Management of Pleural Infection
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REVIEW
Management of Pleural Infection Anand Sundaralingam
. Radhika Banka . Najib M. Rahman
Received: August 29, 2020 / Accepted: November 16, 2020 Ó The Author(s) 2020
ABSTRACT Pleural infection is a millennia-spanning condition that has proved challenging to treat over many years. Fourteen percent of cases of pneumonia are reported to present with a pleural effusion on chest X-ray (CXR), which rises to 44% on ultrasound but many will resolve with prompt antibiotic therapy. To guide treatment, parapneumonic effusions have been separated into distinct categories according to their biochemical, microbiological and radiological characteristics. There is wide variation in causative organisms according to geographical location and healthcare setting. Positive cultures are only obtained in 56% of cases; therefore, empirical antibiotics should provide Grampositive, Gram-negative and anaerobic cover whilst providing adequate pleural penetrance. With the advent of next-generation sequencing techniques, yields are expected to improve. A. Sundaralingam (&) R. Banka N. M. Rahman Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK e-mail: [email protected] N. M. Rahman Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK N. M. Rahman Oxford NIHR Biomedical Research Centre, Oxford, UK
Complicated parapneumonic effusions and empyema necessitate prompt tube thoracostomy. It is reported that 16–27% treated in this way will fail on this therapy and require some form of escalation. The now seminal Multicentre Intrapleural Sepsis Trials (MIST) demonstrated the use of combination fibrinolysin and DNase as more effective in the treatment of empyema compared to either agent alone or placebo, and success rates of 90% are reported with this technique. The focus is now on dose adjustments according to the patient’s specific ‘fibrinolytic potential’, in order to deliver personalised therapy. Surgery has remained a cornerstone in the management of pleural infection and is certainly required in late-stage manifestations of the disease. However, its role in early-stage disease and optimal patient selection is being re-explored. A number of adjunct and exploratory therapies are also discussed in this review, including the use of local anaesthetic thoracoscopy, indwelling pleural catheters, intrapleural antibiotics, pleural irrigation and steroid therapy.
Keywords: Chest drain; Effusion; Empyema; Intrapleural enzyme therapy; Intrapleural fibrinolytic therapy; Parapneumonic; Pleural infection; Management
Pulm Ther
Key Summary Points Parapneumonic effusions are separated into distinct categories according to their biochemical, microbiological and radiological characteristics. It is increasingly recognised there exists heterogeneity within these groups, and there is a paucity of evidence for the optimal first-line intervention, in the form of head-to-head comparator trials. The causative organism varies widely according to geographical location and healthcare se
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