Burden of all-cause and organism-specific parapneumonic empyema hospitalization rates prior to the SARS-CoV-2 pandemic in the United States.

BACKGROUND AND AIMS: Parapneumonic empyema, a severe pneumonia complication, decreased shortly after 13-valent pneumococcal conjugate vaccine (PCV13) introduction in US children, though the long-term impact remains poorly described. It is also unclear whether PCV13 introduction in 2010 or the 2014 US recommendation for PCV13 use in older adults was associated with declines in empyema among adults. We examined overall and organism-specific parapneumonic empyema rates among US children and adults from 2006 to 2019, prior to the SARS-CoV-2 pandemic and the updated recommendations for PCV15 and PCV20 in the US. METHODS: We used the National Inpatient Sample and US Census Data to calculate national annual all-cause and pneumococcal empyema hospitalization rates by age group (2006-2019). We examined rates during the late-PCV13 era (October 2015-2019) after transition to ICD10 codes compared to rates in the late-PCV7 (2006-2009) and early-PCV13 era (2011-September 2015). We also examined the rate of empyema with thoracentesis-related procedures and according to the causative organism type. RESULTS: Compared to the late-PCV7 era, all-cause empyema hospitalization rates were lower among child age groups (<1, 1, 2-4 and 5-17 years) in the late-PCV13 era. In contrast, among most adult age groups (18-34, 50-64, 65+ years), all-cause empyema rates were higher in the late-PCV13 era compared to the late-PCV7 era. CONCLUSION: Early declines in all-cause empyema-related hospitalizations observed right after PCV13 introduction among children in 2010 were sustained through 2019, though rates did not decline among adults.

[Effect of the Pneumococcal Conjugated Vaccines on Burden of all Cause Pneumonia, Bacterial Pneumonia and Empyema in Children]. / ÜKonjuge Pnömokok Asilarinin Çocuklarda Tüm Nedenli Pnömoniler, Bakteriyel Pnömoni ve Ampiyem Hastalik Yükü Üzerine Etkisinin Arastirilmasi.

The aim of this single-center retrospective study was to determine the changes in the burden of allcause pneumonia, bacterial pneumonia and empyema in children aged 0-18 years after the availability of 7-valent pneumococcal conjugated vaccine (PCV7) and 13-valent pneumococcal conjugated vaccine (PCV13) in our country. Children aged 0-18 years who were hospitalized with the diagnosis of pneumonia and treated in Ankara between January 1, 2006 and December 30, 2019 were included in the study. The burden of disease according to the years was calculated as follows: after determining the number of patients with all-cause pneumonia, bacterial pneumonia and the empyema who were admitted to the pediatric infectious diseases service, we divided those numbers to admission numbers to all outpatient clinics in that year as the ratio in 100 000. The years 2006-2007 were accepted as pre-vaccine period, 2009-2010 as PCV7 period and 2012-2019 as PCV13 period. As 2008 and 2011 were the years when PCV7 and PCV13 vaccines implemented into the routine vaccination schedule, they were accepted as transition years and the patient data from these years were not used. All of the patients data were obtained from the patient files. There was a significant decrease in the disease burden of all-cause pneumonia in 0-18 years age and 0-24 months age group after PCV13 period compared to PCV7 period (p<0.001 and p<0.001). A statistically significant decrease was found in all-cause pneumonia among children older than 60 months after PCV13 period compared to PCV7 period and pre-vaccine period (p<0.05 and p<0.01, respectively). When pre-PCV13 (PCV7 and pre-vaccine periods together) and post-PCV13 periods were compared; in 0-18 years age, 0-24 months age and 24-60 months age groups, there was a significant decrease in the burden of disease due to all-cause pneumonia after PCV13 (p<0.001, p<0.001 and p<0.05) period. When the bacterial pneumonia disease burden in PCV13 period was evaluated, bacterial pneumonia disease burden in 0-18 years and 0-24 months age group was found to be significantly lower than in both pre-vaccine and PCV7 periods (p<0.001 and p<0.001). After PCV13 vaccine, the disease burden due to bacterial pneumonia was found to be significantly lower in 0-18 years age, 0-24 months age and older than 60 months age groups compared to pre-PCV13 period (p<0.001, p<0.001 and p<0.01). When PCV7 and PCV13 periods were compared in 0-18 years age group, a significant decrease was found in hospitalizations due to empyema after PCV13 (p<0.05). In conclusion, PCV7 and PCV13 led to a significant reduction in the incidence of all-cause pneumonia and bacterial pneumonia in children.

