Chest
Volume 148, Issue 1, July 2015, Pages 235-241
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Original Research
Disorders of the Pleura
Survival in Patients With Malignant Pleural Effusions Who Developed Pleural Infection

https://doi.org/10.1378/chest.14-2199Get rights and content

OBJECTIVE

Malignant pleural effusion (MPE) incidence is increasing, and prognosis remains poor. Indwelling pleural catheters (IPCs) relieve symptoms but increase the risk of pleural infection. We reviewed cases of pleural infection in patients with IPCs for MPE from six UK centers between January 1, 2005, and January 31, 2014.

METHODS

Survival in patients with pleural infection was compared with 788 patients with MPE (known as the LENT [pleural fluid lactate dehydrogenase, Eastern Cooperative Oncology Group performance status, serum neutrophil to lymphocyte ratio, and tumor type] cohort) and with national statistics.

RESULTS

Of 672 IPCs inserted, 25 (3.7%) became infected. Most patients (20 of 25) had mesothelioma or lung cancer. Median survival in the pleural infection cohort appeared longer than in the LENT cohort, although this result did not achieve significance (386 days vs 132 days; hazard ratio, 0.67; P = .07). Median survival with mesothelioma and pleural infection was twice as long as national estimates for mesothelioma survival (753 days vs < 365 days) and double the median survival of patients with mesothelioma in the LENT cohort (339 days; 95% CI, nonoverlapping). Survival with lung and breast cancer did not differ significantly between the groups. Sixty-one percent of patients experienced early infection. There was no survival difference between patients with early and late infection (P = .6).

CONCLUSIONS

This small series of patients with IPCs for MPE suggests pleural infection may be associated with longer survival, particularly in patients with mesothelioma. Results did not achieve significance, and a larger study is needed to explore this relationship further and investigate whether the local immune response, triggered by infection, is able to modulate mesothelioma progression.

Section snippets

Materials and Methods

All IPCs inserted for MPE between January 1, 2005, and January 31, 2014, in six UK centers were reviewed and cases of pleural infection identified. Recruitment periods differed between centers according to when services were established. Details are shown in e-Table 1. Pleural infection was defined as clinical symptoms and signs consistent with pleural infection, necessitating antibiotic treatment, with or without positive pleural fluid microscopy or culture. Superficial wound infections at IPC

Results

Six hundred seventy-two IPCs were inserted during the study period. Twenty-five patients (3.7%) were identified as having experienced pleural infection. Each patient had a single episode of pleural infection, affecting a unilateral IPC. One individual with pleural infection also appeared in the LENT cohort. This patient was removed from the LENT group prior to analysis. Baseline characteristics of patients with pleural infection are summarized in Table 1, and a patient flow diagram is shown in

Discussion

This retrospective review of practice from six UK hospitals suggests that patients who develop pleural infection with an IPC in situ for MPE may live longer than those without infection. Hazard modeling in this small sample did not achieve significance (P = .07); however, the trend toward significance, the appearance of the Kaplan-Meier survival curves, and the CIs that do not overlap (for the overall population and mesothelioma) raise the possibility of a genuine effect. Further research in

Conclusions

In summary, this review of 25 cases of pleural infection in patients with IPC for MPE suggests enhanced survival, particularly in patients with mesothelioma. Similarities between our population and previously published series indicate that this cohort is representative and support the possibility that this observation represents a genuine effect. The study has limitations, and statistical significance is not achieved; however, despite this, the Kaplan-Meier survival curves suggest a possible

Acknowledgments

Author contributions: A. C. B. and N. A. M. are the guarantors of the article and take responsibility for the manuscript, the data, and the analysis. A. C. B. and N. A. M. contributed to conceiving the article, collated and analyzed the data, and wrote the manuscript; A. O. C. contributed to providing data from the LENT cohort and contributed significantly to data analysis and manuscript writing; G. C. S., A. J. M., J. F., I. P., J. C. T. P., M. G. S., A. E. S., and N. M. R. contributed to

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This research was presented in abstract form (S117) at the British Thoracic Society Winter Meeting, December 5, 2014, London, England.

FUNDING/SUPPORT: The authors have reported to that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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