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EMPYEMA IN TRAUMA PATIENTS: MICROBIOLOGY, SURGERY, AND OUTCOME

University of Maryland School of Medicine, Shock Trauma Center, Baltimore, MD

PURPOSE: Empyema is a serious condition, well described following both pneumonia and lung resection. There is less data on empyema occurring after trauma. We reviewed our experience in trauma patients with empyema, examining pre-operative status, surgical procedures, pathogens and outcome.

METHODS: Trauma registry from 9/01 to 10/05 was retrospectively reviewed abstracting data on empyema, defined as culture positive pleural fluid or purulence at operation. Data collected included demographics, injury mechanism, thoracic injuries, co-morbidity, organ dysfunction, chest tube duration, pathogens isolated, surgical procedures, outcomes and follow up.

RESULTS: 71 consecutive patients with empyema were identified. Average Injury Severity Score and age were 25 and 39 years. Fifty nine had co-morbid conditions. 58 were male, 44 sustained blunt injury and 65 had chest trauma. Fifty two had prior chest tubes with average duration of 7 days. Eleven had pneumonia, 10 chest wall infection and 8 lung abscess when empyema was diagnosed. All underwent surgery with decortication and pleurectomy; thoracotomy in 58, the remainder thoracoscopy. At the time of operation, 52 were on mechanical ventilation and 18 required vasoactive medication. Time from injury to operation averaged 23 days. Pathogens isolated were: Gram positive cocci (GPC) 75, Gram negative rods 24, Gram positive rods 14, anaerobes 27, fungi 2, and polymicrobial flora in 32. Average duration of antibiotic therapy was 18 days. Of the 71 patients, 64 were cured, 4 had recurrence and 3 were indeterminate. Overall there were 5 deaths, 3 unrelated to surgery or infection; the two (2.8%) operative deaths occurred in patients with lung abscess. In those with recurrence, three required re-operation; all had GPC initially and in recurrence.

CONCLUSION: Trauma patients with empyema represent a subset of critically ill patients with substantial co-morbidity, diverse pathogens and polymicrobial flora. In this population, risk factors for empyema include chest tubes, chest trauma and concomitant infection. The presence of lung abscess may increase operative risk.

CLINICAL IMPLICATIONS: The combination of appropriate surgical management and specific antibiotic therapy yields excellent results with acceptable risk.

DISCLOSURE: James O Connor, No Financial Disclosure Information; No Product/Research Disclosure Information