DOCSLIB.ORG

Medical and Surgical Management of Empyema

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Medical and Surgical Management of Empyema 361 Medical and Surgical Management of Empyema Mark S. Godfrey, MD1 Kyle T. Bramley, MD1 Frank Detterbeck, MD2 1 Pulmonary, Critical Care and Sleep Medicine, Yale New Haven Address for correspondence Frank Detterbeck, MD, 330 Cedar Street, Hospital, New Haven, Connecticut P.O. Box 208062, New Haven, CT 06520 2 Section of Thoracic Surgery, Yale University School of Medicine, (e-mail: [email protected]). New Haven, Connecticut Semin Respir Crit Care Med 2019;40:361–374. Abstract Infection of the pleural space is an ancient and common clinical problem, the incidence which is on the rise. Advances in therapy now present clinicians of varying disciplines with an array of therapeutic options ranging from thoracentesis and chest tube drainage (with or without intrapleural fibrinolytic therapies) to video-assisted thoracic surgery (VATS) or thoracotomy. A framework is provided to guide decision making, which involves weighing multiple factors (clinical history and presentation, imaging characteristics, comorbidities); Keywords multidisciplinary collaboration and active management are needed as the clinical course ► empyema over a few days determines subsequent refinement. The initial choice of antibiotics depends ► pleural infection on whether the empyema is community-acquired or nosocomial, and clinicians must ► tissue plasminogen recognize that culture results often do not reflect the full disease process. Antibiotics alone activator are rarely successful and can be justified only in specific circumstances. Early drainage with ► deoxyribonuclease or without intrapleural fibrinolytics is usually required. This is successful in most patients; ► thoracoscopy however, when surgical decortication is needed, clear benefit and low physiologic impact ► video-assisted are more likely with early intervention, expeditious escalation of interventions, and care at a thoracic surgery center experienced with VATS. During World War I, the U.S. Army formed an empyema with pleural infection. We refer readers to other literature commission to address an epidemic of empyema among regarding topics not addressed here, such as the clinical and enlisted men in crowded camps and exacerbated by the radiographic presentation of pleural infection,3 management 1918 influenza pandemic.1 Their management recommenda- of postresection pleural space infection and empyema associ- 4,5 tions were (1) early closed pleural drainage (through serial ated with a bronchial or esophageal fistula, nonbacterial Downloaded by: Yale University Library. Copyrighted material. aspiration or closed chest tube), (2) avoidance of early open (mycobacterial, fungal) empyema, and pleural infection in drainage, (3) sterilization and obliteration of the empyema children.6 cavity, and (4) maintenance of the patient’s nutritional status.2 One-hundred years later these remain core principles, despite Incidence and Mortality of Pleural Infection major advances including antibiotic therapy, imaging techni- ques, intrapleural fibrinolytic drugs, and minimally invasive Parapneumonic effusion develops in 14 to 19% of patients with surgical techniques. Despite these advances, the morbidity, community-acquired pneumonia (CAP), and roughly a third of mortality, and burden of pleural infection remain high. Judging these patients will have empyema or complicated parapneu- which interventions are needed to optimally manage an monic effusion (CPE).7,8 However, the notion that empyema individual patient is complex and involves qualitative factors. represents an extension of bacterial pneumonia is currently While clinical studies provide guidance, ambiguity in how to being challenged. Many patients with empyema lack imaging apply the evidence remains. evidence of an underlying pneumonia; in a recent study, chest This review aims to provide practical guidance to the computed tomography (CT) demonstrated evidence of pneu- general or respiratory physician or surgeon managing a patient monia in only 44% (64/164) of community-acquired empyema Issue Theme Pleural Diseases; Guest Copyright © 2019 by Thieme Medical DOI https://doi.org/ Editors: Jonathan Puchalski, MD, and Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0039-1694699. Najib M. Rahman, DPhil, MSc, FRCP New York, NY 10001, USA. ISSN 1069-3424. Tel: +1(212) 584-4662. 