Assessing the impact of the 13 valent pneumococcal vaccine on childhood empyema in Australia.

BACKGROUND: Empyema is a serious complication of pneumonia frequently caused by Streptococcus pneumoniae (SP). We assessed the impact of the 13-valent pneumococcal conjugate vaccine (13vPCV) on childhood pneumonia and empyema after inclusion in the Australian National Immunisation Program. METHODS: For bacterial pneumonia and empyema hospitalisations, we ascertained incidence rates (IRs) using the National Hospital Morbidity Database International Statistical Classification of Disease discharge codes and relevant population denominators, and calculated incidence rate ratios (IRR) comparing the 13vPCV period (June 2012-May 2017) with the 7vPCV period (June 2007-May 2011). Blood and pleural fluid (PF) cultures and PF PCR of 401 children with empyema from 11 Australian hospitals during the 13vPCV period were compared with our previous study in the 7vPCV period. FINDINGS: Across 7vPCV and 13vPCV periods, IRs per million children (95% CIs) were 1605 (1588 to 1621) and 1272 (1259 to 1285) for bacterial pneumonia, and 14.23 (12.67 to 15.79) and 17.89 (16.37 to 19.42) for empyema hospitalisations. IRRs were 0.79 (0.78 to 0.80) for bacterial pneumonia and 1.25 (1.09 to 1.44) for empyema. Of 161 empyema cases with SP serotypes, 147 (91.3%) were vaccine types. ST3 accounted for 76.4% of identified serotypes in the 13vPCV period, more than double than the 7vPCV period (p<0.001); ST19A decreased from 36.4% to 12.4%. No cases of ST1 empyema were identified in the 13vPCV period versus 14.5% in the 7vPCV period. INTERPRETATION: 13vPCV resulted in a significant reduction in all-cause hospitalisations for bacterial pneumonia but empyema hospitalisations significantly increased, with emergence of pneumococcal ST3 as the dominant serotype in empyema. TRIAL REGISTRATION NUMBER: Australian and New Zealand Clinical Trial Registry ACTRN 12614000354684.

Evaluation of effects of perioperative oral care intervention on hospitalization stay and postoperative infection in patients undergoing lung cancer intervention.

PURPOSE: This retrospective study investigated the effect of perioperative oral care intervention on postoperative outcomes in patients undergoing lung cancer resection, in terms of the length of postoperative hospital stay and the incidence of postoperative respiratory infections. METHODS: In total, 585 patients underwent lung resection for lung cancer, 397 received perioperative oral care intervention, whereas the remaining 188 did not. This study retrospectively investigated the demographic and clinical characteristics (including postoperative complications and postoperative hospital stay) of each group. To determine whether perioperative oral care intervention was independently associated with either postoperative hospital stay or postoperative respiratory infections, multivariate analysis, multiple regression analysis, and multivariate logistic regression analysis were conducted. RESULTS: Parameters significantly associated with a prolonged postoperative hospital stay in lung cancer surgery patients were older age, postoperative complications, increased intraoperative bleeding, more invasive operative approach (e.g., open surgery), and lack of perioperative oral care intervention (standard partial regression coefficient (ß) = 0.083, p = 0.027). Furthermore, older age and longer operative time were significant independent risk factors for the occurrence of postoperative respiratory infections. Lack of perioperative oral care intervention was a potential risk factor for the occurrence of postoperative respiratory infections, although not statistically significant (odds ratio = 2.448, 95% confidence interval = 0.966-6.204, p = 0.059). CONCLUSION: These results highlight the importance of perioperative oral care intervention prior to lung cancer surgery, in order to shorten postoperative hospital stay and reduce the risk of postoperative respiratory infections.

A Randomized Trial of Antimicrobial Prophylaxis in Patients Undergoing Medical Thoracoscopy (APT).

