Respiratory Medicine (2014) 108, 1e8
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/rmed
REVIEW
Clinical characteristics of septic pulmonary embolism in adults: A systematic review Rui Ye, Li Zhao*, Cuihong Wang, Xiaojie Wu, Hengyi Yan Department of Respiratory Medicine, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, Shenyang City, China Received 27 June 2013; accepted 8 October 2013 Available online 17 October 2013
KEYWORDS Septic pulmonary embolism; Clinical characteristics; Systematic review
Summary Objectives: To describe the clinical characteristics of septic pulmonary embolism in adults in order to improve its diagnosis and treatment. Methods: Specific search terms were used for retrieval from commonly used Chinese and English databases and the articles were selected in accordance with the inclusion and exclusion criteria. Cases from the included articles were pooled; then the following parameters were analyzed: major risk factors, clinical manifestations, imaging findings, characteristics of pathogenic microorganisms, complications and other clinical characteristics. Results: After strictly selected by the inclusion and exclusion criteria, 76 articles were selected (2 Chinese articles and 74 English articles) that described 168 cases. The major risk factors for SPE were intravenous drug use (n Z 44), intravascular indwelling catheter (n Z 21) and skin or soft tissue purulent infection (n Z 10). The most frequent clinical manifestations were fever (n Z 144), dyspnea (n Z 81), chest pain (n Z 82) and cough (n Z 69). Chest CT showed multiple peripheral nodules in both lungs (n Z 89), cavitation (n Z 75), focal or wedge-shaped infiltrates (n Z 48) and pleural effusion (n Z 40). Echocardiography often revealed vegetations (n Z 52). Blood cultures grew methicillin-resistant Staphylococcus aureus (MRSA) (n Z 27), methicillin-sensitive Staphylococcus aureus (MSSA) (n Z 48) and Candida (n Z 6). Seventeen cases died and 101 cases were cured. Conclusions: SPE is a rare disease without specific clinical manifestations. For high-risk groups, such as intravenous drug users or patients with intravascular indwelling catheters, fever and imaging findings of multiple nodules or local infiltrates, with or without cavitation, are highly suggestive of SPE. Early diagnosis and prompt antimicrobial therapy or surgical intervention can lead to a successful treatment outcome. ª 2013 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ86 18940251639; fax: þ86 24 23845961. E-mail address: [email protected] (L. Zhao). 0954-6111/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.rmed.2013.10.012
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R. Ye et al.
Contents Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Sources of data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Inclusion and exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Information extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Description of the selected articles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Sociodemographic description of the cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Primary infective foci . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical manifestations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Imaging results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Blood culture results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Septic pulmonary embolism (SPE) is a rare type of pulmonary embolism in which emboli containing pathogens embolize to the pulmonary artery and cause pulmonary embolism and focal lung abscesses. In 1978, a study [1] reported 60 cases of SPE, 78% of these were intravenous drug users [1]. Due to the increasing use of intravascular devices and catheters, more catheter-related SPE reports have been published [2]; most were small case series or individual case reports. In order to understand more thoroughly the clinical and epidemiological features of SPE, we systematic reviewed reports of SPE published from June 1978 to September 2012. The results are reported below.
Materials and methods Sources of data Septic pulmonary embolism was the search term used for retrieval from the Chinese Biomedical Literature Database on Disc, China National Knowledge Infrastructure, Wanfang Data Periodicals System and VIP Chinese Biomedical Journals. In addition, “septic pulmonary embolism” and “septic pulmonary emboli” were the search terms for retrieval from PubMed, EBSCO, SpringerLink, ScienceDirect Editons and EMBASE full-text database. Articles published in the time period June 1,1978 to September 1, 2012 were included. The retrieval was supplemented by literature tracing to collect relevant articles as comprehensively as possible. First, two investigators independently read the titles and abstracts of the articles retrieved; second, after excluding obviously ineligible reports, we browsed the full texts of articles that might meet the inclusion criteria; third, we cross-checked the results of the included articles. In case of disagreement, eligibility was decided through discussion or by a third investigator.
Inclusion and exclusion criteria Inclusion criteria were as follows: (1) Eligible study designs included individual case reports, case series, caseecontrol studies or cohort studies. (2) Case definition of SPE included the following [2]: a. focal or multifocal lung infiltrates compatible with septic embolism to the lung, b. presence of active extra pulmonary infection as potential embolic source, c. exclusion of other potential explanation for lung infiltrates and d. resolution of lung infiltrates with appropriate antimicrobial therapy. (3) Study objectives included a descriptive analysis of clinical manifestations of SPE. (4) Study results could be either a qualitative description of clinical manifestations or a quantitative representation of the frequency of various clinical manifestations. (5) The patients in the studies were older than 14 years of age. Exclusion criteria follow: (1) articles that only focused on certain clinical characteristics of SPE, for example, imaging characteristics; (2) articles that repeated another published report or contained data that significantly overlapped with that of another published report; (3) systematic review, guidelines and other descriptive articles and (4) articles without an available full text version or published in languages other than Chinese and English.
Information extraction EpiData 3.1 software was used to extract the relevant information from the eligible articles, including first author, publication year, number of cases, age, sex, risk factors and number of patients with these risk factors, clinical manifestations, imaging findings, blood culture results and outcomes, etc.
A system review on clinical characteristics of septic pulmonary embolism
Statistical analysis SPSS13.0 software was used for statistical analysis of the data. The included cases served as independent large sample data for statistical analysis of various risk factors, clinical symptoms, imaging characteristics, blood culture results and outcomes.
Results Description of the selected articles In this study, we retrieved 338 relevant articles, 31 in Chinese and 307 in English. After rigorous application of the inclusion and exclusion criteria 76 eligible articles were included, 2 in Chinese [3,4] and 74 in English [2,5e77]. All included articles were individual case reports or serial case reports; the distribution of the articles by publication year is shown in Fig. 1.
