Increase in Streptococcus pneumoniae serotype 3 associated parapneumonic pleural effusion/empyema after the introduction of PCV13 in Germany.

INTRODUCTION: Pediatric pneumococcal pneumonia complicated by parapneumonic pleural effusion/empyema (PPE/PE) remains a major concern despite general immunization with pneumococcal conjugate vaccines (PCVs). METHODS: In a nationwide pediatric hospital surveillance study in Germany we identified 584 children <18 years of age with bacteriologically confirmed PPE/PE from October 2010 to June 2018. Streptococcus pneumoniae was identified by culture and/or PCR of blood samples and/or pleural fluid and serotyped. RESULTS: S. pneumoniae was identified in 256 of 584 (43.8%) children by culture (n = 122) and/or PCR (n = 207). The following pneumococcal serotypes were detected in 114 children: serotype 3 (42.1%), 1 (25.4%), 7F (12.3%), 19A (7.9%), other PCV13 serotypes (4.4%) and non-PCV13 serotypes (7.9%). Between October 2010 and June 2014 serotype 1 (38.1%) and serotype 3 (25.4%) were most prevalent, whereas between July 2014 and June 2018 serotype 3 (62.7%) and non-PCV13 serotypes (15.7%) were dominant. Compared to children with other pneumococcal serotypes, children with serotype 3 associated PPE/PE were younger (median 3.2 years [IQR 2.1-4.3 years] vs. median 5.6 years [IQR 3.8-8.2 years]; p < 0.001) and more frequently admitted to intensive care (43 [89.6%] vs. 48 [73.8%]; p = 0.04). Seventy-six of 114 (66.7%) children with pneumococcal PPE/PE had been vaccinated with pneumococcal vaccines. Thirty-nine of 76 (51.3%) had received a vaccine covering the serotype detected. Thirty of these 39 breakthrough cases were age-appropriately vaccinated with PCV13 and considered vaccine failures, including 26 children with serotype 3, three children with serotype 19A and one child with serotype 1. CONCLUSION: Following the introduction of PCV13 in general childhood vaccination we observed a strong emergence of serotype 3 associated PPE/PE in the German pediatric population, including a considerable number of younger children with serotype 3 vaccine breakthrough cases and failures. Future PCVs should not only cover newly emerging serotypes, but also include a more effective component against serotype 3.

Oral Antibiotics for Treating Children With Community-Acquired Pneumonia Complicated by Empyema.

No consensus exists on management of children with community-acquired pneumonia complicated by empyema (CAP-Em). We evaluated outpatient oral (O-Abx) compared with parenteral antibiotics (OPAT) in children with CAP-Em. We also evaluated inflammatory markers to guide length of treatment. We conducted a retrospective cohort study of patients discharged (2006-2016) with CAP-Em. Primary outcome measured was treatment success (no change in antibiotics or readmission to hospital for treatment of CAP-Em). White blood cell (WBC) count, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) serial measurements were identified. Success was achieved in 133/144 (92.4%) O-Abx and 7/12 (58%) OPAT patients (P = .0031). WBC and CRP decreased early; and ESR increased initially (admit and switch to O-Abx) and decreased by end of treatment. O-Abx is the modality of choice for treatment of CAP-Em after hospital discharge. WBC and CRP are useful to monitor success of O-Abx switch; and ESR provides guidance for length of treatment.

Pleural fluid amino-terminal brain natriuretic peptide in patients with pleural effusions.

BACKGROUND: Definite diagnosis of transudative or exudative pleural fluids often presents a diagnostic dilemma. The aim of this study was to evaluate whether amino-terminal brain natriuretic peptide (NT-proBNP) levels in pleural fluid has a diagnostic value for discriminating heart-failure-related pleural effusions from non-heart-failure effusions. METHODS: Sixty-six subjects (40 male, mean age 61 ± 18 y) with pleural effusions were included. Samples of pleural fluid and serum were obtained simultaneously from each subject. Biochemical analysis, bacterial and fungal culture, acid-fast bacilli smear and culture, and cytology were performed on the pleural fluid. RESULTS: Subjects with heart-failure-related pleural effusion had significantly higher pleural NT-proBNP levels than other subjects (P < .001). Pleural and serum NT-proBNP measures were closely correlated (r = 0.90, P < .001). An NT-proBNP cutoff value of ≥ 2,300 pg/mL in pleural fluid had a sensitivity of 70.8%, a specificity of 97.6%, and positive and negative predictive values of 94.4% and 85.4%, respectively, for discriminating transudates caused by heart failure from exudates. Eight heart-failure subjects were misclassified as exudates by Light's criteria, 5 of whom received diuretics before thoracentesis. All misclassified subjects had pleural NT-proBNP levels higher than 1,165 pg/mL, which predicted heart-failure-associated transudates with 95.8% sensitivity and 85.7% specificity. CONCLUSIONS: Pleural fluid NT-proBNP measurement in the routine diagnostic panel may be useful in differentiation of heart-failure-related pleural effusions and exudative pleural fluids with reasonable accuracy, especially in heart-failure patients treated with diuretics.

