Chest ACCP Member Benefits
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Guest Access | Sign In via User Name/Password
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Erratum (v129,p216)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via ISI Web of Science (2)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Cheng, G.
Right arrow Articles by Vintch, J. R.E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Cheng, G.
Right arrow Articles by Vintch, J. R.E.
(Chest. 2005;128:3284-3290.)
© 2005 American College of Chest Physicians

A Retrospective Analysis of the Management of Parapneumonic Empyemas in a County Teaching Facility From 1992 to 2004*

Glena Cheng, MD and Janine R.E. Vintch, MD

* From the Division of Respiratory and Critical Care, Physiology and Medicine, Kaiser Permanente, Torrance, CA.

Correspondence to: Glena Cheng, MD, Department of Pulmonary and Critical Care, Kaiser-Permanente, Bellflower Medical Center, 9400 E. Rosecrans Avenue, Bellflower, CA 90706; e-mail: glenacheng{at}hotmail.com


   Abstract
TOP
 Abstract
Introduction
 Methods and Patients
 Results
 Discussion
 Conclusion
 References
 
Objectives: To characterize how patients with empyemas are managed initially at our facility and to determine how "less aggressive" treatments (eg, no drainage, repeat thoracentesis, or tube thoracostomy) affect short-term outcomes (ie, inpatient mortality and the need for a second intervention) compared to "more aggressive" treatments (eg, intrapleural fibrinolytic agents, video-assisted thoracoscopic surgery, or other surgery). We will also assess whether earlier diagnosis, earlier antibiotic treatment, fewer patient comorbidities, and consulting appropriate services improve mortality.

Design: Retrospective chart analysis.

Setting: County teaching hospital in Los Angeles, CA.

Patients: Seventy-two adult inpatients with parapneumonic empyemas.

Interventions: Mortality and the need for second intervention rates were calculated and compared with data published in the 2000 American College of Chest Physicians consensus statement on the management of parapneumonic effusions using the Fisher exact test. Comparisons were made between empyema survivors and nonsurvivors using t tests and {chi}2 tests.

Results: All 72 patients were managed with less aggressive initial treatments. There were no differences in mortality when our patients were compared to the less aggressive group from the literature (6% vs 9%, respectively; p = 0.40; relative risk, 0.6; 95% confidence interval [CI], 0.23 to 1.62) or the more aggressive group from the literature (6% vs 3%, respectively; p = 0.29; relative risk, 1.8; 95% CI, 0.64 to 5.23). There was no difference between the second intervention rate of our patients and that of the less aggressive group from the literature (47% vs 43%, respectively; p = 0.47; relative risk, 1.1; 95% CI, 0.86 to 1.42), although there was a difference when compared to the more aggressive group (47% vs 11%, respectively; p < 0.0001; relative risk, 4.5; 95% CI, 3.20 to 6.31). There were no statistically significant differences in time of diagnosis, the timing of antibiotic treatment, the number of patient comorbidities, or the number of services consulted when survivors and nonsurvivors from the study were compared.

Conclusions: Patients with empyemas at our hospital are treated with less aggressive initial treatments and have a higher second intervention rate when compared to patients described in the literature who were initially managed with more aggressive treatments.

Key Words: chest tube • empyema • pleural effusion • pneumonia • thoracotomy • video-assisted thoracoscopic surgery


   Introduction
TOP
 Abstract
 Introduction
Methods and Patients
 Results
 Discussion
 Conclusion
 References
 
The proper management of empyemas has been debated since the time of Hippocrates. Long after Hippocrates first described using rib resection and intercostal drainage in 400 BC,1 the Empyema Commission2 headed by Graham and Bell published in 1918 the first set of guidelines for treating empyemas, which emphasized treating the infected pleural space, but avoiding immediate open drainage.

