Gallstone Disease

Gallstone Disease
By:Tad Kim, M.D.

Overview
* Gallstone pathogenesis
* Definitions
* Differential Diagnosis of RUQ pain
* 7 Cases

Gallstone Pathogenesis
* Bile = bile salts, phospholipids, cholesterol
o Also bilirubin which is conjugated b4 excretion
* Gallstones due to imbalance rendering cholesterol & calcium salts insoluble
* Pathogenesis involves 3 stages:
o 1. cholesterol supersaturation in bile
o 2. crystal nucleation
o 3. stone growth

Definitions
Infection within bile ducts usu due to obstrux of CBD. Charcot triad: RUQ pain, jaundice, fever (seen in 70% of pts), can lead to septic shock

Cholangitis
Gallstone in the common bile duct (primary means originated there, secondary = from GB)

Choledocho-lithiasis
GB inflammation due to biliary stasis(5% of time) and not stones(95%). Seen in critically ill pts

Acalculous cholecystitis
Recurrent bouts of colic/acute chol’y leading to chronic GB wall inflamm/fibrosis. No fever/WBC.

Chronic cholecystitis
Acute GB inflammation due to cystic duct obstruction. Persistent RUQ pain +/- fever, ↑WBC, ↑LFT, +Murphy’s = inspiratory arrest

Acute cholecystitis
Wax/waning postprandial epigastric/RUQ pain due to transient cystic duct obstruction by stone, no fever/WBC, normal LFT

Symptomatic cholelithiasis
Differential Diagnosis of RUQ pain

* Biliary disease
o Acute chol’y, chronic chol’y, CBD stone, cholangitis
* Inflamed or perforated duodenal ulcer
* Hepatitis
* Also need to rule out:
o Appendicitis, renal colic, pneumonia or pleurisy, pancreatitis
Case 1

* 46yo F w RUQ pain x4hr, after a fatty meal, radiating to the R scapula, also w nausea. Pt is pain-free now.
* No prior episodes
* Minimal RUQ tenderness, no Murphy’s
* WBC 8, LFT normal
* RUQ U/S reveals cholelithiasis without GB wall thickening or pericholecystic fluid
* Diagnosis: ?

Symptomatic cholelithiasis

* aka “biliary colic”
* The pain occurs due to a stone obstructing the cystic duct, causing wall tension; pain resolves when stone passes
* Pain usually lasts 1-5 hrs, rarely > 24hrs
* Ultrasound reveals evidence at the crime scene of the likely etiology: gallstones
* Exam, WBC, and LFT normal in this case
* Treatment: Laparoscopic cholecystectomy

Spectrum of Gallstone Disease
Cholelithiasis
Asymptomatic
cholelithiasis
Symptomatic
cholelithiasis
Chronic
calculous
cholecystitis
Acute
calculous
cholecystitis
* Symptomatic cholelithiasis can be a herald to:
o an attack of acute cholecystitis
o or ongoing chronic cholecystitis
* May also resolve

Case 2
* Same case, except pt has had multiple prior attacks of similar RUQ pain
* No fever or WBC
* Ultrasound reveals gallstones, thickened GB wall, no pericholecystic fluid
* Diagnosis: ?
Chronic calculous cholecystitis

* Recurrent inflammatory process due to recurrent cystic duct obstruction, 90% of the time due to gallstones
* Overtime, leads to scarring/wall thickening
* Treatment: laparoscopic cholecystectomy

Case 3
* Same pt, now > 24hrs of RUQ pain radiating to the R scapula, started after fatty meal, a/w nausea, vomiting, fever
* Exam: Palpable, tender gallbladder, guarding, +Murphy’s = inspiratory arrest
* WBC 13, Mild LFT
* U/S: gallstones, wall thickening (>4mm), GB distension, pericholecystic fluid, sonographic Murphy’s sign (very specific)
* Diagnosis: ?
* Curved arrow
o Two small stones at GB neck
* Straight arrow
o Thickened GB wall
* GB also appears distended