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pneumonia, 2 cases had septic abortions, 1 case had a prostate abscess and 1 case had a subarachnoid abscess. Eleven cases had infections at two sites.
Clinical manifestations In all 168 SPE cases, the symptoms were not specific, most manifested as bacteremia, dyspnea, chest pain, cough and other respiratory symptoms as well as symptoms of the extra pulmonary primary infective focus. There was fever in 144 cases (85.71%) (the highest temperature, described in 48 of these 144 cases, was 37.5e40.6 C (mean 38.37 0.92 C)), dyspnea in 81 cases (48.21%), chest pain in 82 cases (48.81%), cough in 69 cases (41.07%), fatigue in 44 cases (26.19%), anemia in 31 cases (18.45%), hemoptysis in 24 cases (14.29%), disease progression to respiratory failure in 26 cases (15.48%), septic shock in 18 cases (10.71%), empyema in 14 cases (8.33%) and renal insufficiency in 9 cases (5.36%).
Imaging results Sociodemographic description of the cases The 76 articles included a total of 168 cases of SPE, 113 males (67.26%) and 55 females (32.74%). All the cases were 14e81years old (mean 37.20 16.63 years). National and regional distribution follow: 65 cases (38.69%) were from the USA, 25 cases (14.88%) from the PRC, 23 cases (13.69%) from South Korea, 13 cases (7.74%) from Taiwan, 13 cases (7.74%) from Japan, 6 cases (3.57%) from Turkey, 4 cases (2.38%) from the UK, 4 cases (2.38%) from Australia, 2 cases from Germany, 2 cases from Portugal and 1 case each from the Netherlands, Italy, Spain, Poland, Romania, Canada, Egypt, Denmark, Malaysia, Brazil and India.
Primary infective foci Among all cases, the primary infective focus was unknown in 10 cases; 44 cases (26.19%) were drug addicts; 21 cases (12.5%) had intravascular indwelling catheters; 20 cases (11.91%) had infective endocarditis, 15 cases (8.93%) had liver abscesses, 10 cases (5.95%) had skin and soft tissue infections, 10 cases (5.95%) had septic thrombophlebitis, 9 cases (5.36%) had lemierre’s syndrome, 9 cases (5.36%) had dental and periodontal infections; 5 cases (2.98%) had heart pacemakers, 4 cases had throat abscesses, 4 cases had pyomyositis, 3 cases had renal and perirenal abscesses, 3 cases had septic osteomyelitis, 3 cases had septic arthritis, 3 cases had urinary tract infections, 2 cases had
Figure 1
In 168 cases, 135 cases underwent chest X-ray examination, 134 cases chest CT examination, 12 cases enhanced chest CT examination and 1 case underwent a lung ventilation perfusion scan. The main imaging findings are shown in Table 1.
Echocardiography Altogether, 107 cases were evaluated by echocardiography; 82 by transthoracic echocardiography, 44 by transesophageal echocardiography and 19 by both transthoracic and transesophageal echocardiography. Echocardiography revealed vegetations in 52 cases (48.60%), including vegetations on the tricuspid valve in 45 cases (86.54%), vegetations on the pulmonary valve in 2 cases and vegetations on the atrium and endocardium in 5 cases (vegetations attached to the pacemaker in 3 of these 5 cases). In 6 cases, transesophageal echocardiography revealed vegetations that were not visible with transthoracic echocardiograghy.
Blood culture results Altogether, 151 cases underwent blood culture, results were positive results in 137 cases (90.73%); some cases had multiple positive blood cultures. Blood cultures grew methicillin-resistant Staphylococcus aureus (MSSA) in 48
Publication years of the included articles.
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R. Ye et al. Table 1
Imaging findings of 168 SPE cases.
Imaging findings
Chest X-ray n(%)
Chest CT n(%)
Bilateral abnormality Nodules opacities Local infiltrates Wedge-shaped lesions Cavitation feeding vessel sign Pleural effusion
110(81.48) 89(65.93) 54(40.00) 5(3.70) 44(32.59) 0 32(23.70)
110(82.09) 89(66.42) 48(35.82) 23(17.16) 75(55.97) 37(27.61) 40(29.85)
cases, methicillin-sensitive Staphylococcus aureus (MRSA) in 27 cases, Fusobacteria in 11 cases, Klebsiella pneumoniae in 11 cases, Candida in 6 cases and Streptococcus viridans in 4 cases. The distribution of blood culture results according to clinical risk factors is shown in Table 2.
Treatment All cases in this group were treated with antibiotics, usually for 4e9 weeks; for 122 cases, the course of treatment was described in detail, as shown in Table 3. In addition to medical treatment, 18 cases received surgical treatment, including valve replacement or repair in 7 cases, surgical embolectomy in 7 cases and cardiac surgery in 4 cases. Twenty-two cases who had empyema and pleural effusion underwent closed thoracic drainage, the abscesses of 16 cases were drained, with the local infected lesions of 5 cases were removed, 14 cases with associated thrombosis received anticoagulant treatment, and the catheters were removed from the cases with catheter-related infections.
Outcomes The outcomes were unknown in 3 cases, 101 cases (60.12%) were cured, 47 cases (27.98%) were improved and 17 cases Table 2
(10.12%) died. The causes of death included septic shock (6 cases), hemoptysis (2 cases), gastrointestinal bleeding (2 cases), pulmonary edema (1 case), recurrent pulmonary embolism (1 case), multiple organ failure (2 cases), progressive renal insufficiency (1 case), cerebral hemorrhage (1 case), tumor (1 case) and unknown cause (1 case). Four cases underwent autopsy, which revealed emboli in the pulmonary artery in 2 cases.