In the American College of Chest Physicians (ACCP) consensus statement on the management of parapneumonic effusions guidelines published in 2000 (hereafter referred to as the ACCP 2000 guidelines), the expert panel recommends drainage of category 3 parapneumonic pleural effusions (ie, pleural effusions that are large and free-flowing [greater than or equal to one half a hemithorax], loculated, or associated with thickened parietal pleura; a positive Gram stain or culture result; or a pH < 7.20) and category 4 (grossly purulent) parapneumonic pleural effusions.3 In a metaanalysis3 of 24 articles on the management of parapneumonic effusions, the panel found that the pooled mortality was higher for patients whose initial treatment was no drainage, therapeutic thoracentesis, or tube thoracostomies, compared to those who received immediate treatment with intrapleural fibrinolytic agents, video-assisted thoracoscopic surgery (VATS), or other surgical interventions. There was an overlap in the 95% confidence intervals (CIs) for these mortality rates, but there was no overlap in the comparison of the percentage of patients needing a second intervention, favoring the latter three "more aggressive" modalities over the first three "less aggressive" treatment modalities.3

Harbor-UCLA Medical Center (HUMC) is a county teaching hospital with 340 funded beds in Los Angeles County, in Southern California. We hope by reviewing the management of the cases of patients cared for by both our medical and surgical services, we will be able to discern how different our general approach to draining these infections in our facility is compared to the ACCP 2000 guidelines and to determine whether these differences and/or other patient or management factors affect short-term outcomes.

We hypothesize that patients at HUMC with empyemas are not managed as aggressively with early invasive drainage procedures as is favored by the 2000 ACCP guidelines, and that, despite this, they do not have worse short-term outcomes with respect to inpatient mortality or the need for a second intervention, compared to statistics published in the ACCP 2000 guidelines for the more aggressive treatment group. We also hypothesize that fewer patient comorbidities, earlier diagnosis, earlier antibiotic treatment, and consulting appropriate services will be associated with better outcome.


   Methods and Patients
TOP
 Abstract
 Introduction
 Methods and Patients
Results
 Discussion
 Conclusion
 References
 
A retrospective chart analysis on adult patients in whom parapneumonic empyemas were diagnosed from 1992 to 2004 at HUMC was performed. We used a similar definition of "need for a second intervention" as used by the authors of the ACCP 2000 guidelines, which was any additional form of drainage performed after the initial drainage procedure, including additional tube thoracostomy, radiologic-guided drainage, or any form of surgical intervention, including rib resection, thoracotomy, and VATS (G. L. Colice, MD, and J. Heffner, MD; personal communication; 2005). Comparison rates were calculated based on data in the ACCP 2000 guidelines.

In order to find subjects, a query was done for the primary diagnosis of "empyema" on (1) the internal pulmonary consult computerized database, which lists inpatient consultations from 1997 to 2004, and (2) the general hospital computerized medical records database of inpatients from 1992 to 2004. In order to capture more subjects who may have not been properly given the diagnosis of "empyema," a chart query was also performed over the same time period using the primary diagnosis of "pneumonia" and the secondary diagnosis of "pleural effusion."

For the purpose of this project, the definition of an empyema was expanded from that used by Light,4 "pus in the pleural space," to any pleural fluid that was grossly purulent and/or had a positive Gram stain or culture.567 As it is possible to have iatrogenic empyemas from prior attempts at thoracentesis or thoracostomy tube placement, only patients who had nonpurulent fluid and positive pleural fluid Gram stains and/or cultures from the first pleural fluid samples were included. However, patients with pus found on initial or subsequent pleural fluid samples were included, as it is possible that a loculated pocket of pus was not initially sampled.

Only patients who were ≥ 18 years of age with community-acquired parapneumonic empyemas were considered in this study. Patients were excluded from the study if the empyema developed secondary to a procedure, secondary to hospital-acquired or ventilator-associated pneumonia, or secondary to a nonpulmonary primary infection; was diagnosed at an outside hospital before the patient was transferred to HUMC or was previously inadequately treated on an earlier hospital admission; had incomplete data regarding pleural fluid characteristics so that the diagnosis of empyema could not be confirmed; was secondary to tuberculous or fungal infections; or was associated with pulmonary malignancies or pulmonary metastases. The charts, laboratory data, and/or hospital discharge summaries of all identified potential patients were reviewed to see whether appropriate inclusion and exclusion criteria were met. The study protocol was reviewed and approved by the Los Angeles Biomedical Research Institute Institutional Review Board at HUMC.

