The impact of the COVID-19 pandemic on pleural infection incidence: a UK multicentre retrospective analysis

Bedawi, Eihab; Rehman, Khalil Ur; Sivakumar, Parthipan; Ferguson, Katie; Ajmal, Syed; Graham, Emma; Panchal, Rakesh; Corcoran, John; Blyth, Kevin G.; Rahman, Najib M.; West, Alex

doi:10.1183/23120541.00206-2022

Cited by 3 publications

(3 citation statements)

References 13 publications

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“…Hospitalizations became predominantly COVID-19–related, and a substantial reduction in non–COVID-19–related admissions was observed across the Western world ( 34 – 36 ). Data from our own centers in a related study estimated that the incidence of pleural infection hospitalizations was reduced by approximately one third ( 26 ). The reasons for this are uncertain but likely attributed to the combined effect of shielding and isolation of vulnerable populations, reduced social mixing, widespread use of personal protective equipment, and liberal use of antibiotics to prevent secondary bacterial infections in patients with viral illness.…”

Section: Discussionmentioning

confidence: 99%

“…The main impact was to trial recruitment rates, which, having been ahead of target, decreased substantially (Figure E1 in the online supplement). Based on a separate analysis of screening data, pleural infection rates in the United Kingdom decreased by approximately one third during the pandemic ( 26 ), with hospital admissions and research efforts predominantly COVID-19–related. Performing timely surgery and intervention in the context of COVID-19 became challenging as infection and prevention control measures became more restrictive and theater capacity was reduced.…”

Section: Methodsmentioning

confidence: 99%

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Early Video-assisted Thoracoscopic Surgery or Intrapleural Enzyme Therapy in Pleural Infection: A Feasibility Randomized Controlled Trial. The Third Multicenter Intrapleural Sepsis Trial—MIST-3

Bedawi,

Stavroulias,

Hedley

et al. 2023

Am J Respir Crit Care Med

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Rationale Assessing the early use of video-assisted thoracoscopic surgery (VATS) or intrapleural enzyme therapy (IET) in pleural infection requires a phase III randomized controlled trial (RCT). Objectives To establish the feasibility of randomization in a surgery-versus-nonsurgery trial as well as the key outcome measures that are important to identify relevant patient-centered outcomes in a subsequent RCT. Methods The MIST-3 (third Multicenter Intrapleural Sepsis Trial) was a prospective multicenter RCT involving eight U.K. centers combining on-site and off-site surgical services. The study enrolled all patients with a confirmed diagnosis of pleural infection and randomized those with ongoing pleural sepsis after an initial period (as long as 24 h) of standard care to one of three treatment arms: continued standard care, early IET, or a surgical opinion with regard to early VATS. The primary outcome was feasibility based on >50% of eligible patients being successfully randomized, >95% of randomized participants retained to discharge, and >80% of randomized participants retained to 2 weeks of follow-up. The analysis was performed per intention to treat. Measurements and Main Results Of 97 eligible patients, 60 (62%) were randomized, with 100% retained to discharge and 84% retained to 2 weeks. Baseline demographic, clinical, and microbiological characteristics of the patients were similar across groups. Median times to intervention were 1.0 and 3.5 days in the IET and surgery groups, respectively ( P = 0.02). Despite the difference in time to intervention, length of stay (from randomization to discharge) was similar in both intervention arms (7 d) compared with standard care (10 d) ( P = 0.70). There were no significant intergroup differences in 2-month readmission and further intervention, although the study was not adequately powered for this outcome. Compared with VATS, IET demonstrated a larger improvement in mean EuroQol five-dimension health utility index (five-level edition) from baseline (0.35) to 2 months (0.83) ( P = 0.023). One serious adverse event was reported in the VATS arm. Conclusions This is the first multicenter RCT of early IET versus early surgery in pleural infection. Despite the logistical challenges posed by the coronavirus disease (COVID-19) pandemic, the study met its predefined feasibility criteria, demonstrated potential shortening of length of stay with early surgery, and signals toward earlier resolution of pain and a shortened recovery with IET. The study findings suggest that a definitive phase III study is feasible but highlights important considerations and significant modifications to the design that would be required to adequately assess optimal initial management in pleural infection.The trial was registered on ISRCTN (number 18,192,121).