Discussion SPE is a rare but serious disease. Since a study [1] reported 60 cases of SPE in 1978, most of the reports are case reports with few cases. It can be seen from the distribution of articles included in this study by publication years of that the number of reports of SPE has risen in recent years. In terms of geographical distribution, SPE has been reported primarily from densely populated countries with more advanced medical resources, which may be related to the technologies required to diagnose SPE, as well as the risk factors for SPE. Therefore, we systematically reviewed the clinical characteristics of SPE patients reported after 1978, and thereby identified temporal changes in the epidemiological characteristics of SPE. The common causes for SPE include intravenous drug use, infective endocarditis of the tricuspid valve, septic thrombophlebitis, suppurative angina, periodontal abscess, purulent infection of skin and soft tissues, pelvic thrombophlebitis, intravascular catheters, pacemakers, liver abscess and hemodialysis [1,58]. In the 1970s, 76%e78% of the SPE patients were intravenous drug users [1,78]. In this study, however, only 26.19% were intravenous drug users, while the 15.5% percent of patients had intravascular indwelling catheters or pacemakers, which may be related to the recent increase in use of indwelling catheters for cancer chemotherapy and parenteral nutrition support. Moreover, with the development of cardiovascular
Blood culture results in SPE patients by clinical risk factors.
Clinical risk factor
Infective focus IV drug abuse Catheter-related infection Skin and soft tissue infection Liver abscess Infective endocarditis Septic thromobphlebitis Lemierre’s syndrome Medical conditions Diabetes Chemoradiotherapy Immunocompromiseda Complications Empyema
Microorganism isolated from blood cultures MSSA
MRSA
Fusobacterim
KP
Candida
VS
n
n
n
n
n
n
26 3 10 0 0 0 0
11 4 10 0 5 3 0
2 0 0 0 0 2 5
1 1 1 6 0 0 0
0 5 0 0 1 0 0
0 0 0 0 4 0 0
1 2 0
1 0 2
0 0 0
5 0 0
1 2 3
0 0 0
6
1
3
0
0
0
MSSA: Methicillin-sensitive Staphylococcus aureus; MRSA: Methicillin-resistant Staphylococcus aureus; KP: Klebsiella Pneumonia; VS: Viridians Streptococci. a Immunocompromised from long-term oral administration of steroids, splenectomy and other reasons.
A system review on clinical characteristics of septic pulmonary embolism Table 3 Patient outcomes of patients by antimicrobial given for initial treatment and regimen change. Antimicrobial
Outcomes Improved Cured Dead Regimen change N
n
Initial treatment Penicillins 12 14 Cephalosporins 9 3 Quinolones 0 3 Carbapenems 2 2 Vancomycin 4 23 Teicoplanin 2 0 Amphotericin B 2 0 Treatment after regimen change Penicillins 3 4 Cephalosporins 4 2 Carbapenems 1 7 Vancomycin 3 4 2 3 Daptomycina a
n
n
4 4 0 1 0 1 1
14 13 4 1 3 0 0
0 0 0 0 0
Daptomycin þ rifampicin combination therapy.
intervention, more endovascular stents and pacemakers have been used in clinical practice. In this group, SPE was caused by pacemakers in 5 cases. The clinical manifestations of SPE patients are not specific. In these 168 cases, the main clinical manifestations were fever (85.71%), dyspnea (48.21%), chest pain (48.81%) and cough (41.07%). Pulmonary thromboembolism patients also often have dyspnea, chest pain and other symptoms, and some patients also have fever. However, in such patients, the highest body temperature rarely exceeds 38.5 C and extra pulmonary infection lesions are rarely found; these differences, can help distinguish SPE from pulmonary thromboembolism. SPE has unique imaging findings, such as nodules, patchy infiltrates, cavity and pleural effusion. Most cases have more than two imaging manifestations simultaneously, commonly multiple nodules or patchy infiltrates of both lungs, especially near the pleura, with or without cavity and pleural effusion. Among the 40 cases with the complication of pleural effusion, 14 cases had empyema that was considered related to S. aureus(S. aureus) infection [41], 7 cases were definitively caused by S.aureus. For detection of pulmonary infiltrates and lesions, X-ray and CT findings were very similar, but CT could more clearly show more subtle lesions such as feeding vessels. In 12 cases, the enhanced chest CT examination clearly indicated the formation of pulmonary arterial emboli, which helped to better differentiate SPE from simple lung infection, especially from S. aureus pneumonia. Echocardiography showed that 86.54% of the vegetations in the SPE patients were tricuspid vegetations, consistent with the published reports [79]. SPE is usually considered to originate from the right ventricular system, consistent with SPE’s association with intravenous drug use and catheterrelated infection and with the flow of emboli through the right ventricle leading to pulmonary arterial embolism. The presence of tricuspid vegetations not only supports the diagnosis of infective endocarditis, but also helps to
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indicate the source of septic emboli and contributes to the diagnosis of SPE. Patients with highly suspected endocardial vegetations but negative results with transthoracic echocardiography should be evaluated with transesophageal echocardiography, because the detection rate can be improved. The incidence of cardiac device endocarditis is 1e7% of those who receive a cardiac device, and 27% cardiac device endocarditis is associated with SPE [80]. In this group, right atrial vegetations were found in 6 cases; 4 of there were attached to the pacemakers. Therefore, for patients with a cardiac device, if echocardiography suggests infective endocarditis, complicated SPE should be considered. S. aureus is the most common pathogen in intravenous drug abusers and patients with skin and soft tissue and catheter-related infections. The blood culture results in this group also revealed that S. aureus was the most frequent pathogen. Candida is a common pathogen that causes catheter-related infections. As shown by the blood culture results in this group, 6 cases were infected with Candida, which was from intravascular indwelling catheters in 5 cases who had complicated immune hypofunction or tumor. A study [81] reported that fungal embolism was found in 90% of the SPE patients with an underlying disease of leukemia or lymphoma, prodominantly Candida and Aspergillus embolism. K. pneumoniae is the pathogen that most frequently causes liver abscess [82]. The blood culture in this group grew K. pneumoniae in 11 cases, including 6 cases with liver abscess and 5 cases with diabetes. Fusobacterium is a common oropharyngeal anaerobic genus. The blood culture in this group grew fusobacteriam