Role of respiratory secretion culture in surgical outcome prediction of bacterial empyema

doi:10.21203/rs.3.rs-3722145/v1

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Role of respiratory secretion culture in surgical outcome prediction of bacterial empyema

https://doi.org/10.21203/rs.3.rs-3722145/v1

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Background:

Thoracic empyema is a serious infectious disease worldwide. Video-assisted thoracoscopic surgery is strongly recommended as a treatment, and pleural fluid and tissue cultures can be obtained intraoperatively. The combination of a pleural peels tissue culture and a pleural fluid culture improves the positive culture rate. We aimed to investigate the role of respiratory secretion cultures to determine the optimal management for improving surgical outcome.

Methods:

This retrospective study identified 1197 patients with phase II or III thoracic empyema from our institution. Patients who underwent decortication of the pleura from April 2011 to May 2022 with a positive pleural culture were included.

Results:

There were 225 empyema patients with either a positive pleural fluid culture or a positive pleural peel tissue culture. Of these, 76 patients had positive respiratory secretion culture findings during hospitalization. The most common species of pathogens were Pseudomonas aeruginosa (44%), Klebsiella pneumoniae (16%), and Staphylococcus aureus (10%) in the respiratory secretion cultures and Streptococcus spp. (38%), Klebsiella pneumoniae (12%), and Staphylococcus aureus (11%) in the pleural cultures. There were 30 patients who had a common pathogen in a respiratory secretion culture and in the pleural fluid/tissue culture. Poor outcome measures were found in these patients, including the longer use of antibiotics preoperatively (19.03 ± 37.66 days versus 9.59 ± 27.09 days, p = 0.006) and a higher mortality rate during hospitalization (40.0% versus 17.4%, p = 0.002).

Conclusions:

The respiratory secretion culture plays an essential role in prediction of surgical outcome in bacterial empyema. Obtaining the respiratory secretion specimen promptly through proper methods helps to improve the survival of empyema patients.

bacterial empyema

respiratory secretion culture

pleural effusion culture

pleural tissue culture

surgical outcome

Thoracic empyema is increasingly recognized as a serious infectious disease worldwide. Despite the application of advanced vaccine and antibiotics for prevention and treatment, the USA still reports approximately 60,000 patients annually, with an increasing incidence rate over the past decade.^{[1, 2]} The adult mortality rate was about 20% in the 1990s, and recently it was around 8.7% for those who underwent thoracic decortication.^{[2, 3]}

According to the 2017 American Association for Thoracic Surgery guidelines, empyema can be classified into the early exudative phase (stage I), intermediate fibroproliferative phase (stage II), and organizing phase (stage III).^[4] Surgical intervention and chest tube drainage are not required for stage I empyema treatment.^[5] For stage II and stage III empyema, closed drainage and decortication are strongly recommended. Recent studies revealed that video-assisted thoracoscopic surgery (VATS) provides similar surgical outcomes and fewer postoperative complications.^[6–10]

Bacterial pneumonia is the most common etiology of empyema, and 20–40% of bacterial pneumonia patients develop parapneumonic effusions that may progress to empyema.^[11] Obtaining an accurate culture result early is essential for proper antibiotics usage in treating empyema or preventing it at the pneumonia stage. Previous literatures report a pleural fluid culture positive rate ranging from 19–49%, obtained through thoracentesis or intraoperatively.^{[12, 13]} Combining pleural peels tissue culture and a pleural fluid culture, obtainable through VATS decortication, has been shown to improve the positive culture rate in empyema.^[14] While respiratory secretion culture is the simplest and the most direct pathway to acquire pneumonia pathogens, its role in treating bacterial empyema has rarely been discussed in the literature. The relationship between respiratory secretion cultures and pleural fluid/tissue cultures also remains unknown.

This study aimed to investigate the consistency of respiratory secretion cultures and intraoperative pleural effusion/tissue cultures to determine optimal management for improving surgical outcomes in bacterial empyema patients.

