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Pleural empyema represents a significant healthcare burden due to extended hospital admissions and potential requirement for surgical intervention. This study aimed to assess changes in incidence and management of pleural empyema in England over the past 10 years and the potential impact of influenza on rates. Hospital Episode Statistics data were used to identify patients admitted to English hospitals with pleural empyema between 2008 and 2018. Linear regression was used to analyse the relationship between empyema rates and influenza incidence recorded by Public Health England. The relationship between influenza and empyema was further explored using serological data from a prospective cohort study of patients presenting with pleural empyema. Between April 2008 and March 2018 there were 55 530 patients admitted with pleural empyema. There was male predominance (67% versus 33%), which increased with age. Cases have increased significantly from 4447 in 2008 to 7268 in 2017. Peaks of incidence correlated moderately with rates of laboratory-confirmed influenza in children and young adults (r=0.30). For nine of the 10 years studied, the highest annual point incidence of influenza coincided with the highest admission rate for empyema (with a 2-week lag). In a cohort study of patients presenting to a single UK hospital with pleural empyema/infection, 24% (17 out of 72) had serological evidence of recent influenza infection, compared to 7% in seasonally matched controls with simple parapneumonic or cardiogenic effusions (p, Rates of pleural empyema are increasing in English hospitals without any improvement in patient outcomes. This study also found that male predominance of empyema increased with age, and rates increased in winter and during peaks of influenza. https://bit.ly/3oiJ870

Introduction: Several factors imply a viral role in the development of pleural infection including low yield on bacterial culture and seasonal variation. The relationship between respiratory viruses and pneumococcal pneumonia is well known but no studies have tested the association with pleural infection. Additionally, Epstein-Barr virus (EBV) has been implicated as a possible cause of ‘undiagnosed effusions’ without being validated. Methods: We analysed serum and pleural fluid (pf) from a prospective cohort of patients with effusions due to infection and biopsy-proven inflammatory pleuritis (IP). Nucleic acids were extracted from pf using the QIAsymphony DSP Virus/Pathogen Kit. Real-time PCR was performed using TaqMan array with 48 pathogen targets. Serum complement fixation testing using influenza and RSV antigen was performed alongside EBV serological tests. Results: From 193 patients including 60 empyema, 50 parapneumonic, 28 IP and 55 cardiac transudates (controls) there were no significant respiratory viral titres in pf. In patients with infective effusions, 21% had serological evidence of recent viral infection (Influenzas A&B or RSV). EBV was present at low levels in 22 pf samples (11%). There was no evidence of acute or re-activated EBV infection in the sera of patients with EBV DNA in pf. Conclusion: This is the first prospective study to test for the presence of viruses in pleural infection. We found no evidence of respiratory viruses within the effusions of either infection or control groups. However, there was serological evidence of recent flu/RSV infection in patients with pleural infection indicating a precedent illness. Results from pf EBV analysis demonstrated latent infection in 11% but no causative role.

Unilateral pleural effusions are a common diagnostic challenge for the respiratory physician. In the majority a diagnosis can be made after medical history, computerised tomography (CT) and pleural fluid analysis [1]. A proportion of patients will require a pleural biopsy but following this a minority will remain undiagnosed and are defined as idiopathic/inflammatory pleuritis (IP) [2]. These patients often require extended follow up to ensure effusion resolution and exclude malignancy. Footnotes This manuscript has recently been accepted for publication in the European Respiratory Journal . It is published here in its accepted form prior to copyediting and typesetting by our production team. After these production processes are complete and the authors have approved the resulting proofs, the article will move to the latest issue of the ERJ online. Please open or download the PDF to view this article. Conflict of interest: Dr. Arnold has nothing to disclose. Conflict of interest: Dr. Suri has nothing to disclose. Conflict of interest: Dr. Hamilton has nothing to disclose. Conflict of interest: Dr. Morley has nothing to disclose. Conflict of interest: Dr. Medford has nothing to disclose. Conflict of interest: Dr. Vipond has nothing to disclose. Conflict of interest: Dr. Muir has nothing to disclose. Conflict of interest: Dr. Maskell has nothing to disclose.