Statistical Analysis
The overall mortality rate and the rate at which patients needed a second intervention were estimated with a 95% CI using binomial proportion distributions. These rates were compared with external rates from the literature that were published in the ACCP 2000 guidelines with Fisher exact tests. For mortality subgroup analysis, continuous factors were compared between survivors and nonsurvivors using two-tailed t tests. Noncontinuous factors were analyzed with the {chi}2 test. A p value of < 0.05 was considered to be statistically significant.

For precision, using 100 subjects, the 95% confidence limit for the calculated mortality rate was expected to be no greater than ± 4%. One hundred subjects provided an 80% power to detect, with a p value of < 0.05, a mortality rate difference of ≥ 11% compared to an estimate from the literature of 3% associated with the more aggressive treatment modalities.3 Similarly, 100 subjects provided an 80% power to detect, with a p value of < 0.05, a difference in the rate of the need for a secondary intervention at ≥ 22% compared to an estimate from the literature of 11% associated with the more aggressive treatment modalities.3


   Results
TOP
 Abstract
 Introduction
 Methods and Patients
 Results
Discussion
 Conclusion
 References
 
From the internal pulmonary consult database, 68 potential empyema patients were identified. Thirty-seven patients were excluded from the study, and one chart could not be located. Using the primary diagnosis of "empyema" and excluding duplicate subjects from the internal pulmonary consult database, 192 potential subjects were identified from the general hospital database. Of these, 148 subjects were excluded, and two charts could not be located. When the query was repeated using a primary diagnosis of "pleural effusion" and a secondary diagnosis of "pneumonia," 118 additional potential subjects were identified, but none met the appropriate criteria.

Thus, from all the different databases, a total of 72 patients (19% of 378 patients) were included in the study. For both empyema groups, the most common reason for study exclusion was that the pleural fluid did not meet the criteria of this study for empyema, although they did fulfill the other criteria of Light4 for complicated parapneumonic effusions. For the pleural effusion and pneumonia subsets of potential subjects, patients were most commonly excluded from the study because there was no documentation of the presence of a pleural effusion or evidence of pleural fluid being sampled.

Sixty patients (83%) were men. Thirty-nine percent of the patients were white, 29% were Hispanic, 22% were black, and 10% were Asian. The mean age (± SD) of the patients was 45 ± 14 years (age range, 18 to 84 years). Fifty-four percent of the patients had at least one comorbid medical illness. The most common medical comorbidities were diabetes, liver disease, and heart failure (Table 1 ). The most common social comorbidities included alcohol, tobacco, and non-IV drug use (Table 2 ).


View this table:
[in this window]
[in a new window]

  		Table 1.. Medical Comorbidities of the 72 Empyema Patients

 

View this table:
[in this window]
[in a new window]

  		Table 2.. Social Comorbidities of the 72 Empyema Patients

 
The mean symptom duration was 3.1 ± 2.5 weeks (range, 1 day to 12 weeks). The most common symptoms were cough, shortness of breath, and fever (Table 3 ). Sixty-one percent of the patients were febrile during the first 24 h of hospital admission.


View this table:
[in this window]
[in a new window]

  		Table 3.. Frequency of Symptoms Among 72 Empyema Patients

 
For all subsequent reports of timing, all reported times will be related to the initial time the patient was checked into triage or the clinic, as documented on the nursing notes. The mean time it took to obtain a pleural sample from these patients was 32 ± 41 h (range, 2 to 288 h).