Patient population and selection

A search of the database of our institution (Changhua Christian Hospital, Changhua, Taiwan) identified 1197 patients over 18 years old with phase II or III thoracic empyema who underwent video-assisted thoracoscopic decortication of the pleura between April 2011 and May 2022. Exclusion criteria for the study were as follows: (1) the empyema patients’ chest X-ray or chest CT scan presented negative finding of pneumonia patch. (n = 256), (2) patients had an operation without a positive finding from neither an intraoperative pleural fluid culture nor a intraoperative pleural peel tissue culture (n = 441), (3) patients that had no respiratory secretion culture during hospitalization (n = 194), (4) respiratory secretion culture yielded Mycobacterium tuberculosis or fungus (n = 43), (5) poor quality of respiratory secretion culture such as mixture with saliva or low specimen amount (n = 38). The remaining 225 patients were analyzed as subjects of this study.

Specimen obtaining

Once the patients’ chest image presented loculated pleural effusion, there would be highly suspicion of phase II/III empyema, which indicated for surgical intervention. We performed video-assisted thoracoscopic decortication and obtained both a pleural fluid culture and a pleural peel tissue culture intraoperatively. Respiratory secretion cultures were obtained one to four times from each patient through three methods: patient expectorating actively, aspiration by suction tube once the patient was under endotracheal tube intubation or with tracheostomy, and bronchoalveolar lavage (BAL). Both aerobic cultures and anaerobic cultures were done routinely for different specimens.

Clinical features and data collection

We analyzed the age, gender, empyema location, empyema phase, comorbidities, lab data, pleural fluid data, antibiotics usage, chest tube drainage duration, length of intensive care unit stay (ICLOS), length of hospital stay (HLOS), pathogen and mortality. Two mortalities were analyzed: death during hospitalization and death within thirty postoperative days. All our observations were defined according to the 2017 American Association for Thoracic Surgery consensus guidelines. The indicators of infectious pleural fluid include pH value less than 7.2, glucose less than 40 mg/dL, and lactate dehydrogenase (LDH) greater than 1000 IU/L. The primary outcomes for our study were the respiratory secretion culture positive rate and the consistency of pathogen between respiratory secretion culture and either pleural fluid culture or pleural peel tissue culture. The secondary outcomes were ICLOS, HLOS, mortality, and culture positive rate by method of specimen obtainment.

Statistical analyses

Clinical factors including age, gender, empyema location, empyema phase, comorbidities, lab data, pleural fluid data, antibiotics usage, chest tube drainage duration, ICLOS, HLOS, pathogen and mortality were analyzed. We used the Mann-Whitney U test and independent t test to evaluate the continuous variables in this study. As for the categorical variables, we used the chi-squared test to compare the proportions. A p-value less than 0.05 was considered to indicate statistical significance. All statistical analyses were performed using SPSS statistical software (SPSS package, version 23.0; SPSS, Chicago, IL, USA).

Two hundred and twenty-five stage II to stage III thoracic empyema patients, who underwent video-assisted thoracoscopic decortication and had a positive pleural fluid or pleural peel tissue culture, were included in this study. From these patients, one to four sets of respiratory secretion cultures were collected during the period of hospitalization. For 76 patients, at least one respiratory secretion culture set showed a positive finding, and 149 patients had only negative respiratory secretion culture results.

The clinical demographic data of the patients are shown in Table 1. The mean age was about 63 years old, and most of the patients were males (75.6%). Right-side empyema was predominant (56.0%), and only one patient had bilateral empyema. There was more stage II empyema (76.0%) than stage III empyema (24.0%). As for the comorbidities, congestive heart failure was the only one for which the respiratory secretion culture positive group had a statistically significantly higher ratio (15.8% versus 6.0%, p = 0.033). No differences in serum leukocyte count and pleural fluid analysis were noted between the two groups. Treatment outcome measures such as preoperative antibiotics use days, chest tube drainage duration, ICLOS, HLOS, and hospital mortality rate were statistically significantly lower in the respiratory secretion culture negative group. There was no 30-day mortality case in the positive respiratory secretion culture cohort.

