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ORIGINAL ARTICLE
Year : 2018  |  Volume : 11  |  Issue : 4  |  Page : 318-323  

Assessment of factors associated with drainage duration and hospital stay of nontuberculous empyema in a tertiary care hospital of West Bengal: A prospective study


1 Department of Pulmonary Medicine, Burdwan Medical College, Bardhaman, West Bengal, India
2 Department of Community Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India
3 Department of Chest Medicine, Raghunathpur Superspeciality Hospital, Purulia, West Bengal, India
4 Department of Community Medicine, Burdwan Medical College, Bardhaman, West Bengal, India

Date of Web Publication2-Aug-2018

Correspondence Address:
Aditya Prasad Sarkar
31, N Bose Road, Telmarui, Bardhaman - 713 101, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.MJDRDYPU_219_17

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  Abstract 


Context: Empyema thoracis is a common cause of morbidity and mortality. A number of factors could affect the treatment outcome of empyema cases. Aims: To assess the clinical and microbiological characteristics of non-tuberculous empyema and the factors associated with duration of chest drainage and hospital stay. Settings and Design: The Department of Pulmonary Medicine of a teaching institution in eastern India. A prospective observational study. Material and Methods: The study was conducted among the admitted non tuberculous empyema cases over the period of 18 months. The demographic profile, clinical features, duration of chest drainage and hospital stay of 80 cases who were admitted during the data collection period was recorded. Statistical analysis used: Data were analysed using unpaired t test, Bivariate Correlation, Chi square test and Fisher's exact test with the help of SPSS 22.0 software. Results: Majority of cases were male and from rural area. Mean duration of intercostal chest tube drainage and hospital stay were 16 ± SD 5.2 and 17.7 ± SD 5.1 days respectively which were significantly increased with prolongation of interval between symptom onset and chest drain insertion (P = 0.000 and P= 0.000) and in presence of comorbidity (P = 0.022 and P= 0.026), pleural fluid loculations (P = 0.015 and P= 0.029), positive culture growth (P= 0.012 and P= 0.021) and presence of gram negative organism (P =0.005 and P = 0.008) in pleural fluid. Conclusions: Chest drain duration and hospital stay could be used as surrogate indicators for treatment outcome measures.

Keywords: Duration of chest drainage, length of hospital stay, non tuberculous empyema


How to cite this article:
Ghosh S, Sarkar AP, Pal S, Roy RN. Assessment of factors associated with drainage duration and hospital stay of nontuberculous empyema in a tertiary care hospital of West Bengal: A prospective study. Med J DY Patil Vidyapeeth 2018;11:318-23

How to cite this URL:
Ghosh S, Sarkar AP, Pal S, Roy RN. Assessment of factors associated with drainage duration and hospital stay of nontuberculous empyema in a tertiary care hospital of West Bengal: A prospective study. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2019 Oct 22];11:318-23. Available from: http://www.mjdrdypv.org/text.asp?2018/11/4/318/238173




  Introduction Top


Empyema thoracis or thoracic empyema is a common cause of morbidity and mortality due to chest disease. It is a quite common cause of inpatient admission in chest wards. These patients usually need prolonged hospital stay. This picture is quite similar in India as well as western world.

Therapy of thoracic empyema requires the use of appropriate antibiotics and early drainage of pleural fluid. However, the method of drainage can be non surgical such as thoracentesis, tube thoracostomy, and image-guided catheter drainage. Surgical options are video-assisted thoracoscopic surgery, decortications, and/or open thoracostomy. Surgical treatment may cause lesser duration of hospital stay in comparison to non surgical treatment both in adult and children.[1],[2] However, surgical treatment is not widely available in India. Therefore, the non surgical (tube thoracostomy) approach is the usual clinical practice here. Most of the studies showed that tuberculous thoracic empyema has poorer outcome in comparison to nontuberculous empyema in respect to complication, duration of treatment and drainage and need for surgery.[3],[4] A number of factors could affect the treatment outcome of empyema cases. The chest drain duration and hospital stay could be important surrogate indicators for treatment outcome measures. There is paucity of information regarding the factors affecting the chest drain duration and hospital stay in empyema cases in the eastern part of the county. With this background, a study was undertaken to assess the clinical and microbiological characteristics of nontuberculous empyema and to find out the factors affecting the drain duration and hospital stay in those cases in a tertiary care hospital of West Bengal.