in 11 cases, mostly in cases of oropharyngeal infection or Lemierre’s syndrome. In this group, 101 cases were cured and 47 cases improved; all were treated with antibiotics. Initially, the patients were most frequently treated with broadspectrum penicillins and cephalosporins; antibiotics were adjusted promptly according to the blood culture results. All patients were treated for 4e9 weeks. For S. aureus infection, this study indicated that the efficacy of vancomycin in the treatment of MSSA infection was not superior to that of nafcillin or oxacillin [83]. For blood culturepositive MRSA infection, the infected lesions should be removed first; in the event of associated empyma, adequate drainage should be combined with systemic intravenous medication. For such infections vancomycin or daptomycin are recommended for 4e6 weeks; the addition of gentamicin to vancomycin is not recommended [84]. For fungal infections, the intravascular indwelling catheters should be removed first, fluconazole or an echinocandin is recommended for initial therapy and an echinocandin is recommended for neutropenic patients. The recommended duration of therapy for candidemia, without persistent fungemia or metastatic complications, is 2 weeks after documented clearance of Candida from the bloodstream, resolution of symptoms attributable to candidemia and resolution of neutropenia [85]. SPE treatment usually does not involve the application of anticoagulants because of the risk of bleeding of infective emboli. In our study, anticoagulants were used in 14 cases, usually to treat thrombosis or thrombophlebitis; 18 cases were treated surgically, predominately targeted at valvular vegetations. In patients
6 with difficult to control infections, the focus of infection be removed surgically as soon as possible. Based on the results of our study, SPE should be suspected in high-risk patients with a history of intravenous drug use or underlying disease, if they have fever, dyspnea, chest pain and other clinical manifestations and their lung images suggest multiple nodules or plaques with or without pleural effusion. Enhanced chest CT examination should be performed to identify the emboli and blood culture, liver ultrasonography, echocardiography and other examinations should be performed to detect the source of the emboli. Early removal of infected lesions, indwelling catheters or cardiac devices is highly recommended. Before the results of blood culture are available, they should be given empiric antibiotics against S. aureus infection. For patients with liver abscess, antibiotics active against K. pneumoniae should be selected. In addition, Candida infection should be considered in patients with catheter-related infection who are immunocompromised or have a malignancy. SPE has a high mortality. Seventeen of the 168 cases in this review died, including 15 deaths due to SPE; death was caused most frequently by septic shock accompanied by multiple organ failure. Therefore, for patients with SPE, attention should be paid not only the to course of the local focus of infection but also to end-organ function to detect and correct shock as early as possible and thereby improve prognosis.
Conflict of interest
R. Ye et al.
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[49] Wijesekera NT, Sheppard MN, Mullen MJ. Candida endocarditis with mycotic pulmonary emboli following re-do Rastelli operation. Heart 2004;90(6):e34. [50] Kamano Y, Ohashi H, Kikuchi T, et al. Liver abscess and Aeromonas bacteremia with septic pulmonary embolism. Intern Med 2003;42(10):1047e9. [51] Abid Q, Price D, Stewart MJ, et al. Septic pulmonary emboli caused by a hemodialysis catheter. Asian Cardiovasc Thorac Ann 2002;10(3):251e3. [52] Dorsey ST. A critically ill young man with septic emboli to the lungs. J Emerg Med 2002;22(4):415e7. [53] Gressianu MT, Dhruva VN, Arora RR, et al. Massive septic thrombus formation on a superior vena cava indwelling catheter following Torulopsis (Candida) glabrata fungemia. Intensive Care Med 2002;28(3):379e80. [54] McKerlie I, Bloom C, Kreisman H. Staphylococcus aureus septic pulmonary emboli presenting as angioinvasive aspergillosis: case report. Can Assoc Radiol J 2001;52(6):395e8. [55] Avery RK, Barnes DS, Teran JC, et al. Listeria monocytogenes tricuspid valve endocarditis with septic pulmonary emboli in a liver transplant recipient. Transpl Infect Dis 1999;1(4): 284e7. [56] Marinella MA. Septic pulmonary emboli complicating lip cellulitis. Ann Emerg Med 2001;37(1):117. [57] Fred HL, Basaria S. Liver abscess with septic pulmonary emboli. N Engl J Med 1997;336(20):1428. [58] Zenda T, Araki I, Hiraiwa Y, et al. Septic pulmonary emboli secondary to pyogenic liver abscess in a diabetic patient. Intern Med 1995;34(1):42e5. [59] Hughes CE, Spear RK, Shinabarger CE, et al. Septic pulmonary emboli complicating mastoiditis: Lemierre’s syndrome revisited. Clin Infect Dis 1994;18(4):633e5. [60] Kelly RF, Yellin AE, Weaver FA. Candida thrombosis of the innominate vein with septic pulmonary emboli. Ann Vasc Surg 1993;7(4):343e6. [61] Chowdhury P, Stein DS. Pyogenic hepatic abscess and septic pulmonary emboli associated with Klebsiella ozaenae bacteremia. South Med J 1992;85(6):638e41. [62] Cervia JS, Caputo TA, Davis SD, et al. Septic pulmonary embolism complicating a central venous catheter. Chest 1990;98(6):1526. [63] Coughlin WF, Knott PE. Right atrial myxoma. A cause of septic pulmonary emboli in an adolescent female. J Adolesc Health Care 1990;11(4):351e4. [64] Stine KC, Friedman HS, Kurtzberg J, et al. Pulmonary septic emboli mimicking metastatic rhabdomyosarcoma. J Pediatr Surg 1989;24(5):491e3. [65] Wyzan D, Gonzalez-Rothi RJ. Septic pulmonary embolization caused by Citrobacter diversus. Respiration 1989;55(3):189e92. [66] Kronborg G. Septic pulmonary embolism caused by Candida albicans: a fatal complication to bone marrow transplantation. Scand J Infect Dis 1989;21(1):113e5. [67] Bach MC, Roediger JH, Rinder HM. Septic anaerobic jugular phlebitis with pulmonary embolism: problems in management. Rev Infect Dis 1988;10(2):424e7. [68] Lam D, Emilson B, Rapaport E. Septic pulmonary embolic secondary to an infected right atrial thrombus. Am Heart J 1987;114(1 Pt 1):178e80. [69] Webb DW, Thadepalli H. Hemoptysis in patients with septic pulmonary infarcts from tricuspid endocarditis. Chest 1979; 76(1):99e100. [70] Osei C, Berger HW, Nicholas P. Septic pulmonary infarction: clinical and radiographic manifestations in 11 patients. Mt Sinai J Med 1979;46(2):145e8. [71] Hadlock FP, Wallace Jr RJ, Rivera M. Pulmonary septic emboli secondary to parapharyngeal abscess; postanginal sepsis. Radiology 1979;130(1):29e33.