Of the 63 patients for whom information was available, 60% had purulent fluid obtained from the first pleural fluid sample. Of the 69 patients for whom information was available, 68% had positive Gram stains of their pleural fluid (only Gram-positive cocci, 51%; only Gram-positive rods, 4%; only Gram-negative rods, 6%; polymicrobial, 38%). Of the 65 patients who had pleural fluid cultures sent, 54 patients had positive culture findings. Streptococcus viridans was the most common organism isolated (Table 4 ). For patients with available data, the pleural fluid parameters were consistent with exudative pleural processes (Table 5 ). The mean serum WBC count on hospital admission was 17.6 ± 8.6 x 109 cells/L (range, 4.7 to 43.9 x 109 cells/L).


View this table:
[in this window]
[in a new window]

  		Table 4.. Pleural Fluid Culture Results for 65 Patients

 

View this table:
[in this window]
[in a new window]

  		Table 5.. Pleural Fluid Analysis of the Empyemas*

 
On average, patients received their first dose of antibiotics during the 15th hour of the hospitalization ± 40 h (range, 1 to 336 h). The most commonly administered antibiotics were ceftriaxone, clindamycin, and erythromycin.

Of all patients, 81% had pulmonary consultants, 38% had infectious disease consultants, and 94% had cardiothoracic surgery consultants. The average hospital day on which patients were seen by the consultants is listed in Table 6 .


View this table:
[in this window]
[in a new window]

  		Table 6.. Use of Consulting Services to Manage Patients With Empyemas

 
All patients except one received some form of additional drainage after the empyema was diagnosed. Three percent of the patients were treated by repeat thoracentesis, 85% had thoracostomy tubes placed, and 31% underwent radiologic-guided drainage.

For the 61 patients who received thoracostomy tubes, tubes were placed on mean hospital day 2.7 ± 2.1 (range, hospital day 1 to 16). Patients had a mean number of 1.4 ± 0.7 intercostal drains (including radiologic-guided drains) placed during hospitalization (range, 1 to 4 drains). Of the 69 patients who had intercostals drains placed, 86% had drains removed during the hospitalization or underwent VATS or open thoractomy during the same hospitalization, 10% of the patients were discharged to home after conversion of the thoracostomy tube into an empyema tube, 1% of the patients were transferred to another facility with a thoracostomy tube, 1% of patients were discharged to home with a pigtail catheter, and 1% of patients died with a chest tube in place.

None of the 72 patients was treated with intrapleural fibrinolytic agents, VATS, or other surgical interventions as first-line therapy for their empyemas. Although five patients died, only four died secondary to the consequences of the empyema, resulting in an empyema-related mortality rate of 6%.

Thirty-four patients (47%) "failed" their first procedure. Four patients underwent additional tube thoracostomy placement and surgery during their first hospitalization, 5 patients underwent surgery during their first hospitalization, 21 patients had additional intercostal drainage, 2 patients were readmitted to the hospital and underwent repeat tube thoracostomy drainage, 1 patient was readmitted to the hospital twice, ultimately requiring decortication, and 1 patient was referred as an outpatient to undergo further surgical treatment.

Of the nine patients (13%) who underwent surgical interventions, one VATS procedure was performed on hospital day 28. The eight patients who underwent thoracotomies underwent surgery on mean hospital day 7 ± 4 (range, hospital day 3 to 14).

Subgroup Analysis Based on Mortality
No statistically significant differences were found for patient characteristics and symptoms between empyema survivors and nonsurvivors, although there was a trend for nonsurvivors to have a higher number of medical comorbidities (Table 7 ). With regard to laboratories, nonsurvivors tended to have their initial pleural samples obtained later, and had a statistically lower percentage of purulent fluid obtained from the first pleural sample, statistically lower pleural fluid glucose levels, and statistically lower pleural fluid WBC counts (Table 8 ).