  Subjects and Methods Top


Study settings and design

This prospective observational study was conducted in the Department of Pulmonary Medicine of Burdwan Medical College and Hospital, Bardhaman, West Bengal from January 2014 to June 2015. The study was approved by Institutional Ethics Committee and written informed consent was obtained from every participants.

Subjects

All patients above 12 years of age who were diagnosed as cases of nontuberculous empyema and admitted in the hospital during the study period were included in the study. The patients were selected on the basis of clinical indicators of infection such as fever, other chest symptoms, presence of pleural effusion in chest x-ray, and meeting any of the following criteria: (1) presence of frank pus on thoracentesis, (2) pleural fluid neutrophil predominance, and/or (3) presence of organism in pleural fluid identified by microscopic examination by Gram stain and isolated by culture.[5]

Patients were excluded if empyema was secondary to chest trauma, any prior chest procedure like thoracentesis or pleural biopsy, or had contiguous septic focus in abdomen or neck. Cases having acid fast bacilli in sputum or in pleural fluid and/or chest x-ray or CT scan thorax suggestive of tuberculosis were excluded from the study. Empyema with the presence of bronchopleural fistula was also excluded. The individuals who declined or unable to undertake the specified management and/or did not give consent were excluded.

Complete enumeration of all eligible patients admitted during the study period was done. Total number of patients participated in the study was 80 after necessary exclusions.

Methods

All patients undergone diagnostic thoracentesis under aseptic condition and subjected to examination by biochemical methods, cell types, and count including gross examination. Microbiological examination by Gram staining, Ziehl– Neelsen staining and culture and sensitivity for pyogenic bacteria were done. Anaerobic culture and culture for Mycobacteria were not done because of lack of facility in the hospital. Pleural fluid and sputum examination for Mycobacterium tuberculosis by cartridge-based nucleic acid amplification test was not done as programmatic management of drug-resistant tuberculosis was not practised at our institution at that time. Chest X-ray was done during follow-up in hospital course and chest ultrasound and contrast-enhanced CT (CECT) scan thorax were done in selected cases when necessary.

Broad-spectrum antibiotics such as injection piperacillin and tazobactam and infusion metronidazole were started empirically in all patients. Antibiotics were changed or adjusted according to culture sensitivity results, in patients failing to respond clinically (subsidence of fever and empyema drainage amount) and radiologically within 3–5 days.

A chest tube of size 24–32 F was inserted into 5th intercostal space along midaxillary line or in the suitable dependent part and connected with under water seal drainage bag. Chest and systemic symptoms, pleural fluid drainage amount, and chest x-ray were the parameters monitored regularly. Chest tubes were removed when the drainage amount was <50 ml/day for 2 consecutive days. Thrombolytic like streptokinase or urokinase was used intrapleurally in none of the patients as it was not available at the institution at that time.

A maximum of 30 days were observed. If the patient did not improve in symptoms (persistence of pleural fluid drainage), he/she would be referred to another institution for opinion and necessary action for surgical treatment. Those cases were not followed.

Data collection

The following data were collected for each patient: age, gender, residence, occupation, body mass index (BMI), clinical symptoms, smoking history, history of preexisting lung disease or tuberculosis, immunosuppression, other comorbidities, interval from the onset of symptoms to treatment initiation, pleural effusion amount (seen by chest x-ray), the duration of chest tube drainage, pleural fluid consistency, pleural fluid loculations (detected by ultrasonography or CECT scan thorax), post drainage residual pleural thickening (detected by chest X-ray or CECT scan thorax), duration of hospitalization, any complication, etc.

