Recent developments in the management of pleural infection: A comprehensive review

Abstract

Pleural infection is a common disease with significant morbidity and mortality, as well as a considerable economic burden. The role of medical management is expanding thanks to the widespread use of newer treatments.

Diagnostic Value of C-Reactive Protein in Discrimination between Uncomplicated and Complicated Parapneumonic Effusion

“…If the PPE is empyema: loculations will be present in the pleural cavity, the Gram stain or culture of the pleural fluid will be positive, the effusion will be large (≥1/2 hemithorax), and thickening of the parietal pleura will be present, tube thoracostomy is absolutely indicated regardless of the pH value, glucose and LDH levels [ 1 , 2 , 3 , 4 , 5 , 6 ]. However, the diagnostic sensitivity of the Gram stain or culture of the pleural fluid for CPPE is low, with only about 40% of these effusions being positive [ 3 , 7 , 8 ]. In cases where the effusion is not empyema, not loculated, not large, with the Gram stain and culture of the pleural fluid being negative, and where the parietal pleura is not thickened, the decision to insert a chest tube depends mainly on the pH value which was found to be superior to values of glucose and LDH in predicting CPPE [ 8 , 9 , 10 ].…”

“…However, the diagnostic sensitivity of the Gram stain or culture of the pleural fluid for CPPE is low, with only about 40% of these effusions being positive [ 3 , 7 , 8 ]. In cases where the effusion is not empyema, not loculated, not large, with the Gram stain and culture of the pleural fluid being negative, and where the parietal pleura is not thickened, the decision to insert a chest tube depends mainly on the pH value which was found to be superior to values of glucose and LDH in predicting CPPE [ 8 , 9 , 10 ]. Furthermore, some studies have shown that a pleural fluid level of LDH > 1000 IU/L and a glucose level < 60 mg/dL do not improve the diagnostic yield of CPPE and will only be used if the pH cannot be determined [ 9 , 10 ].…”

“…The minority (about 30%) are CPPEs that follow a complicated course requiring, in addition to antibiotic treatment, more aggressive intervention, such as chest tube thoracostomy or pleural space decortication. Patients with CPPE have a significantly higher morbidity and mortality rate [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 ].…”

Concurrent fusobacterial pyogenic liver abscess and empyema

“…Classically, it is thought of bacterial empyema to be an extension of parenchymal lung infection with the bacteria gaining access to the visceral pleura, recent studies showing difference in bacterial causative agents between pneumonia and empyema led to challenging this concept 18 20–22. In addition to parapneumonic, empyema can be a stand-alone condition, as in trauma with infected hemothorax, postsurgical with introduction of bacteria into the pleural space, hematogenous spread or even direct spread from contagious infections like PLA 20 23. Data from the MIST1 trial which enrolled 454 patients showed that the leading causative organism of community acquired empyema is the Streptococcus milleri group while it is Staphylococcus aureus in hospital-acquired empyema with pure anaerobes making up to 20% and 8% of the isolates, respectively.…”

A Case of Empyema and a Review of Practice in a District General Hospital

“…This is in line with known evidence. 9,10 A score for mortality prediction in pleural infection has recently been developed called the RAPID score. 11 Patients with a RAPID score of 0-2 are considered low-risk, a score of 3-4 indicates a medium-risk, and a score of 5-7 indicates high-risk mortality at 3 months.…”