Tremblay, Alain MD; Stather, David R. MD; MacEachern, Paul MD
Department of Medicine, University of Calgary, Calgary, Alberta, Canada
Reprints: Alain Tremblay, MD, University of Calgary, 3330 Hospital Dr. NW, Calgary, AB T2N4N1 Canada (e-mail: email@example.com).
The use of tunneled pleural catheters (TPCs) has become commonplace in the management of malignant pleural effusions. Touted advantages of this approach have included outpatient placement, liberal patient selection, rapid and persistent improvement in symptoms, and significant spontaneous pleurodesis rates.1 In addition, complication rates associated with this technique seem low and manageable. Nevertheless, as more and more of these catheters are placed, complications associated with their use will be seen proportionately more frequently. Empyema is perhaps the most severe complication occurring in patients treated with TPCs.
The 2 most commonly reported infectious complications after TPC placement have been cellulitis and empyema. The incidence of each of these complications seems to be 1.9% (14 of 744 catheters) when the 4 largest published case series are combined.2–5 These rates are in the same range as those reported after pleurodesis procedures (0.7% to 2.5%).6–10
Cellulitis typically appears in the first 2 weeks after insertion, likely as a consequence of the procedure itself and secondary wound infection from normal skin flora. Patients typically feel well overall, but may complain of irritation or discomfort at the catheter site. Patients and their caregivers should be made aware of the possibility of this complication and instructed to contact the responsible physician if there is any evidence of infection. Fortunately, this complication can be treated on an outpatient basis with oral antibiotics directed toward Gram-positive organisms (eg, cloxacillin, amoxicillin-clavulanic acid, cefazolin, or clindamycin). If there is no delay in the diagnosis and treatment, then removal of the catheter is not required. Drainage can be continued as per the predetermined schedule. It is important to ensure that the infection is limited to the skin and does not extend along the subcutaneous tunnel or into the pleural space, as then more aggressive treatment may be required. In addition, it is important to ensure that the catheter tissue cuff remains in position, as wound healing will be impaired by the infection. Should the cuff be dislodged, it has been our practice to remove the catheter.
In the January issue of the Journal of Bronchoscopy & Interventional Pulmonology, Drs Mahmood and Bower describe their experience with 3 cases of TPC-related empyema.11 Although it is difficult to make significant conclusions from these cases, they do show many features that mirror our experience with this complication.
Empyemas typically occur after many weeks of drainage and without evidence of cellulitis, as seen in cases 2 and 3, suggesting that contamination of the system at the drainage port is the site of entry for bacteria. Less frequently, empyemas develop early after insertion as a consequence of untreated cellulitis and tunnel infection, as shown by their first case. Even less frequently, empyema can occur as a consequence of pneumonia and true parapneumonic infection. Patients are typically systemically ill with fever and increased white blood cell count, and change in the appearance of the pleural fluid is often noted. Elevated pleural fluid white cells and lactate dehydrogenase will be noted, and culture results will more commonly reflect the microbiology of nosocomial empyema rather than community-acquired infections. Staphylococcus aureus, noted in 2 of these 3 cases, has also been the most commonly isolated organism in our center, with methicillin resistance paralleling the frequency of this organism in our community and hospital. Nevertheless, a variety of other organisms and occasionally polymicrobial infections including Gram-negative organisms have been detected, emphasizing the importance of obtaining adequate blood and pleural fluid cultures before initiating antibiotic treatment.
The management of TPC-associated empyema should follow the 2 main principles of empyema treatment: appropriate administration of antimicrobial agents and adequate drainage of the pleural space. It has been our approach to admit these patients to the hospital to initiate treatment, but outpatient management could be considered in stable patients who express a strong preference to avoid hospitalization. Selection of antibiotics should be based on commonly encountered organisms in this particular clinical setting. Intravenous broad-spectrum antibiotics are favored, ensuring adequate S. aureus coverage, and for methicillin-resistant S. aureus if the prevalence of this organism is significant in a particular setting. Of course, once clinical status has stabilized, pleural drainage is achieved, and results of microbiologic testing are available, antibiotics can be narrowed and converted to oral regimens accordingly. Although evidence is lacking,12 a 3-week to 6-week treatment course with antibiotics would be reasonable, as was done in these cases. We do not have experience with the use of intrapleural antibiotics as described in these 3 cases. Most antibiotics achieve adequate pleural penetration when administered intravenously and there is a lack of high-level evidence that intrapleural administration is more effective than intravenous treatment. As such, we cannot advocate for their use based on this small series.
The optimal approach to pleural drainage remains controversial in the treatment of empyema in general, with thoracentesis, small and large bore drains, thoracoscopy, and decortication each playing a potential role in the management of these patients.12 In this series of 3 cases, drainage was achieved with thoracentesis, additional chest drain, and through the TPC itself in each case respectively. It has also been our approach to avoid more invasive surgical procedures in these patients with advanced malignancies and have found that empyema can usually be drained successfully through the same TPC, often with the use of intrapleural thrombolytics13 to break down loculations and adhesions. We do prefer to connect the TPC to continuous drainage rather than intermittent drainage in an attempt to more thoroughly drain the infected space. Additional percutaneous drains are occasionally required if this initial approach fails. Interestingly, as was noted in 2 of the cases, pleurodesis is common after resolution of empyema and the TPC can be removed without recurrence of the effusion. In fact, it has been our practice to remove the TPC before discontinuing antibiotics, as it is unlikely that this foreign body can truly be sterilized.
The particular problem of empyema developing in the setting of a trapped lung warrants further comment. Unfortunately in these cases, as the lung cannot reexpand to obliterate the infected pleural space, it becomes very difficult to eradicate the infection with drainage and antibiotics alone. Surgical decortication intuitively would seem to be the treatment of choice, but this may not be a particularly well-tolerated procedure in this palliative patient population. In many cases, the TPC can be maintained in place chronically to maintain pleural drainage in a medical variant of the Claggett procedure, with antibiotics maintained in the long term to suppress the infection.
As physicians place more TPCs for the treatment of malignant pleural effusions, the occasions when they will have to manage their associated complications will increase. Empyema is perhaps the most serious complication noted with TPCs, but in our experience and as noted in this publication, the majority can be managed successfully by ensuring adequate antibiotic treatment and pleural drainage, often without the need for additional pleural procedures. Patients and their caregivers should be made aware of potential infectious complications of this treatment approach and should have rapid access to the treatment team if a problem arises. Careful attention to sterile techniques, both during insertion and the drainage procedure, is likely an important factor in minimizing this risk.
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