362 Medical and Surgical Management of Empyema Godfrey et al. (CAE) cases and 27% (88/324) of health care associated empy- (n ¼ 128) among 1,080 patients with invasive pneumococcal ema (HCAE).9 Retrospective cohorts demonstrate no seasonal infection was the pneumococcal serotype (not any clinical or variation in empyema incidence, in contrast with the season- demographic features).34 Notably, pneumonia-specificand ality of pneumonia. The microbiology of CAP is remarkably generic sepsis scores (such as the pneumonia severity index different from that of CAE (see “Microbiology”). While occa- or CURB-65) on admission do not predict development of CPE sionally pleural infection arises through hematogenous spread, or empyema.8 from subdiaphragmatic infection, trauma, or iatrogenically Because there are no clinical characteristics that identify an from procedures, the mechanism for the development of uncomplicated effusion in patients with pneumonia or sepsis, many empyemas is unclear. thoracentesis should be performed whenever such patients The crude and/or age-adjusted incidence of adult pleural have >10 mm of pleural fluid.4,35,36 A pleural effusion should infection is consistently rising in diverse cohorts and health bespecifically sought for when patients with pneumonia fail to systems (e.g., in Canada,10,11 Denmark,12 Finland,13 and the respond within 48 to 72 hours of antibiotic therapy, or in United States).14,15 The largest incidence ratio increase is in elderly patients (who often lack overtly infectious symptoms the elderly.11,12 Because the 30-day/in-hospital case fatality and present with dyspnea, anemia, or weight loss).37 rate of empyema (7–11%) has remained stable for over 30 Classification schemas for pleural infection differ regarding years,14,15 the rising incidence is not likely due to improved pleural fluid glucose thresholds (6038 vs. 40 mg/dL35,39)and detection of clinically less-significant disease. This would be inclusion35,38 or not39 of pleural fluid lactate dehydrogenase expected to dilute the case fatality rate, in fact one study measurement.40 All classifications include pH measurement, found both an increasing incidence of empyema and inci- but pH can be affected by residual air, heparin, or lidocaine in dence of empyema-specific deaths.16 the sample,41 can significantly vary between individual Long-term outcomes of patients with pleural infection locules,42 or be elevated by urease-producing organisms demonstrate high rates of readmission and repeated inter- such as Proteus.43 Therefore, a pleural effusion should not be ventions. Among 4,095 patients with empyema, 21% were classified and managed as uncomplicated solely by biochemi- readmitted within 90 days and 27% of these readmissions cal features; for borderline laboratory results the clinical were specifically secondary to the empyema.17 Additionally, context of the patient must be considered. Escalating therapy a subsequent procedure within 30 days was required in 51 empirically or resampling the effusion is indicated whenever and 39%, respectively, of patients managed initially with a clinical questions linger. chest tube or with initial surgery.17 Although their baseline status is unclear, 22 to 31% of pleural infection patients are Timely Management of Pleural Infection reportedly discharged to a facility instead of home.11,14 A three-stage classification of parapneumonic effusion (exuda- A substantial late mortality is reported after a pleural tive, fibrinopurulent, and organizing) was proposed in 1962.44 infection. The 1-, 3-, and 5-year mortality was 15, 24, and Early observations suggested that it took 2 to 3 weeks for the 30%, respectively, among 191 patients with empyema or CPE18; early exudate to become frankly purulent.2 However, the time their 3-month mortality of 8% was similar to those of other to progression from one stage to another is highly variable. prospective cohorts.19 The majority (66%) of late mortality in Therefore, interventions should be performed expeditiously, patients with empyema is attributable to causes other than and treatments escalated rapidly when the pleural process did pneumonia or empyema.20 Empyema often stems from under- not improve within a few days. There is no role for protracted lying vulnerability—the high long-term mortality likely reflects “expectant” management of a potentially infected pleural Downloaded by: Yale University Library. Copyrighted material. these patients’ substantial burden of comorbid disease.21 space; delaying diagnostic thoracentesis of a parapneumonic effusion