BACKGROUND: There is no data on the role of prophylactic antibiotics in patients undergoing medical thoracoscopy. OBJECTIVE: In this study, we evaluated the efficacy and safety of a single dose of intravenous cefazolin in subjects undergoing medical thoracoscopy. METHODS: Subjects undergoing medical thoracoscopy were randomized 1:1 to receive either intravenous cefazolin 2 g (antibiotic group) or intravenous saline (control group). The primary outcome was the incidence of infections (surgical site infections and empyema) in the study groups, while the secondary outcomes were complications related to intravenous antibiotics. RESULTS: Of the 121 subjects screened, 100 (mean age ± SD: 52.2 ± 15.2 years; 38 [38%] women) were randomized to the study groups. The incidence of postprocedural infections was not different between the antibiotic and the control group (4 [8%] vs. 6 [12%], p = 0.28). Surgical site infection occurred in 1 subject (2%) in the antibiotic group and 3 subjects (6%) in the saline group (p = 0.62); empyema occurred in 3 subjects (6%) in each group (p = 1.00). There was no association between age, comorbid illness (diabetes mellitus or chronic kidney disease), study group allocation, type of thoracoscope used, duration of procedure, histological diagnosis (benign or malignant), and the occurrence of infections in the postprocedural period. CONCLUSION: The use of a single dose of cefazolin prior to medical thoracoscopy was not associated with a reduction in the occurrence of postprocedural infection.

Additive impact of pneumococcal conjugate vaccines on pneumonia and empyema hospital admissions in England.

OBJECTIVES: A wider spectrum 13-valent pneumococcal vaccine (PCV13) replaced PCV7 in the child immunization schedule in England from 2010. We assessed the additional impact of PCV13 over PCV7 on all-cause pneumonia and empyema admissions. METHODS: We extracted Hospital Episode Statistics data from 2001 to 2014 on all-cause pneumonia (ICD-10 codes J12-18) and empyema admissions (J86.0, J86.9) for children <16 years in England. Trend analysis and rate ratios (RR) were calculated comparing the Pre-vaccine era to September 2006, the PCV7 era and the PCV13 era from April 2010. RESULTS: Annual hospital admissions for pneumonia and empyema were increasing in the Pre-vaccine era peaking in 2005 at 15,733 pneumonia and 382 empyema cases (158.6 and 3.9 per 100,000 children, respectively). These rates fell following PCV7 introduction in 2006 but began to climb soon afterwards until PCV13 was introduced. By 2013, admission rates for pneumonia and empyema were 102.2 and 1.9 per 100,000 children, respectively. We found no added benefit of PCV13 over PCV7 on pneumonia admissions following PCV13 introduction but there was a significant decrease in empyema admissions in children aged <2 years (RR 0.58; 95% CI 0.34-0.99). CONCLUSIONS: Additional serotypes covered by PCV13 may be more important in the aetiology of empyema and invasive disease than as a cause of uncomplicated pneumonia.

Has the incidence of empyema in Scottish children continued to increase beyond 2005?

BACKGROUND: The incidence of empyema increased dramatically in children during the 1990s and early 2000s. We investigated the relationship between changes in the incidence of childhood empyema in Scotland following the 2006 introduction of routine heptavalent conjugate pneumococcal vaccination (PCv-7) and the 2010 introduction of the 13-valent (PCV-13) vaccine. METHODS: This was a whole-population study of Scottish hospital admissions between 1981 and 2013 using ICD (International Classification of Diseases)-9 and ICD-10 diagnostic codes for empyema. The number of admissions for pneumonia and croup was also captured to give insight into secular trends in admissions with other related and unrelated respiratory presentations. RESULTS: There were 217 admissions with empyema between 1981 and 2005 (mean incidence 9 cases/million/year) and 323 between 2006 and 2013 (mean incidence 47 cases/million/year), p<0.001. The introduction of conjugate vaccines in 2006 was associated with an overall increase in admissions for empyema of 2.0 (95% CI 1.4 to 2.8) per 100 000 children, however, the incidence rate ratio for empyema admission between 2010 and 2013 was lower relative to 2006-2009 (0.78 (95% CI 0.63 to 0.98)). Secular changes in pneumonia, but not croup, were comparable with those for empyema. CONCLUSIONS: The incidence of empyema in Scottish children initially rose in children aged 1 to 9 years after the introduction of routine conjugate pneumococcal vaccination, however, empyema incidence has fallen since 2010 when the PCV-13 was introduced.

[Perioperative antibiotic therapy in thoracic surgery]. / Perioperative Antibiotikatherapie in der Thoraxchirurgie.