Table 1

Clinical characteristics of the patients
Factors (Mean ± SD)	Total cohort(n = 225)	Culture positive (n = 76)	Culture negative (n = 149)	P value
Age, y	62.86 ± 16.52	64.59 ± 15.98	61.98 ± 16.77	0.263
Gender
Male	170(75.6%)	54(71.1%)	116(77.9%)	0.566
Female	55(24.4%)	22(28.9%)	33(22.1%)	0.327
Location
Right	126(56.0%)	40(52.6%)	86(57.7%)	0.635
Left	98(43.6%)	35(46.1%)	63(42.3%)	0.670
Bilateral	1(0.4%)	1(1.3%)	0(0.0%)	0.317
Phase
II	171(76.0%)	60(78.9%)	111(74.5%)	0.747
III	54(24.0%)	16(21.1%)	38(25.5%)	0.466
Comorbidity
Malignancy	61(27.1%)	24(31.6%)	37(24.8%)	0.354
DM	82(36.4%)	34(44.7%)	48(32.2%)	0.138
HTN	134(59.6%)	51(67.1%)	83(55.7%)	0.321
Liver cirrhosis	19(8.4%)	7(9.2%)	12(8.1%)	0.808
ESRD	25(11.1%)	11(14.5%)	14(9.4%)	0.221
CHF	21(9.3%)	12(15.8%)	9(6.0%)	0.033
COPD	54(24.0%)	21(27.6%)	33(22.1%)	0.396
Lab data
WBC, Mean ± SD (10³/µL)	15.30 ± 6.38	14.54 ± 6.66	16.13 ± 6.19	0.075
ANC, Mean ± SD (10³/µL)	13.27 ± 6.04	12590.03 ± 6223.27	13707.69 ± 5856.05	0.221
Pleural data
Pleural pH ( ≦ 7.2)	112(57.1%)	39(59.1%)	73(56.2%)	0.780
Pleural glucose ( ≦ 40 mg/dL)	112(54.1%)	34(48.6%)	78(56.9%)	0.437
Pleural LDH ( ≧ 1000 IU/L)	152(73.8%)	51(72.9%)	101(74.3%)	0.934
Pre-OP ABX usage (days)	7.28 ± 19.38	13.32 ± 31.78	4.21 ± 5.30	0.015
Pre-OP chest tube drainage duration	1.89 ± 5.24	3.07 ± 7.86	1.29 ± 3.03	0.061
Post-OP chest tube drainage duration	16.13 ± 22.07	22.37 ± 30.26	12.95 ± 15.59	0.012
Chest tube drainage duration	18.02 ± 24.72	25.43 ± 34.67	14.24 ± 16.53	0.009
Length of ICU admission	10.77 ± 15.64	18.83 ± 22.20	6.66 ± 8.37	< 0.001
Length of hospital stay	25.78 ± 18.68	31.80 ± 20.94	22.71 ± 16.67	< 0.001
Hospital mortality	36(16.0%)	20(26.3%)	16(10.7%)	0.014
Mortality in 30 days	19(8.4%)	9(11.8%)	10(6.7%)	0.191
DM: diabetes mellitus; HTN: hypertension; ERDS: end stage renal disease; CHF: congestive heart failure; COPD: chronic obstructive pulmonary disease; WBC: white blood cell; ANC: absolute neutrophil count; LDH: lactate dehydrogenase; OP: operative; ABX: antibiotics; ICU: intensive care unit

We analyzed the patients based on the number of sets of respiratory secretion cultures (Fig. 1). Those with only one respiratory secretion culture set had a 24% positive rate, and similar positive culture rates were found in the patients with two sets (26%) and three sets (26%). In comparison, patients with four sets of respiratory secretion cultures had a significantly higher positive rate (56%).