for an anticipated response to antibiotics alone is General Principles of Management associated with increased hospital length of stay (LOS) and costs.45 Similarly, delaying a chest tube >3 days after recogni- Timely Identification of Pleural Infection tion of pleural fluid is associated with increased mortality.46 An empyema is defined as pus in the pleural space or pleural Preclinical models of pleural infection have demonstrated fluid with organisms present on Gram stain or culture. CPE is rapid progression of pleural organization within hours to defined as pleural fluid pH <7.20 or pleural fluid glucose days. In a Pasteurella rabbit model, less pleural rind was <60 mg/dL with clinical evidence of
Load more

Recommended publications
  • Unusual Case of Non-Resolving Necrotizing Pneumonia: a Last Resort Measure for Cure
    eCommons@AKU Department of Surgery Department of Surgery June 2016 Unusual case of non-resolving necrotizing pneumonia: a last resort measure for cure. Naseem Salahuddin Aga Khan University, [email protected] Naila Baig Ansari Aga Khan University Saulat H. Fatimi Aga Khan University, [email protected] Follow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surg Part of the Surgery Commons Recommended Citation Salahuddin, N., Ansari, N., Fatimi, S. (2016). Unusual case of non-resolving necrotizing pneumonia: a last resort measure for cure.. JPMA: Journal of the Pakistan Medical Association, 66(6), 754-756. Available at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/566 754 CASE REPORT Unusual case of non-resolving necrotizing pneumonia: A last resort measure for cure Naseem Salahuddin, 1 Naila Baig-Ansari, 2 Saulat Hasnain Fatimi 3 Abstract pathogen of acute CAP, 2,3 and accounts for most cases of To our knowledge, this is an unusual case of a community- slowly resolving pneumonia.The majority of previously acquired pneumonia (CAP) with sepsis secondary to healthy hospitalized patients with severe CAP responded Streptococcus pneumoniae that required lung resection satisfactorily to prompt initiation of appropriate antibiotic for a non-resolving consolidation. A 74 year old previously therapy; however, it is estimated that 10% of hospitalized healthy woman, presented with acute fever, chills and CAP patients have slowly resolving or nonresolving pleuritic chest pain in Emergency Department (ED). A disease. 4 diagnosis of CAP was established with a Pneumonia Severity Index CURB-65 score of 5/5. In the ER, she was Case Report promptly and appropriately managed with antibiotics History: A 74 year old woman who was previously and aggressive supportive therapy.
    [Show full text]
  • Toman's Tuberculosis Case Detection, Treatment, and Monitoring
    TOMAN’S TUBERCULOSIS TOMAN’S TUBERCULOSIS CASE DETECTION, TREATMENT, AND MONITORING The second edition of this practical, authoritative reference book provides a rational basis for the diagnosis and management of tuberculosis. Written by a number of experts in the field, it remains faithful to Kurt Toman’s original question-and-answer format, with subject matter grouped under the three headings Case detection, Treatment, and Monitoring. It is a testament to the enduring nature of the first edition that so much CASE DETECTION, TREA material has been retained unchanged. At the same time, the new edition has had not only to address the huge resurgence of tuber- culosis, the emergence of multidrug-resistant bacilli, and the special needs of HIV-infected individuals with tuberculosis, but also to encompass significant scientific advances. These changes in the profile of the disease and in approaches to management have inevitably prompted many new questions and answers and given a different complexion to others. Toman’s Tuberculosis remains essential reading for all who need to AND MONITORING TMENT, QUESTIONS learn more about every aspect of tuberculosis – case-finding, manage- ment, and effective control strategies. It provides invaluable support AND to anyone in the front line of the battle against this disease, from ANSWERS programme managers to policy-makers and from medical personnel to volunteer health workers. SECOND EDITION ISBN 92 4 154603 4 WORLD HEALTH ORGANIZATION WHO GENEVA Toman’s Tuberculosis Case detection, treatment, and monitoring – questions and answers SECOND EDITION Edited by T. Frieden WORLD HEALTH ORGANIZATION GENEVA 2004 WHO Library Cataloguing-in-Publication Data Toman’s tuberculosis case detection, treatment, and monitoring : questions and answers / edited by T.
