*Department of Medicine, Section of Pulmonary and Critical Care
†Department of Radiology, Mercy Hospital and Medical Center, Chicago, IL
Source of Financial Support: None.
Disclosures: Kamran Mahmood has no conflict of interest to disclose.
Reprints: Kamran Mahmood, MD, MPH, Mercy Hospital and Medical Center, 2525 S Michigan Avenue, Chicago, IL 60616 (e-mail: email@example.com).
Received for publication July 11, 2009; accepted September 14, 2009
Charles Bower has 100 shares of Merck, 100 shares of GE, 300 shares of Pfizer, and 100 shares of Eli Lilly. He has no direct conflict of interest with the Pleurx catheter manufacturer, Denver Biomedicals, Golden, CO.
Chronic indwelling tunneled pleural catheters are increasingly used for the treatment of malignant pleural effusions. Some common complications of these catheters include empyema and local site infection. Empyema is generally treated with the removal of the pleural catheter and the administration of systemic antibiotics. We propose a more conservative but effective method of treating empyema associated with infected tunneled pleural catheters.
An 82-year-old woman with breast cancer and malignant left pleural effusion with trapped lung had a tunneled pleural catheter (Pleurx catheter 15.5 F, Cardinal Health, Dublin, OH) placement. The patient developed left-sided chest tenderness, erythema, and swelling 6 weeks after catheter insertion (Fig. 1). Pleural fluid cell count showed 12,000 white cells/μL, mostly neutrophils, lactate dehydrogenase (LDH; 1000 IU/L), and protein (3.4 g/dL). Streptococcus agalactiae was isolated from the fluid culture. Two grams of cefazolin in 25 mL of normal saline was instilled into the pleural cavity, and she was started on broad-spectrum parenteral antibiotics. Once the susceptibility profile of the S. agalactiae became available, the patient was switched to oral therapy with amoxicillin/clavulanate (875 mg twice a day). The pleural fluid culture turned negative after 2 days. Intermittent catheter drainage was continued on a daily schedule until the pleural fluid was sterilized. She received a total of 4 weeks of antibiotics. The cellulitis around the Pleurx catheter resolved (Fig. 2) and computed tomography (CT) of the chest showed small loculated effusion and persistent trapped lung, with the resolution of inflammation around the catheter (Figs. 3, 4). The pleurx stopped draining after a total of 13 weeks and was removed. The patient was doing well 3 months after the catheter removal.
A 60-year-old man with adenocarcinoma of the right lung, complicated by trapped lung and malignant pleural effusion, underwent tunneled pleural catheter insertion (Pleurx catheter 15.5 F). Four months after pleural catheter placement, he developed fever and leukocytosis. The pleural fluid had 10,800 white cells/μL, mostly neutrophils, LDH (7600 IU/L), protein (2 g/dL), and glucose (5 mg/dL). The culture of his pleural fluid yielded methicillin-sensitive Staphylococcus aureus. He had 2 g of cefazolin instilled into the pleural space through the Pleurx catheter, and was started on oral clindamycin (450 mg four times a day), as S. aureus was sensitive. His fever and leukocytosis resolved and his pleural fluid culture turned negative after 7 weeks. The pleural catheter was drained once a day until the cultures were negative. He was on antibiotics for 8 weeks. The patient was eventually admitted to a hospice 2 weeks after the completion of treatment of empyema for general deterioration of his health, where he subsequently died.
A 60-year-old woman with left malignant pleural effusion secondary to breast cancer had a tunneled pleural catheter (Pleurx catheter 15.5 F) placement. She developed empyema with methicillin-sensitive S. aureus 4 months after pleural catheter insertion. The pleural fluid had 13,750/μL white cells, mostly neutrophils, LDH (500 IU/L), protein (4 g/dL), and glucose (<19 mg/dL). The pleural catheter had stopped draining. A CT scan of the chest revealed a loculated pleural fluid collection that was separate from the pleurx catheter. Unlike in the above cases, the catheter was removed as it did not communicate with the loculated empyema. She was treated with parenteral broad-spectrum antibiotics and was later switched to oral levofloxacin (500 mg daily), based on the sensitivity of S. aureus. Levofloxacin was continued for 6 weeks. She required 2 outpatient CT-guided thoracenteses to completely drain the loculated infected pleural effusion, and 1 g of cefazolin was instilled at the last thoracentesis. Eighteen months after treatment, she remains asymptomatic, without significant reaccumulation of effusion.