Statistical methods

Data were analyzed using statistical software SPSS version 22.0 (IBM Corporation, Armonk, New York, USA) Mean, standard deviation (SD), and proportion were used for descriptive statistical analysis. Unpaired t-test, bivariate correlation, Chi-square test, and Fisher's exact test were used for inferential statistical analysis.


  Results Top


Patient characteristics

One hundred and fifty empyema patients were screened. Among them, 70 patients were excluded (three patients did not give consent for intercostal chest drain [ICD], four patients left against medical advice, and 63 patients were diagnosed as cases of tuberculous empyema). A total of 80 patients fulfilled the inclusion criteria and took part in the study. Male patients contributed more than four-fifth (65, 81.2%) of total patients. Majority of the patients (72, 90%) were from rural areas and more than half of the patients (52.5%) were associated with agriculture. The age of the patients ranged from 20 to 68 years. Majority of empyema occurred in the age group 36–45 years comprising 35% cases. The mean age of patients was 40.8 ± SD 11.8 years. Mean BMI of patients was found to be 20.6 ± SD 2.7 (range: 15.9–27.5) [Table 1].
Table 1: Demographic and clinical profile of study participants (n=80)

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Fever was the most common symptom (61, 76%) followed by cough and chest pain. Few patients (7, 8.7%) had pain abdomen [Figure 1]. Mean time interval from onset of symptoms to initiation of treatment in our hospital was 16 ± SD 6.5 days.
Figure 1: Distribution of study participants according to presenting symptoms

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Comorbid illness was found in 38 (45%) patients among whom the most common was diabetes mellitus [Figure 2]. More than one comorbid illnesses were present in 5 (6.25%) patients while two patients had bronchogenic carcinoma. Immunosuppression was presumably related to diabetes, malnutrition, and chronic liver disease and the number is 17 (21.2% of patients). There was no case of HIV positive. Preexisting lung disease was found clinically and radiologically in 19 (23.7%) patients. In chest X–ray, pleural effusion was moderate in 43 and rest (37, 46.2%) were massive. Drainage fluid was both thin and thick. Residual pleural thickening was found in 29 (36.2%) patients. A good number of patients (n = 60) had undergone ultrasound chest to detect any septation or loculations when there was a delay in drainage and it was found to be present in 18 patients.
Figure 2: Distribution of study participants according to comorbidity

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Microbiology

The results of initial pleural fluid culture were positive in only 23 (28.7%) cases among 80 individuals. Predominant organisms were Pseudomonas aeruginosa, Staphylococcus aureus, Klebsiella pneumonia, etc. Among positive culture isolates, majority (60.9%) were Gram negative. Analysis of demographic features of patients revealed that patients with Gram-negative empyema, when compared with Gram-positive empyema, had a higher prevalence of underlying comorbidities (88.9% vs. 50%) which was not statistically significant (Fisher's exact P= 0.063) [Table 2].
Table 2: Distribution of study participants according to comorbidity and Gram positivity of plural fluid culture (n=80)

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The yield of culture growth positivity was very low. It could be attributed to the presence of anaerobic organisms and/or prior use of antibiotic before admission. Twenty-one patients had taken oral antibiotic and 12 patients received parenteral treatment. Except two, all patients who received prior antibiotic were culture growth negative, whereas culture was negative only in 26, among 47 patients who did not receive any prior treatment with antibiotic. Therefore, pretreatment with antibiotic was found to be significantly associated with culture growth negativity (P < 0.001) [Table 3].
Table 3: Distribution of study participants according to pretreatment with antibiotic and culture positivity of pleural fluid (n=80)

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Pleural fluid Gram-stain yield was very low. Nine patients showed the presence of organisms, where majority (seven) were Gram negatives.

Treatment outcome

All patients received broad-spectrum intravenous antibiotic for the period ranging from 7 to 28 days followed by appropriate oral antibiotic for 15–20 days. Average duration of ICD was 16 ± SD 5.2 days, and average duration of hospital stay was 17.7 ± SD 5.1 days.