Acute calculous cholecystitis
* Persistent cystic duct obstruction leads to GB distension, wall inflammation & edema
* Can lead to: empyema, gangrene, rupture
* Pain usu. persists >24hrs & a/w N/V/Fever
* Palpable/tender or even visible RUQ mass
* Nuclear HIDA scan shows nonfilling of GB
o If U/S non-diagnostic, obtain HIDA
* Tx: NPO, IVF, Abx (GNR & enterococcus)
* Sg: Cholecystectomy usu within 48hrs
* 87yo M critically ill, on long-term TPN w RUQ pain, fever, WBC
* Ultrasound: GB wall thickening, pericholecystic fluid, no gallstones

Acute acalculous cholecystitis
* In 5-10% of cases of acute cholecystitis
* Seen in critically ill pts or prolonged TPN
* More likely to progress to gangrene, empyema, perforation due to ischemia
* Caused by gallbladder stasis from lack of enteral stimulation by cholecystokinin
* Tx: Emergent cholecystectomy usu open
* If pt is too sick, perc cholecystostomy tube and interval cholecystectomy later on

Complications of acute cholecystitis
Less commonly, perforates into adjacent viscus = cholecystoenteric fistula & the stone can cause SBO (gallstone ileus)
Occurs in 10% of acute chol’y, usually becomes a contained abscess in RUQ
Perforated gallbladder
More commonly in men and diabetics. Severe RUQ pain, generalized sepsis. Imaging shows air in GB wall or lumen
Emphysematous cholecystitis
Pus-filled GB due to bacterial proliferation in obstructed GB. Usu. more toxic, high fever
Empyema of gallbladder

Case 5
* 46yo F p/w RUQ pain, jaundice, acholic stools, dark tea-colored urine, no fevers
* Known history of cholelithiasis
* Exam: unremarkable
* WBC 8, T.Bili 8, AST/ALT NL, HepB/C neg
* Ultrasound: Gallstones, CBD stone, dilated CBD > 1cm

Choledocholithiasis
* Can present similarly to cholelithiasis, except with the addition of jaundice
* DDx: cholelithiasis, hepatitis, sclerosing cholangitis, less likely CA with pain
* Tx: Endoscopic retrograde cholangiopancreatography (ERCP)
o Stone extraction and sphincterotomy
* Interval cholecystectomy after recovery from ERCP

Case 6
* 46yo F p/w fever, RUQ pain, jaundice (Charcot’s triad)
* If also altered mental status and signs of shock = Raynaud’s pentad
* VS tachycardic, hypotensive
* ABC’s, Resuscitate
o 2 large bore IV, Foley, Continuous monitor
o 1-2L fluid bolus, repeat until resuscitated
* Diagnosis: ?

Cholangitis
* Infection of the bile ducts due to CBD obstruction 2ndary to stones, strictures
* Charcot’s triad seen in 70% of pts
* May lead to life-threatening sepsis and septic shock (Raynaud’s pentad)
* Tx: NPO, IVF, IV Abx
* Emergent decompression via ERCP or perc transhepatic cholangiogram (PTC)
* Used to require emergency laparotomy

Case 7
* 46yo F p/w persistent epigastric & back pain
* Known history of symptomatic gallstones
* No EtOH abuse
* Exam: Tender epigastrum
* Amylase 2000, ALT 150
* Ultrasound: Gallstones
* Diagnosis: ?

Gallstone pancreatitis
* 35% of acute pancreatitis 2ndary to stones
* Pathophysiology
o Reflux of bile into pancreatic duct and/or obstruction of ampulla by stone
* ALT > 150 (3-fold elevation) has 95% PPV for diagnosing gallstone pancreatitis
* Tx: ABC, resuscitate, NPO/IVF, pain meds
* Once pancreatitis resolving, ERCP w stone extraction/sphincterotomy
* Cholecystectomy before hospital discharge

Take Home Points
* As always, ABC & Resuscitate before Dx
* Understanding the definitions is key
* Is this acute cholecystitis? (fever, WBC, tender on exam with positive Murphy’s)
* Or simply cholelithiasis vs ongoing chronic cholecystitis? (no fever/WBC)
* Is patient sick or toxic-appearing, to suspect empyema, gangrene or even perforation?
* Elicit h/o jaundice, acholic stools, tea-colored urine
* Rule out cholangitis, because this will kill the patient unless dx & tx early

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Lower Respiratory Tract Infections

Lower Respiratory Tract Infections
By: Divya Ahuja, M.D.

