Pleural empyema represents a significant healthcare burden due to extended hospital admissions and potential requirement for surgical intervention. This study aimed to assess changes in incidence and management of pleural empyema in England over the last 10 years and the potential impact of influenza on rates.Hospital Episode Statistics (HES) data was used to identify patients admitted to English hospitals with pleural empyema between 2008 and 2018. Linear regression was used to analyse the relationship between empyema rates and influenza incidence recorded by Public Health England. The relationship between influenza and empyema was further explored using serological data from a prospective cohort study of patients presenting with pleural empyema.Between April 2008 and March 2018 there were 55 530 patients admitted with pleural empyema. There was male predominance (67% versus 33%) which increased with age. Cases have significantly increased from 4447 in 2008 to 7268 in 2017. Peaks of incidence correlated moderately with rates of laboratory-confirmed influenza in children and young adults (r=0·30). For 9 of the 10 years studied the highest annual point incidence of influenza coincided with the highest admission rate for empyema (with a 2-week lag). In a cohort study of patients presenting to a single UK hospital with pleural empyema/infection, 24% (17/72) had serological evidence of recent influenza infection compared to 7% in seasonally matched controls with simple parapneumonic or cardiogenic effusions (p<0·001).Rates of empyema admissions in England have steadily increased with a seasonal variation that is temporally related to influenza incidence. Patient-level serological data from a prospective study supports the hypothesis that influenza may play a pathogenic role in empyema development.

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