Empyema Occurring in the Multiply Traumatized Patient

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Abstract
During an 11-mo. period 31 cases of nosocomial empyema were identified in 29 of 741 multiply traumatized patients were hospitalized for more than 3 days. Nosocomial empyema was defined as purulent culture-positive material drained from the pleural space after 5 days'' hospitalization. All patients had fever and leukocytosis. Possible risk factors included previous aspiration in 5 patients but none developing pneumonia, prior respiratory tract infection in 9 but none with the same pathogen as their empyema, prior antibiotic use in over 50% of the patients, and severe head or chest injury in 2/3 of the patients. Thirty-eight pathogens were recovered: Staphylococcus aureus, 14; .beta.-streptococci, 3; Pseudomonas, 6; Klebsiella, 2; Enterobacter, 2; Escherichia coli, 2; other Gram-negative bacilli, 6; and anaerobes, 3. Fourteen infections were polymicrobic and bacteremia occurred in 42% of the patients. Of these 29 patients, 27 had chest tubes inserted for fluid in the pleural cavity before development of empyema; 9 for hemo- or pneumothorax secondary to chest trauma, 11 for pneumothorax while on ventilators, and 7 for unexplained sterile pleural effusion. If empyema complicated a prior hemothorax it was usually caused by Staphylococcus aureus and occurred about 10 days after draining blood from pleural cavity. If empyema was a complication of pneumothorax or serothorax it was usually due to Gram-negative organisms colonizing the upper respiratory tract and occurred within 4 days of draining the fluid. Of all patients who had chest tubes placed for fluid in their pleural cavity, 16% subsequently developed empyema. An association between prior sterile fluid in the chest requiring chest tube placement and development of subsequent empyema was found to be highly significant (P < 0.00003). All patients with empyema were treated with antibiotics and continued drainage. Nine patients required a formal thoracic operation. Nine patients had rib resection and 3 had subsequent decortication. Seventeen had clinical resolution of their disease, 3 had recurrent empyema, 4 patients expired secondary to infection, and 7 expired due to intercurrent disease. Nosocomial empyema associated with the use of chest tubes for prior fluid in the pleural cavity accounted for 10% of all nosocomial infections in a trauma patient population.

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