The collection method of a respiratory secretion specimen was taken into consideration. In our center, we collected patients’ respiratory secretion in three ways: (1) patient expectorates by oneself, (2) aspiration through endotracheal tube or tracheostomy, (3) BAL under bronchoscopy. We analyzed the positive culture rates of these three methods separately (Fig. 2) and discovered significantly higher positive culture rates when the specimen was derived through bronchoscopy (40%) or aspiration via endotracheal tube or tracheostomy (32%).

Figure 3 shows the pathogen distributions for the respiratory secretion cultures and the intraoperative pleural fluid and tissue peel cultures. In our study, the most common species of pathogens in the respiratory secretion cultures was Pseudomonas aeruginosa (44%), which was followed by Klebsiella pneumoniae (16%), Staphylococcus aureus (10%), Acinetobacter baumannii (10%), and Streptococcus spp. (4%). The most common species of pathogens in the pleural fluid cultures and pleural tissue peel cultures was Streptococcus spp. (20%), Klebsiella pneumoniae (16%), and Staphylococcus aureus (11%).

To see the concordance rate of pathogens between the respiratory secretion cultures and the intraoperative pleural fluid/tissue peel cultures, we divided those patients with positive respiratory secretion cultures into an identical group and a distinct group (Table 2). We defined the identical group as the patients for which a respiratory secretion culture and the pleural fluid/tissue culture had a common pathogen (n = 30). The distinct group was defined as the patients who had no pathogen in common between the sets of respiratory secretion culture and the pleural fluid/tissue culture (n = 46). In comparing these two groups, we noted that the age, gender, location and phase of empyema, laboratory data, and pleural analysis data were similar, but a longer use of antibiotics preoperatively was found in the identical group (19.03 ± 37.66 days versus 9.59 ± 27.09 days, p = 0.006). For the surgical outcomes, the duration of chest tube drainage, ICLOS, and HLOS were longer in the identical group, but the differences were not statistically significant. However, the mortality rate during hospitalization was significantly higher in the identical group (40.0% versus 17.4%, p = 0.002).

Table 2

Concordance rate between species from respiratory secretion culture and pleural effusion or tissue culture (at least one pathogen is the same)
Factors	Distinct (n = 46)	Identical (n = 30)	p-value
Age, y	65.33 ± 16.16	63.47 ± 15.91	0.527
Gender, Male	32(69.6%)	22(73.3%)	0.723
Location, right	21(45.7%)	19(63.3%)	0.262
Phase, II	38(82.6%)	22(73.3%)	0.332
Pre-OP ABX usage (days)	9.59 ± 27.09	19.03 ± 37.66	0.006
Lab data
WBC, Mean ± SD (10³/µL)	14.45 ± 6.44	14.68 ± 7.08	0.811
ANC, Mean ± SD (10³/µL)	12.47 ± 6.13	12.77 ± 6.46	0.983
Pleural data
Pleural pH ( ≦ 7.2)	23(54.8%)	16(66.7%)	0.344
Pleural glucose ( ≦ 40 mg/dL)	21(48.8%)	13(48.1%)	0.955
Pleural LDH ( ≧ 1000 IU/L)	29(67.4%)	22(81.5%)	0.199
Pre-OP chest tube drainage duration	1.83 ± 4.18	4.97 ± 11.25	0.226
Post-OP chest tube drainage duration	18.11 ± 14.10	28.90 ± 44.47	0.746
Chest tube drainage duration	19.94 ± 15.08	33.87 ± 51.33	0.602
ICU duration (day)	16.91 ± 16.61	21.77 ± 28.85	0.957
Hospital duration (day)	31.46 ± 17.24	32.33 ± 25.94	0.466
Hospital mortality	8(17.4%)	12(40.0%)	0.029
30-day mortality	4(8.7%)	5(16.7%)	0.293
OP: operative; ABX: antibiotics; WBC: white blood cell; ANC: absolute neutrophil count; LDH: lactate dehydrogenase; ICU: intensive care unit;