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Early Video-assisted Thoracoscopic Surgery or Intrapleural Enzyme Therapy in Pleural Infection: A Feasibility Randomized Controlled Trial. The Third Multicenter Intrapleural Sepsis Trial—MIST-3

Bedawi,

Stavroulias,

Hedley

et al. 2023

Am J Respir Crit Care Med

Self Cite

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“…None of the patients were treated for pleural infection, which strengthens the finding of Bedawi et al of approximately 32.6% reduction in pleural infection rate during COVID-19 pandemic compared with prepandemic levels. 67 This is interesting given the widespread use of immunosuppressive treatments in severe COVID-19 patients may have theoretically increased the risk of pleural infection.…”

Section: Pleural Effusion With Covid-19mentioning

confidence: 99%

COVID-19-Related Pleural Diseases

Iqbal

Rahman

Hallifax

2023

Semin Respir Crit Care Med

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Coronavirus disease 2019 (COVID-19)-related pleural diseases are now well recognized. Since the beginning of the pandemic, increasing cases of pleural diseases including pneumothorax, pneumomediastinum, and pleural effusion with severe COVID-19 infection have attracted the attention of physicians and are not incidental or due to barotrauma. The complicated course of COVID-19 illness highlights the complex pathophysiological underpinnings of pleural complications. The management of patients with pneumothorax and pneumomediastinum is challenging as the majority require assisted ventilation; physicians therefore appear to have a low threshold to intervene. Conversely, pleural effusion cases, although sharing some similar patient characteristics with pneumothorax and pneumomediastinum, are in general managed more conservatively. The evidence suggests that patients with COVID-19-related pleural diseases, either due to air leak or effusion, have more severe disease with a worse prognosis. This implies that prompt recognition of these complications and targeted management are key to improve outcomes.

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A feasibility randomised trial comparing therapeutic thoracentesis to chest tube insertion for the management of pleural infection: results from the ACTion trial

et al. 2022

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Background Pleural infection is a complex condition with a considerable healthcare burden. The average hospital stay for pleural infection is 14 days. Current standard of care defaults to chest tube insertion and intravenous antibiotics. There have been no randomised trials on the use of therapeutic thoracentesis (TT) for pleural fluid drainage in pleural infection. Aims and objectives To assess the feasibility of a full-scale trial of chest tube vs TT for pleural infection in a single UK centre. The primary outcome was defined as the acceptability of randomisation to patients. Methods Adult patients admitted with a pleural effusion felt to be related to infection and meeting criteria for drainage (based on international guidelines) were eligible for randomisation. Participants were randomised (1:1) to chest tube insertion or TT with daily review assessing need for further drainages or other therapies. Neither participant nor clinician were blinded to treatment allocation. Patients were followed up at 90 days post-randomisation. Results From September 2019 to June 2021, 51 patients were diagnosed with pleural infection (complex parapneumonic effusion/empyema). Eleven patients met the inclusion criteria for trial and 10 patients were randomised (91%). The COVID-19 pandemic had a substantial impact on recruitment. Data completeness was high in both groups with no protocol deviations. Patients randomised to TT had a significantly shorter overall mean hospital stay (5.4 days, SD 5.1) compared to the chest tube control group (13 days, SD 6.0), p = 0.04. Total number of pleural procedures required per patient were similar, 1.2 in chest tube group and 1.4 in TT group. No patient required a surgical referral. Adverse events were similar between the groups with no readmissions related to pleural infection. Conclusions The ACTion trial met its pre-specified feasibility criteria for patient acceptability but other issues around feasibility of a full-scale trial remain. From the results available the hypothesis that TT can reduce length of stay in pleural infection should be explored further. Trial registration: ISRCTN: 84674413.

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The impact of the COVID-19 pandemic on pleural infection incidence: a UK multicentre retrospective analysis

Cited by 3 publications

References 13 publications

Early Video-assisted Thoracoscopic Surgery or Intrapleural Enzyme Therapy in Pleural Infection: A Feasibility Randomized Controlled Trial. The Third Multicenter Intrapleural Sepsis Trial—MIST-3

Early Video-assisted Thoracoscopic Surgery or Intrapleural Enzyme Therapy in Pleural Infection: A Feasibility Randomized Controlled Trial. The Third Multicenter Intrapleural Sepsis Trial—MIST-3

COVID-19-Related Pleural Diseases

A feasibility randomised trial comparing therapeutic thoracentesis to chest tube insertion for the management of pleural infection: results from the ACTion trial

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