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The Bacteriology of Pleural Infection by Genetic and Standard Methods and Its Mortality Significance

Department of Respiratory Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol; Department of Microbiology, Royal Free Hospital, London; Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford Radcliffe Hospital, Headington, Oxford; and Department of Respiratory Medicine, Royal Berkshire Hospital, Reading, United Kingdom

Correspondence and requests for reprints should be addressed to R.J.O. Davies, D.M., F.R.C.P., Reader and Consultant in Respiratory Medicine, Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital Site, Oxford Radcliffe Hospital, Headington, Oxford, OX3 7LJ UK. E-mail: robert.davies{at}ndm.ox.ac.uk

Background: Antibiotic choices for pleural infection are uncertain as its bacteriology is poorly described.

Methods: Pleural fluid from 434 pleural infections underwent standard culture and a screen for bacteria by amplification and sequencing of bacterial 16S ribosomal RNA gene.

Results: Approximately 50% of community-acquired infections were streptococcal, and 20% included anaerobic bacteria. Approximately 60% of hospital-acquired infections included bacteria frequently resistant to antibiotics (methicillin-resistant Staphylococcus aureus, 25%; Enterobacteriaceae, 18%; Pseudomonas spp., 5%, enterococci, 12%). Mortality was increased in hospital-acquired infection (hospital, 17/36 [47%]; community, 53/304 [17%]; relative risk, 4.24; 95% confidence interval, 2.07–8.69; p < 0.00001; ², 1 df = 17.47) and in gram-negative (10/22 [45%]), S. aureus (15/34 [44%]), or mixed aerobic infections (13/28 [46%]), compared with streptococcal infection (23/137 [17%]) and infection including anaerobic bacteria (10/49 [20%]; p < 0.00001, ², 4 df = 23.35).

Conclusion: Pleural infection differs bacteriologically from pneumonia and requires different treatment. Antibiotics for community-acquired infection should treat aerobic and anaerobic bacteria. Hospital-acquired, gram-negative S. aureus and mixed aerobic infections have a high mortality rate.

Key Words: empyema • ISRCTN 39138989 • MIST1 trial • parapneumonic effusion • pleural infection

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