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 array:22 [
  "pii" => "S0014256516000047"
  "issn" => "00142565"
  "doi" => "10.1016/j.rce.2016.01.001"
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  "cita" => "Rev Clin Esp. 2016;216:172-4"
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    "doi" => "10.1016/j.rce.2015.12.005"
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      "titulo" => "Influencia de la informaci&#243;n cl&#237;nica en la interpretaci&#243;n electrocardiogr&#225;fica"
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    "titulo" => "Adult patients with parapneumonic empyema who may not require pleural drainage"
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        "autoresLista" => "J&#46;M&#46; Porcel, H&#46; Valencia, S&#46; Bielsa"
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            "entidad" => "Pleural Medicine Unit&#44; Department of Internal Medicine&#44; Arnau de Villanova University Hospital&#44; Lleida&#44; Spain"
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        "titulo" => "Pacientes adultos con empiema paraneum&#243;nico que pueden no requerir drenaje pleural"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The American College of Chest Physicians<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> and the British Thoracic Society<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> strongly encourage prompt chest drainage when pus is obtained upon pleural aspiration&#46; The underlying reason is that empyema is considered to be the last stage of a pleural infection and delays in initiating effective drainage may increase morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> However&#44; no previous series have systematically examined whether antibiotics alone could result in complete resolution of empyema in individual cases and&#44; if so&#44; which predictors might support such a conservative approach&#46; The aim of this study was to address this void&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We retrospectively reviewed the medical charts of all consecutive patients discharged from the Arnau de Villanova University Hospital &#40;Lleida&#44; Spain&#41; with the diagnosis of thoracic empyema over the last 20 years&#46; The local ethics committee approved the study protocol&#46; Empyema was defined as the aspiration of macroscopic pus through a diagnostic thoracentesis procedure&#46; Its parapneumonic origin was determined by the presence of associated lung infiltrates and&#47;or the exclusion of other potential causes &#40;e&#46;g&#46;&#44; surgical procedures&#44; esophageal perforation&#44; subdiaphragmatic infection&#44; spontaneous bacterial empyema&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The following variables were collected&#58; demographics&#44; history of diabetes&#44; white blood cell count at admission&#44; size and laterality of pleural effusions and presence of loculated fluid on chest radiographs&#44; pleural fluid and blood cultures&#44; duration and type of antibiotic therapy&#44; chest tube sizes and use of intrapleural fibrinolytic agents in patients who underwent pleural drainage&#44; co-administration of nonsteroidal anti-inflammatory drugs&#44; and infection-related mortality&#46; The size of the effusion was assessed by standard posteroanterior radiographic views&#44; whenever possible&#44; and by visually estimating the area of the hemithorax occupied by pleural fluid&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Empyema patients were classified into those who underwent pleural drainage &#40;i&#46;e&#46;&#44; therapeutic or iterative thoracentesis&#44; chest tube&#44; surgery&#41; in addition to antibiotic therapy &#40;group 1&#41;&#44; and those who were solely treated with antibiotics &#40;group 2&#41;&#59; a decision made by the patient&#39;s attending physician&#46; Therapeutic thoracentesis was defined as the maximum evacuation of fluid&#46; Between-group comparisons for qualitative and quantitative variables were performed with the Fisher exact and Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> tests&#44; respectively&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">After excluding 38 patients for whom outcome data or medical history was incomplete or unavailable and 16 with a non-parapneumonic empyema &#40;6 esophageal perforation&#44; 5 abdominal surgery&#44; 2 trauma&#44; and 1 each pneumonectomy&#44; pleurodesis and ventriculoperitoneal shunt&#41;&#44; the study population comprised 129 empyema patients &#40;77&#37; men&#41; with a median age of 56 &#40;42&#8211;72&#41; years&#44; whose main characteristics are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; There were 110 patients in group 1 and 19 in group 2&#46; Definitive pleural drainage modalities in the former were&#58; therapeutic thoracenteses &#40;2 cases&#44; 1&#46;8&#37;&#41;&#59; thoracic surgery&#44; for which 4 cases was the initial treatment and 11 more followed chest tube drainage failure &#40;15 cases&#44; 13&#46;6&#37;&#41;&#59; and tube thoracostomy &#40;93 cases&#44; 84&#46;5&#37;&#41;&#46; Intercostal drain insertion was done using either small- &#40;&#8804;12<span class="elsevierStyleHsp" style=""></span>F&#44; 58&#37;&#41; or large-bore &#40;16&#8211;32<span class="elsevierStyleHsp" style=""></span>F&#44; 42&#37;&#41; chest tubes&#46; Intrapleural fibrinolytics were administered in 57&#37; of the patients&#44; urokinase being the preferred agent &#40;90&#37;&#41;&#46; In 84&#37; of patients&#44; the chest tube was placed during the first 24<span class="elsevierStyleHsp" style=""></span>h of the diagnostic thoracentesis&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Overall&#44; 63&#37; of empyema fluids were culture positive&#46; The bacteria most commonly isolated were <span class="elsevierStyleItalic">Streptococcus viridans</span> &#40;39&#37;&#41;&#44; <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> &#40;23&#37;&#41;&#44; and Gram-negative aerobic organisms &#40;20&#37;&#41;&#44; with an equal distribution between groups 1 and 2&#46; Antibiotic selection was also similar for both groups&#44; and mainly consisted of &#946;-lactam&#47;&#946;-lactamase inhibitors &#40;62&#37;&#41; and third-generation cephalosporins &#40;17&#37;&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Apart from the uncertain clinical relevance of a slight difference based on the effusion&#39;s laterality&#44; the effusion&#39;s size itself was the most significantly different parameter between patients who were