Recent Insights into the Management of Pleural Infection

Abstract

Pleural infection in adults has considerable morbidity and continues to be a lifethreatening condition. The term "pleural infection" encompasses complicated parapneumonic effusions and primary pleural infections, and includes but is not limited to empyema, which refers to collection of pus in the pleural cavity. The incidence of pleural infection in adults has been continuously increasing over the past two decades, particularly in older adults, and most of such patients have comorbidities. Management of pleural infection requires prolonged duration of hospitalization (average 14 days). There are recognized differences in microbial etiology of pleural infection depending on whether the infection was acquired in the community or in a health-care setting. Anaerobic bacteria are acknowledged as a major cause of pleural infection, and thus anaerobic coverage in antibiotic regimens for pleural infection is mandatory. The key components of managing pleural infection are appropriate antimicrobial therapy and chest-tube drainage. In patients who fail medical therapy by manifesting persistent sepsis despite standard measures, surgical intervention to clear the infected space or intrapleural fibrinolytic therapy (in poor surgical candidates) are recommended. Recent studies have explored the role of early intrapleural fibrinolytics or first-line surgery, but due to considerable costs of such interventions and the lack of convincing evidence of improved outcomes with early use, early intervention cannot be recommended, and further evidence is awaited from ongoing studies. Other areas of research include the role of routine molecular testing of infected pleural fluid in improving the rate of identification of causative organisms. Other research topics include the benefit of such interventions as medical thoracoscopy, high-volume pleural irrigation with saline/antiseptic solution, and repeated thoracentesis (as opposed to chest-tube drainage) in reducing morbidity and improving outcomes of pleural infection. This review summarizes current knowledge and practice in managing pleural infection and future research directions.

Inflammation of the Pleural Cavity: A Review on Pathogenesis, Diagnosis and Implications in Tumor Pathophysiology

“…The incidence of tuberculous pleural effusion (Figures 4 and 5) in tuberculosis patients varies from 3 to 25% and thoracoscopy shows 92 to 100% sensitivity in diagnosing tuberculous pleural effusion [17]. The incidence of pleural infection is 6.7-9.9 cases/100,000 population [18]. Pleural infection shows an overall mortality of 10% at 3 months and 19% at 12 months [19].…”

From Chest Wall Resection to Medical Management: The Continued Saga of Parapneumonic Effusion Management and Future Directions

“…The patency of the small-bore flexible chest tube can be facilitated by flushing the catheter with 20 -30ml saline every six hours via a three-way tap. Resolution of pleural fluid, clinical improvement, and decreased output from the chest tube are indications for removal of the chest tube [ 3 , 17 , 19 ].…”

“…There have been recent advances in establishing validated scoring systems as predictive models to stratify patients into risk categories. One such model is the RAPID score system developed by Rahman et al to assess three-month mortality and hospital length of stay for patients with pleural effusions using the MIST1 and two cohorts [ 19 ]. However, there is a need to extend such a scoring system to assist clinicians in decision-making regarding choosing a specific modality of treatment for specific risk categories.…”

“…However, there is a need to extend such a scoring system to assist clinicians in decision-making regarding choosing a specific modality of treatment for specific risk categories. More studies to apply this score to the outpatient settings and assess the need for de-escalation and tapering of antibiotic course is underway (NCT04615286) [ 19 ]. The use of medical thoracoscopy as a therapeutic modality to allow lysis of adhesions and facilitate chest tube drainage of pleural fluid has been studied in smaller patient series showing success rates and not requiring any further interventions.…”

Why do Patients with Acute Pneumonia Receive Intravenous Infusions?

“…The additional information presented above gives an idea of one of the pathogenetic mechanisms of stimulating the inflammatory process in the lungs. Such an analysis allows us to understand why the frequency of parapneumonic effusion in community-acquired pneumonia reaches 20-50% of cases, and the empyema of the pleura can be sterile in microbiological studies [25].…”