A New Approach to Pleural Infection: Let It Be?

Bedawi, Eihab; George, Vineeth; Rahman, N M

doi:10.1007/s13665-019-00230-1

Cited by 2 publications

(4 citation statements)

References 61 publications

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“…The duration of antibiotic therapy in pleural infection has not been robustly assessed and is largely based on expert opinion and extrapolation from lung abscess treatment data. A minimum of 4 weeks of treatment including both oral and intravenous antibiotics is usually recommended [ 48 ]. There are two randomised studies addressing reduction in antibiotic treatment course in pleural infection, but both of these were underpowered [ 49 , 50 ].…”

Section: Management Of Pleural Infectionmentioning

confidence: 99%

Diagnosis and management of pleural infection

Elsheikh,

Bhatnagar,

Rahman

2023

Breathe

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Pleural infection remains a medical challenge. Although closed tube drainage revolutionised treatment in the 19th century, pleural infection still poses a significant health burden with increasing incidence. Diagnosis presents challenges due to non-specific clinical presenting features. Imaging techniques such as chest radiographs, thoracic ultrasound and computed tomography scans aid diagnosis. Pleural fluid analysis, the gold standard, involves assessing gross appearance, biochemical markers and microbiology. Novel biomarkers such as suPAR (soluble urokinase plasminogen activator receptor) and PAI-1 (plasminogen activator inhibitor-1) show promise in diagnosis and prognosis, and microbiology demonstrates complex microbial diversity and is associated with outcomes. The management of pleural infection involves antibiotic therapy, chest drain insertion, intrapleural fibrinolytic therapy and surgery. Antibiotic therapy relies on empirical broad-spectrum antibiotics based on local policies, infection setting and resistance patterns. Chest drain insertion is the mainstay of management, and use of intrapleural fibrinolytics facilitates effective drainage. Surgical interventions such as video-assisted thoracoscopic surgery and decortication are considered in cases not responding to medical therapy. Risk stratification tools such as the RAPID (renal, age, purulence, infection source and dietary factors) score may help guide tailored management. The roles of other modalities such as local anaesthetic medical thoracoscopy and intrapleural antibiotics are debated. Ongoing research aims to improve outcomes by matching interventions with risk profile and to better understand the development of disease.

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Section: Management Of Pleural Infectionmentioning

confidence: 99%

Diagnosis and management of pleural infection

Elsheikh,

Bhatnagar,

Rahman

2023

Breathe

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“…The duration of antimicrobial therapy in pleural infection is an evidence-free zone and is largely based on expert opinion and extrapolation from recommendations for the treatment of lung abscess. The recommended duration varies from 2 to 6 weeks, and the authors recommend a minimum of 4 weeks (in total, including intravenous and oral treatment) [26]. Current BTS guidelines recommend switching from intravenous to oral antibiotics when there has been clinical improvement with cessation of pyrexia, resolution of inflammatory markers and radiological improvement [6].…”

Section: Stagementioning

confidence: 99%

“…Despite this, a large retrospective population-based observation study demonstrated much higher levels of mortality for patients managed non-operatively, even after adjusting for differences in age and comorbidity (11.1% 30-day mortality vs 3.3%), and this finding is supported by other retrospective studies [ 101 – 103 ]. What is clear, however, is the distinct lack of head-to-head, prospective data to settle this debate [ 19 , 26 ]. Even a recent Cochrane review into the question could only produce 8 trials across 391 participants, of which 6 trials were within a paediatric population.…”

Section: Surgerymentioning

confidence: 99%

“…It is important to note that this approach has not been validated through trial data, nor is it likely to be, given the small numbers of such patients. Broadly speaking, pleural infection remains a contraindication to IPC insertion and a complication thereof [ 26 ]. However, this treatment approach offers an alternative to repeated tube thoracostomy and may facilitate a more holistic approach to caring for patients on a palliative pathway.…”

Section: Alternative Therapies and Future Directionsmentioning

confidence: 99%

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Management of Pleural Infection

2020

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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 Gram-positive, Gram-negative and anaerobic cover whilst providing adequate pleural penetrance. With the advent of next-generation sequencing techniques, yields are expected to improve. 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 Multi-centre 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.

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A New Approach to Pleural Infection: Let It Be?

Cited by 2 publications

References 61 publications

Diagnosis and management of pleural infection

Diagnosis and management of pleural infection

Management of Pleural Infection

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