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Empyema Thoracis: New Insights Into an Old Disease

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Empyema Thoracis: New Insights Into an Old Disease Eur Respir Rev 2010; 19: 117, 220–228 DOI: 10.1183/09059180.00005610 CopyrightßERS 2010 REVIEW: ENDOSCOPY Empyema thoracis: new insights into an old disease F.J.H. Brims*,#, S.M. Lansley", G.W. Waterer" and Y.C.G. Lee#," ABSTRACT: Pleural infection is a disease of historical importance and is still a modern menace, AFFILIATIONS with incidences rising in adults and children, and a significant mortality in adults. Basic research is *Respiratory Dept, Portsmouth Hospitals NHS Trust, Portsmouth, hampered by limitations with in vivo models, and the bacteriology of empyema is complex. The role UK. of thoracic ultrasound in guiding investigation and drainage of empyema is clear. Prompt treatment #Respiratory Dept, Sir Charles with appropriate systemic antibiotics and chest tube drainage are the key; in cases of failure of Gairdner Hospital, Perth, and " these measures, thoracic surgery is of proven efficacy in the treatment of this age-old disease. School of Medicine and Pharmacology and Lung Institute of Western Australia, University of KEYWORDS: Empyema, infection, mesothelial, pleural, pneumonia Western Australia, Perth, Australia. CORRESPONDENCE leural infection is one of the oldest and Pleural infection can also complicate thoracic Y.C.G. Lee severest diseases. Drainage of the pleural (open or closed) trauma and iatrogenic proce- University Dept of Medicine, 4/F, G Block cavity was attempted by Hippocrates over dures, such as surgery (especially lung resection) P QE II Medical Center 2,000 years ago to treat empyema. During the or oesophageal rupture. ‘‘Spontaneous’’ bacterial Perth influenza pandemic of 1917–1919, closed pleural empyema is rare. It is possible that genetic pre- WA 6009 drainage became widely practiced to treat post- disposition contributes to development of empy- Australia pneumonic empyema [1]. Throughout history, ema in some patients [13]. Despite numerous E-mail: [email protected] many famous physicians, such as Dr Guillaume studies the best management of pleural infection Dupuytrens and Sir William Osler, have died remains controversial with widespread varia- Received: from empyemas. Rapid recognition of the devel- tions in practice [14]. May 25 2010 Accepted: opment of empyema is crucial to successful This review will examine novel themes of trans- May 27 2010 treatment; even with appropriate therapeutic lational research, highlighting areas of clinical attempts, the mortality of patients with empyema importance and fields in need of further investi- PROVENANCE is 15–20% [2–4] and higher in immunocompro- gation, as well as evaluating the current best Publication of this peer-reviewed mised patients [5]. clinical management of pleural infection. article was supported by GlaxoSmithKline, Belgium (principal The definition of empyema is pus in the pleural sponsor, European Respiratory space [6], although most clinical trials and studies PATHOGENESIS Review issue 117). use the term pleural infection to encompass both Animal models of pleural infection empyemas and complicated parapneumonic Pleural infection remains difficult to treat in part, effusions. It can affect any age group, sex and as the underlying disease mechanisms are poorly ethnicity and over 65,000 patients suffer from a elucidated. Basic laboratory research in pleural pleural infection each year in the UK and USA infection is hampered by a lack of suitable in vivo [7], with an estimated hospital cost of 500 million models. Attempts have been made using a variety USD. The incidence of empyema is rising in both of species, including mice, rats, rabbits, guinea developed and developing countries, including pigs and sheep, to develop a clinically reliable in paediatric populations. In Scotland, the inci- model of empyema. Many models require injury dence of empyema has risen 10 times in 1–4 yr to the pleura to precede pathogen instillation old children since 1998 [8], with similar reports [15–19], as direct bacterial administration into the from the USA, Canada and elsewhere in Europe, pleural space often results in their complete and the trend is mirrored in adults [9–12]. The clearance [20] or severe sepsis [21]. Other studies prevalence of HIV/AIDS, wider use of immuno- have suggested that a pleural effusion is required suppressants and organ transplantation, and as a substrate for bacterial growth [22, 23]. One increasing age of the population mean pleural commonly used method involves the intrapleural European Respiratory Review infection will continue to remain a common and injection of turpentine, which results in pleural Print ISSN 0905-9180 significant illness. inflammation and an exudative effusion, prior to Online ISSN 1600-0617 220 VOLUME 19 NUMBER 