Lower respiratory infections: anatomic classification
* Tracheitis; bronchitis; tracheobronchitis
* Bronchiolitis
* Bronchopneumonia
* Segmental pneumonia
* Lobar pneumonia
* Interstitial pneumonia

Case #1
* 40-year-old man
* no underlying lung disease
* 7-day history of mild shortness of breath with exertion, and a productive cough.
* Temperature = 37°C, pulse 84 beats/min, and his respiratory rate 17 breaths per minute.
* no rales are heard; scattered wheezes are heard in the lung bases.

Acute bronchitis (“chest cold”)
* Usually of viral etiology(influenza, rhinovirus, parainfluenza, RSV, human metapneumovirus)
* A common cause for overuse of antibiotics
* Bacteria implicated are
o Bordetella pertussis (whooping cough)
o Mycoplasma pneumoniae
o Chlamydia pneumoniae

Acute bronchitis
* Similar to URIs but more prolonged
* Cough persists > 5 days (upto 40 days)
* 40% will have reduction in pulmonary function
* Main differential includes
o Asthma/ bronchiolitis
o Bronchiectasis
o Chronic bronchitis (cough and sputum for 3 months during 2 years

Acute Bronchitis

* Cough in the absence of fever, tachycardia, and tachypnea suggests bronchitis, rather than pneumonia
* Antimicrobial agents are not recommended in most cases of acute bronchitis
* Antimicrobial therapy is indicated when a treatable pathogen is identified (influenza, Bordetella pertussis )

Acute exacerbations of chronic bronchitis

* Chronic bronchitis is associated with cigarette smoking and COPD
* Extent to which specific bacterial pathogens explain exacerbations is controversial.
* However, repeated bacterial infections (especially H. influenzae) contribute to deterioration of lung function.

Case # 2

* 54 year male, chronic cough x 1 year. no hemoptysis. Denies fevers, shakes, chills. No sick contacts

Bronchiectasis
* Abnormal dilatation of bronchi with chronic productive cough.
* Can be clue to cystic fibrosis in younger patients (associated with S. aureus and Pseudomonas species)
* Uncommon associations: immunodeficiency disorders, dyskinetic cilia syndrome

Case # 3
* 54 year old male
* Flu like illness 2 weeks ago
* 5 day history of chills, fever, difficulty breathing, right sided pleuritic chest pain, cough and yellow sputum

Pneumonia
* 6th leading cause of death in U.S.A.
* About 3 million cases per year; > 500,000 hospital admissions
* About 50% of cases and the majority of deaths are due to bacteria
* Precise diagnosis is usually desirable but difficult to obtain

Acute pneumonia

* History
* Symptoms-cough, sputum, fever, malaise
* Clinical setting-community acquired, nosocomial
* Defects in host defense- HIV, neutropenia
* Possible exposures

Organisms in community acquired pneumonia

Organisms:
S pneumoniae
H influenzae
o P aeruginosa
o S aureus
o Atypicals
+ Chlamydia, Legionella
+ Mycoplasma, Bordetella

Pneumonia (2)
* Streptococcus pneumoniae the most common cause of community-acquired pneumonia requiring hospitalization
* Haemophilus influenzae and Moraxella catarrhalis are increasing in frequency
* Legionella species and Chlamydia pneumoniae have emerged
* Pneumocystis carinii (HIV disease)

Pneumonia: pathogenesis
* Endogenous vs. exogenous (inhalation)
* Bronchogenous vs. lymphohematogenous
* “Pulmonary clearance”: mucociliary blanket, alveolar macrophages
* Factors that impair pulmonary clearance: viral URI; smoking; alcohol; uremia; bronchial obstruction; 100% oxygen; others

“Typical” versus “atypical” pneumonia

* “Typical” (virulent bacteria): abrupt onset; productive cough with purulent sputum; pleuritic chest pain; impressive physical findings; leukocytosis or leukopenia
* “Atypical” (viral, Mycoplasma pneumoniae, others): gradual onset, nonproductive cough; substernal chest pain; unimpressive physical exam; white blood count normal

Typical versus atypical pneumonia

Classic pneumococcal pneumonia

* Antecedent upper respiratory infection
* Sudden onset with single violent chill, then fever
* Pleuritic chest pain
* Signs of lobar consolidation on exam
* If untreated, terminates gradually by “lysis” or suddenly by “crisis”