    [Show full text]
  • Translational Deep Phenotyping of Deaths Related to the COVID-19 Pandemic: Protocol for a Prospective Observational Autopsy Study
    Open access Protocol BMJ Open: first published as 10.1136/bmjopen-2021-049083 on 27 August 2021. Downloaded from Translational deep phenotyping of deaths related to the COVID-19 pandemic: protocol for a prospective observational autopsy study Mikkel Jon Henningsen ,1 Apameh Khatam- Lashgari,1 Kristine Boisen Olsen,1 Christina Jacobsen,1 Christian Beltoft Brøchner ,2 Jytte Banner1 To cite: Henningsen MJ, ABSTRACT Strengths and limitations of this study Khatam- Lashgari A, Olsen KB, Introduction The COVID-19 pandemic is an international et al. Translational deep emergency with an extreme socioeconomic impact and a ► A standardised, prospective autopsy study on COVID- phenotyping of deaths high mortality and disease burden. The COVID-19 outbreak related to the COVID-19 19- related deaths with systematic data collection. is neither fully understood nor fully pictured. Autopsy studies pandemic: protocol for a ► A multidisciplinary, translational approach elucidat- can help understand the pathogenesis of COVID-19 and has prospective observational ing changes from protein level to whole human. already resulted in better treatment of patients. Structured autopsy study. BMJ Open ► A comprehensive biobank and extensive registry and systematic autopsy of COVID-19- related deaths will 2021;11:e049083. doi:10.1136/ data as an umbrella for planned and future research. bmjopen-2021-049083 enhance the mapping of pathophysiological pathways, not ► The internal control group partly compensates for possible in the living. Furthermore, it provides an opportunity Prepublication history and the observational design. ► to envision factors translationally for the purpose of disease additional supplemental material ► Limited by a selected sample of COVID-19 diseased prevention in this and future pandemics.
    [Show full text]
  • Treatment and Outcomes of Community-Acquired Pneumonia at Canadian Hospitals Research Brian G
    Treatment and outcomes of community-acquired pneumonia at Canadian hospitals Research Brian G. Feagan,* Thomas J. Marrie,† Catherine Y. Lau,‡ Recherche Susan L. Wheeler,‡ Cindy J. Wong,* Margaret K. Vandervoort* From *the London Clinical Abstract Trials Research Group, London, Ont.; †the Background: Community-acquired pneumonia is a common disease with a large Department of Medicine, economic burden. We assessed clinical practices and outcomes among patients University of Alberta, with community-acquired pneumonia admitted to Canadian hospitals. Edmonton, Alta.; Methods: A total of 20 hospitals (11 teaching and 9 community) participated. Data and ‡Janssen–Ortho from the charts of adults admitted during November 1996, January 1997 and Incorporated, Toronto, Ont. March 1997 were reviewed to determine length of stay (LOS), admission to an intensive care unit and 30-day in-hospital mortality. Multivariate analyses exam- This article has been peer reviewed. ined sources of variability in LOS. The type and duration of antibiotic therapy and the proportion of patients who were treated according to clinical practice CMAJ 2000;162(10):1415-20 guidelines were determined. Results: A total of 858 eligible patients were identified; their mean age was 69.4 (standard deviation 17.7) years. The overall median LOS was 7.0 days (in- terquartile range [IQR] 4.0–11.0 days); the median LOS ranged from 5.0 to 9.0 days across hospitals (IQR 6.0–7.8 days). Only 22% of the variability in LOS could be explained by known factors (disease severity 12%; presence of chronic obstructive lung disease or bacterial cause for the pneumonia 2%; hospital site 7%).
    [Show full text]
  • Respiratory Tract Infections in the Tropics
    9.1 CHAPTER 9 Respiratory Tract Infections in the Tropics Tim J.J. Inglis 9.1 INTRODUCTION Acute respiratory infections are the single most common infective cause of death worldwide. This is also the case in the tropics, where they are a major cause of death in children under five. Bacterial pneumonia is particularly common in children in the tropics, and is more often lethal. Pulmonary tuberculosis is the single most common fatal infection and is more prevalent in many parts of the tropics due to a combination of endemic HIV infection and widespread poverty. A lack of diagnostic tests, limited access to effective treatment and some traditional healing practices exacerbate the impact of respiratory infection in tropical communities. The rapid urbanisation of populations in the tropics has increased the risk of transmitting respiratory pathogens. A combination of poverty and overcrowding in the peri- urban zones of rapidly expanding tropical cities promotes the epidemic spread of acute respiratory infection. PART A. INFECTIONS OF THE LOWER RESPIRATORY TRACT 9.2 PNEUMONIA 9.2.1 Frequency Over four million people die from acute respiratory infection per annum, mostly in developing countries. There is considerable overlap between these respiratory deaths and deaths due to tuberculosis, the single commonest fatal infection. The frequency of acute respiratory infection differs with location due to host, pathogen and environmental factors. Detailed figures are difficult to find and often need to be interpreted carefully, even for tuberculosis where data collection is more consistent. But in urban settings the enormity of respiratory infection is clearly evident. Up to half the patients attending hospital outpatient departments in developing countries have an acute respiratory infection.