INTRODUCTION: In Germany no official guidelines exist for a specific perioperative antibiotic prophylaxis (PAP) in thoracic surgery. In this review, data regarding the PAP as well as antibiotic therapy of the postoperative pneumonia (POP) in thoracic surgery are described. METHODS: Selective literature researches were carried out in Medline with consideration of the official recommendations of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) as well as Paul-Ehrlich-Gesellschaft für Chemotherapie e. V. (PEG). RESULTS: The PAP is defined as a short and single application of an antibiotic agent preoperatively or during a surgical intervention. A PAP with first-generation or second-generation cephalosporins could significantly reduce the rate of surgical site infections after thoracic surgery. However, these few randomised trials could not demonstrate a distinct effect on the rate of POP and postoperative empyema. The incidence of POP is approximately 20-25 % after major thoracic surgery. Antibiotic therapy of POP should be performed early and be based on antibiotic sensitivity. CONCLUSION: Based on the few prospective, randomised studies a single dose of intravenous PAP with a cephalosporin is recommended in thoracic surgery. Therapy of the POP should include general procedures combined with a specific antibiotic therapy according to antibiotic sensitivity.

Safety of an intercostal approach for imaging-guided percutaneous drainage of subdiaphragmatic abscesses.

OBJECTIVE: The objective of our study was to test the hypothesis that an intercostal approach to imaging-guided percutaneous subdiaphragmatic abscess drainage is as safe as a subcostal approach. MATERIALS AND METHODS: A cohort of 258 consecutive patients with one or more subdiaphragmatic abscesses referred for imaging-guided (CT or ultrasound) percutaneous drainage was identified. Demographic characteristics and clinical outcomes were compared between patients who underwent drainage catheter placement via an intercostal approach versus those who underwent drainage catheter placement via a subcostal approach. RESULTS: Percutaneous drainage was performed for 441 abscesses in 258 patients in 409 separate procedures (214 via an intercostal approach, 186 by a subcostal approach, and nine by a combined approach). The total number of pleural complications was significantly higher in the intercostal group (56/214 [26.2%]) than the subcostal group (15/186 [8.1%]; p < 0.001). These complications included a significantly higher pneumothorax rate in the intercostal group than the subcostal group (15/214 [7.0%] vs 0/186 [0%], respectively; p < 0.01) and a higher incidence of new or increased pleural effusions (38/214 [17.8%] vs 14/186 [7.5%]; p < 0.01). The incidence of empyema was low and similar between the two groups (intercostal vs subcostal, 3/214 [1.4%] vs 1/186 [0.5%]; p = 0.63). A few of the complications in the patients who underwent an intercostal-approach drainage were clinically significant. Four of the 15 pneumothoraces required thoracostomy tubes and eight of 38 (21.1%) pleural effusions required thoracentesis, none of which was considered infected. CONCLUSION: An intercostal approach for imaging-guided percutaneous drainage is associated with a higher risk of pleural complications; however, most of these complications are minor and should not preclude use of the intercostal approach.

Efficacy of pre-operative nasal staphylococcus aureus screening and chlorhexidine chest scrub in decreasing the incidence of post-resection empyema.

BACKGROUND: We evaluated the efficacy of pre-operative Staphylococcus aureus (SA) screening and chlorhexidine chest scrub in decreasing the incidence of empyema after major pulmonary resections. METHODS: For two years, a strategy aimed at decreasing post-resection empyema was instituted. This entailed pre-operative screening for nasal SA and chlorhexidine chest scrub the night before surgery (Group Swab-Scrub, n=192). Patients screened positive for SA, methicillin-resistant (MRSA) and methicillin-sensitive (MSSA), received 5 d of nasal mupirocin. Group Swab-Scrub was compared with patients two years earlier, who did not receive this pre-operative maneuver (Group Control, n=173). The extent of resection considered was lobectomy or greater. All patients received cefazolin (or clindamycin if allergic) prior to incision and 24 h postoperatively, except for patient in Group Swab-Scrub screening positive for MRSA, who received vancomycin. All patients had povidone-iodine skin preparation. RESULTS: In Group Swab-Scrub, prevalence of nasal SA was 8.9% (17/192) two with MRSA and 15 with MSSA. There was no difference in patient demographics or operative characteristics between the Group Swab-Scrub and Group Control. There was also no difference in prolonged air-leak, empyema, wound infection, pneumonia, or mortality rates between the two groups. When stratifying for the extent of procedure, there was no difference in the incidence of empyema after lobectomy (Group Swab-Scrub, 3.9% [7/177] versus Group Control, 2.0% [3/151]; p=0.352) or pneumonectomy (Group Swab-Scrub, 6.7% [1/15] versus Group Control, 13.6% [3/22]; p=0.633). In both univariate and multivariable analysis, prolonged air-leak and pneumonectomy were significant risk factors for empyema. CONCLUSIONS: Preoperative screening for nasal SA and chlorhexidine chest scrub does not seem to decrease empyema rates after major pulmonary resection. Prolonged air-leak and pneumonectomy continue to be significant risk factors for developing empyema. The number of patients undergoing pneumonectomy in this study is small and further studies are needed for this patient population.