8 [72] Brueck M, Rauber K, Wizemann V, et al. Infective tricuspid valve endocarditis with septic pulmonary emboli due to puncture of an endogenous arteriovenous fistula in a chronic hemodialysis patient. J Infection 2003;46(3):188e91. [73] Ong ML. Endocarditis of the tricuspid valve associated with congenital coronary arteriovenous fistula. Br Heart J 1993; 70(3):276e7. [74] Serefhanoglu K, Bayindir Y, Ersoy Y. Septic pulmonary embolism secondary to dental focus. Quintessence Int 2008; 39(9):753e6. [75] Shiota Y, Arikita H, Horita N. Septic pulmonary embolism associated with periodontal disease: reports of two cases and review of the literature. Chest 2002;121(2):652e4. [76] Christensen PJ, Kutty K, Adlam RT. Septic pulmonary embolism due to periodontal disease. Chest 1993;104(6): 1927e9. [77] Russi EW, Dazzi H, Ga ¨umann N. Septic pulmonary embolism due to periodontal disease in a patient with hereditary hemorrhagic telangiectasia. Respiration 1996;63(2):117e9. [78] Jaffe RB, Koschmann EB. Septic pulmonary emboli. Radiology 1970:527e32. [79] Moss R, Munt B. Injection drug use and right sided endocarditis. Heart 2003;89:577e81.
R. Ye et al. [80] Massoure PL, Reuter S, Lafitte S, et al. Pacemaker endocarditis: clinical features and management of 60 consecutive cases. Pacing Clin Electrophysiol 2007 Jan;30(1):12e9. [81] Doran HM, Sheppard MN, Collins PW, et al. Pathology of the lung in leukaemia and lymphoma: a study of 87 autopsies. Histopathology 1991;18:211e9. [82] Pastagia M, Arumugam V. Klebsiella pneumoniae liver abscesses in a public hospital in Queens, New York. Travel Med Infect Dis 2008;6(4):228e33. [83] Korzeniowski O, Sande MA. Combination antimicrobial therapy for Staphylococcus aureus endocarditis in patients addicted to parenteral drugs and in nonaddicts: a prospective study. Ann Intern Med 1982;97:496e503. [84] Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clin Infect Dis 2011;52(3):285e92. [85] Pappas PG, Kauffman CA, Andes D, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;48(5):503e35.
Available online at www.sciencedirect.com
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REVIEW
Clinical characteristics of septic pulmonary embolism in adults: A systematic review Rui Ye, Li Zhao*, Cuihong Wang, Xiaojie Wu, Hengyi Yan Department of Respiratory Medicine, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, Shenyang City, China Received 27 June 2013; accepted 8 October 2013 Available online 17 October 2013
KEYWORDS Septic pulmonary embolism; Clinical characteristics; Systematic review
Summary Objectives: To describe the clinical characteristics of septic pulmonary embolism in adults in order to improve its diagnosis and treatment. Methods: Specific search terms were used for retrieval from commonly used Chinese and English databases and the articles were selected in accordance with the inclusion and exclusion criteria. Cases from the included articles were pooled; then the following parameters were analyzed: major risk factors, clinical manifestations, imaging findings, characteristics of pathogenic microorganisms, complications and other clinical characteristics. Results: After strictly selected by the inclusion and exclusion criteria, 76 articles were selected (2 Chinese articles and 74 English articles) that described 168 cases. The major risk factors for SPE were intravenous drug use (n Z 44), intravascular indwelling catheter (n Z 21) and skin or soft tissue purulent infection (n Z 10). The most frequent clinical manifestations were fever (n Z 144), dyspnea (n Z 81), chest pain (n Z 82) and cough (n Z 69). Chest CT showed multiple peripheral nodules in both lungs (n Z 89), cavitation (n Z 75), focal or wedge-shaped infiltrates (n Z 48) and pleural effusion (n Z 40). Echocardiography often revealed vegetations (n Z 52). Blood cultures grew methicillin-resistant Staphylococcus aureus (MRSA) (n Z 27), methicillin-sensitive Staphylococcus aureus (MSSA) (n Z 48) and Candida (n Z 6). Seventeen cases died and 101 cases were cured. Conclusions: SPE is a rare disease without specific clinical manifestations. For high-risk groups, such as intravenous drug users or patients with intravascular indwelling catheters, fever and imaging findings of multiple nodules or local infiltrates, with or without cavitation, are highly suggestive of SPE. Early diagnosis and prompt antimicrobial therapy or surgical intervention can lead to a successful treatment outcome. ª 2013 Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ86 18940251639; fax: þ86 24 23845961. E-mail address: [email protected] (L. Zhao). 0954-6111/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.rmed.2013.10.012
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R. Ye et al.