Procoagulant activity in children with community acquired pneumonia, pleural effusion and empyema.

UNLABELLED: In patients with community-acquired pneumonia (CAP), bacterial-cell-wall-derived fragments may induce the coagulation cascade. To contribute to the knowledge of underlying mechanisms, we have studied the fibrinolytic activity in children with CAP and parapneumonic effusions. PATIENTS AND METHODS: Twenty previously healthy children admitted to our Department with CAP were studied; with (n = 11) or without (n = 9) pleural effusion (PPE). We also investigated 10 children with empyema. In all children we analyzed coagulation and fibrinolytic parameters and compared the results to nine controls. RESULTS: Prothrombin time (PT) and activated partial thromboplastin time (aPTT) were not significantly modified in the three groups as compared to controls (P = 0.975, P = 0.535, respectively). The fibrinogen levels were significantly increased in respect to the control group (P < 0.0001). The median values of D-dimer showed an increasing trend that was statistically significant: children with pneumonia 244 microg/L, with pneumonia and PPE 751 microg/L and with empyema 2003 microg/L, in respect to values (48 microg/L) of our control group (P < 0.0001). CONCLUSION: The results suggest that plasma level of D-dimer can give an additional contribution for the evaluation of the severity of CAP and its complications in children.

Malignant mesothelioma associated with chronic empyema with elevation of serum CYFRA19: A case report.

Malignant neoplasms are reported to occur with long-standing tuberculous pleuritis or chronic empyema. During the clinical course of chronic empyema, subjective symptoms such as chest pain and deterioration of dyspnea and abnormal clinical signs such as increased abnormal chest shadows have frequently been found. Though difficult, differentiating the occurrence of malignant tumors from worsening chronic inflammation is crucial. We report here a case of malignant mesothelioma associated with chronic empyema with elevation of serum CYFRA19.

Pneumococcal pneumonia with empyema and hemolytic uremic syndrome in children: report of three cases.

Streptococcus pneumoniae is an uncommon etiological organism in children with hemolytic uremic syndrome (HUS). Patients with S. pneumoniae-associated HUS commonly have a pneumonia or meningitis. Historically, S. pneumoniae-associated HUS usually has a poor clinical outcome. We report 3 pediatric cases of pneumococcal pneumonia-induced HUS. All 3 patients were <2 years old, had an empyema complicating pneumococcal pneumonia, and developed renal failure with oliguria and required peritoneal dialysis for a period of 9 to 26 days. All children received several transfusions of unwashed packed red cells and platelets. All of the patients survived. Of the 3 cases, 2 had a normal renal function at discharge, and 1 had a mild renal impairment at 16-month follow-up. Our report suggests S. pneumoniae-associated HUS remains a rare but severe complication of invasive pneumococcal infection in children. It is important for pediatricians to note that children with pneumococcal pneumonia with severe hematologic and renal dysfunction should be investigated for evidence of S. pneumoniae-associated HUS.

A case of Streptococcus intermedius empyema.