    [Show full text]
  • 2017 Pulmonary Coding and Payment Quick Reference
    2017 Coding & Payment Quick Reference Select Pulmonary Procedures Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all-inclusive list. We recommend consulting your relevant manuals for appropriate coding options. Medicare Physician, Hospital Outpatient, and ASC Payments The bronchoscopy procedures listed below (except CPT® Codes 31622, 31660, and 31661) all include a diagnostic bronchoscopy when performed by the same physician. 2017 Medicare National Average Payment RVUs Physician‡,2 Facility3 CPT® Total Total Hospital Code Description Work In-Office In-Facility ASC Code1 Office Facility Outpatient Biopsy 31625 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, 3.11 9.43 4.53 $338 $163 $1,270† $569 when performed; with bronchial or endobronchial biopsy(s), single or multiple sites 31628 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, 3.55 10.00 5.09 $359 $183 $2,431† $1,117 when performed; with transbronchial lung biopsy(s), single lobe 31632 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, 1.03 1.84 1.42 $66 $51 $0 $0 when performed; with transbronchial lung biopsy(s), each additional lobe (List separately in addition to code for primary procedure)* Cytology and Brush 31622 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, 2.53 6.86 3.81 $246 $137 $1,270† $569 when performed; diagnostic,
    [Show full text]
  • Community Acquired Pneumonia
    Community Acquired Pneumonia MELISSA PALMER AGACNP Objectives Know the target population for the 2019 American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) Community-acquired Pneumonia (CAP) guidelines 2019 Know when to perform testing for CAP: sputum cultures, blood cultures, Legionella and pneumococcal urinary antigen testing, influenza testing, and procalcitonin Be able to discuss the utilization of steroids in patients with CAP Know the selection of initial empiric antibiotic therapy for community-acquired pneumonia and duration of treatment for inpatients Criteria for hospitalization versus the need for ICU admission in adults diagnosed with CAP based on Pneumonia severity index (PSI) compared to CURB-65 Discuss the differences between the 2019 and 2007 ATS/IDSA Community-acquired Pneumonia Guidelines. COVID-19 Identify and Isolate. Pneumonia and CAP definition Pneumonia Infection of the alveoli, distal airways and the interstitium of the lung. Clinical: a new or changing radiographic density (infiltrate). Usually accompanied by constitutional symptoms of lung inflammation. Community Acquired Pneumonia acquired outside the hospital Signs and symptoms of pneumonia with radiographic confirmation *Patient must not have been hospitalized nor resided in a long-term-care facility for, at minimum, 14 days prior to the onset of symptoms Impact of Pneumonia leading infectious cause of hospitalization and death among U.S. adults more than 1.5 million adults hospitalized annually medical costs exceeding
    [Show full text]
  • IDSA/ATS Consensus Guidelines on The
    SUPPLEMENT ARTICLE Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults Lionel A. Mandell,1,a Richard G. Wunderink,2,a Antonio Anzueto,3,4 John G. Bartlett,7 G. Douglas Campbell,8 Nathan C. Dean,9,10 Scott F. Dowell,11 Thomas M. File, Jr.12,13 Daniel M. Musher,5,6 Michael S. Niederman,14,15 Antonio Torres,16 and Cynthia G. Whitney11 1McMaster University Medical School, Hamilton, Ontario, Canada; 2Northwestern University Feinberg School of Medicine, Chicago, Illinois; 3University of Texas Health Science Center and 4South Texas Veterans Health Care System, San Antonio, and 5Michael E. DeBakey Veterans Affairs Medical Center and 6Baylor College of Medicine, Houston, Texas; 7Johns Hopkins University School of Medicine, Baltimore, Maryland; 8Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi School of Medicine, Jackson; 9Division of Pulmonary and Critical Care Medicine, LDS Hospital, and 10University of Utah, Salt Lake City, Utah; 11Centers for Disease Control and Prevention, Atlanta, Georgia; 12Northeastern Ohio Universities College of Medicine, Rootstown, and 13Summa Health System, Akron, Ohio; 14State University of New York at Stony Brook, Stony Brook, and 15Department of Medicine, Winthrop University Hospital, Mineola, New York; and 16Cap de Servei de Pneumologia i Alle`rgia Respirato`ria, Institut Clı´nic del To`rax, Hospital Clı´nic de Barcelona, Facultat de Medicina, Universitat de Barcelona, Institut d’Investigacions Biome`diques August Pi i Sunyer, CIBER CB06/06/0028, Barcelona, Spain. EXECUTIVE SUMMARY priate starting point for consultation by specialists. Substantial overlap exists among the patients whom Improving the care of adult patients with community- these guidelines address and those discussed in the re- acquired pneumonia (CAP) has been the focus of many cently published guidelines for health care–associated different organizations, and several have developed pneumonia (HCAP).