Expansion of serotype coverage in the universal pediatric vaccination calendar: short-term effects on age- and serotype-dependent incidence of invasive pneumococcal clinical presentations in Madrid, Spain.

In Madrid, Spain, the 13-valent pneumococcal conjugate vaccine (PCV13) replaced PCV7 in the pediatric universal vaccination calendar in June 2010. A prospective clinical surveillance that included all children hospitalized with culture- and/or PCR-confirmed invasive pneumococcal disease (IPD) was performed in all Madrid hospitals. The incidence rates (IRs) (defined as the number of cases/100,000 inhabitants aged <15 years) in the PCV7 (May 2007 to April 2010) versus PCV13 (May 2011 to April 2012) periods were compared. There were 499 cases in the PCV7 period and 79 cases in the PCV13 period. Globally, the IR significantly decreased from 17.09 (PCV7 period) to 7.70 (PCV13 period), with significant decreases (PCV7 versus PCV13 periods) in all age groups for bacteremic pneumonia (5.51 versus 1.56), parapneumonic pneumococcal empyema (PPE) (5.72 versus 3.12), and meningitis (2.16 versus 0.97). In the PCV13 period, significant reductions (the IR in the PCV7 period versus the IR in the PCV13 period) were found in IPDs caused by PCV13 serotypes (13.49 versus 4.38), and specifically by serotypes 1 (globally [4.79 versus 2.53], for bacteremic pneumonia [2.23 versus 0.97], and for PPE [2.26 versus 1.17]), serotype 5 (globally [1.88 versus 0.00], for bacteremic pneumonia [0.89 versus 0.00], and for PPE [0.55 versus 0.00]), and serotype 19A (globally [3.77 versus 0.49], for bacteremic pneumonia [0.72 versus 0.00], for PPE [0.89 versus 0.00], and for meningitis [0.62 versus 0.00]). IPDs caused by non-PCV13 serotypes did not increase (IR, 3.60 in the PCV7 period versus 3.31 in the PCV13 period), regardless of age or presentation. No IPDs caused by the PCV13 serotypes were found in children who received 3 doses of PCV13. The number of hospitalization days and sanitary costs were significantly lower in the PCV13 period. The switch from PCV7 to PCV13 in the universal pediatric vaccination calendar provided sanitary and economical benefits without a replacement by non-PCV13 serotypes.

The increasing incidence of empyema.

PURPOSE OF REVIEW: The aim of this review is to highlight recent changes concerning the incidence of empyema. In this article we have focused on community-acquired empyema RECENT FINDINGS: The incidence of empyema seems to have been increasing both in children and adults worldwide in the past decades, mainly in healthy young adults and in older patients. The bacteriology of pleural infection is changing as well. In children, the most common microorganism that causes empyema continues to be Streptococcus pneumoniae. Interestingly, the widespread use of the seven valent conjugate vaccine has produced a replacement phenomenon with the emergence of some pneumococcal serotypes such as serotypes 1, 3 and 19A, which have a higher propensity to cause empyema. Moreover increases in the incidence of empyema due to Staphylococcus aureus have also been observed. In adults, increases in the rate of empyema due to Streptococcus milleri group and S. aureus have been reported. SUMMARY: Continued surveillance in the epidemiology of empyema is needed. Progress in new strategies of prevention, such as a new generation of conjugate pneumococcal vaccines and protein-based vaccines, could become an important step in the control of this important complication.

Intracranial suppurations in the African child: a severe but preventable complication.