Atypical pneumococcal pneumonia

* Caught early: signs of consolidation may be absent
* Elderly: fever, classic history may be absent
* COPD: CXR and physical findings are distorted
* Ethanolism: blunted history; prostration, leukopenia
* Epilepsy: lack of history; fever and tachycardia may be attributed to seizures; anaerobes may co-exist
* Recurrent pneumonia: In same area, suggests obstruction or bronchiectasis

Some current problems with pneumococcal disease

* Failure of antibiotic therapy to improve survival during first 3 days
* Vaccine efficacy and distribution
* Resistance to penicillin G
* Overwhelming sepsis in asplenic persons
* Need for developing better diagnostic techniques

Group A streptococcal pneumonia

* Rare, except during influenza epidemics
* Large empyema (“pus in the chest”) is characteristic

Hemophilus influenzae pneumonia

* 2% to 18% of community-acquired pneumonias;
* Predisposition: underlying lung disease, alcoholism, recent URI, advanced age
* Often a patchy segmental pneumonia or bronchopneumonia
* Virtually-diagnostic Gram’s stain: small, pleomorphic gram-negative coccobacilli

Moraxella catarrhalis pneumonia

* AKA: Neisseria catarrhalis; Branhamella catarrhalis
* A large gram-negative diplococcus
* Causes pneumonia and bronchitis especially in persons with chronic lung disease
* Often a patchy bronchopneumonia

Mycoplasma pneumoniae pneumonia

* The classic “primary atypical pneumonia”
* Typically occurs in younger adults, often the parents of young children
* Subtle presentation
* Favors lower lobes
* Pleural effusion may occur (up to 20%)

Some nonrespiratory manifestations of Mycoplasma pneumoniae pneumonia

* Myringitis (sometimes bullous)
* Hemolytic anemia
* Arthritis, arthralgias, myalgias
* Pericarditis, myocarditis
* Hepatitis (mild)
* Erythema multiforme, other rashes
* Meningitis, meningoencephalitis, neuropathy

Chlamydia pneumoniae pneumonia

* Accounts for <5% of community-acquired pneumonias
* C. pneumoniae more commonly causes pharyngitis and hoarseness
* Bronchitis is often insidious
* Pneumonia usually mild and localized but difficult to eradicate

Legionella pneumophila pneumonia

* Up to 23% of community-acquired pneumonias but with wide geographic distribution
* L. pneumophila is not part of the normal flora; a true inhalation disorder
* CXR: patchy or nodular infiltrates that may progress rapidly; up to 50% are bilateral

Legionella pneumophila pneumonia (2)

* Relative bradycardia in 65%
* Neurologic findings in 26%
* Gram’s stain may show purulence without a predominant microorganism
* Laboratory: may have hyponatremia; elevations of AST (SGOT), alkaline phosphatase, and bilirubin; proteinuria, hematuria, and renal failure

Treatment

* S. pneumoniae resistance is increasing
* Options are cephalosporins, amox/clvulanic acid, macrolides, doxycycline, a respiratory fluoroquinolone
* All atypicals are covered by the macrolides , doxycycline and the fuoroquinolones
* Judge the severity to see if outpatient treatment will suffice

Aspiration (“mouth flora”) pneumonia

* usually presents as a subacute illness in patients with some combination of alcoholism, malnutrition, homelessness, and poor dentition
* sputum often has foul odor
* Necrotizing pneumonia; lung abscess(es) with air-fluid levels; empyema

Pneumonia: some clues
* Tularemia: rabbits and hares; ticks and fleas; inhalation (e.g., after mowing over carcasses)
* Psittacosis: birds
* Plague: ground squirrels, chipmunks, rabbits, prairie dogs, rats
* Legionnaire’s disease: contaminated aerosols (air coolers; hospital water supplies)
* Histoplasmosis: dust from soil enriched with bird or bat droppings; Mississippi and Ohio River valleys
* Coccidiodomycosis: southern California (esp.. San Joachin Valley); southwest Texas, Arizona, N Mexico
* Pneumocystis carinii: HIV risk factors
* Relative bradycardia: viral infection; Mycoplasma pneumoniae; Psittacosis; Tularemia; Legionella
* Q fever (Coxiella burnetii): goats, cattle, sheep
* Meliodosis: travel to S.E. Asia, East Indies, Australia, Guam, South or Central America
* Brucellosis: cattle; goats; pigs; abattoir works and veterinarians
* Anthrax: cattle, swine, horses; goat hair, wool, or hides

