Epidemiology of pleural empyema in English hospitals and the impact of influenza David T. Arnold 1 , Fergus W. Hamilton 2 , Tim T. Morris 3 , Tim Suri 4 , Anna Morley 1 , Vicky Frost 4 , Ian B. Vipond 4 , Andrew R. Medford 1 , Rupert A. Payne 5 , Peter Muir 4 and Nick A. Maskell 1 Affiliations: 1 Bristol Academic Respiratory Unit, Learning and Research Centre, Southmead Hospital, Bristol, UK. 2 Dept of Microbiology, North Bristol NHS Trust, Bristol, UK. 3 MRC Integrative Epidemiology Unit, Bristol Medical School, University of Bristol, Bristol, UK. 4 Public Health England South West Regional Laboratory, National Infection Service, Pathology Sciences Building, Science Quarter, Southmead Hospital, Bristol, UK. 5 Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK. Correspondence: David T. Arnold, Level 2, Learning and Research Building, Southmead Hospital, Bristol, BS10 5NB, UK. E-mail: arnold.dta@gmail.com @ERSpublications Rates of pleural empyema are increasing in English hospitals without any improvement in patient outcomes. This study also found that male predominance of empyema increased with age, and rates increased in winter and during peaks of influenza. https://bit.ly/3oiJ870 Cite this article as: Arnold DT, Hamilton FW, Morris TT, et al. Epidemiology of pleural empyema in English hospitals and the impact of influenza. Eur Respir J 2021; 57: 2003546 [https://doi.org/10.1183/ 13993003.03546-2020]. ABSTRACT Pleural empyema represents a significant healthcare burden due to extended hospital admissions and potential requirement for surgical intervention. This study aimed to assess changes in incidence and management of pleural empyema in England over the past 10 years and the potential impact of influenza on rates. Hospital Episode Statistics data were used to identify patients admitted to English hospitals with pleural empyema between 2008 and 2018. Linear regression was used to analyse the relationship between empyema rates and influenza incidence recorded by Public Health England. The relationship between influenza and empyema was further explored using serological data from a prospective cohort study of patients presenting with pleural empyema. Between April 2008 and March 2018 there were 55530 patients admitted with pleural empyema. There was male predominance (67% versus 33%), which increased with age. Cases have increased significantly from 4447 in 2008 to 7268 in 2017. Peaks of incidence correlated moderately with rates of laboratory- confirmed influenza in children and young adults (r=0.30). For nine of the 10 years studied, the highest annual point incidence of influenza coincided with the highest admission rate for empyema (with a 2-week lag). In a cohort study of patients presenting to a single UK hospital with pleural empyema/ infection, 24% (17 out of 72) had serological evidence of recent influenza infection, compared to 7% in seasonally matched controls with simple parapneumonic or cardiogenic effusions (p<0.001). Rates of empyema admissions in England have increased steadily with a seasonal variation that is temporally related to influenza incidence. Patient-level serological data from a prospective study support the hypothesis that influenza may play a pathogenic role in empyema development. This article has supplementary material available from erj.ersjournals.com Received: 17 Sept 2020 | Accepted: 25 Nov 2020 Copyright ©The authors 2021. This version is distributed under the terms of the Creative Commons Attribution Non- Commercial Licence 4.0. For commercial reproduction rights and permissions contact permissions@ersnet.org https://doi.org/10.1183/13993003.03546-2020 Eur Respir J 2021; 57: 2003546 | ORIGINAL ARTICLE PLEURAL DISEASE