Pneumococcal Empyema: Toronto, Ontario 1995-2006

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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

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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)

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

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Development of Empyema
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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.

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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.

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Demographics
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Rates per 100,000 Age Adjusted
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Microbiology
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Empyema as an Invasive Pneumococcal Disease
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• 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

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Vaccine Strains by Year
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Clustering of Resistance
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Resistance to Multiple Agents
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Resistance to Multiple Agents
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Resistance over Time
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Outcomes
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Survival
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ICU Admissions and Deaths By Year
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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
  Jan41(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

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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

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Acknowledgements

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

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