In addition, we performed univariate and multivariate analysis of the factors associated with in-hospital mortality in Table 3. In the univariate analysis, we found that comorbidity of end-stage renal disease, the pH value of pleural effusion, positive respiratory secretion culture result, common pathogen between respiratory secretion and pleural effusion/peel cultures, the duration of chest tube drainage, ICLOS, and HLOS were the independent factors affecting intra-hospital mortality. Furthermore, we performed multivariate analysis and resulted that those patients with older age, positive respiratory secretion culture, higher concordance rate between respiratory secretion and pleural effusion/peel cultures, and longer ICLOS would have higher intra-hospital mortality rate.

Table 3

Univariable and multivariable analyses of factors affecting hospital mortality
	Univariate		Multivariate
Variables	Odds ratio	p-value	Odds ratio	p-value
Age, y	1.02(1.00-1.05)	0.061	1.09(1.03–1.16)	0.005
Gender
Male	1		1
Female	1.04(0.45–2.36)	0.933	0.46(0.10–2.13)	0.321
Location
Right	1		1
Left	0.83(0.40–1.74)	0.627	0.82(0.21–3.26)	0.779
Bilateral	8.08E + 09	> 0.999	4.64E + 10	> 0.999
Phase
II	1		1
III	1.75(0.81–3.79)	0.156	1.21(0.24–6.14)	0.818
Comorbidity
Malignancy	1.92(0.91–4.06)	0.086	1.72(0.61–4.84)	0.478
DM	1.95(0.95–4.01)	0.068	1.63(0.42–6.24)	0.544
HTN	1.44(0.68–3.04)	0.345	1.46(0.36–6.93)	0.602
Liver cirrhosis	2.02(0.68-6.00)	0.207	6.14(1.04–36.40)	0.046
ESRD	6.77(2.77–16.53)	< 0.001	5.36(1.24–23.14)	0.025
CHF	1.27(0.40–4.01)	0.69	1.02(0.15–7.12)	0.981
COPD	0.73(0.30–1.77)	0.486	0.05(0.01–0.52)	0.012
Lab data
WBC, Mean ± SD (10³/µL)	0.97(0.91–1.03)	0.253	1.17(0.70–1.97)	0.549
ANC, Mean ± SD (10³/µL)	0.97(0.91–1.03)	0.353	0.81(0.46–1.40)	0.445
Pleural data
Pleural pH ( ≦ 7.2)	2.59(1.10–6.10)	0.029	3.73(0.86–16.10)	0.079
Pleural glucose ( ≦ 40 mg/dL)	1.26(0.60–2.65)	0.547	1.55(0.30–1.20)	0.605
Pleural LDH ( ≧ 1000 IU/L)	1.13(0.48–2.69)	0.779	0.18(0.03–1.20)	0.076
Positive culture
Pleural effusion	1.33(0.55–3.24)	0.527	0.79(0.13–4.71)	0.799
Tissue	1.39(0.66–2.90)	0.387	2.64(0.68–10.33)	0.163
Respiratory secretion	2.97(1.43–6.15)	0.003	0.11(0.01–0.88)	0.037
Culture concordance rate	4.75(2.04–11.07)	< 0.001	56.79(5.29-609.82)	0.001
Chest tube drainage duration	1.03(1.01–1.04)	0.003	1.02(0.98–1.06)	0.286
Length of ICU admission	1.08(1.05–1.12)	< 0.001	1.16(1.06–1.27)	0.001
Length of hospital stay	1.04(1.02–1.06)	< 0.001	0.99(0.94–1.04)	0.555
DM: diabetes mellitus; HTN: hypertension; ERDS: end stage renal disease; CHF: congestive heart failure; COPD: chronic obstructive pulmonary disease; WBC: white blood cell; ANC: absolute neutrophil count; LDH: lactate dehydrogenase; ICU: intensive care unit