Contents Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Sources of data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Inclusion and exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Information extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Description of the selected articles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Sociodemographic description of the cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Primary infective foci . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical manifestations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Imaging results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Blood culture results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Septic pulmonary embolism (SPE) is a rare type of pulmonary embolism in which emboli containing pathogens embolize to the pulmonary artery and cause pulmonary embolism and focal lung abscesses. In 1978, a study [1] reported 60 cases of SPE, 78% of these were intravenous drug users [1]. Due to the increasing use of intravascular devices and catheters, more catheter-related SPE reports have been published [2]; most were small case series or individual case reports. In order to understand more thoroughly the clinical and epidemiological features of SPE, we systematic reviewed reports of SPE published from June 1978 to September 2012. The results are reported below.
Materials and methods Sources of data Septic pulmonary embolism was the search term used for retrieval from the Chinese Biomedical Literature Database on Disc, China National Knowledge Infrastructure, Wanfang Data Periodicals System and VIP Chinese Biomedical Journals. In addition, “septic pulmonary embolism” and “septic pulmonary emboli” were the search terms for retrieval from PubMed, EBSCO, SpringerLink, ScienceDirect Editons and EMBASE full-text database. Articles published in the time period June 1,1978 to September 1, 2012 were included. The retrieval was supplemented by literature tracing to collect relevant articles as comprehensively as possible. First, two investigators independently read the titles and abstracts of the articles retrieved; second, after excluding obviously ineligible reports, we browsed the full texts of articles that might meet the inclusion criteria; third, we cross-checked the results of the included articles. In case of disagreement, eligibility was decided through discussion or by a third investigator.
Inclusion and exclusion criteria Inclusion criteria were as follows: (1) Eligible study designs included individual case reports, case series, caseecontrol studies or cohort studies. (2) Case definition of SPE included the following [2]: a. focal or multifocal lung infiltrates compatible with septic embolism to the lung, b. presence of active extra pulmonary infection as potential embolic source, c. exclusion of other potential explanation for lung infiltrates and d. resolution of lung infiltrates with appropriate antimicrobial therapy. (3) Study objectives included a descriptive analysis of clinical manifestations of SPE. (4) Study results could be either a qualitative description of clinical manifestations or a quantitative representation of the frequency of various clinical manifestations. (5) The patients in the studies were older than 14 years of age. Exclusion criteria follow: (1) articles that only focused on certain clinical characteristics of SPE, for example, imaging characteristics; (2) articles that repeated another published report or contained data that significantly overlapped with that of another published report; (3) systematic review, guidelines and other descriptive articles and (4) articles without an available full text version or published in languages other than Chinese and English.
Information extraction EpiData 3.1 software was used to extract the relevant information from the eligible articles, including first author, publication year, number of cases, age, sex, risk factors and number of patients with these risk factors, clinical manifestations, imaging findings, blood culture results and outcomes, etc.
A system review on clinical characteristics of septic pulmonary embolism
Statistical analysis SPSS13.0 software was used for statistical analysis of the data. The included cases served as independent large sample data for statistical analysis of various risk factors, clinical symptoms, imaging characteristics, blood culture results and outcomes.
Results Description of the selected articles In this study, we retrieved 338 relevant articles, 31 in Chinese and 307 in English. After rigorous application of the inclusion and exclusion criteria 76 eligible articles were included, 2 in Chinese [3,4] and 74 in English [2,5e77]. All included articles were individual case reports or serial case reports; the distribution of the articles by publication year is shown in Fig. 1.
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pneumonia, 2 cases had septic abortions, 1 case had a prostate abscess and 1 case had a subarachnoid abscess. Eleven cases had infections at two sites.
Clinical manifestations In all 168 SPE cases, the symptoms were not specific, most manifested as bacteremia, dyspnea, chest pain, cough and other respiratory symptoms as well as symptoms of the extra pulmonary primary infective focus. There was fever in 144 cases (85.71%) (the highest temperature, described in 48 of these 144 cases, was 37.5e40.6 C (mean 38.37 0.92 C)), dyspnea in 81 cases (48.21%), chest pain in 82 cases (48.81%), cough in 69 cases (41.07%), fatigue in 44 cases (26.19%), anemia in 31 cases (18.45%), hemoptysis in 24 cases (14.29%), disease progression to respiratory failure in 26 cases (15.48%), septic shock in 18 cases (10.71%), empyema in 14 cases (8.33%) and renal insufficiency in 9 cases (5.36%).
Imaging results Sociodemographic description of the cases The 76 articles included a total of 168 cases of SPE, 113 males (67.26%) and 55 females (32.74%). All the cases were 14e81years old (mean 37.20 16.63 years). National and regional distribution follow: 65 cases (38.69%) were from the USA, 25 cases (14.88%) from the PRC, 23 cases (13.69%) from South Korea, 13 cases (7.74%) from Taiwan, 13 cases (7.74%) from Japan, 6 cases (3.57%) from Turkey, 4 cases (2.38%) from the UK, 4 cases (2.38%) from Australia, 2 cases from Germany, 2 cases from Portugal and 1 case each from the Netherlands, Italy, Spain, Poland, Romania, Canada, Egypt, Denmark, Malaysia, Brazil and India.
Primary infective foci Among all cases, the primary infective focus was unknown in 10 cases; 44 cases (26.19%) were drug addicts; 21 cases (12.5%) had intravascular indwelling catheters; 20 cases (11.91%) had infective endocarditis, 15 cases (8.93%) had liver abscesses, 10 cases (5.95%) had skin and soft tissue infections, 10 cases (5.95%) had septic thrombophlebitis, 9 cases (5.36%) had lemierre’s syndrome, 9 cases (5.36%) had dental and periodontal infections; 5 cases (2.98%) had heart pacemakers, 4 cases had throat abscesses, 4 cases had pyomyositis, 3 cases had renal and perirenal abscesses, 3 cases had septic osteomyelitis, 3 cases had septic arthritis, 3 cases had urinary tract infections, 2 cases had
Figure 1
In 168 cases, 135 cases underwent chest X-ray examination, 134 cases chest CT examination, 12 cases enhanced chest CT examination and 1 case underwent a lung ventilation perfusion scan. The main imaging findings are shown in Table 1.
