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Peer-reviewedCC BY 4.0Journal of Clinical Medicine

Routinely Available Prognostic Factors for Adverse Outcomes in Adults with Complicated Parapneumonic Effusion and Empyema: A Systematic Review and Meta-Analysis

  • Madalina Alexandra Balica1
  • Catalin Balan1
  • Delia Hutanu2
  • Norbert Wellmann3,4
  • Lavinia Balan5
  • Norberth-Istvan Varga6,7
  • Iulia Cristina Bagiu7,8
  • Ovidiu Rosca9
  • Cristian Ion Mot10
  • Corneluta Fira-Mladinescu11
  • Ovidiu Fira-Mladinescu4,12
12 affiliations
  1. 1Doctoral School, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
  2. 2Department of Biology, Chemistry-Biology-Geography Faculty, West University of Timisoara, Pestalozzi Street, No 16 A, 300115 Timisoara, Romania
  3. 3Pulmonology University Clinic, Clinical Hospital of Infectious Diseases and Pneumophthisiology Dr. Victor Babeș, 300310 Timisoara, Romania
  4. 4Center of Research and Innovation in Personalized Medicine of Respiratory Diseases (CRIPMRD), “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
  5. 5Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
  6. 6Department of Nursing, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
  7. 7Multidisciplinary Research Center on Antimicrobial Resistance (MULTI-REZ), Microbiology Department, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, 300041 Timisoara, Romania
  8. 8Department of Microbiology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square No. 2, 300041 Timisoara, Romania
  9. 9Department XIII, Discipline of Infectious Diseases, “Victor Babeș” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
  10. 10Department of Ear Nose Throat, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
  11. 11Discipline of Hygiene, Department of Microbiology, Center for Studies in Preventive Medicine, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
  12. 12Second Department of Pulmonology, Clinical Hospital of Infectious Diseases and Pulmonology “Victor Babes” Timisoara, Gheorghe Adam Street No. 13, 300310 Timisoara, Romania
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Abstract

Background: Pleural infection remains associated with substantial morbidity, mortality, and frequent treatment escalation. This systematic review and meta-analysis evaluated routinely available prognostic factors associated with adverse clinical outcomes in adults with pleural infection, including complicated parapneumonic effusion and pleural empyema. Methods: PubMed, Scopus, Web of Science Core Collection, and the Cochrane Library were searched from inception to 6 July 2026. Studies evaluating routinely available clinical, biochemical, microbiological, pleural fluid, radiological, or composite prognostic factors were included. Methodological quality was assessed using the Newcastle–Ottawa Scale (NOS). Comparable data were synthesized using random-effects meta-analysis. Results: Thirty studies involving 8443 participants were included. The evaluated outcomes comprised treatment failure, short-term mortality, need for surgery, intensive care unit admission, recurrence, readmission, and length of hospital stay. Five studies (877 participants) contributed to the RAPID score meta-analysis. High-risk RAPID classification was associated with greater short-term mortality than combined low- and intermediate-risk classification (RR 4.52, 95% CI 2.71–7.55; primary OR 6.09, 95% CI 3.25–11.38; I2 = 0% for the OR analysis). In a limited meta-analysis of three studies (1239 participants), each 10-year increase in age was associated with higher odds of short-term mortality (OR 1.54, 95% CI 1.02–2.30; I2 = 30.4%); however, mortality was assessed in hospital in two studies and at 90 days in one study. Additional prognostic factors associated with adverse outcomes included comorbidity burden, renal dysfunction, hypoalbuminemia, serial C-reactive protein trajectories, bacteremia, pleural fluid biochemical markers, pleural thickening, loculation, and delayed or ineffective drainage, although heterogeneous reporting precluded further quantitative synthesis. Conclusions: The RAPID score is the most consistently supported routinely available predictor of short-term mortality in adults with pleural infection. Increasing age may also be prognostic, but its pooled estimate is based on only three studies with different mortality windows and should be interpreted cautiously. Future prospective multicenter studies using standardized outcome definitions are needed to validate additional prognostic markers and improve risk-guided clinical decision-making.

