ERS/ESTS statement on the management of pleural infection in adults

Abstract

Pleural infection is a common condition encountered by respiratory physicians and thoracic surgeons alike. The European Respiratory Society (ERS) and European Society of Thoracic Surgeons (ESTS) established a multidisciplinary collaboration of clinicians with expertise in managing pleural infection with the aim of producing a comprehensive review of the scientific literature.Six areas of interest were identified including the epidemiology of pleural infection, the optimal antibiotic strategy, diagnostic parameters for chest tube drainage, the status of intrapleural therapies, the role of surgery and the current place of outcome prediction in management.The literature revealed that recently updated epidemiological data continue to show an overall upwards trend in incidence, but there is an urgent need for a more comprehensive characterisation of burden of pleural infection in specific populations such as immunocompromised hosts. There is a sparsity of regular analyses and documentation of microbiological patterns at a local level to inform geographical variation and ongoing research efforts are needed to improve antibiotic stewardship. The evidence remains in favour of a small-bore chest tube optimally placed under image guidance as an appropriate initial intervention for most cases of pleural infection. With a growing body of data suggesting delays to treatment are key contributors to poor outcomes, this suggests that earlier consideration of combination intrapleural enzyme therapy (IET) with concurrent surgical consultation should remain a priority. Since publication of the MIST-2 study, there has been considerable data supporting safety and efficacy of IET, but further studies are needed to optimise dosing using individualised biomarkers of treatment failure. Pending further prospective evaluation, the MIST-2 regimen remains the most evidence based. Several studies have externally validated the RAPID score, but it requires incorporating into prospective intervention studies prior to adopting into clinical practice.

Pleural Space Infections

“…Despite recent advances in medical care, the incidence of pleural space infections has steadily increased over the past two decades [ 11 , 12 , 13 , 14 , 15 ]. Between 2005 and 2014, it is estimated that 150,469 adult patients (age > 18) were admitted to United States hospitals for pleural infections.…”

“…Serum CRP levels may be valuable for monitoring response to therapy and resolution of pleural space infections [ 15 ]. However, the utility of following CRP levels after procedural intervention is less useful.…”

“…Specific factors that should be considered are the clinical history of the patient (and any risk factors for resistant organisms or hospital-acquired organisms), local antibiotic resistance pattern, pharmacologic characteristics of the potential antibiotics, ability to penetrate the pleural space, and local antibiotic institutional stewardship [ 1 , 4 ]. Specifically, penicillin, ceftriaxone, metronidazole, and clindamycin have all shown good penetration into the pleural space [ 15 ].…”

“…Specifically, Staphylococcus aureus will comprise approximately 50% of positive pleural fluid cultures in patients with hospital-acquired pleural infections, with MRSA representing about two-thirds of these cases and the remainder being Gram-negative organisms (predominantly E. coli, Enterobacter, and Pseudomonas) [ 1 ]. Data for direct inoculation of antibiotic therapy into the pleural space is lacking and is currently not supported by any guidelines, with one possible exception being in specific post-surgical scenarios [ 4 , 8 , 15 ].…”

“…The 2010 British Thoracic Society offers perhaps the most granular guidance on when surgery should be considered, stating that patients with persistent sepsis that fails to resolve in 5–7 days, in association with non-draining fluid in a pleural infection who are on appropriate antibiotic therapy should prompt consideration for surgery [ 1 ]. More recently, the ERS also proposed goals of surgery by day 10 if required, with surgical consultation on day 3, with factors meriting consideration being ongoing sepsis, failure of radiographic resolution, or clinical deterioration [ 15 ]. The newly drafted but unpublished BTS guidelines from June 2022 do not appear to definitively address this question [ 61 ].…”