From the Guidelines
Sympathetic pneumonic effusion, also known as sympathetic pleural effusion, should be treated with antibiotics and drainage of the effusion if it is moderate or large in size, or if the patient is not responding to treatment, as recommended by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America 1.
Diagnosis and Treatment
The diagnosis of sympathetic pneumonic effusion involves confirming the presence of pneumonia and parapneumonic effusion, and then categorizing the size of the effusion. The treatment of sympathetic pneumonic effusion involves addressing the underlying pneumonia with appropriate antibiotics, and drainage of the effusion if necessary.
- Small, uncomplicated effusions can be treated with antibiotic therapy alone, as they often resolve on their own 1.
- Moderate or large effusions, or those associated with respiratory distress, should be drained, either through thoracentesis or chest tube placement 1.
- The choice of drainage procedure depends on local expertise, but both chest thoracostomy tube drainage with the addition of fibrinolytic agents and video-assisted thoracoscopic surgery (VATS) have been shown to be effective methods of treatment 1.
Antibiotic Treatment
The duration of antibiotic treatment depends on the adequacy of drainage and the clinical response of the patient, but typically ranges from 2-4 weeks 1.
- The choice of antibiotics should be based on the treatment recommendations for patients hospitalized with community-acquired pneumonia (CAP) 1.
Drainage Options
The options for drainage of sympathetic pneumonic effusion include:
- Chest tube alone
- Chest tube with fibrinolytics
- VATS Chest tube with fibrinolytics is a reasonable first option for patients with moderate to large effusions that are free flowing, but VATS may be necessary if the patient is not responding to treatment 1.
From the Research
Diagnosis of Sympathetic Pneumonic Effusion
- The diagnosis of sympathetic pneumonic effusion, also known as sympathetic pleural effusion, is typically made based on the presence of a pleural effusion on chest X-ray (CXR) or ultrasound in a patient with pneumonia 2.
- The diagnosis can be guided by the biochemical, microbiological, and radiological characteristics of the pleural effusion 2.
- Positive cultures are only obtained in 56% of cases, therefore, empirical antibiotics should provide Gram-positive, Gram-negative, and anaerobic cover whilst providing adequate pleural penetrance 2.
Treatment of Sympathetic Pneumonic Effusion
- The treatment of sympathetic pneumonic effusion typically involves the use of antibiotics, with the choice of antibiotic depending on the suspected or confirmed causative organism 3.
- Empirical antibiotics such as ceftriaxone plus azithromycin or levofloxacin may be used to treat community-acquired pneumonia (CAP) with pleural effusion 4, 5.
- The duration of antibiotic therapy can vary, but studies have shown that 7-10 days of therapy may be sufficient for uncomplicated CAP 6.
- In some cases, tube thoracostomy may be necessary to drain the pleural effusion, especially if it is complicated or empyema is present 2.
- Other treatments such as intrapleural fibrinolysin and DNase, surgery, and adjunct therapies like local anaesthetic thoracoscopy and indwelling pleural catheters may also be considered in certain cases 2.