Pneumococcal pneumonia: Predisposing factors
* Sickle cell disease
* Asplenia
* IgG disorders: agammaglobulinemia, myeloma, chronic lymphocytic leukemia
* Nephrotic syndrome
* Cirrhosis
* Alcoholism

Case # 4
* RA 57 year Caucasian male
* Cough , dyspnea, diarrhea for weeks
* No response to cephalexin
* CT sinuses - normal
* Progressive malaise and presented to ER
* pO2 on 100% NRB- 90, Creatinine 1.8, WBC: 12
* CXR-read as normal, HIV positive

Pneumonia in AIDS patients
* When in doubt, respiratory isolation for Tb
* S. pneumoniae is the number 1 cause
* Investigations
o Obtain sputum for gram stain and culture
o Other serology and antigen testing as indicated (histoplasma, cryptococcus, PCP, coccidio, etc.
o AFB stain if indicated(sensitivity with 3 specimens is about 60%)

PCP: Diagnosis (Imaging)
Chest x ray: PCP pneumonia with bilateral, diffuse granular opacities.
Credit: L, Huang, MD, HIV InSite

Chest x ray: PCP pneumonia with bilateral perihilar opacities, interstitial prominence, hyperlucent cystic lesions. Credit: HIV Web Study, www.hivwebstudy. org, © 2006 University of Washington

PCP
* PCP is a SUBACUTE pneumonia, CD4 usually <200
* Dyspnea, dry cough, chest discomfort
* In 30% patients
o CD4 > 200
o CXR normal
* TMP/SMX and steroids if hypoxic

Tuberculosis in HIV patients
* Occurs at any CD4 count
* Primary TB
o Occurs especially in people with advanced HIV infection
o Comprises about 1/3 of TB cases in HIV patients
* Reactivation of latent TB
o More likely in HIV-infected patients
o 7-10% annual risk in HIV-infected patients with positive tuberculin skin test (TST)
+ In HIV uninfected, 5-10% lifetime risk
* Patients with TB have HIV viral loads and faster progression of HIV

Case # 5
* 45 year female
* Intubated in the ICU for 7 days
* Now has worsening fever, leukocytosis and increased oxygen requirement

Nosocomial pneumonia
* Role of oropharyngeal colonization, especially of gram-negative rods (Pseudomonas, acinetobacter, etc.) : by end of one week, 45% of ICU patients are colonized; pneumonia develops in 23% of colonized patients versus 3.3% of non-colonized patients
* Risk factors to colonization: more advanced illness, longer duration in the hospital, antibiotics, intubation, azotemia, underlying pulmonary disease

Case # 6
* 23 year male, acute leukemia and bone marrow transplant
* Is severely neutropenic due to chemotherapy

Cavitary pneumonia
* Tuberculosis
Actinomyces
Nocardia
Klebsiella
Staphylococcus aureus
Anaerobic organisms
* Fungal infection Histoplasmosis
Coccidiomycosis, aspergillus

Complications of pneumonia
* Pleuropulmonary: lung abscess; adult respiratory distress syndrome (ARDS); pleural effusion; empyema; bronchopleural fistula; bronchiectasis; fibrosis; slow resolution
* Extrapulmonary: meningitis; brain abscess; endocarditis; pericarditis; arthritis; osteomyelitis

Lung Abscess
* Lung abscesses are usually caused by mouth flora(viridans strep, anaerobes, etc.)
* They need prolonged courses of antibiotics
* Options are the clindamycin, amox/clavulanic acid, pip/tazo, carbapenems

Pneumonia: Summary
* 6th leading cause of death and most common nosocomial infection causing death
* Precise diagnosis desirable but all-too-often not obtained
* Bronchoalveolar lavage and endobronchial sampling are now standard in nosocomial or difficult to diagnose pneumonia


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Tube Thoracostomy: Complications and the Role of Prophylactic Antibiotics

Tube Thoracostomy: Complications and the Role of Prophylactic Antibiotics
By Ashley Laird

