INFECTION OF THE PLEURAL SPACE - 08/09/11

Doi : 10.1016/S0272-5231(05)70240-9

John E. Heffner, MD ^{^{*
Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina}}

Résumé

Parapneumonic effusions complicate the course of 20% to 60% of patients hospitalized with bacterial pneumonia. ^{73Heffner J.E., McDonald J., Barbieri C., et al. Management of parapneumonic effusions. An analysis of physician practice patterns Arch Surg 1995 ; 130 : 433

Cliquez ici pour aller à la section Références, 114Light R.W., Girard E.M., Jenkinson S.G., et al. Parapneumonic effusions Am J Med 1980 ; 69 : 507 [cross-ref]

Cliquez ici pour aller à la section Références, 184Taryle D.A., Potts D.E., Sahn S.A. The incidence and clinical correlates of parapneumonic effusions in pneumococcal pneumonia Chest 1978 ; 74 : 170 [cross-ref]

Cliquez ici pour aller à la section Références} Most of these effusions follow an “uncomplicated” course and resolve with antibiotic therapy of the underlying pneumonia. In approximately 5% to 10% of patients, however, the parapneumonic effusion becomes “complicated” and progresses to frank intrapleural pus unless drained by a chest tube or a surgical procedure.^{114Light R.W., Girard E.M., Jenkinson S.G., et al. Parapneumonic effusions Am J Med 1980 ; 69 : 507 [cross-ref]

Cliquez ici pour aller à la section Références} The presence of intrapleural pus is termed an empyema, which increases the morbidity and likelihood of mortality of pneumonia. The mortality rate of empyema ranges between 25% and 70% in elderly patients^{46de la Rocha A.G. Empyema thoracis Surg Gynecol Obstet 1982 ; 155 : 839

Cliquez ici pour aller à la section Références, 51Finland M., Barnes M.W. Changing etiology of acute bacterial empyema: Occurrence and mortality at Boston City Hospital during 12 selected years from 1935–1972 J Infect Dis 1978 ; 137 : 274

Cliquez ici pour aller à la section Références, 64Grant D.R., Finley R.J. Empyema: Analysis of treatment techniques Can J Surg 1985 ; 28 : 449

Cliquez ici pour aller à la section Références, 89Jess P. Mortality in thoracic empyema Scan J Thorac Cardiovasc Surg 1981 ; 18 : 86

Cliquez ici pour aller à la section Références, 169Smith J.A., Mullerworth M.H., Westlake G.W., et al. Empyema thoracis: 14-year experience in a teaching center Ann Thorac Surg 1991 ; 51 : 39 [cross-ref]

Cliquez ici pour aller à la section Références, 192Varkey B., Rose H.D., Kutty C.P., et al. Empyema thoracis during a 10-year period. Analysis of 72 cases and comparison to a previous study (1952–1967) Arch Intern Med 1981 ; 141 : 1771

Cliquez ici pour aller à la section Références} and in patients with chronic debilitation. ^{53Forty J., Yeatman M., Wells F.C. Empyema thoracis: A review of a 4½ year experience of cases requiring surgical treatment Respir Med 1990 ; 84 : 147

Cliquez ici pour aller à la section Références, 169Smith J.A., Mullerworth M.H., Westlake G.W., et al. Empyema thoracis: 14-year experience in a teaching center Ann Thorac Surg 1991 ; 51 : 39 [cross-ref]

Cliquez ici pour aller à la section Références}

Because of the negative impact of empyema on clinical outcome, modern therapy of pneumonia directs clinicians toward early detection and prompt evaluation of parapneumonic effusions, with urgent initiation of pleural drainage in patients with complicated effusions to prevent progression to an empyema. Delays in initiating effective drainage increase morbidity, duration of hospitalization, and, in some studies, mortality. ^{4Ali I., Unruh H. Management of empyema thoracis Ann Thorac Surg 1990 ; 50 : 355 [cross-ref]

Cliquez ici pour aller à la section Références, 11Ashbaugh D.G. Empyema thoracis. Factors influencing morbidity and mortality Chest 1991 ; 99 : 1162 [cross-ref]

Cliquez ici pour aller à la section Références, 34Cham C.W., Haq S.M., Rahamim J. Empyema thoracis: A problem with late referral? Thorax 1993 ; 48 : 925 [cross-ref]

Cliquez ici pour aller à la section Références, 73Heffner J.E., McDonald J., Barbieri C., et al. Management of parapneumonic effusions. An analysis of physician practice patterns Arch Surg 1995 ; 130 : 433

Cliquez ici pour aller à la section Références, 152Pothula V., Krellenstein D.J. Early aggressive surgical management of parapneumonic empyemas Chest 1994 ; 105 : 832 [cross-ref]

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Plan

CAUSES

EPIDEMIOLOGY

PATHOPHYSIOLOGY OF PLEURAL SPACE INFECTIONS

BACTERIAL PATHOGENS

CLINICAL MANIFESTATIONS

DIAGNOSIS

Diagnostic Thoracentesis

ANTIBIOTIC THERAPY

PLEURAL DRAINAGE

Clinical Factors

Microbiologic Considerations

Imaging Studies

Pleural Fluid Analysis

PLEURAL FLUID DRAINAGE

Single or Repeated Thoracentesis

Fibrinolytic Therapy

Surgical Drainage Techniques

SUMMARY

Address reprint requests to John E. Heffner, MD, Department of Medicine, Medical University of South Carolina, School of Medicine, 96 Jonathan Lucas Drive, PO Box 250623, Charleston, SC 29425