Malignant pleural effusions are seen in advanced metastatic cancers and are associated with significant morbidity and poor survival. Indwelling tunneled pleural catheters can be easily placed in the outpatient setting, allowing for convenient, intermittent, at-home drainage by the patient or their caregivers. They provide immediate relief of symptoms and subsequent spontaneous pleurodesis in 40% to 60% of the cases.1–3 This has been confirmed in a randomized trial comparing tunneled pleural catheters with doxycycline pleurodesis through tube thoracostomy for the treatment of recurrent, malignant pleural effusions.3
The infectious complications related to tunneled pleural catheters include localized cellulitis at the catheter insertion site and empyema. We encountered the 3 described cases of infectious complications (6.1%) in a total of 49 tunneled pleural catheters placed at our institution. The infectious complications related to tunneled pleural catheters are reported to be in the range of 2% to 16% in the literature.1–8 However, treatment options are not always addressed or may be conflicting. Musani et al4 reported 3 cases of empyema (12.5%) and 3 cases of cellulitis (12.5%) out of 24 patients with malignant pleural effusion and tunneled pleural catheter insertion. They removed the pleural catheter in all the 3 reported cases of empyema and administered intravenous antibiotics, with chest tube insertion in 1 case. Cellulitis was treated with oral antibiotics without the removal of the pleural catheter.4 Sioris et al5reported 3 cases of empyema (5.8%) out of 51 cases of malignant pleural effusion. Streptococcus viridans, S. aureus, and Eschericia coli were grown in the cultures. The pleural catheters were removed in all cases and intravenous antibiotics administered. One case of local cellulitis (2%) was treated with intravenous antibiotics without the removal of the catheter. All the infections occurred 3 to 6 months after catheter implantation.5 Putnam et al3 reported an incidence of 1 case of empyema (1%) and 6 cases of cellulitis (7%) out of 91 tunneled catheter placements in a randomized trial comparing the tunneled catheters to doxycycline pleurodesis in the management of malignant pleural effusions. The treatment of empyema was not described. However, cellulitis was treated with oral antibiotics without the removal of the catheter.3 In a later publication, Putnam et al6 reported an empyema incidence of 5%. Warren et al1 reported a 0.3% incidence of empyema and 1.3% localized cellulitis in their case series of 295 patients with malignant pleural effusion. The management of the infections was not detailed. Tremblay and Michaud2 had 8 cases of empyema (3.2%) and 4 cases of cellulitis (1.6%) in their case series of 250 catheters. Empyema was treated by in-hospital intravenous antibiotics and continuous drainage, with thrombolytics and drainage of loculated effusion as needed. van den Toorn et al7 reported 1 case of empyema and 1 case of localized infection in their case series of 17 patients.
Meticulous precautions and strict aseptic technique should be used for catheter insertion. This includes skin antisepsis with 2% chlorhexidine and maximal sterile barrier precautions. Some investigators have used systemic prophylactic antibiotics and monofilament suture.5 However, these have not proven to be of benefit. The patients who receive the catheters have predisposing risk factors, including immunosuppression related to cancer and its treatment, postobstruction pneumonia and atelectasis, and ongoing exposure to healthcare settings. Breaches of the sterile technique can also occur during handling of the catheter at home. The patients and their caregivers should be educated about the care of the catheter, including the use of sterile gloves for handling the catheter, cleaning with 2% chlorhexidine, covering the site with a dressing, and changing the dressing when it is damp or soiled.
Cellulitis around the catheter site has been described commonly, but we have shown for the first time that cellulitis and inflammation may travel along the tunnel and may therefore represent a tunnel infection, as shown on the chest CT. The experience from cuffed, tunneled, hemodialysis catheters describes 2 distinct localized infections: exit site versus tunnel infection, based on whether the infection is distal or proximal to the cuff, respectively.8 Exit site infection is generally treated with antibiotics, whereas tunnel infection may necessitate catheter removal. Localized cellulitis or tunnel infection in pleural catheters can be treated with oral or parenteral antibiotics without removing the pleural catheter.
Treatment of empyema associated with tunneled pleural catheters may entail the removal of the catheter, with or without drainage with tube thoracostomy, and systemic antibiotics in inpatient settings.4,5 As patients with these catheters often have limited survival, this treatment may take away significant time from their families and friends. The authors suggest retaining the infected tunneled pleural catheter in the setting of empyema and local site infection, and use of oral antibiotics, if the sensitivity allows. The catheters should be drained once daily on a regular basis, until the pleural fluid sterilize, and the patients should be closely followed as outpatients to ensure appropriate response. It is interesting to note that Davies et al9 used tunneled pleural catheters to treat chronic empyema.
Intrapleural instillation of antibiotics may be considered as an adjuvant therapy. It can be performed easily at the bedside through the tunneled pleural catheter using a commercially available adapter. The concept of using intrapleural instillation or irrigation of antibiotics for the treatment of empyema is not new.10 Although there is substantial evidence that various antibiotics penetrate the infected pleural space and achieve a reasonable therapeutic level,11,12 the use of pleural space irrigation with antibiotics is shown to be effective in the treatment of postpneumonectomy empyema.13,14 It could be of value in the treatment of empyema associated with trapped lung, which is more difficult to treat. However, the dose and frequency of various antibiotics cannot be recommended based on our limited experience.
There is no consensus on the duration of systemic antibiotic therapy in empyema. Three to 4 weeks of antibiotics is generally recommended, based on clinical response.15 We used antibiotics in our patients for 4 to 8 weeks, based on clinical improvement and until the cultures turned negative.
Another interesting finding in our case series is that the infection was seen after more than 6 weeks and was unlikely related to contamination during insertion. All the infections were caused by Gram-positive cocci, which were sensitive to several antibiotics, allowing the use of oral agents.
In conclusion, the conservative approach may be a treatment option for infected tunneled pleural catheters and may avoid additional procedures and hospitalization. Our series is limited by small sample size, and the treatment of infected pleural catheters warrants further study.
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13. Gharagozloo F, Trachiotis G, Wolfe A, et al. Pleural space irrigation and modified Clagett procedure for the treatment of early postpneumonectomy empyema. J Thorac Cardiovasc Surg. 1998;116:943–948.
14. Ng T, Ryder BA, Maziak DE, et al. Treatment of postpneumonectomy empyema with debridement followed by continuous antibiotic irrigation. J Am Coll Surg. 2008;206:1178–1183.
15. Davies CW, Gleeson FV, Davies RJ, et al. BTS guidelines for the management of pleural infection. Thorax. 2003;58(suppl 2):ii18–ii28.
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