A 10-year experience with bacteriology of acute thoracic empyema: Emphasis on Klebsiella pneumoniae in patients with diabetes mellitus

Study objectives: To provide an updated evaluation of the bacteriology of acute thoracic empyema for more efficacious treatment. Design: The medical and microbiological records of all patients who received a diagnosis of acute thoracic empyema were reviewed. Based on the bacteria isolated from the pleural fluid, the patients were classified into the following four groups: aerobic or facultative Gram-positive; aerobic Gram-negative; anaerobic; and mixed. Setting: A university-affiliated tertiary medical center. Patients and methods: From January 1989 to December 1998, 171 patients with a diagnosis of acute thoracic empyema were treated. A comparative analysis of the isolates from pleural effusions, the mean length of hospital stay, the mean duration of chest tube drainage, the mean duration between the onset of symptoms and the establishment of diagnosis, treatment efficacy, and the need for subsequent intervention was performed. Results: A total of 163 microorganisms were isolated from the pleural fluid of 139 patients. These patients were classified according to the following types of isolates: aerobic or facultative Gram-positive (n = 47); aerobic Gram-negative (n = 59); anaerobic (n = 14); and mixed (n = 19). Klebsiella pneumoniae was the most commonly isolated pathogen (24.4%) and was strongly associated with a diagnosis of diabetes mellitus. The mortality rate of patients with aerobic Gram-negative bacilli isolated was the highest (22.0%), followed by those with mixed pathogens isolated (15.7%), aerobic or facultative Gram-positive (6.4%), and anaerobic (0%). Conclusions: The increasing incidence of acute thoracic empyema caused by Gram-negative bacilli, especially by K pneumoniae, has become an increasing problem. The isolation of aerobic Gram-negative bacilli or multiple pathogens from pleural fluid is associated with a poor prognosis and indicates a need for more aggressive antimicrobial chemotherapy.