Echocardiography Altogether, 107 cases were evaluated by echocardiography; 82 by transthoracic echocardiography, 44 by transesophageal echocardiography and 19 by both transthoracic and transesophageal echocardiography. Echocardiography revealed vegetations in 52 cases (48.60%), including vegetations on the tricuspid valve in 45 cases (86.54%), vegetations on the pulmonary valve in 2 cases and vegetations on the atrium and endocardium in 5 cases (vegetations attached to the pacemaker in 3 of these 5 cases). In 6 cases, transesophageal echocardiography revealed vegetations that were not visible with transthoracic echocardiograghy.
Blood culture results Altogether, 151 cases underwent blood culture, results were positive results in 137 cases (90.73%); some cases had multiple positive blood cultures. Blood cultures grew methicillin-resistant Staphylococcus aureus (MSSA) in 48
Publication years of the included articles.
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R. Ye et al. Table 1
Imaging findings of 168 SPE cases.
Imaging findings
Chest X-ray n(%)
Chest CT n(%)
Bilateral abnormality Nodules opacities Local infiltrates Wedge-shaped lesions Cavitation feeding vessel sign Pleural effusion
110(81.48) 89(65.93) 54(40.00) 5(3.70) 44(32.59) 0 32(23.70)
110(82.09) 89(66.42) 48(35.82) 23(17.16) 75(55.97) 37(27.61) 40(29.85)
cases, methicillin-sensitive Staphylococcus aureus (MRSA) in 27 cases, Fusobacteria in 11 cases, Klebsiella pneumoniae in 11 cases, Candida in 6 cases and Streptococcus viridans in 4 cases. The distribution of blood culture results according to clinical risk factors is shown in Table 2.
Treatment All cases in this group were treated with antibiotics, usually for 4e9 weeks; for 122 cases, the course of treatment was described in detail, as shown in Table 3. In addition to medical treatment, 18 cases received surgical treatment, including valve replacement or repair in 7 cases, surgical embolectomy in 7 cases and cardiac surgery in 4 cases. Twenty-two cases who had empyema and pleural effusion underwent closed thoracic drainage, the abscesses of 16 cases were drained, with the local infected lesions of 5 cases were removed, 14 cases with associated thrombosis received anticoagulant treatment, and the catheters were removed from the cases with catheter-related infections.
Outcomes The outcomes were unknown in 3 cases, 101 cases (60.12%) were cured, 47 cases (27.98%) were improved and 17 cases Table 2
(10.12%) died. The causes of death included septic shock (6 cases), hemoptysis (2 cases), gastrointestinal bleeding (2 cases), pulmonary edema (1 case), recurrent pulmonary embolism (1 case), multiple organ failure (2 cases), progressive renal insufficiency (1 case), cerebral hemorrhage (1 case), tumor (1 case) and unknown cause (1 case). Four cases underwent autopsy, which revealed emboli in the pulmonary artery in 2 cases.
Discussion SPE is a rare but serious disease. Since a study [1] reported 60 cases of SPE in 1978, most of the reports are case reports with few cases. It can be seen from the distribution of articles included in this study by publication years of that the number of reports of SPE has risen in recent years. In terms of geographical distribution, SPE has been reported primarily from densely populated countries with more advanced medical resources, which may be related to the technologies required to diagnose SPE, as well as the risk factors for SPE. Therefore, we systematically reviewed the clinical characteristics of SPE patients reported after 1978, and thereby identified temporal changes in the epidemiological characteristics of SPE. The common causes for SPE include intravenous drug use, infective endocarditis of the tricuspid valve, septic thrombophlebitis, suppurative angina, periodontal abscess, purulent infection of skin and soft tissues, pelvic thrombophlebitis, intravascular catheters, pacemakers, liver abscess and hemodialysis [1,58]. In the 1970s, 76%e78% of the SPE patients were intravenous drug users [1,78]. In this study, however, only 26.19% were intravenous drug users, while the 15.5% percent of patients had intravascular indwelling catheters or pacemakers, which may be related to the recent increase in use of indwelling catheters for cancer chemotherapy and parenteral nutrition support. Moreover, with the development of cardiovascular
Blood culture results in SPE patients by clinical risk factors.
Clinical risk factor
Infective focus IV drug abuse Catheter-related infection Skin and soft tissue infection Liver abscess Infective endocarditis Septic thromobphlebitis Lemierre’s syndrome Medical conditions Diabetes Chemoradiotherapy Immunocompromiseda Complications Empyema
Microorganism isolated from blood cultures MSSA
MRSA
Fusobacterim
KP
Candida
VS
n
n
n
n
n
n
26 3 10 0 0 0 0
11 4 10 0 5 3 0
2 0 0 0 0 2 5
1 1 1 6 0 0 0
0 5 0 0 1 0 0
0 0 0 0 4 0 0
1 2 0
1 0 2
0 0 0
5 0 0
1 2 3
0 0 0
6
1
3
0
0
0
MSSA: Methicillin-sensitive Staphylococcus aureus; MRSA: Methicillin-resistant Staphylococcus aureus; KP: Klebsiella Pneumonia; VS: Viridians Streptococci. a Immunocompromised from long-term oral administration of steroids, splenectomy and other reasons.