OBJECTIVE: To report a case of empyema caused by Streptococcus intermedius as a complication of community-acquired pneumonia (CAP). CASE SUMMARY: An 85-year-old woman with a history of chronic obstructive pulmonary disease, asthma, heart failure, and hypothyroidism developed empyema as a result of 2 episodes of CAP and an acute exacerbation of chronic bronchitis within the past 2 months. Therapy with intravenous levofloxacin 750 mg every 48 hours was initiated. Culture results of the empyema fluid yielded pure growth of a rarely encountered microorganism, S. intermedius. Intravenous piperacillin/tazobactam 3.375 g every 6 hours was added to the antimicrobial therapy at that time. However, cultures continued to show S. intermedius. Surgical decortication was unsuccessful, and the patient died after a 30 day hospital stay. DISCUSSION: Early, appropriate antimicrobial therapy is the mainstay of CAP treatment. Although rare, empyema or thoracic abscess can occur despite this therapy, due to mucosal changes caused by CAP. Historically, antimicrobial therapy used to treat organisms that typically cause CAP also has activity against S. intermedius. However, growth of this microorganism and failure to respond to therapy should alert clinicians to the possibility of empyema or abscess formation. CONCLUSIONS: Despite historical in vitro susceptibility data of S. intermedius, antimicrobial therapy may be ineffective, and more extreme measures may be needed to achieve a successful outcome. Early, appropriate antimicrobial therapy needs to remain the mainstay of the treatment of CAP in an attempt to prevent fatal complications such as this from occurring.

C-reactive protein: a sensitive marker in the management of treatment response in parapneumonic empyema of children.

C-reactive protein (CRP) is one of the best indicators of the acute phase response to inflammation. The rapid kinetics of CRP metabolism appears to closely parallel the degree of inflammation. The purpose of this prospective study was to analyze the clinical value of CRP, erythrocyte sedimentation rate (ESR), and white blood cell count (WBC) in the assessment response to treatment in children with parapneumonic empyema. Thirty-eight children were prospectively studied. CRP was elevated in all patients on the day of hospital admission. With antibiotic treatment, serum CRP levels fell rapidly within the first days, and in 32 patients who had uncomplicated course, serial CRP levels fell progressively at each measurement. All but four patients had normal CRP levels on the day of hospital discharge. ESR was also elevated in all patients on the day of hospital admission. Despite antibiotic treatment, ESR continued to increase in all patients in the first few days, with peak values reached on day 3. Only three patients had normal ESR levels on the day of hospital discharge. In six patients who had a complicated course, after an initial decrease, CRP levels began to rise earlier than ESR and WBC count. Plasma CRP level is a sensitive marker not only in the diagnosis of parapneumonic empyema, but also in the management of treatment response.

Bilateral epidural empyemas in an adolescent.

Epidural empyema is an unusual cause of headache that may be encountered in the emergency department. The collection of suppurative fluid usually results from local spread of sinusitis, although many other predisposing factors have also been described. Patients with epidural empyema usually present with nonspecific cephalalgia that may be accompanied by fever and leukocytosis but is unlikely to be associated with focal neurological findings. The case of an adolescent who presented to our emergency department twice in 6 days with persistent headache is reported; cranial computed tomography performed on the second visit demonstrated bilateral epidural empyema. This entity is uncommon, but may certainly be encountered by the emergency physician.

[Megakaryocytopoiesis in patients with acute infectious destruction of the lungs]. / Megakariotsitopoèz u bol'nykh ostrymi infektsionnymi destruktsiiami legkikh.

Partial megakaryocytograms were studied in patients with acute infectious destructions of the lungs. Acid phosphatase and glycogen megakaryocytic levels, overall number of megakaryocytes elucidated the role of the central link of the system megakaryocyte--platelet in the onset of thromboembolism and hemorrhagic complications arising in the above patients. Inefficiency of megakaryocytopoiesis in pulmonary and pleural acute pyo-destructions is under discussion.

[Disorders of erythrocyte deformability in patients with acute suppurative-septic diseases of the lung and pleura]. / Narushenie deformiruemosti éritrotsitov u bol'nykh ostrymi gnoino-septicheskimi zabolevaniiami legkikh i plevry.

In 163 patients with acute suppurations of lungs and pleura a substantial reduction of deformability of erythrocytes was established. The maximum increased rigidity of blood red cells was noted at the peak of the pyo-destructive process and postoperative period as well as in the complicated course of the postoperative period. The curative plasmapheresis, general hyperbaric oxygenation exert positive influence upon plastic properties of erythrocytes.

[Participation of leukocytes in primary hemostasis]. / Uchastie leikotsitov v pervichnom gemostaze.

Introduction of a hemolysate of erythrocytes and ADP in the plasma containing leucocytes and platelets results in the formation of mixed-cell (leucocytic-thrombocytic) aggregates, aggregation rate depending on the number of leucocytes involved. In healthy donors this process is ensured equally by both cell types. In inflammation and especially in chronic myelocytic leukemia leucocytes play the main role in mixed-cell aggregation. Aggregate formation in such patients is characterized by a high intensity which may be related with an increase in total function of pathological leucocytes.

