Italian multicentre study on the management of pLeural infection and empyema: IMPLE study

Introduction: Pleural infection is a significant global healthcare challenge. While medical thoracoscopy (MT) is well-established for undiagnosed or malignant pleural effusion, its effectiveness in management of pleural infection lacks robust evidence. Moreover, data on the optimal timing of intervention in pleural infection are still scarce. Objective: To assess the probability of subsequent surgical referral in adult hospitalized patients with stage 2-3 pleural infection/empyema according to type and time of first procedures accounting for confounders. Methods: We conducted a multi-centre observational study. We retrospectively collected baseline demographic and clinical characteristics, RAPID score, type and time of first-line intervention. We evaluated their impact on probability of surgical referral, length of hospital stay (LOS) and 90-day mortality using multivariable logistic/multiple quantile regression models. Results: We included 509 patients from 14 Italian centres (75.4% male, median (interquartile range) age 63 (49-76) years). Thoracentesis and chest tube placement were associated with a significant higher probability of subsequent surgical referral compared to MT (OR 6.0, 95% CI 1.8-20.6, p=0.004; OR 7.8, 95% CI 2.6-22.5, p<0.001, respectively). Additionally, chest drain insertion and upfront surgery were related to a longer LOS compared to MT (Regression Coefficient Estimates: 4.9; 95% CI 1.5-8.4; 5.2; 95% CI 1.0-9.5, respectively). Furthermore, a delayed intervention, regardless of type, resulted in a longer LOS. Conclusion: Our large real-world study provides valuable insights into management and outcomes of pleural infection, revealing different approaches among centres and suggesting that a timely MT, when adopted as first-line intervention, could reduce the probability of subsequent surgical referral, However, further prospective studies are required to confirm these findings.