Bacteriology, antibiotic resistance and risk stratification of patients with culture-positive, community-acquired pleural infection

Marianthi Iliopoulou; Vasileios Skouras; Zoe Psaroudaki; Magda Makarona; Evangelos Vogiatzakis; Eleni Tsorlini; Eleni Katsifa; Dionisios Spyratos; Dimitra Siopi; Ourania Kotsiou; Stelios Xitsas; Maria Martsoukou; Ioanna Sigala; Ioannis Kalomenidis

doi:10.21037/jtd-20-2786

Bacteriology, antibiotic resistance and risk stratification of patients with culture-positive, community-acquired pleural infection

J Thorac Dis. 2021 Feb;13(2):521-532. doi: 10.21037/jtd-20-2786.

Authors

Affiliations

¹ 7th Respiratory Medicine, Athens Chest Hospital "Sotiria", Athens, Greece.
² Department of Pulmonary Medicine, 401 General Army Hospital, Athens, Greece.
³ Department of Clinical Microbiology, "Evangelismos" Hospital, Athens, Greece.
⁴ Microbiology Laboratory and National Reference Center for TB, Athens Chest Hospital "Sotiria", Athens, Greece.
⁵ Department of Microbiology, "G. Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
⁶ Department of Pulmonary Medicine, "G. Papanikolaou" Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
⁷ Department of Respiratory Medicine, University of Thessaly, Larissa, Greece.
⁸ Department of Microbiology, University Hospital of Larissa, Larissa, Greece.
⁹ Department of Microbiology, "Sismanoglion" General Hospital, Athens, Greece.
¹⁰ 1st Department of Critical Care and Pulmonary Medicine, National and Kapodistrian University of Athens, "Evangelismos" Hospital, Athens, Greece.

Abstract

Background: Community-acquired pleural infection (CAPI) is a growing health problem worldwide. Although most CAPI patients recover with antibiotics and pleural drainage, 20% require surgical intervention. The use of inappropriate antibiotics is a common cause of treatment failure. Awareness of the common causative bacteria along with their patterns of antibiotic resistance is critical in the selection of antibiotics in CAPI-patients. This study aimed to define CAPI bacteriology from the positive pleural fluid cultures, determine effective antibiotic regimens and investigate for associations between clinical features and risk for death or antibiotic-resistance, in order to advocate with more invasive techniques in the optimal timing.

Methods: We examined 158 patients with culture positive, CAPI collected both retrospectively (2012-2013) and prospectively (2014-2018). Culture-positive, CAPI patients hospitalized in six tertiary hospitals in Greece were prospectively recruited (N=113). Bacteriological data from retrospectively detected patients were also used (N=45). Logistic regression analysis was performed to identify clinical features related to mortality, presence of certain bacteria and antibiotic resistance.

Results: Streptococci, especially the non-pneumococcal ones, were the most common bacteria among the isolates, which were mostly sensitive to commonly used antibiotic combinations. RAPID score (i.e., clinical score for the stratification of mortality risk in patients with pleural infection; parameters: renal, age, purulence, infection source, and dietary factors), diabetes and CRP were independent predictors of mortality while several patient co-morbidities (e.g., diabetes, malignancy, chronic renal failure, etc.) were related to the presence of certain bacteria or antibiotic resistance.

Conclusions: The dominance of streptococci among pleural fluid isolates from culture-positive, CAPI patients was demonstrated. Common antibiotic regimens were found highly effective in CAPI treatment. The predictive strength of RAPID score for CAPI mortality was confirmed while additional risk factors for mortality and antibiotic resistance were detected.

Keywords: Clinical epidemiology; bacteria; empyema; pleural disease; respiratory infections.