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Incidence, Length of Stay, and Prognosis of Hospitalized Patients With Pleural Empyema

2014; Elsevier BV; Volume: 145; Issue: 1 Linguagem: Inglês

10.1378/chest.13-1912

1931-3543

Mette Søgaard, Marie Germund Nielsen, Mette Nørgaard, Jette Brommann Kornum, Henrik Carl Schønheyder, Reimar W. Thomsen,

Chronic Obstructive Pulmonary Disease (COPD) Research

Empyema hospitalization rates appear to be increasing in western populations, but updated population-based data are sparse. The few existing population-based studies of adult empyema have reported increases between 30% and 97% over the past decades in the United States and Canada.1Grijalva CG Zhu Y Nuorti JP Griffin MR Emergence of parapneumonic empyema in the USA.Thorax. 2011; 66: 663-668Crossref PubMed Scopus (206) Google Scholar, 2Finley C Clifton J Fitzgerald JM Yee J Empyema: an increasing concern in Canada.Can Respir J. 2008; 15: 85-89Crossref PubMed Scopus (168) Google Scholar, 3Farjah F Symons RG Krishnadasan B Wood DE Flum DR Management of pleural space infections: a population-based analysis.J Thorac Cardiovasc Surg. 2007; 133: 346-351Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar, 4Bender JM Ampofo K Sheng X Pavia AT Cannon-Albright L Byington CL Parapneumonic empyema deaths during past century, Utah.Emerg Infect Dis. 2009; 15: 44-48Crossref PubMed Scopus (66) Google Scholar Most of these studies were conducted in large referral centers only. We examined health registries covering all Danish hospitals for temporal changes in nationwide incidence, length of hospital stay, and 30-day mortality associated with empyema-related hospitalizations during 1997 to 2011. We included all patients aged ≥ 15 years receiving a first-time diagnosis of empyema (International Classification of Diseases, 10th Revision, codes J86.0 and J86.9). The positive predictive value of these empyema codes is approximately 90%.5Søgaard M Kornum JB Schønheyder HC Thomsen RW Positive predictive value of the ICD-10 hospital diagnosis of pleural empyema in the Danish National Registry of Patients.Clin Epidemiol. 2011; 3: 85-89Crossref PubMed Scopus (19) Google Scholar In total, 6,878 hospitalized patients had empyema in Denmark during 1997 to 2011. More than 40% had preexisting comorbidities, and this proportion increased over time (Table 1). The median length of hospital stay decreased from 22 days (interquartile range, 12-43 days) to 17 days (interquartile range, 10-28 days). The age- and sex-standardized incidence rate (IR) increased by 26% from 8.7 per 100,000 person-years in 1997 to 11.8 per 100,000 person-years in 2011. The IR increased the most among older people aged ≥ 80 years (87.3% [from 20.4 per 100,000 in 1997 to 38.2 per 100,000 in 2011]) compared with people aged 40 to 64 years (27.8% [from 10.7 per 100,000 in 1997 to 12.6 per 100,000 in 2011]) (Fig 1). Rates among those aged 15 to 39 years fluctuated around 2.5 to 3.5 per 100,000 person-years. Rates were 1.7- to 3.1-fold higher in men than in women, and the IR rose sharply with increasing age. The crude 30-day mortality improved modestly from 10.5% from 1997 to 2001 to 9.0% from 2007 to 2011, corresponding to an adjusted 30-day mortality rate ratio of 0.69 (95% CI, 0.57-0.84) (Table 1). Thirty-day mortality ranged from only 1.2% in patients aged 15 to 39 years to 20.2% in those