View this table:
[in this window]
[in a new window]

  		Table 7.. Comparison of Patient Demographics Based on Mortality Secondary to Empyema

 

View this table:
[in this window]
[in a new window]

  		Table 8.. Comparison of Laboratory Data Based on Mortality Secondary to Empyema

 
Antibiotics were administered at the 9th hour of the hospitalization in the nonsurvivor group compared to the 15th hour of hospitalization in the survivor group (p = 0.44). The use of all consultants was higher in the nonsurvivor group, although it was not statistically different for any consultant (pulmonary consultant, 100% vs 78%, respectively [p = 0.29]; infectious diseases consultant, 75% vs 35%, respectively [p = 0.09]; cardiothoracic surgery consultant, 100% vs 94%, respectively [p = 0.61]).

As shown in Table 9 , there were no significant differences in mortality rates when our patients are compared with either treatment group discussed in the literature. However, the proportion of our patients needing to undergo a secondary procedure was statistically higher than that of the more aggressive group in the ACCP 2000 guidelines, but was not statistically different from that of the less aggressive group in the ACCP 2000 guidelines (Table 10 ).


View this table:
[in this window]
[in a new window]

  		Table 9.. Comparison of Mortality Rates Between Patients in Current Study and ACCP 2000 Guidelines Based on Initial Intervention*

 

View this table:
[in this window]
[in a new window]

  		Table 10.. Comparison of Percentage of Patients Needing a Second Intervention Between Patients in the Current Study and ACCP 2000 Guidelines Based on Initial Intervention*

 

   Discussion
TOP
 Abstract
 Introduction
 Methods and Patients
 Results
 Discussion
Conclusion
 References
 
This retrospective study describes the empyema population seen at a county teaching facility in Los Angeles County between 1992 and 2004. The findings demonstrate that patients at HUMC with empyemas are all managed in a less aggressive manner initially.

Despite our hypotheses that fewer patient comorbidities, earlier diagnosis, earlier antibiotic treatment, and consulting appropriate services would be associated with decreased mortality, none of these factors were statistically different between the survivors and nonsurvivors. However, although not statistically significant, later thoracenteses may have contributed to mortality as a delay in thoracentesis may lead to a delay in the diagnosis and treatment of an empyema.

The finding that the timing of the administration of antibiotics was not statistically different between the two groups also does not rule out that a delay in the administration of antibiotics did not contribute to empyema-related mortalities. While it is recommended in the 2003 update of the Infectious Diseases Society of America community-acquired pneumonia guidelines8 to administer antibiotics "within four hours after registration," based on the study of Houck et al9 of improved outcome in Medicare patients who received therapy with antimicrobial agents within this time period, it took an average of > 9 h to administer antibiotics to patients who died secondary to their empyemas.

Although our initial hypothesis was that consulting more specialists would improve empyema-related mortality, it was found was that the nonsurvivors tended to have seen a higher percentage of consultants. This finding likely reflects the fact that more consultants were asked to see patients whose conditions were more complicated, were more ill, and had, therefore, higher risks for mortality than those patients who did not see as many consultants.

It was not surprising that there were no differences in mortality from the current study group to either treatment group reported in the ACCP 2000 guidelines as there were no differences in mortality between the two groups in the metaanalysis. Although our subjects had a similar rate of patients needing second interventions compared to the rate reported in the literature for the less aggressive treatment group, they had a statistically higher rate than the rate reported for the more aggressive treatment group, contrary to our hypothesis that our care was comparable to the more aggressive strategy.

Although primary therapy with intrapleural fibrinolytic agents, VATS, and other surgical procedures does not seem to collectively improve mortality, their potential to reduce the need for a second procedure may be of significant benefit. By decreasing the need for a second procedure, there may be a decrease in the morbidity associated with delayed treatment as well as a decrease in the number of days and the costs of prolonged hospitalization or readmission to the hospital and associated iatrogenic complications.