Indications for Tube Thoracostomy
* PTX (spontaneous, iatrogenic, traumatic)
* Hemothorax
* Chylothorax
* Decreased breath sounds in unstable patient after blunt or penetrating trauma
* Multiple rib fractures, sucking chest wound, subcutaneous air in intubated trauma patient
* Complicated pleural effusion, empyema, lung abscess
* Thoracotomy, decortication
* Pleural lavage for active rewarming for hypothermia

Complications
* Undrained PTX, hemothorax, or effusion despite TT clotted hemothorax, empyema, fibrothorax
* Improper placement +/- iatrogenic injuries (lung, diaphragm, subclavian, right atrium)
* Recurrent PTX after tube removal
* Intrapleural collections following tube removal
* Thoracic empyema

Factors Influencing Complications: Louisville study
* Prior studies report TT complication rates of 3-36%
* Etoch SW, Bar-Natan MF, Miller FB, Richardson JD. Tube Thoracostomy: Factors related to complications. Arch Surg. 1995; 130:521-525.
o Retrospective chart review (U of Louisville)
o 379 trauma pts, 599 tubes

Factors Influencing Complications: Louisville study
* Complications:
o Empyema
o Undrained PTX or effusion
o Improper tube placement (+/- iatrogenic injury)
o Post-tube PTX
o Other
* Measures:
o Rate of complications in association w/ TT setting, operator, patient characteristics, MOI, and severity of injury

Factors Influencing Complications: Louisville study
* Overall rate of complications: 21% per patient (16% per tube)
* 8.2% of complications required thoracotomy

Factors Influencing Complications: Setting
* 48% of tubes placed in ED, 23% in OR, 12% in ICU, 7% on floor, and 9% at OSH prior to transfer
* Significantly higher complication rate when TT performed in outside hospital prior to transfer (33%, p<.0001)
* No significant difference in complication rates between TT in ED (9%) vs. TT in other areas of study hospital (7%)

Factors influencing Complications: Operator
* 59% of tubes placed by surgeons, 26% by ED physicians, 8% by physicians prior to transfer
* Highest complication rate for tubes placed by physicians in outside hospitals, mostly nonsurgeon physicians (38%)
* Complication rates for TT’s in study hospital: 13% for ED physicians, 6% for surgeons (p<.0001)
* For TT’s in ED: 13% complication rate for ED physicians vs 5% complication rate for surgeons (p<.01)

Factors influencing Complications: Mechanism/Severity of Injury

* No difference in complication rate related to:
o Age and sex of patients
o Mechanism of injury (23% for blunt vs 18% for penetrating)
o ISS
* Significantly increased complication rate related to:
o ICU admission (29% vs 11%, p<.0001)
o Mechanical ventilation (29% vs 15%, p<.002)
o Presence of hypotension (SBP<90) on admission (31% vs 17%, p<.003)

Factors Influencing Complications: University Hospital study
* Deneuville M. Morbidity of percutaneous tube thoracostomy in trauma patients. Eur J CT Surg. 2002; 22:673-678.
o Prospective observational study (University Hospital, Guadeloupe)
o 128 trauma pts, 134 tubes
o ‘Non-thoracic’ operators vs. thoracic surgeons

Factors Influencing Complications: University Hospital study
* Overall complication rate 25% (29% per tube)
o 5 (12.8%) improper placement, no iatrogenic injury
o 4 (10.3%) improper placement w/ iatrogenic injury (lung x 2, diaphragm, subclavian artery)
o 4 (10.3%) undrained hemothorax/PTX
o 12 (30.8%) post-removal PTX
o 7 (18%) post-removal fluid collection
o 3 (2.3%) empyema
o 4 (10.3%) combined
* 18 (46.2%) of complications required surgery (thoracotomy or VATS)

Factors Influencing Complications: University Hospital study
* No difference in complication rate related to:
o Blunt trauma vs. penetrating wounds
o Indication for TT: hemothorax vs PTX
o Presence of pulmonary contusion, abdominal injury, or need for immediate abdominal surgery
* Significantly increased risk of complication related to:
o Polytrauma (RR 2.7, p<0.05)
o Need for assisted ventilation (RR 2.7, p<.003)
o TT by non-thoracic surgeons (RR 8.7, p<.0001 for blunt trauma and RR 12.5%, p<.0001 for penetrating trauma)

