacuation of clotted hemothorax with no mortality and an average hospital stay of only 10 days. When progression to empyema occurred, the mortality rate increased to 9.4 percent and the average hospital stay to 37.9 days. The most common related event in the development of empyema was concurrent injury to intraabdominal organs and the inevitable bacterial contamination of the thorax. In a small number of patients, tube thoracostomy drainage is inadequate and results in residual clotted hemothorax. Despite recent pleas for conservative, expectant management, it is our experience that early evacuation of clotted hemothorax is not only cost-effective, it is also associated with lower morbidity, lower mortality, and reduces the chance of development of empyema.