[Disorders of the functional properties of thrombocytes causing thromboembolism in acute suppurative destructive diseases of the lungs and pleura]. / Narusheniia funktsional'nykh svoistv trombotsitov, sposobstvuiushchie formirovaniiu tromboembolii, pri ostrykh gnoino-destruktivnykh zabolevaniiakh legkikh i plevry.

An examination of 96 patients has established that the development of a pyo-destructive process in the lungs and pleura is accompanied by an increase of concentration of circulating thrombocytes as well as their adhesive-aggregating activity and degenerative-dystrophic alterations. These parameters were most pronounced in patients 1-3 days before their sudden death from thromboembolism of the pulmonary artery without a clinically detected source. Persantine, aspirin, pyrazolones and heparin in generally accepted therapeutic doses were shown not to possess evident anti-aggregative properties.

[Aggregative properties of the erythrocytes in acute suppurative-destructive diseases of the lungs and pleura]. / Agregatsionnye svoistva éritrotsitov pri ostrykh gnoino-destruktivnykh zabolevaniiakh legkikh i plevry.

The investigation of aggregation properties of erythrocytes in 218 patients with acute pyo-destructive diseases of lungs and pleura at different stages of the conservative and operative treatment has revealed a pronounced hyperaggregation of erythrocytes. The aggregation mechanisms are to be studied and new methods of correction of the aggregation properties of blood red cells are to be searched for.

The contribution of leukocytes and bacteria to the low pH of empyema fluid.

Empyema fluid characteristically has a low pleural fluid pH, and it has been demonstrated that this fluid has a high acid-generating capacity. To evaluate the contribution of leukocytes and bacteria to the low pH of empyema fluid, an experimental model of empyema was used. After the production of a sterile pleural effusion by turpentine in both normal and neutropenic New Zealand white rabbits, either live Streptococcus pneumoniae, killed Streptococcus pneumoniae, or Acinetobacter, an organism that does not undergo fermentation or produce substantial acid, were injected into the pleural fluid. With these manipulations, the contribution of leukocytes and bacteria alone could be assessed. The results showed that both leukocyte phagocytosis and bacterial metabolism contribute to the low pH of empyema fluid and that the number of polymorphonuclear leukocytes per se in clinically observed ranges is not critical to the change in pleural fluid pH.

[Hyperbaric oxygenation in the treatment of patients with acute purulent-destructive lung and pleural diseases]. / Giperbaricheskaia oksigenatsiia v lechenii bol'nykh ostrymi gnoino-destruktivnymi porazheniiami legkikh i plevry.

In experiments in rabbits the authors have elaborated safe (in relation to a barotrauma of the lungs) regimens of the pressure changes taking place while performing HBO. In the treatment of 127 patients with acute suppurations of the lungs and pleura it was established that a short course of HBO (4-5 sessions) in the regimens used was safe and clinically effective. The method is recommended for the treatment of patients with spreaded injuries of the pulmonary tissue developing with a pronounced endogenous intoxication.

[Method of estimating kininogenesis in blood plasma]. / Metod otsenki kininogeneza v plazme krovi.

It is suggested that the kininogenesis should be assessed from 3 forms of kallikrein which are detected on the basis of their kininogenase activity in whole blood plasma. Heating of blood plasma acidified to pH 3.0 for 15-20 min at 61 degrees C allows for the conditions under which the kallikrein inhibitors (alpha 1-antitrypsin, alpha 2-macroglobulin) are destroyed whereas kallikrein, prekallikrein, low- and high-molecular kininogens (HMK) are preserved, thus constituting a complex of proteins making the kininogenase reaction feasible. Addition of purified preparations of HMK to the neutralized samples of normal and sick individuals' plasma permitted the demonstration that as the kallikrein is raised, the kininogenesis gets actually activated, during which the blood manifests, in the presence of kallikrein hyperactivity, a sufficient amount of HMK. Provided the kallikrein content drops by 50%, the kininogenesis is reduced, which is accounted for by depletion of blood HMK. A 70%- and a greater decrease in the kallikrein content attests to the kininogenesis reduction because of the diminished levels of HMK, prekallikrein and kallikrein. The regularities described have been confirmed by the agreement between the blood plasma kallikrein level and the concentration of blood free kinins revealed during examination of 68 normal individuals and 231 patients suffering from different inflammatory-allergic diseases of the respiratory and hepatobiliary organs, and from diabetes mellitus.