Intrapleural fibrinolytic agents have received renewed attention since the publication in 2005 by Maskell et al10 of the first large, multicenter, randomized, double-blind study of the treatment of pleural infections with intrapleural streptokinase. The treatment group did not have any improvement in mortality rate or the rate of surgery compared to patients treated with chest-tube drainage alone. It is important to note that in other studies in which there have been positive results associated with the use of intrapleural streptokinase, subjects had chest tubes placed under radiographic guidance.1112 In addition, the need for the insertion or reinsertion of chest tubes was not reported as a secondary end point in the study by Maskell et al10 as it was in the ACCP 2000 guidelines, which may be a clinically relevant outcome that is affected by therapy with intrapleural fibrinolytic agents.

The lack of large, multicenter, randomized, double-blinded studies evaluating the role of thoracotomies in the treatment of empyemas results in difficulty defining the exact role of this invasive procedure in the management of empyemas. In a retrospective review13 of patients undergoing thoractomy and decortication for acute pleural effusions, 63 patients with and without other underlying diseases were treated with "early" open thoracotomy and decortication. Given the relatively small percentage of recurrence and postoperative deaths in the group with comorbidities, Mayo concluded that "the severely ill patient can better withstand the ordeal of operation than the deleterious effects of a lingering empyema."13 In a prospective, controlled, but nonrandomized study by Lim and Chin,7 82 patients underwent simple tube drainage, tube drainage and intrapleural streptokinase, or early surgery. Compared to the other groups, the hospitalization and mortality rates were significantly lower in the early group.7

In the 1990s, VATS was introduced into the operating room, allowing surgeons to perform a less invasive procedure compared to formal thoracotomy for treatment of certain empyema cases.14 In a prospective cohort study15 of 48 patients with parapneumonic empyemas, 12 patients underwent thoractomy and decortication while 36 patients underwent an attempt at VATS. Although the procedure in 41% of the patients in the VATS group had to be converted to formal thoractomy, those who successfully underwent VATS received perioperative benefits, as demonstrated by significantly shorter operating room times and postoperative hospital stays. In a prospective, randomized, single-center study16 comparing the use of intrapleural fibrinolytic agents and VATS in empyema patients, the VATS group was found to have a statistically significant higher primary treatment success rate, shorter chest tube duration, and shorter hospitalizations. Of note, although not statistically significant, the hospital costs also tended to be lower in the VATS group.16

One of the weaknesses of this study is that it is a retrospective study, prohibiting the equal randomization of patients undergoing different procedures. In addition, we relied on the rates published in the metaanalysis in the ACCP 2000 guidelines to make comparisons, which may not accurately reflect rates at HUMC if our patients had received the same initial aggressive treatments.

The strict entry criteria for this study may have excluded a significant proportion of patients with category 3 parapneumonic effusions, which, per ACCP guidelines, also meet the criteria for drainage procedures and have only a moderate risk for a bad outcome compared to category 4 effusions, which have a high risk of a poor outcome. This may have resulted in our patients having a falsely elevated mortality rate and rate of the need for a second intervention compared to rates in the 2000 ACCP guidelines. However, our "need for a second intervention" rates may be underestimated because outpatient follow up was not complete for this patient population as many patients missed follow-up appointments and left against medical advice, and subjects may have received further treatment or second interventions at other facilities.

The failure to obtain 100 patients as originally planned for this retrospective analysis may limit the interpretation of some of the statistical data from this study. However, the rate of the need for a second intervention of 47% that was found in this study was larger than the 22% needed to demonstrate a significant difference for a study population of 100 patients. In addition, when the power calculation was redone for 72 subjects, a rate of 24% was found to be needed to demonstrate a significant difference, suggesting that the difference detected in the rates of the need for a second intervention for our 72 patients exists.


   Conclusion
TOP
 Abstract
 Introduction
 Methods and Patients
 Results
 Discussion
 Conclusion
References
 
From this study, one can conclude that patients with empyemas at our county teaching facility are treated with less aggressive primary interventions. Although there is no significant difference in mortality when our patients are compared to the estimate of the mortality rate in the literature among patients who are treated with more aggressive primary interventions, there is clearly an increased need in our patients for a second therapeutic intervention. Given all the new literature demonstrating the benefits associated with VATS, it would be worthwhile to evaluate how the addition of VATS as a primary treatment for empyemas at an institution such as HUMC would be able to improve patient outcomes.


