The microbiology of pleural infection in adults: a systematic review

Abstract

Background and objectivesPleural infection is a major cause of morbidity and mortality among adults. Identification of the offending organism is key to appropriate antimicrobial therapy. It is not known whether the microbiological pattern of pleural infection is variable temporally or geographically. This systematic review aimed to investigate available literature to understand the worldwide pattern of microbiology and the factors that might affect such pattern.Data sources and eligibility criteriaOvid MEDLINE and Embase were searched between 2000 and 2018 for publications that reported on the microbiology of pleural infection in adults. Both observational and interventional studies were included. Studies were excluded if the main focus of the report was paediatric population, tuberculous empyema or post-operative empyema.Study appraisal and synthesis methodsStudies of ≥20 patients with clear reporting of microbial isolates were included. The numbers of isolates of each specific organism/group were collated from the included studies. Besides the overall presentation of data, subgroup analyses by geographical distribution, infection setting (community versus hospital) and time of the report were performed.ResultsFrom 20 980 reports returned by the initial search, 75 articles reporting on 10 241 patients were included in the data synthesis. The most common organism reported worldwide was Staphylococcus aureus. Geographically, pneumococci and viridans streptococci were the most commonly reported isolates from tropical and temperate regions, respectively. The microbiological pattern was considerably different between community- and hospital-acquired infections, where more Gram-negative and drug-resistant isolates were reported in the hospital-acquired infections. The main limitations of this systematic review were the heterogeneity in the method of reporting of certain bacteria and the predominance of reports from Europe and South East Asia.ConclusionsIn pleural infection, the geographical location and the setting of infection have considerable bearing on the expected causative organisms. This should be reflected in the choice of empirical antimicrobial treatment.

A systematic review of comorbidities and outcomes of adult patients with pleural infection

“…Ovid MEDLINE and Embase were searched between 2000 and 2017 using the keywords “empyema”, “pleural infection” and “pleuritis”. The full search strategy is reported in detail elsewhere [8, 9].…”

Diagnostics in Pleural Disease

“…Whilst the PF biochemistry may be suggestive of pleural infection, the gold standard for diagnosing the condition is with positive microbiological growth within the PF. Unfortunately, yields from PF are quite poor; a recent systematic review across 75 studies suggests that PF culture is only positive in 56% of cases [36]. This yield may be improved further by inoculating the PF into enrichment medium [37].…”

Management of Pleural Infection

“…There is wide variation in causative organism according to geographical location and the healthcare setting of infection (Table 2). In a recent systematic review encompassing 75 studies and more than 10,000 participants, Staphylococcus aureus (20.7%) appears to have overtaken the Streptococcus viridans group (18%) as the most commonly cultured pathogen globally [18]. Hitherto, Streptococcus milleri, the most common subgroup of S. viridans, was thought to be the commonest isolate [6,19].…”

“…Although this runs the risk of opening up a minefield of interpretation and management decisions, it will likely advance our understanding of the pleural microbiome, in disease and in health. In culture-negative pleural infections, empirical antimicrobial therapy should be based on local resistance patterns and antimicrobial stewardship policies [18]. The British Thoracic Society (BTS) and American Association for Thoracic Surgery suggest broad-spectrum antibiotics with Gram-positive, Gramnegative and anaerobic cover until culture and sensitivities are available [6,8].…”