    [Show full text]
  • Acute Empyema. the Primary Cause of Acute Empyema Is Seldom from Without; It Is Almost from Within the and to Such Conditions As
    Postgrad Med J: first published as 10.1136/pgmj.14.154.251 on 1 August 1938. Downloaded from August, 1938 THE DIAGNOSIS OF EMi~PYEMA 251 THE DIAGNOSIS AND TREATMENT OF EMPYEMA. By R. R. TRAIL, M.A., M.D., F.R.C.P. (Physician, Royal Chest Hospital and Papworth Village Settlement.) Few diseases conform so seldom to their classical book diagnosis as empyema or purulent pleurisy in its various types. If even the majority of cases showed consecutive layers from below upwards on one side of the chest, of dullness with absent breath sounds and increased vocal resonance and fretnitus, aegophony, and then tubular breathing, with displacement of the heart to the opposite side, there would be little difficulty in differential diagnosis, nor should we see the tragedies of long-standing chronic empyema which are still admitted to our hospitals. The reason is that it is very unusual for empyema to be anatomically complete. It may, of course, be so found in infections with malignant haemolytic streptococci where the onset is acute and limiting adhesions are not present. In most cases, however, the effusion is so tied down by adhesions that division can be made into types according to the position of such restricting bands; for example, interlobar, mediastinal or diaphragmatic empyema. It follows that the basic infective pneumonitis which is the true primary cause of both conditions will often make the differential diagnosis as between interlobar empyema and lung abscess exceedingly difficult; every physician will agree that the patient's future depends so much on accurate definition and localisation that by copyright.
    [Show full text]
  • Diagnosis and Treatment of Community-Acquired Pneumonia M
    Diagnosis and Treatment of Community-Acquired Pneumonia M. NAWAL LUTFIYYA, PH.D., ERIC HENLEY, M.D., M.P.H., and LINDA F. CHANG, PHARM.D., M.P.H., B.C.P.S. University of Illinois College of Medicine at Rockford, Rockford, Illinois STEPHANIE WESSEL REYBURN, M.D., M.P.H., Mayo School of Graduate Medical Education, Rochester, Minnesota Patients with community-acquired pneumonia often present with cough, fever, chills, fatigue, dyspnea, rigors, and pleuritic chest pain. When a patient presents with suspected community-acquired pneu- monia, the physician should first assess the need for hospitalization using a mortality prediction tool, such as the Pneumonia Severity Index, combined with clinical judgment. Consensus guidelines from several organizations recommend empiric therapy with macrolides, fluoroquinolones, or doxycycline. Patients who are hospitalized should be switched from parenteral antibiotics to oral antibiotics after their symptoms improve, they are afebrile, and they are able to tolerate oral medications. Clinical pathways are important tools to improve care and maximize cost-effectiveness in hospitalized patients. (Am Fam Physician 2006;73:442-50. Copyright © 2006 American Academy of Family Physicians.) ILLUSTRATION BY MARK E. SCHULER Members of various ommunity-acquired pneumonia rates from CAP increase with the presence family medicine depart- (CAP) is defined as pneumonia of comorbidity and increased age; the condi- ments develop articles for “Practical Therapeutics.” not acquired in a hospital or a tion affects persons of any race or sex equally. This article is one in a long-term care facility. Despite the The decrease in death rates from pneumonia series coordinated by the C availability of potent new antimicrobials and and influenza are largely attributed to vac- Department of Family 1 Medicine at the University effective vaccines, an estimated 5.6 million cines for vulnerable populations (e.g., older of Illinois at Chicago cases of CAP occur annually in the United and immunocompromised persons).