In this retrospective study, surgical outcomes were poor, with a higher in-hospital mortality rate observed among patients with a common pathogen in the intraoperative pleural fluid/tissue culture and a respiratory secretion culture set. After confirming diagnosis of stage II to stage III thoracic empyema, decortication was performed, and pleural fluid and tissue cultures were obtained intraoperatively. Additionally, respiratory secretion cultures were obtained if recurrence or progression of the pulmonary infection was suspected, and antibiotic use was adjusted accordingly. To explain the higher in-hospital mortality in the identical pathogen group, the consistency between a patient’s respiratory secretion culture and intraoperative pleural fluid/tissue culture may imply the larger bacterial colony, the development of drug resistance, the inefficacy of antibiotics treatment, or inadequate length of therapy. It is essential for surgeons to recognize this result to consider the causes for improving surgical outcomes.

A previous study revealed that approximately twenty percent of community-acquired pneumonia cases developed parapneumonic effusions, and only 1.4% of those met the criteria of empyema.^[15] The upper airway appears to be the most common route of pathogen invasion, and the cause of secondary bacterial invasion to pleural space is not completely understood. Several studies suggest that pleural infection can occur spontaneously even in the absence of underlying lung consolidation.^[16–18] This finding implies there is another route causing infection in the pleural space. Possible mechanisms include visceral pleural defects or fistula formation, dispersion from the mediastinum, transdiaphragmatic infection, hematogenous spread, and trauma or iatrogenic injury.^[19] In our data, 195 out of 225 patients had completely different pathogens cultured from respiratory secretion specimens and pleural space.

Based on positive interoperative pleural effusion or tissue culture findings, we differentiated the methods of obtaining respiratory secretion cultures to determine the most effective one for pathogen identification. In an early research, Fabrice et al. investigated the role of routine endotracheal aspiration respiratory secretion culture on ventilator-associated pneumonia (VAP) patients. They compared endotracheal aspiration culture results to positive BAL cultures and found an 82% identical rate among the patients with less than 5 days of mechanical ventilation and an 86% identical rate among those with more than 5 days of mechanical ventilation.^[20] This suggests that VAP can be detected sooner, allowing for the prescription of adequate antibiotics for treatment. However, Johannes et al. recently reviewed diagnostic studies of endotracheal aspiration and BAL culture methods for VAP and concluded in favor of BAL analysis due to the poor positive predictive value of endotracheal aspiration cultures.^[21] In our research, the positive rate of BAL cultures is higher than endotracheal aspiration cultures (40% versus 32%), and the comparison of concordance rates to the pleural cultures showed an opposite result that was not statistically significant (25% versus 37%, p = 0.346). Both endotracheal aspiration and BAL culture methods provide an efficacy in antibiotic therapy adjustment and surgical outcome prediction in empyema patients.

The pathogen spectrum varies geographically and in terms of the timing of cultures. In a major review of microbiology of pleural infection by Hassan et al, Staphylococcus aureus was reported as the most common organism worldwide, with pneumococci and viridans streptococci being the most common organism in tropical regions.^[22] The cases we collected were all from Taiwan, a tropical island, and in our study, the most common organism causing pleural infection was Streptococcus species, which was compatible to the geographical trends reported in the review.

