Diagnosis and management of pleural infection

Abstract

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.

Infective Pleural Effusions—A Comprehensive Narrative Review Article

“…Pleural fluid PH below 7.20, glucose levels below 60 mg/dl, or lactate dehydrogenase that is more than three times the upper limit of serum (or above 1000 U/L) remain the gold standard tests to differentiate between complicated and uncomplicated parapneumonic effusions [Table 1 summarizes such findings] [11]. In cases of suspected pleural infection, microbiological confirmation is recommended to guide antibiotic therapy given the rising prevalence of drug-resistant organisms [35]. The yield from standard pleural culture was only 56% in a recently published systemic review of over 10,000 patients; however, rates improve when fluid is inoculated into blood culture bottles [20].…”

“…In cases of suspected pleural infection, microbiological confirmation is recommended to guide antibiotic therapy given the rising prevalence of drug-resistant organisms [ 35 ]. The yield from standard pleural culture was only 56% in a recently published systemic review of over 10,000 patients; however, rates improve when fluid is inoculated into blood culture bottles [ 20 ].…”

Diagnosing and managing pleural disease

“…Managing pleural infection can be a tricky business, but as discussed by E lsheikh et al [ 2 ], a series of pivotal trials have allowed a much better understanding of the complementary roles of medical therapies and surgery in surmounting this challenge. Other highlights of this review are comprehensive discussions of diagnostic approaches in suspected pleural infection and of pleural microbiology.…”