aged ≥ 80 years. Mortality also varied substantially according to level of comorbidity.Table 1—Temporal Trends in Crude and Adjusted Mortality Within 30 d Among Patients With a First-Time Hospitalization for Empyema1997-20012002-20062007-2011CharacteristicPatientsDeathsCrude MRR (95% CI)AdjustedaAdjusted for age, sex, comorbidity, and alcoholism-related conditions. MRR (95% CI)PatientsDeathsCrude MRR (95% CI)Adjusted MRR (95% CI)PatientsDeathsCrude MRR (95% CI)Adjusted MRR (95% CI)Overall1,841 (100)193 (10.5)1.01.0 (ref)2,391 (100)216 (9.0)0.85 (0.70-1.04)0.79 (0.65-0.96)2,646 (100)239 (9.0)0.86 (0.71-1.04)0.69 (0.57-0.84)Sex Female565 (30.7)57 (10.1)1.01.0845 (35.3)79 (9.0)0.88 (0.63-1.25)0.85 (0.60-1.20)937 (35.4)67 (7.2)0.70 (0.49-1.00)0.59 (0.42-0.85) Male1,276 (69.3)136 (10.7)1.01.01,546 (64.7)140 (9.1)0.84 (0.66-1.06)0.76 (0.60-0.96)1,709 (64.6)172 (10.1)0.94 (0.75-1.18)0.73 (0.58-0.92)Age group 15-39 y241 (13.1)01.01.0249 (10.4)3 (1.2)……243 (9.2)3 (1.2)…… 40-64 y829 (45.0)64 (7.7)1.01.01,118 (46.8)60 (5.4)0.69 (0.48-0.98)0.66 (0.46-0.94)1,208 (45.7)65 (5.4)0.70 (0.49-0.98)0.60 (0.42-0.85) 65-79 y594 (32.3)78 (13.1)1.01.0731 (30.6)79 (10.8)0.81 (0.59-1.10)0.81 (0.60-1.11)804 (30.4)92 (11.4)0.86 (0.64-1.16)0.81 (0.59-1.09) ≥ 80 y177 (9.6)51 (28.8)1.01.0293 (12.3)74 (25.3)0.85 (0.60-1.22)0.83 (0.58-1.19)391 (14.8)79 (20.2)0.66 (0.47-0.94)0.63 (0.44-0.90)CCI Low (0)1,046 (56.8)63 (6.0)1.01.01,334 (55.8)70 (5.3)0.86 (0.62-1.22)0.78 (0.56-1.10)1,291 (48.8)61 (4.7)0.78 (0.55-1.11)0.69 (0.49-0.99) Medium (1-2)583 (31.7)82 (14.1)1.01.0729 (30.5)84 (11.5)0.81 (0.60-1.10)0.77 (0.56-1.04)884 (33.4)101 (11.4)0.80 (0.60-1.08)0.70 (0.52-0.95) High (> 2)212 (11.5)48 (22.6)1.01.0328 (13.7)62 (18.9)0.81 (0.56-1.18)0.80 (0.55-1.16)471 (17.8)77 (16.4)0.69 (0.48-0.99)0.65 (0.45-0.94)Data are presented as No. (%) unless otherwise indicated. CCI = Charlson Comorbidity Index; MRR = mortality rate ratio; ref = reference.a Adjusted for age, sex, comorbidity, and alcoholism-related conditions. Open table in a new tab Data are presented as No. (%) unless otherwise indicated. CCI = Charlson Comorbidity Index; MRR = mortality rate ratio; ref = reference. The finding of an increasing empyema incidence over the past 15 years is in-line with previous studies1Grijalva CG Zhu Y Nuorti JP Griffin MR Emergence of parapneumonic empyema in the USA.Thorax. 2011; 66: 663-668Crossref PubMed Scopus (206) Google Scholar, 2Finley C Clifton J Fitzgerald JM Yee J Empyema: an increasing concern in Canada.Can Respir J. 2008; 15: 85-89Crossref PubMed Scopus (168) Google Scholar, 3Farjah F Symons RG Krishnadasan B Wood DE Flum DR Management of pleural space infections: a population-based analysis.J Thorac Cardiovasc Surg. 2007; 133: 346-351Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar; however, the present study may be the first to examine nationwide trends in 30-day mortality following empyema. Short-term mortality is likely to be closely related to the infection, and it is notable that comorbidity had such a strong influence on 30-day mortality. Importantly, we found improvements in empyema survival over time, in particular when taking increasing patient comorbidity into account. Advanced age and comorbidity are strong prognostic factors, and empyema remains a serious condition requiring a long hospital stay. Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.