Mean duration of ICD and hospital stay were significantly associated with factors such as comorbidity (P = 0.022 and P= 0.026, respectively), pleural fluid loculations (P = 0. 015 and P= 0. 029), culture growth positivity (P = 0.012 and P= 0.021), and presence of Gram-negative organisms (P = 0.005 and P= 0.008, respectively) in pleural fluid [Table 4] and [Table 5].
Table 4: Distribution of study participants according to different variables and duration of intercostal drainage (n=80)

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Table 5: Distribution of study participants according to different variables and duration of hospital stay (n=80)

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The interval between onset of symptoms and chest drain was significantly associated with duration of intercostal drainage (P = 0.000) and duration of stay in hospital (P = 0.000).

Other factors such as smoking, preexisting lung disease, immunosuppression, size of empyema, consistency of pleural fluid, and residual pleural thickening do not significantly affect the outcome.

Eight (10%) patients did not improve clinically within 30 days and therefore were referred for surgical treatment of empyema. One patient with lung cancer succumbed to death. Rest 71 (88.8%) patients were treated successfully and discharged with oral antibiotics.


  Discussion Top


This study reports the clinical and microbiological parameters which significantly affect the outcome of treatment in 80 consecutive cases of nontuberculous empyema which were treated with antibiotic and intercostal chest tube drainage.

Our study shows that prolongation of interval between the onset of symptoms and definitive treatment (antibiotic and ICD), presence of comorbid disease, loculations in pleural fluid, positive culture growth, and presence of Gram-negative organism in pleural fluid were significantly associated with increased duration of chest tube drainage and hence hospital stay. Prior treatment with antibiotics was significantly associated with pleural fluid culture growth negativity which indirectly indicates good prognosis and shorter ICD duration and hospital stay.

The place of this study is a medical college where the majority of patient population are from rural area. The facility of cardiothoracic surgery was not available. As a cheap and easy method, tube thoracostomy was the most acceptable choice for drainage of pleural pus.

Comorbid illness is a common association in this empyema series, and it is comparable to other studies.[3],[6],[7],[8] The presence of comorbid illness causes significant prolongation of treatment duration, as observed in this study. In their report, Chen et al.[6] showed that the presence of Klebsiella in empyema fluid was significantly associated with increased prevalence of comorbidities, especially diabetes. Our study shows increased prevalence of Gram-negative empyema in the presence of comorbidities which was also statistically significant.

The present study shows increased prevalence of Gram-negative organisms in empyema fluid. This is in contrary with our textbook knowledge and idea from earlier studies.[4],[9] However, a similar high rate of isolation of Gram negative organisms from pleural fluid culture was reported in India [3],[7],[10],[11] and abroad.[6],[12] An explanation of increased prevalence of Gram negative bacteria in pleural pus is early antibiotic therapy which was usually directed against Gram positive organisms.[10],[13] The presence of Gram-negative organism in empyema fluid was significantly associated with increased duration of tube drainage and hospital stay, as observed in our study. Similar observation was also found in other studies.[14],[15]

Average length of hospital stay in our study was 17.7 days, which is comparable to few recent other studies.[3],[4],[12],[15] In our study, the proportion of culture-negative group is more than two-third of cases. Apart from anaerobic organisms, another contributor may be prior use of antibiotic therapy before admission to hospital.[4],[11] Our study shows a significant association between prior antibiotic therapy and culture growth negativity. Duration of tube drainage and hospital stay was increased significantly in the presence of culture growth positivity in our study. Light[5] and Arunagirinathan et al.[13] also showed that demonstration of organism in pleural fluid was the risk factor for poor treatment outcome, in cases of empyema.

Strengths and limitations

The present study was a prospective study which has provided the scope of daily monitoring of the cases. However, the study has noted only the immediate outcome of the cases and not assessed the long-term follow-up of the cases.


