Pneumococcal Empyema: Toronto, Ontario 1995-2006

1. Pneumococcal Empyema: Toronto, Ontario 1995-2006 Dr. Todd C. Lee Karen Green, Dr. A. McGeer, Dr. D. Low for the Toronto Invasive Bacterial Diseases Network Presented Nov 15, 2007

2. What is Empyema? • Empyema is an infection of the normally sterile pleural space • Can be diagnosed when pleural fluid is floridly purulent. A complicated effusion is one that meets the criteria below (CID Dec 1, 2007)

3. Microbiological diagnosis • sputum culture • pleural fluid culture • blood culture or in some studies • molecular techniques such as pleural fluid PCR or streptococcal antigen.

4. Development of Empyema

5. Why Study Empyema? • Within the past several years and co-incident with (but perhaps predating) the introduction of the pneumococcal conjugate vaccine (PCV) in many jurisdictions there has been a dramatic reduction in the overall incidence of invasive pneumococcal disease (IPD). This is particularly noticeable for vaccine strain serotypes and this effect has been seen on multiple continents. • Simultaneous increase in the incidence of pneumococcal empyema (PEMP) • emergence of serotype 1 which is consistently associated with a disproportionate percentage • The majority of studies have focussed on paediatric empyema. Ours would represent one of the largest studies of an adult predominant cohort of patients with empyema recently reported.

6. Methods • Population based surveillance for invasive pneumococcal disease has been ongoing through TIDBN since 1995. • A database exists for the collection of clinical data from cases with information obtained from the patients themselves, their treating physicians, and retrospective chart review. This data is matched with microbiological data obtained from the isolates. • Empyema in this study was defined as pleural fluid consistent with complicated pleural effusion or empyema with: • (1) a positive pleural fluid culture for pneumococcus • (2) a clinical diagnosis of empyema with positive blood culture for pneumococcus.

8. Demographics

10. Rates per 100,000 – Age Adjusted

11. Microbiology

12. Empyema as an Invasive Pneumococcal Disease

14. Conjugate Vaccine 4,6B, 9V, 14, 18C, 19F, 23F Polyvalent Vaccine 1 2 3 4 5 6B 7F 8 9N 9V 10A 11A 12F 14 15B 17F 18C 19F 19A 20 22F 23F 33F

15. Vaccine Strains by Year

16. Clustering of Resistance

17. Resistance to Multiple Agents

18. Resistance to Multiple Agents

19. Resistance over Time

20. Outcomes

21. Survival

22. ICU Admissions and Deaths By Year

23. Limitations • Culture negative pneumococcal empyema and patients with sputum cultures only would not be captured by our surveillance. • Eltringham G, Kearns A, Freeman R, Clark J, Spencer D, Eastham K, et al. Culture-negative childhood empyema is usually due to penicillin-sensitive Streptococcus pneumoniae capsular serotype 1. J Clin Microbiol 2003 Jan;41(1):521-2. • ~70% of culture negative were pneumoccoccus according to PCR assays. ~60% of these were serotype 1 • Examining complicated pleural effusion and empyema rather than empyema exclusively • Limited access (at this point) to patient specific data

24. Conclusions In our cohort of patients with pneumococcal empyema: • Population based rates were highest in patients older than 65 • Cases more likely to be alcohol abusers or have underlying lung disease • Cases were more likely to be failing outpatient therapy • There was a high morbidity (40% ICU admission) and mortality (20% death) associated with pneumococcal empyema • Death associated with underlying disease states and more severe illness • Serotype 1 was more common in empyema than in other IPD • Isolates found in empyema were more likely to be resistant to macrolides, ciprofloxacin (not shown) and levofloxacin but not penicillin or moxifloxacin

25. Acknowledgements • Refik Saskin • Karen Green • Dr. Allison McGeer • Dr. D. Low • Toronto Invasive Bacterial Diseases Network

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