A system review on clinical characteristics of septic pulmonary embolism Table 3 Patient outcomes of patients by antimicrobial given for initial treatment and regimen change. Antimicrobial
Outcomes Improved Cured Dead Regimen change N
n
Initial treatment Penicillins 12 14 Cephalosporins 9 3 Quinolones 0 3 Carbapenems 2 2 Vancomycin 4 23 Teicoplanin 2 0 Amphotericin B 2 0 Treatment after regimen change Penicillins 3 4 Cephalosporins 4 2 Carbapenems 1 7 Vancomycin 3 4 2 3 Daptomycina a
n
n
4 4 0 1 0 1 1
14 13 4 1 3 0 0
0 0 0 0 0
Daptomycin þ rifampicin combination therapy.
intervention, more endovascular stents and pacemakers have been used in clinical practice. In this group, SPE was caused by pacemakers in 5 cases. The clinical manifestations of SPE patients are not specific. In these 168 cases, the main clinical manifestations were fever (85.71%), dyspnea (48.21%), chest pain (48.81%) and cough (41.07%). Pulmonary thromboembolism patients also often have dyspnea, chest pain and other symptoms, and some patients also have fever. However, in such patients, the highest body temperature rarely exceeds 38.5 C and extra pulmonary infection lesions are rarely found; these differences, can help distinguish SPE from pulmonary thromboembolism. SPE has unique imaging findings, such as nodules, patchy infiltrates, cavity and pleural effusion. Most cases have more than two imaging manifestations simultaneously, commonly multiple nodules or patchy infiltrates of both lungs, especially near the pleura, with or without cavity and pleural effusion. Among the 40 cases with the complication of pleural effusion, 14 cases had empyema that was considered related to S. aureus(S. aureus) infection [41], 7 cases were definitively caused by S.aureus. For detection of pulmonary infiltrates and lesions, X-ray and CT findings were very similar, but CT could more clearly show more subtle lesions such as feeding vessels. In 12 cases, the enhanced chest CT examination clearly indicated the formation of pulmonary arterial emboli, which helped to better differentiate SPE from simple lung infection, especially from S. aureus pneumonia. Echocardiography showed that 86.54% of the vegetations in the SPE patients were tricuspid vegetations, consistent with the published reports [79]. SPE is usually considered to originate from the right ventricular system, consistent with SPE’s association with intravenous drug use and catheterrelated infection and with the flow of emboli through the right ventricle leading to pulmonary arterial embolism. The presence of tricuspid vegetations not only supports the diagnosis of infective endocarditis, but also helps to
5
indicate the source of septic emboli and contributes to the diagnosis of SPE. Patients with highly suspected endocardial vegetations but negative results with transthoracic echocardiography should be evaluated with transesophageal echocardiography, because the detection rate can be improved. The incidence of cardiac device endocarditis is 1e7% of those who receive a cardiac device, and 27% cardiac device endocarditis is associated with SPE [80]. In this group, right atrial vegetations were found in 6 cases; 4 of there were attached to the pacemakers. Therefore, for patients with a cardiac device, if echocardiography suggests infective endocarditis, complicated SPE should be considered. S. aureus is the most common pathogen in intravenous drug abusers and patients with skin and soft tissue and catheter-related infections. The blood culture results in this group also revealed that S. aureus was the most frequent pathogen. Candida is a common pathogen that causes catheter-related infections. As shown by the blood culture results in this group, 6 cases were infected with Candida, which was from intravascular indwelling catheters in 5 cases who had complicated immune hypofunction or tumor. A study [81] reported that fungal embolism was found in 90% of the SPE patients with an underlying disease of leukemia or lymphoma, prodominantly Candida and Aspergillus embolism. K. pneumoniae is the pathogen that most frequently causes liver abscess [82]. The blood culture in this group grew K. pneumoniae in 11 cases, including 6 cases with liver abscess and 5 cases with diabetes. Fusobacterium is a common oropharyngeal anaerobic genus. The blood culture in this group grew fusobacteriam in 11 cases, mostly in cases of oropharyngeal infection or Lemierre’s syndrome. In this group, 101 cases were cured and 47 cases improved; all were treated with antibiotics. Initially, the patients were most frequently treated with broadspectrum penicillins and cephalosporins; antibiotics were adjusted promptly according to the blood culture results. All patients were treated for 4e9 weeks. For S. aureus infection, this study indicated that the efficacy of vancomycin in the treatment of MSSA infection was not superior to that of nafcillin or oxacillin [83]. For blood culturepositive MRSA infection, the infected lesions should be removed first; in the event of associated empyma, adequate drainage should be combined with systemic intravenous medication. For such infections vancomycin or daptomycin are recommended for 4e6 weeks; the addition of gentamicin to vancomycin is not recommended [84]. For fungal infections, the intravascular indwelling catheters should be removed first, fluconazole or an echinocandin is recommended for initial therapy and an echinocandin is recommended for neutropenic patients. The recommended duration of therapy for candidemia, without persistent fungemia or metastatic complications, is 2 weeks after documented clearance of Candida from the bloodstream, resolution of symptoms attributable to candidemia and resolution of neutropenia [85]. SPE treatment usually does not involve the application of anticoagulants because of the risk of bleeding of infective emboli. In our study, anticoagulants were used in 14 cases, usually to treat thrombosis or thrombophlebitis; 18 cases were treated surgically, predominately targeted at valvular vegetations. In patients
6 with difficult to control infections, the focus of infection be removed surgically as soon as possible. Based on the results of our study, SPE should be suspected in high-risk patients with a history of intravenous drug use or underlying disease, if they have fever, dyspnea, chest pain and other clinical manifestations and their lung images suggest multiple nodules or plaques with or without pleural effusion. Enhanced chest CT examination should be performed to identify the emboli and blood culture, liver ultrasonography, echocardiography and other examinations should be performed to detect the source of the emboli. Early removal of infected lesions, indwelling catheters or cardiac devices is highly recommended. Before the results of blood culture are available, they should be given empiric antibiotics against S. aureus infection. For patients with liver abscess, antibiotics active against K. pneumoniae should be selected. In addition, Candida infection should be considered in patients with catheter-related infection who are immunocompromised or have a malignancy. SPE has a high mortality. Seventeen of the 168 cases in this review died, including 15 deaths due to SPE; death was caused most frequently by septic shock accompanied by multiple organ failure. Therefore, for patients with SPE, attention should be paid not only the to course of the local focus of infection but also to end-organ function to detect and correct shock as early as possible and thereby improve prognosis.
Conflict of interest
R. Ye et al.
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YE Rui and other co-authors have no conflict of interest.
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