INTRODUCTION: Intracranial suppurations (ICS) are collections of pus of infectious origin in the skull. The authors present their experience. PATIENTS AND METHOD: All children operated for ICS at the Central Hospital of Yaoundé from January 2000 to December 2008 were retrospectively included. RESULTS: Thirty-five patients were recruited: 26 (74.29 %) males and 9 (25.71 %) females. These represent 82.9 % of all ICS operated in our institution. ICS represented 14.3 % of intracranial space-occupying lesions. The mean age was 8.34 years. They presented with headaches (80.77 %), altered consciousness (20 %), convulsions (76 %), vomiting (20 %), unilateral motor deficit (69.23 %), speech disorders (12 %), and fever (89.29 %). Bergman's triad (51.86 %) was frequent. The primary infection was: meningitis, eight cases (22.85 %); sinusitis, six cases (17.14 %); head trauma, five cases (14.28 %); otitis media, one case (2.85 %); suppurations of the face, three cases (8.56 %); cardiopathy, one case (2.85 %); and craniotomy, one case (2.85 %). In seven cases (20 %), the origin was unknown. The lesions were empyema in 23 cases (65.71 %), cerebral abscess in 8 cases (22.85 %) and pyoventriculitis in 2 cases (5.72 %). The surgical procedures were burr holes (88.89 % of empyemas) and trepano-puncture-aspiration (75 % of abscesses). The mortality (21.42 %) and morbidity (42.85 %) were recorded. CONCLUSION: ICS are frequent but preventable (early treatment of the primary infection) pathologies of childhood in developing countries. Burr hole drainage (empyemas) and puncture-aspiration (abscesses) are simple, safe, and effective techniques.

Initial suction evacuation of traumatic hemothoraces: a novel approach to decreasing chest tube duration and complications.

Between 2 and 4.4 per cent of all patients with trauma chest tubes develop retained hemothoraces. Retained hemothoraces prolong chest tube duration and hospital length of stay, and increase infectious complications like empyema. Early surgical drainage of retained hemothoraces has been shown to decrease complications and reduce hospital length of stay. However, the high resource and expertise requirement may limit the widespread applicability of surgical drainage. We present the results of a relatively simple and novel intervention for traumatic hemothoraces undertaken by our faculty to shorten chest tube duration and prevent empyema formation. At our Level I trauma center, 10 trauma patients underwent initial suction evacuation of their traumatic hemothoraces using a sterile suction catheter before chest tube placement. Compared with propensity matched controls, patients that underwent initial suction evacuation experienced significantly shorter chest tube duration (4.2 ± 1.9 vs 5.8 ± 2.3 days, P = 0.04). Also, in this population, there was an 8.2 per cent decrease in the number of patients that developed empyema or required additional drainage. Our study suggests that initial suction evacuation of traumatic hemothoraces is an effective and relatively easy intervention that reduces the duration of chest tube therapy, empyema formation, and the need for additional surgical intervention.

[Should videothorascopic surgery be the first choice in isolated traumatic hemothorax? A prospective randomized controlled study]. / Izole travmatik hemotoraksin tedavisinde videotorakoskopik cerrahi ilk tercih olmali mi? Prospektif randomize kontrolü çalisma.

BACKGROUND: In this study, patients with hemothorax due to blunt or penetrating thorax trauma and treated by tube thoracostomy were compared with the patients treated by videothoracoscopic surgery (VATS) in order to determine whether VATS can be the first choice in treatment. METHODS: Sixty patients with hemothorax due to trauma were examined prospectively. Thirty patients with isolated hemothorax and treated by tube thoracostomy were classified as Group I (50%), and 30 patients treated by VATS were classified as Group II (50%). Patients were compared according to healing duration, tube thoracostomy duration, hospitalization duration, success rate of treatment, morbidity, and mortality. RESULTS: When Group I and II were compared according to the duration of tube thoracostomy and hospitalization, Group I was found to have longer duration statistically (p=0.001). When the two groups were compared according to morbidity, statistical morbidity was found higher in Group I (p=0.030). CONCLUSION: VATS seems to be better in the treatment of hemothorax when compared with traditional drainage method because of its advantage of direct diagnosis and hemostasis by diagnostic thoracoscopy. If clotted blood is evacuated, empyema and fibrothorax are preventable. In these cases, chest tube duration and hospital length of stay are shorter. Therefore, these patients can be discharged early.

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

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.

Bronchial stump dehiscence: update on prevention and management.

Bronchial stump dehiscence is a serious complication and is associated with important morbidity and increased mortality. Because of this, efforts to prevent and treat these occurrences are essential. Etiology, risk factors, diagnosis and prevention, as well as current treatment options with an emphasis on surgical repair with muscle flaps are reviewed and discussed.

Chest tube-related empyema due to methicillin-resistant Staphylococcus aureus: could the chest tube be coated with antiseptics?

We reviewed the epidemiology, clinical manifestations, and outcomes of 3 cases of chest tube-related empyema due to methicillin-resistant Staphylococcus aureus (MRSA). Antiseptic-impregnated chest tubes were inserted in cultures containing MRSA isolates from these 3 patients, and zone of inhibition were measured. Chest tube-related MRSA empyema might complicate tube thoracostomy, and coating the chest tube with antiseptic agents could prevent this complication.