117 EUROPEAN RESPIRATORY REVIEW F.J.H. BRIMS ET AL. REVIEW: EMPYEMA THORACIS the introduction of pathogens [18]. This approach, however, has apoptosis and loss of monolayer integrity, which may variable efficacy [19] and turpentine itself may influence the contribute to loss of the normal fibrinolytic milieu of the results. Intrapleural injection of Pasturella multocida (a common pleural space with conversion to a more pro-fibrinogenic, anti- respiratory tract pathogen in rabbits) in brain-heart infu- fibrinolytic environment, with release of TNF-a from mesothe- sion agar into rabbits has been shown to reliably induce lial cells [33] and concurrent upregulation of antifibrinolytic empyema [20]; however, death from overwhelming sepsis mediators, such as plasminogen activator inhibitor-1 and -2 frequently complicates this model unless systemic antibiotics [33]. Infection of mesothelial cells with live mycobacteria are administered. bacille Calmette–Guerin (BCG) results in enhanced vascular endothelial growth factor release [34] and both live BCG and S. The technical issues associated with the current animal models aureus infection increase permeability across the mesothelial of empyema preclude their use in large scale in vivo research. monolayer, in part via downregulation of b-catenin [34, 35]. The aforementioned models differ from common clinical With persistent inflammation, increased vascular and mesothe- scenarios in that empyema is induced in the absence of lial permeability leads to increased plasma extravasation into concurrent pneumonia. The use of animal-specific pathogens and the need to administer antibiotics also limit the transla- the pleural cavity. Activation of the coagulation cascade within tional relevance of these models. the pleural cavity contributes to the development of a ‘‘fibrinopurulent’’ or ‘‘complicated’’ parapneumonic effusion, with fibrin deposition over both pleural surfaces and char- Effect of bacteria on mesothelial cells in vitro acteristic fibrinous septae producing loculated effusions [36]. In the absence of faithful animal models, most research on infection of serosal (pleural and peritoneal) cavities have been in vitro based. Numerous studies have described the potent MICROBIOLOGY biological effects of bacteria, live or attenuated, on both pleural The prevalence of different causative organisms of pleural and peritoneal mesothelial cells. The mesothelial cell responses infection varies among countries; local epidemiological data appear to be dependent on both the state and type of microbial are needed to guide treatment. Series from the UK, Canada species and the origin of the mesothelial cells. Direct exposure and New Zealand all demonstrate that Streptococcus milleri is of mesothelial cells to different types of bacteria have been the most common isolate in adults with community-acquired shown to affect inflammatory responses, coagulation and empyema, with proportions ranging between 32 and 50% of fibrinolysis processes, resulting in a unique mesothelial cell cases [4, 37, 38]. The other common isolated organisms of activation signature [24]. For example, the presence of heat- empyema are Streptococcus pneumoniae and anaerobes for killed Escherichia coli increases elaboration of inflammatory community-acquired pleural infection and S. aureus (including cytokines such as interleukin (IL)-6, IL-8, RANTES (regulated methicillin-resistant S. aureus (MRSA)) for hospital-acquired upon activation, normal T-cell expressed and secreted) and cases [36]. A more recent report from Taiwan has confirmed a monocyte chemotactic protein-1 (MCP-1) from mesothelial higher incidence of aerobic Gram-negative and anaerobic cells, whereas heat-killed Staphylococcus aureus increases IL-6 infections in those with empyema from hospital-acquired and IL-8 but not RANTES or MCP-1 [25]. Variable activation pneumonia [37]. was also observed in a separate study comparing the IL-8 response of peritoneal mesothelial cells cultured with live or S. milleri is part of the viridans streptococci group that heat-killed S. aureus, Staphylococcus epidermidis and E. coli or comprises a heterogeneous group of facultatively anaerobic, bacterial culture supernatants [26]. The live S. aureus and live S. Gram-positive cocci that do not produce catalase or coagulase epidermidis isolates induced mesothelial cell production of IL-8, [39]. S. milleri is a typically benign commensal that is part of the but the live E. coli or any of the heat-killed or bacterial culture normal flora of the human orophayrnx, and it is rarely isolated supernatants did not, suggesting that heat alteration of the in community-acquired pneumonia [40, 41], which makes its bacterial cell wall component may play a role [26]. Peritoneal apparent virulence in empyema seem incongruous. Some mesothelial cells have also been shown
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