    [Show full text]
  • Association Between Hospital Case
    Kumamaru et al. BMC Health Services Research 2014, 14:302 http://www.biomedcentral.com/1472-6963/14/302 RESEARCH ARTICLE Open Access Association between hospital case volume and mortality in non-elderly pneumonia patients stratified by severity: a retrospective cohort study Hiraku Kumamaru1, Yusuke Tsugawa2, Hiromasa Horiguchi3, Kanako Kunishima Kumamaru4, Hideki Hashimoto1 and Hideo Yasunaga5* Abstract Background: The characteristics and aetiology of pneumonia in the non-elderly population is distinct from that in the elderly population. While a few studies have reported an inverse association between hospital case volume and clinical outcome in elderly pneumonia patients, the evidence is lacking in a younger population. In addition, the relationship between volume and outcome may be different in severe pneumonia cases than in mild cases. In this context, we tested two hypotheses: 1) non-elderly pneumonia patients treated at hospitals with larger case volume have better clinical outcome compared with those treated at lower case volume hospitals; 2) the volume-outcome relationship differs by the severity of the pneumonia. Methods: We conducted the study using the Japanese Diagnosis Procedure Combination database. Patients aged 18–64 years discharged from the participating hospitals between July to December 2010 were included. The hospitals were categorized into four groups (very-low, low, medium, high) based on volume quartiles. The association between hospital case volume and in-hospital mortality was evaluated using multivariate logistic regression with generalized estimating equations adjusting for pneumonia severity, patient demographics and comorbidity score, and hospital academic status. We further analyzed the relationship by modified A-DROP pneumonia severity score calculated using the four severity indices: dehydration, low oxygen saturation, orientation disturbance, and decreased systolic blood pressure.
    [Show full text]
  • Empyema and Ruptured Lung Abscess in Adults'
    Thorax: first published as 10.1136/thx.19.6.492 on 1 November 1964. Downloaded from Thorax (1964), 19, 492. Empyema and ruptured lung abscess in adults' ROWAN NICKS From the Thoracic Surgical Unit, Page Chest Pavilion, Royal Prince Alfred Hospital, Melbourne This brief annotation concerns 18 adult patients TABLE II with empyema complicating the rupture of a lung RESULTS OF TREATMENT abscess into the pleural cavity who were referred to my service during the period 1957 to 1962. No. Cure No Cure Medical treatment By different methods of treatment all these Antibiotics .. 18 patients have been returned to health, but in some Primary surgical treatment earlier cases the illness was painful and prolonged Drainage: Infected .9 2 7 and multiple operations were necessary to attain Sterile. I a final cure. Primary decortication These are compared with patients treated Non-infected 5 5 recently in whom convalescence has been rapid, Infected .. 2 I I uncomplicated, and without loss of tissue. Primary pleuro-resection .. 1 Total .. .. 18 10 8 CLINICAL MATERIAL Particulars relevant to the treatment of 18 patients A cure followed simple drainage in three copyright. of comprising the series are summarized in Table I. 10 patients. Five sterile cases treated by primary decortica- TABLE I tion were cured, and, of two infected cases, one EMPYEMA COMPLICATING INTRAPLEURAL RUPTURE OF recurred. LUNG ABSCESS IN ADULTS, 1957 TO 1962 In the one with a localized empyema treated Total no. of cases 18 by pleurolobectomy and thoracoplasty, a curehttp://thorax.bmj.com/ Died. 0 resulted. Final cure .. .. .. 18 Primary surgery failed to achieve a cure in eight Culture: Sterile.
    [Show full text]