Two vs. three weeks of treatment with amoxicillin-clavulanate for stabilized community-acquired complicated parapneumonic effusions. A preliminary non-inferiority, double-blind, randomized, controlled trial

Porcel, José M.; Ferreiro, Lucía; Руми, Л. Р.; Espino-Paisan, E; Civit, Carmen; Pardina, Marina; Arnaiz, Juan Antonio Schoenenberger; Valdés, Luís; Bielsa, Silvia

doi:10.1515/pp-2019-0027

Cited by 15 publications

(18 citation statements)

References 20 publications

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“…A randomized controlled trial (RCT) on patients with complicated parapneumonic effusion who were stable after 2 weeks of antibiotic treatment reported that a 2-week course was probably no inferior to a 3-week course in terms of treatment failures. 66 However, this study did not include patients with primary pleural infection and was unable to recruit the total planned number of participants.…”

Section: Treatmentmentioning

confidence: 99%

Recent Insights into the Management of Pleural Infection

Hassan

Patel

Sadaka

et al. 2021

IJGM

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Pleural infection in adults has considerable morbidity and continues to be a lifethreatening condition. The term "pleural infection" encompasses complicated parapneumonic effusions and primary pleural infections, and includes but is not limited to empyema, which refers to collection of pus in the pleural cavity. The incidence of pleural infection in adults has been continuously increasing over the past two decades, particularly in older adults, and most of such patients have comorbidities. Management of pleural infection requires prolonged duration of hospitalization (average 14 days). There are recognized differences in microbial etiology of pleural infection depending on whether the infection was acquired in the community or in a health-care setting. Anaerobic bacteria are acknowledged as a major cause of pleural infection, and thus anaerobic coverage in antibiotic regimens for pleural infection is mandatory. The key components of managing pleural infection are appropriate antimicrobial therapy and chest-tube drainage. In patients who fail medical therapy by manifesting persistent sepsis despite standard measures, surgical intervention to clear the infected space or intrapleural fibrinolytic therapy (in poor surgical candidates) are recommended. Recent studies have explored the role of early intrapleural fibrinolytics or first-line surgery, but due to considerable costs of such interventions and the lack of convincing evidence of improved outcomes with early use, early intervention cannot be recommended, and further evidence is awaited from ongoing studies. Other areas of research include the role of routine molecular testing of infected pleural fluid in improving the rate of identification of causative organisms. Other research topics include the benefit of such interventions as medical thoracoscopy, high-volume pleural irrigation with saline/antiseptic solution, and repeated thoracentesis (as opposed to chest-tube drainage) in reducing morbidity and improving outcomes of pleural infection. This review summarizes current knowledge and practice in managing pleural infection and future research directions.

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Section: Treatmentmentioning

confidence: 99%

Recent Insights into the Management of Pleural Infection

Hassan

Patel

Sadaka

et al. 2021

IJGM

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“…The median duration of antimicrobial treatment was 26 days in our study. Except for one trail that was terminated early due to slow enrolment, the optimal duration of antimicrobial treatment has not been examined in randomized controlled trials [21]. Most guidelines recommend individualised treatments durations of three weeks, depending on clinical improvement, and one trail is ongoing to validate this [6].…”

Section: Discussionmentioning

confidence: 99%

16S rRNA is a valuable tool in finding bacterial aetiology of community-acquired pleural empyema–a population-based observational study in South Sweden