  Conclusion Top


In the present study, the duration of ICD and hospital stay was longer with the presence of comorbidity, positive culture growth, and Gram-negative organism in pleural fluid. Hence, chest drain duration and hospital stay could be used as surrogate indicators for treatment outcome measures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Redden M D, Chin T Y, van Driel M L. Surgical versus non-surgical management for pleural empyema. Cochrane Database Syst Rev. 2017 Mar 17;3:CD010651. doi:10.1002/14651858.CD010651.pub2.  Back to cited text no. 1
    
2.
Anstadt MP, Guill CK, Ferguson ER, Gordon HS, Soltero ER, Beall AC Jr et al. Surgical versus nonsurgical treatment of empyema thoracis: an outcomes analysis. Am J Med Sci. 2003; 326:9-14.  Back to cited text no. 2
    
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Malhotra P, Aggarwal A N, Agarwal R, Ray P, Gupta D, Jindal SK. Clinical characteristics and outcomes of empyema thoracis in 117 patients: A comparative analysis of tuberculous vs. non-tuberculous aetiologies. Respiratory Medicine 2007;101:423–430.  Back to cited text no. 3
    
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Kundu S, Mitra S, Mukherjee S, Das S. Adult thoracic empyema: A comparative analysis of tuberculous and nontuberculous etiology in 75 patients. Lung India 2010;27:196-201.  Back to cited text no. 4
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Light RW. Parapneumonic Effusions and Empyema. Proc. Am Thorac. Soc. 2006;3:75–80.  Back to cited text no. 5
    
6.
Chen K Y, Hsueh P R, Liaw Y S, Yang P C, Luh K T. A 10-Year Experience With Bacteriology of Acute Thoracic Empyema* Emphasis on Klebsiella pneumoniae in Patients With Diabetes Mellitus. CHEST 2000;117:1685–1689.  Back to cited text no. 6
    
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Acharya P R, Shah K V. Empyema thoracis: A clinical study. Annals of Thoracic Medicine 2007;2:14-17.  Back to cited text no. 7
    
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Søgaard M, Nielsen RB, Nørgaard M, B. Kornum JB, Schønheyder HC, Thomsen RW. Incidence, Length of Stay, and Prognosis of Hospitalized Patients With Pleural Empyema, A 15-Year Danish Nationwide Cohort Study. CHEST;145:189-192.  Back to cited text no. 8
    
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LeMense G P, Strange C, Sahn SA. Empyema thoracis. Therapeutic management and outcome. CHEST 1995;107:1532-37.  Back to cited text no. 9
    
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Jain S, Banavaliker J N. EMPYEMA THORACIS: Bacteriological analysis of pleural fluid from the largest chest hospital in Delhi. IOSR Journal of Dental and Medical Sciences. 2013;3:46-51.  Back to cited text no. 10
    
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Sethy H K, Panda G, Biswal P T, Pradhan S, Sahu G K, Giri P K et al. Empyema thoracis: a current profile at a tertiary care centre. J Evolution Med Dent Sci 2016;5:547-56.  Back to cited text no. 11
    
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Tareen S, Yaseen M, Iqbal Z, Masoom A. Analysis of 42 Consecutive Cases of Empyema Thoracis. Ann. Pak. Inst. Med. Sci. 2010;6:205-209.  Back to cited text no. 12
    
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Arunagirinathan V, Stalin S, Narayanan E. Risk factors associated with adverse outcome in empyema thoracis children aged 1 month-12 years in a tertiary care centre: a nested case control study. Int J Contemp Pediatr. 2017;4:1284-1288.  Back to cited text no. 13
    
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Lin Y C, Tu C Y, Chen W, Tsai Y L, Chen H J, Shih C M et al. An Urgent Problem of Aerobic Gram-Negative Pathogen Infection in Complicated Parapneumonic Effusions or Empyemas. 2007; 46:1173-78. Available from: http://www.naika.or.jp/imindex.html. DOI: 10.2169/internalmedicine.46.6451.  Back to cited text no. 14
    
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Mukherjee S, Begum S, Mitra S, Kundu S. non-tubercular empyema thoracis- a comparative analysis of gram positive and gram negative organism associated empyema. J. Evolution Med. Dent. Sci 2017; 6:4445-49.  Back to cited text no. 15
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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