We emphasized empyema related to bacterial pneumonia and excluded the patients with fungal or tuberculosis empyema. Numerous studies have highlighted that the primary causes of community-acquired pneumonia were Streptococcus species and anaerobes, while hospital-acquired pneumonia was mostly caused by Staphylococcus aureus.^{[23, 24]} Major pathogens of VAP were reported to be Pseudomonas aeruginosa, Klebsiella pneumoniae, and methicillin-resistant Staphylococcus aureus (MRSA).^{[25, 26]} Our data indicated that the primary pathogens of respiratory secretion cultures were Pseudomonas aeruginosa (44%) and Klebsiella pneumoniae (16%), while the main pathogens in pleural effusion/tissue cultures were Streptococcus species (38%), Klebsiella pneumoniae (11%), and Staphylococcus aureus (10%). We performed VATS decortication soon after empyema was diagnosed or when it was suspected, usually within 7 days. Intraoperative pleural cultures could be obtained early in the hospital course. However, 61.8% of our patients experienced ICU admission and received endotracheal tube intubation with ventilator for oxygen support. Respiratory secretion cultures could be collected at any time during the hospital course. Notably, the specimens obtained by endotracheal aspiration or BAL would be highly associated with VAP, potentially explaining our observed pathogen spectrum.

It is essential to start the treatment for empyema with broad-spectrum antibiotics initially.^[4] Additionally, appropriately escalating the antibiotics regimen with anti-Pseudomonas or anti-MRSA agents based on the respiratory secretion culture result is crucial in both adult and pediatric patients.^{[27, 28]} In our center, we initially prescribed empiric anti-Pseudomonas antibiotics when the empyema patients were admitted to ICU. Simultaneously, respiratory secretion and blood cultures were repeatedly collected until the infection was well under control. Further use of therapeutic anti-MRSA agent would be indicated based on the culture results.

Our study has several limitations. Firstly, the data are derived from a single medical center. The pathogen spectrum changes geographically, and the evidence is insufficient to be universally applicable. Secondly, this is a retrospective study, which may involve selection bias. Thirdly, the culture techniques vary among different institutes, potentially affecting sensitivity. A larger database or a multi-center study is needed to confirm our findings. Fourthly, the differences between respiratory secretion and pleural results may be due to the presence of two different and subsequent infections. The lack of data about infection source may cause potential bias. Lastly, the timing to obtain respiratory secretion specimens during hospitalization was not regular. The number of cultures and the collection methods varied among different cases. Despite the limitations, respiratory secretion culture plays a crucial role in the prediction of surgical outcomes in bacterial empyema patients.

In conclusion, our findings suggested that a positive respiratory secretion culture and the concordance between respiratory secretion culture and pleural fluid or tissue culture are associated with a higher hospital mortality rate. The prompt acquisition of a respiratory secretion specimen and early surgical intervention emerge as crucial factors for improving the survival rate and achieving better surgical outcomes for thoracic empyema patients.

BAL	=	bronchoalveolar lavage
HLOS	=	length of hospital stay
ICLOS	=	length of intensive care unit stay
ICU	=	intensive care unit
LDH	=	lactate dehydrogenase
MRSA	=	methicillin-resistant Staphylococcus aureus
VAP	=	ventilator-associated pneumonia
VATS	=	video-assisted thoracoscopic surgery

Ethics approval and consent to participate: The study was approved by the Changhua Christian Hospital, Changhua, Taiwan Institutional Review Board (IRB-220907). Informed consent from all participants was waived by the Changhua Christian Hospital, Changhua, Taiwan Institutional Review Board (IRB-220907). All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication: Not applicable.

Availability of data and materials: The datasets generated and/or analysed during the current study are not publicly available due to the privacy of individuals that participated in the study but are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: Not applicable.

Authors' contributions: Chia-Chi Liu designed the study, collected the study data, and wrote the manuscript. Ya-Fu Cheng designed the study. Yi-Ling Chen collected and analyzed the study data. Ching-Yuan Cheng, Chang-Lun Huang, Wei-Heng Hung, and Bing‑Yen Wang provided the patient data of the study. Bing‑Yen Wang provided the concept of the study and supervised. All authors read and approved the final manuscript.

Acknowledgements: Not applicable.

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No competing interests reported.

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Role of respiratory secretion culture in surgical outcome prediction of bacterial empyema

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