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Cite

BibTeXRIS
BibTeX
@article{balica2026routinely,
  title = {{Routinely Available Prognostic Factors for Adverse Outcomes in Adults with Complicated Parapneumonic Effusion and Empyema: A Systematic Review and Meta-Analysis}},
  author = {Madalina Alexandra Balica and Catalin Balan and Delia Hutanu and Norbert Wellmann and Lavinia Balan and Norberth-Istvan Varga and Iulia Cristina Bagiu and Ovidiu Rosca and Cristian Ion Mot and Corneluta Fira-Mladinescu and Ovidiu Fira-Mladinescu},
  journal = {Journal of Clinical Medicine},
  year = {2026},
  month = oct,
  doi = {10.3390/jcm15207778},
  url = {https://www.mdpi.com/2077-0383/15/20/7778},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Routinely Available Prognostic Factors for Adverse Outcomes in Adults with Complicated Parapneumonic Effusion and Empyema: A Systematic Review and Meta-Analysis
AU  - Madalina Alexandra Balica
AU  - Catalin Balan
AU  - Delia Hutanu
AU  - Norbert Wellmann
AU  - Lavinia Balan
AU  - Norberth-Istvan Varga
AU  - Iulia Cristina Bagiu
AU  - Ovidiu Rosca
AU  - Cristian Ion Mot
AU  - Corneluta Fira-Mladinescu
AU  - Ovidiu Fira-Mladinescu
PY  - 2026
DA  - 2026/10/01
JO  - Journal of Clinical Medicine
DO  - 10.3390/jcm15207778
UR  - https://www.mdpi.com/2077-0383/15/20/7778
AB  - Background: Pleural infection remains associated with substantial morbidity, mortality, and frequent treatment escalation. This systematic review and meta-analysis evaluated routinely available prognostic factors associated with adverse clinical outcomes in adults with pleural infection, including complicated parapneumonic effusion and pleural empyema. Methods: PubMed, Scopus, Web of Science Core Collection, and the Cochrane Library were searched from inception to 6 July 2026. Studies evaluating routinely available clinical, biochemical, microbiological, pleural fluid, radiological, or composite prognostic factors were included. Methodological quality was assessed using the Newcastle–Ottawa Scale (NOS). Comparable data were synthesized using random-effects meta-analysis. Results: Thirty studies involving 8443 participants were included. The evaluated outcomes comprised treatment failure, short-term mortality, need for surgery, intensive care unit admission, recurrence, readmission, and length of hospital stay. Five studies (877 participants) contributed to the RAPID score meta-analysis. High-risk RAPID classification was associated with greater short-term mortality than combined low- and intermediate-risk classification (RR 4.52, 95% CI 2.71–7.55; primary OR 6.09, 95% CI 3.25–11.38; I2 = 0% for the OR analysis). In a limited meta-analysis of three studies (1239 participants), each 10-year increase in age was associated with higher odds of short-term mortality (OR 1.54, 95% CI 1.02–2.30; I2 = 30.4%); however, mortality was assessed in hospital in two studies and at 90 days in one study. Additional prognostic factors associated with adverse outcomes included comorbidity burden, renal dysfunction, hypoalbuminemia, serial C-reactive protein trajectories, bacteremia, pleural fluid biochemical markers, pleural thickening, loculation, and delayed or ineffective drainage, although heterogeneous reporting precluded further quantitative synthesis. Conclusions: The RAPID score is the most consistently supported routinely available predictor of short-term mortality in adults with pleural infection. Increasing age may also be prognostic, but its pooled estimate is based on only three studies with different mortality windows and should be interpreted cautiously. Future prospective multicenter studies using standardized outcome definitions are needed to validate additional prognostic markers and improve risk-guided clinical decision-making.
SN  - 2077-0383
ER  -