Ljungquist

Bläckberg

Hjertman

2021

Infectious Diseases

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Background: The incidence of community-acquired pleural empyema is increasing. Knowledge of the bacterial aetiology is important in order to base recommendations on empirical antimicrobial treatment. The primary aim of the present study was to describe the bacterial aetiology of adult patients with culture proven and/or 16S rRNA-positive community-acquired pleural infection. Methods: We performed a retrospective, population-based observational cohort study in Skåne County, south of Sweden. We included all patients with pleural samples obtained between 1st of January 2011 to 31st of December 2017 in Skåne, south of Sweden, with a positive culture and/or 16S rRNA result. Exclusion criteria were patients with culture-negative and/ or 16S rRNA-negative pleural samples, age < 18 years, pleural empyema caused by trauma or iatrogenesis, pleural infection caused by tuberculosis or fungi, simultaneous lung-or abscess of the abdomen and bacterial species considered to be contaminants. Results: A total of 291 patients were included in the study, of which 63% were men and the median age was 69 years. The dominating bacterial aetiology was viridans streptococci (36%), followed by Streptococcus pneumoniae (14%) and anaerobic bacteria (12%). 16S rRNA added information of bacterial aetiology in addition to standard culturing methods in 63% of the patients. Conclusion:We found that the aetiology of adult patients with culture proven and/or 16S rRNA-positive communityacquired pleural empyema is dominated by viridans streptococci, S. pneumoniae and anaerobic bacteria. Our study shows that 16S rRNA is a valuable tool in finding the bacterial aetiology of community-acquired pleural empyema.

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“…13 Based on expert opinions, antibiotics should be continued for at least 3 weeks, though in selected less severe cases, 2 weeks may be enough. 17…”

Section: Management Of Pleural Infectionsmentioning

confidence: 99%

“…Conversely, TT failed in 17% of patients, thus requiring additional invasive procedures, but IPC succeeded in all. The study was underpowered due to slow enrollment and had two remarkable and interrelated facts that may complicate its interpretation: the larger mean fluid drainage in the IPC group (17,412 vs. 2,901 mL) and the low mean rate of additional thoracentesis (1.3) required in the TT group within the study period. The greater volume of drained fluid probably explained the lower concentrations of serum albumin in the IPC group at 12 weeks (27 vs. 32.5 g/L).…”

Section: Indwelling Pleural Cathetersmentioning

confidence: 99%

Nonmalignant Pleural Effusions

Porcel

2022

Semin Respir Crit Care Med

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Although the potential causes of nonmalignant pleural effusions are many, the management of a few, including complicated pleural infections and refractory heart failure and hepatic hydrothoraces, can be challenging and requires the assistance of interventional pulmonologists. A pragmatic approach to complicated parapneumonic effusions or empyemas is the insertion of a small-bore chest tube (e.g., 14–16 Fr) through which fibrinolytics (e.g., urokinase and alteplase) and DNase are administered in combination. Therapeutic thoracenteses are usually reserved for small to moderate effusions that are expected to be completely aspirated at a single time, whereas video-assisted thoracic surgery should be considered after failure of intrapleural enzyme therapy. Refractory cardiac and liver-induced pleural effusions portend a poor prognosis. In cases of heart failure–related effusions, therapeutic thoracentesis is the first-line palliative therapy. However, if it is frequently needed, an indwelling pleural catheter (IPC) is recommended. In patients with hepatic hydrothorax, repeated therapeutic thoracenteses are commonly performed while a multidisciplinary decision on the most appropriate definitive management is taken. The percutaneous creation of a portosystemic shunt may be used as a bridge to liver transplantation or as a potential definitive therapy in nontransplant candidates. In general, an IPC should be avoided because of the high risk of complications, particularly infections, that may jeopardize candidacy for liver transplantation. Even so, in noncandidates for liver transplant or surgical correction of diaphragmatic defects, IPC is a therapeutic option as valid as serial thoracenteses.

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Two vs. three weeks of treatment with amoxicillin-clavulanate for stabilized community-acquired complicated parapneumonic effusions. A preliminary non-inferiority, double-blind, randomized, controlled trial

Cited by 15 publications

References 20 publications

Recent Insights into the Management of Pleural Infection

Recent Insights into the Management of Pleural Infection

16S rRNA is a valuable tool in finding bacterial aetiology of community-acquired pleural empyema–a population-based observational study in South Sweden

Nonmalignant Pleural Effusions

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