Thoracic Empyema
* Causes of post-traumatic empyema:
o Iatrogenic infection during TT
o Direct infection from penetrating injury
o Secondary infection from associated intra-abdominal injuries w/ diaphragmatic disruption or hematogenous or lymphatic spread to pleural space
o Secondary infection of undrained hemothoraces
o Parapneumonic empyema resulting from posttraumatic pneumonia, contusion, or ARDS

Thoracic Empyema
* Empyema occurred in 1.8% (Louisville study) and 2.3% (University Hospital study) of patients undergoing TT
* No difference in rate of empyema related to setting or operator
* No difference in rate of empyema related to administration of antibiotics within 24 hours of initial TT in Louisville study (2% vs 2%)


‘Prophylactic’ Antibiotics in TT: EAST Guidelines
* Does ‘prophylactic’ antibiotic use in injured patients requiring TT reduce the incidence of empyema and/or pneumonia?
* Paucity of literature, especially well-designed multi-institutional double-blinded trials that control for setting, operator, mechanism of injury, timing of antibiotic administration, choice and dose of antibiotic, and duration of prophylaxis

‘Prophylactic’ Antibiotics in TT: EAST Guidelines
* Luchette FA, Barrie PS, Oswanski MF, Spain DA, Mullins CD, Palumbo F, Pasquale MD. Practice Management Guidelines for Prophylactic Antibiotic Use in Tube Thoracostomy for Traumatic Hemopneumothorax: the EAST Practice Management Guidelines Work Group. J Trauma. 2000; 48(4):753-7.
o MEDLINE search (1977-1997) for references using query words: antibiotic prophylaxis, chest tubes, human, drainage, tube thoracostomy, infection, empyema, and bacterial infection-prevention and control.
o 11 articles reviewed: 9 prospective series, 2 meta-analyses

Prophylactic’ Antibiotics in TT: EAST Guidelines
* Articles classified by Agency for Health Care Policy and Research (AHCPR) methodology
o Class I: prospective, randomized, double-blinded, controlled trials
o Class II: prospective, randomized, non-blinded trial
o Class III: retrospective series of patients or meta-analysis
* Four class I articles, five class II, and two class III meta-analyses

Prophylactic’ Antibiotics in TT: Conclusions and Recommendations
* Incidence of empyema in placebo groups ranged from 0-18%, compared to 0-2.6% in antibiotic groups
* Two class I studies saw a reduced incidence of empyema w/ antibiotic Rx (Cant, 1993; Grover, 1977)
* Two class II studies saw no benefit w/ antibiotics (Mandal, 1985; Demetriades, 1991)
* Other studies didn’t control for MOI
* Insufficient evidence to support prophylactic antibiotics as a standard of care for reducing incidence of empyema or PNA in patients requiring TT

Prophylactic Antibiotics in TT: Conclusions and Recommendations
* Extreme variability in choice of antibiotic, dosing, and duration of therapy among studies
* One class I study reported no empyema in patients receiving cefazolin for 24hrs compared to 5% incidence in placebo group (Cant et al, 1993)
* Administration of antibiotics for >24hrs did not significantly reduce risk of empyema compared with shorter duration (Demetriades, 1991)

Prophylactic’ Antibiotics in TT: Conclusions and Recommendations

* Incidence of pneumonia in placebo groups ranged from 2.5-35.1%, compared to 0-12% in antibiotic groups
* In most reports, significant reduction in pneumonitis seen in patients receiving prolonged antibiotics (but also see increased cost and length of hospital stay)
* Presumptive, rather than prophylactic therapy, in setting of acute trauma

‘Prophylactic’ Antibiotics in TT: Conclusions and Recommendations

* Recommendations (for isolated chest trauma)
o Level I: insufficient data to support level I recommendation as standard of care
o Level II: insufficient data to suggest prophylactic antibiotics reduce incidence of empyema
o Level III: sufficient class I and II data to recommended prophylactic antibiotic use in patients receiving TT after chest trauma. A first generation cephalosporin should be used for no longer than 24hrs. There may be a reduction in incidence of PNA, but not empyema.


Recommendations
* Additional training of all trauma physicians
* Early thoracotomy or VATS in settings of persistent fluid collection or multiple chest tube placements as means to prevent against development of empyema
* First generation cephalosporin for no more than 24 hours
* Further research!

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