Focus on pleural empyema: etiology, epidemiology, infectiology, treatment, and impact of the COVID-19 pandemic-a single-center analysis.

BACKGROUND

Pleural empyema is a potentially life-threatening condition requiring timely interdisciplinary management. Based on the underlying pathophysiology, empyema is classified into three stages: exudative (stage I), fibrinopurulent (stage II), and chronic-organizing (stage III). Despite advances in surgical techniques and perioperative care, pleural empyema remains associated with considerable morbidity. Data on changes in incidence and management during the coronavirus disease 2019 (COVID-19) pandemic remain limited. This study aims to analyze etiology, epidemiology, infectiology, and surgical treatment of pleural empyema, with particular focus on the impact of the COVID-19 pandemic.

METHODS

This retrospective single-center study included all patients surgically treated for pleural empyema between January 2018 and December 2022 at a high-volume thoracic surgery center. Patient characteristics, etiology, empyema stage, microbiological findings, operative approach and length of hospital stay were analyzed. Case numbers before and during the COVID-19 pandemic were compared.

RESULTS

A total of 282 patients were included. Parapneumonic empyema was the most frequent etiology (62%), followed by postoperative empyema (17%). Intraoperative microbiological cultures were positive in 36% of cases, with streptococci predominating in parapneumonic empyema and staphylococci in postoperative cases. During the COVID-19 pandemic, particularly in 2020 and 2021, a significant reduction in surgically treated pleural empyema was observed. Advanced-stage (stage III) empyema was associated with significantly longer operative times, prolonged chest tube duration, and extended hospital stay. In the majority of patients, a minimally invasive approach was employed.

CONCLUSIONS

Parapneumonic infection was the predominant cause of pleural empyema, while microbiological pathogen detection remained limited. During the COVID-19 pandemic, a significant decrease in surgically treated empyema cases was observed. Advanced-stage disease was associated with increased operative complexity and prolonged postoperative recovery. In a specialized thoracic surgery setting, video-assisted thoracoscopic surgery constitutes the standard surgical approach, even in chronic pleural empyema.