   Acknowledgements
 
The authors thank Peter D. Christenson, PhD, for assistance with the biostatistical analysis.


   Footnotes
 
Abbreviations: ACCP = American College of Chest Physicians; CI = confidence interval; HUMC = Harbor-UCLA Medical Center; VATS = video-assisted thoracoscopic surgery

Received for publication March 29, 2005. Accepted for publication May 16, 2005.


   References
TOP
 Abstract
 Introduction
 Methods and Patients
 Results
 Discussion
 Conclusion
 References
 

  1. . Hippocrates (1847) Genuine works of Hippocrates. Translated by Anderer F. Syndeham Society. London, UK:
  2. Empyema, Commission Cases of empyema at Camp Lee, Virginia. JAMA 1918;71,366-373
  3. Colice, GL, Curtis, A, Deslauriers, J, et al ACCP consensus statement: medical and surgical treatment of parapneumonic effusions, an evidence-based guideline. Chest 2000;118,1158-1171[Abstract/Free Full Text]
  4. Light, RW Parapneumonic effusions and empyema. Light, RW eds. Pleural diseases 4th ed. 2001,151-181 Lippincott Williams & Wilkins. Philadelphia, PA:
  5. Storm, HK, Krasnik, M, Bang, K, et al Treatment of pleural empyema secondary to pneumonia: thoracentesis regimen versus tube drainage. Thorax 1992;47,821-824[Abstract/Free Full Text]
  6. Bouros, D, Schiza, S, Patsourakis, G, et al Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusion. Am J Respir Crit Care Med 1997;155,291-295[Abstract]
  7. Lim, TK, Chin, NK Empirical treatment with fibrinolysis and early surgery reduces the duration of hospitalization in pleural sepsis. Eur Respir J 1999;13,514-518[Abstract]
  8. Mandell, LA, Bartlett, JG, Dowell, SF, et al Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis 2003;32,1405-1433
  9. Houck, PM, Bratzler, DW, Nsa, W, et al Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia. Arch Intern Med 2004;164,637-644[Abstract/Free Full Text]
  10. Maskell, NA, Davies, WH, Nunn, AJ, et al U.K. controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 2005;352,865-874[Abstract/Free Full Text]
  11. Davies, RJO, Traill, ZC, Gleeson, FV Randomized controlled trial of intrapleural streptokinase in community acquired pleural infection. Thorax 1997;52,416-421[Abstract]
  12. Diacon, AH, Theron, J, Schuurmans, MM, et al Intrapleural streptokinase for empyema and complicated parapneumonic effusions. Am J Respir Crit Care Med 2004;170,49-53[Abstract/Free Full Text]
  13. Mayo, P Early thoracotomy and decortication for nontuberculous empyema in adults with and without underlying disease. Am Surg 1985;51,230-236[ISI][Medline]
  14. Fry, WA Surgical management of empyema. Kaiser, LR Kroh, IL Spray, TL eds. Master of cardiothoracic surgery 1998,247-256 Lippincott-Raven. Philadelphia, PA:
  15. Waller, DA, Rengarajan, A Thoracoscopic decortication: a role for video-assisted surgery in chronic postpneumonic pleural empyema. Ann Thorac Surg 2001;71,1813-1816[Abstract/Free Full Text]
  16. Wait, MA, Sharma, S, Hohn, J, et al A randomized trial of empyema therapy. Chest 1997;111,1548-1551[Abstract/Free Full Text]




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Erratum (v129,p216)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via ISI Web of Science (2)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Cheng, G.
Right arrow Articles by Vintch, J. R.E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Cheng, G.
Right arrow Articles by Vintch, J. R.E.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS