Medical treatment of pleural infection: antibiotic duration and corticosteroid usefulness

Abstract

The data about the optimal duration of antibiotics and the usefulness of corticosteroids in the management of parapneumonic effusion and pleural infection are scarce. Two randomised controlled trials evaluating short antibiotic courses (ODAPE and SLIM) and another trial assessing the benefit from corticosteroid use (STOPPE) in this setting were recently published. The aim of this journal club is to present these trials and discuss their significance and limitations. ODAPE compared the efficacy and safety of a short (2 weeks)versusan extended (3 weeks) course of amoxicillin–clavulanate in community-acquired complicated parapneumonic effusions, while SLIM compared the efficacy and safety of short (14–21 days)versuslonger (28–42 days) antibiotic courses in patients with community- or hospital-acquired pleural infection. STOPPE assessed the benefit from dexamethasone use in patients with community-acquired pneumonia and concomitant pleural effusion. Both ODAPE and SLIM found that shorter antibiotic courses produce less adverse events while being equally efficacious to the longer courses in a subgroup of patients, such as those with pleural infection that is stabilised with only medical treatment and does not require surgery. In contrast, STOPPE found no benefit from the use of dexamethasone in unselected patients with pneumonia and pleural effusion. Due to the significant limitations of these trials, further studies are required to confirm these findings.Commentary on:Hassan M,et al. The ShortversusLong Antibiotic Course for Pleural Infection Management (SLIM) randomised controlled open-label trial.ERJ Open Res2023; 9: 00635-2022.Porcel JM,et al. Twovs. three weeks of treatment with amoxicillin–clavulanate for stabilized community-acquired complicated parapneumonic effusions. A preliminary non-inferiority, double-blind, randomized, controlled trial.Pleura Peritoneum2020; 5: 20190027.Fitzgerald DB,et al. Steroid Therapy and Outcome of Parapneumonic Pleural Effusions (STOPPE): a pilot randomized clinical trial.Am J Respir Crit Care Med2022; 205: 1093–1101.

Shorter and Longer Antibiotic Durations for Respiratory Infections: To Fight Antimicrobial Resistance—A Retrospective Cross-Sectional Study in a Secondary Care Setting in the UK

“…The principle of administering the minimum effective duration of antibiotic therapy to reduce AMR risk and drug toxicity is a cornerstone of AMS, with evidence from randomised controlled trials supporting short courses for lower respiratory tract infections [ 18 ]. However, the optimal duration of antibiotic therapy for pleural infection remains unclear, with limited high-quality evidence available [ 23 ].…”

Diagnosing and managing pleural disease

“…We also have pleural-themed early career member content in this issue, with our Landmark Papers in Respiratory Medicine article by F alster et al [ 5 ] highlighting a series of key papers which have seen thoracic ultrasound advance from being the preserve of our veterinary colleagues to a critical bedside diagnostic tool. This issue's Journal Club takes an in-depth look at trials evaluating antimicrobial strategies and the use of oral corticosteroids in pleural infection [ 6 ]. Finally, from a pleural perspective, P ietersen et al [ 7 ] report on how the ERS training programme in thoracic ultrasound led to improved theoretical knowledge and technical competency amongst participants.…”