eventually subjected to chest drainage and those who were not &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Among the group 2 empyemas&#44; 67&#37; occupied less than 1&#47;3 of the hemithorax as compared with 7&#37; of group 1&#46; Moreover&#44; in three of four small drained empyemas for which enough information was available&#44; the total amount of withdrawn pus was less than 150<span class="elsevierStyleHsp" style=""></span>mL&#46; Pleural fluid loculations were not good indicators of which patients went on to receive antibiotics or pleural drainage&#46; Of importance&#44; infection-related mortality did not differ between the pleural drainage and antibiotics alone groups &#40;11&#37; vs 20&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;39&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">It was found that nearly 15&#37; of adults with parapneumonic empyema were successfully treated only with antibiotics&#46; All had small effusions &#40;&#8804;1&#47;3 of the thorax filled on chest radiograph&#41;&#44; which may have potentially hampered the placement of a chest catheter&#46; Previous reports on pleural infection management did not make a distinction between non-purulent complicated parapneumonic effusions &#40;i&#46;e&#46;&#44; positive pleural fluid cultures and&#47;or pleural acidosis&#41; and classic empyemas &#40;grossly purulent pleural fluid&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4&#8211;7</span></a> A possible exception is a series of 119 patients with parapneumonic empyemas&#44; defined as &#8220;opaque&#8221; pleural fluids&#44; in which 5 &#40;4&#46;2&#37;&#41; were treated with antibiotics alone and three survived&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The main limitation of this study is its retrospective design with the resultant missing data&#46; The exclusion of 38 cases because of incomplete data or lost to follow-up might have skewed the results&#46; Also&#44; decisions on whether or not to insert a chest tube were based on the subjective criteria of the attending physician&#44; which raises concerns of a potential classification bias&#46; Moreover&#44; it is not completely surprising that some patients with small empyemas may not require drainage&#46; In fact&#44; many patients discharged with a drained empyema still have some residual collections that resolve conservatively&#46; Finally&#44; there was a non-significant trend towards worse outcomes in the non-drainage group &#40;20&#37; vs 11&#37; infection-related mortality rate&#41; that requires further exploration in an adequately powered study&#46; Only a randomized controlled trial could answer the question of whether small volume empyemas can be cured solely with antibiotics&#46; However&#44; it is highly unlikely that this will take place since a treatment branch in which patients with purulent pleural fluids receive antibiotics exclusively is difficult to reconcile with current guideline recommendations&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion&#44; some patients with small volume parapneumonic empyemas can be effectively managed with antibiotics alone&#46; Even so&#44; they require a close clinical reevaluation during treatment as an increase in pleural fluid or failure of the patients&#39;s condition to improve in a short period of time warrants immediate pleural drainage&#46;</p></span>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Data are given as median &#40;IQR&#41; or no&#46; &#40;&#37;&#41; as appropriate&#46; <span class="elsevierStyleItalic">Abbreviations</span>&#58; NSAID&#44; nonsteroidal anti-inflammatory drugs&#59; PE&#44; pleural effusion&#59; WBC&#44; white blood cell&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46; of patients group 1&#47;group 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drained empyemas &#40;group 1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Undrained empyemas &#40;group 2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age&#44; years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">110&#47;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56 &#40;41&#8211;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51 &#40;44&#8211;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Male sex</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">110&#47;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84 &#40;76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">History of diabetes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">108&#47;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">WBC count&#44; &#215;10</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">9</span></span><span class="elsevierStyleItalic">&#47;L</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&#47;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;1 &#40;9&#46;8&#8211;19&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;2 &#40;11&#46;3&#8211;26&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Chest X-ray&#44; PE size</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#60;1&#47;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;67&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>1&#47;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39 &#40;39&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8805;1&#47;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53 &#40;54&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Chest-X ray&#44; PE laterality</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">107&#47;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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abril 2016 Adult patients with parapneumonic empyema who may not require pleural drainage
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Vol. 216. Núm. 3.
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Vol. 216. Núm. 3.
Páginas 172-174 (abril 2016)
Correspondence
DOI: 10.1016/j.rce.2016.01.001
Adult patients with parapneumonic empyema who may not require pleural drainage
Pacientes adultos con empiema paraneumónico que pueden no requerir drenaje pleural
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J.M. Porcel
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jporcelp@yahoo.es

Corresponding author.
, H. Valencia, S. Bielsa
Pleural Medicine Unit, Department of Internal Medicine, Arnau de Villanova University Hospital, Lleida, Spain
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Tablas (1)
Table 1. Characteristics of the study population.

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