What is the treatment for pleurisy?

Treatment for Pleurisy

The treatment for pleurisy must include appropriate antibiotics, chest tube drainage for infected collections, and consideration of intrapleural fibrinolytic therapy when drainage is inadequate. 1

Diagnosis and Initial Management

1. Determine the cause of pleurisy:

   • Infectious (bacterial, viral, tuberculous)
   • Non-infectious (malignancy, autoimmune, pulmonary embolism, heart failure)

2. Immediate interventions:

   • Pain management with NSAIDs or other analgesics
   • Treatment of underlying cause

Treatment Algorithm for Infectious Pleurisy (Pleural Infection)

Antibiotic Therapy

• All patients must receive antibiotics immediately 1

• Antibiotic selection should be guided by culture results when available 1

• When cultures are negative:

  • For community-acquired infection:

    • Cefuroxime 1.5g IV TDS + metronidazole 400mg TDS orally or 500mg TDS IV
    • OR Benzyl penicillin 1.2g QDS IV + ciprofloxacin 400mg BD IV
    • OR Amoxicillin 1g TDS + clavulanic acid 125mg TDS (oral option)
    • OR Clindamycin 300mg QDS (oral option)

  • For hospital-acquired infection:

    • Piperacillin + tazobactam 4.5g QDS IV
    • OR Ceftazidime 2g TDS IV
    • OR Meropenem 1g TDS IV ± metronidazole

• Important cautions:

  • Avoid aminoglycosides (poor pleural penetration, inactive in acidic pleural fluid) 1
  • Adjust doses for renal/hepatic impairment

Drainage Procedures

• Chest tube drainage is indicated for:

  • Purulent pleural fluid (frank pus)
  • Positive gram stain or culture
  • pH < 7.2
  • Loculated effusions
  • Large effusions (>40% of hemithorax)
  • Symptomatic relief 1

• Drainage management:

  • If chest tube becomes blocked, flush with 20-50ml normal saline
  • If poor drainage persists, check tube position with imaging
  • Consider additional chest tubes for loculated collections

Intrapleural Fibrinolytic Therapy

• Combination tissue plasminogen activator (TPA) and DNase should be considered when:

  • Initial chest tube drainage has ceased
  • Residual pleural collection remains 1

• Recommended regimen:

  • 10mg TPA twice daily + 5mg DNase twice daily for 3 days
  • Alternative: 5mg TPA twice daily + 5mg DNase twice daily for 3 days (for higher bleeding risk) 1

• Cautions:

  • Obtain patient consent due to bleeding risk
  • Consider reduced doses in patients on anticoagulation
  • Single-agent TPA or DNase should not be used
  • Streptokinase should not be used 1

Surgical Management

• Consider surgical referral when:

  • Patient fails to improve with optimal medical therapy (typically after 7 days)
  • Large residual collection despite drainage

• Surgical approach:

  • VATS (video-assisted thoracoscopic surgery) is preferred over thoracotomy
  • Benefits include less postoperative pain, shorter hospital stay, fewer complications 1

Treatment for Specific Types of Pleurisy

Tuberculous Pleurisy

• Standard anti-tuberculosis therapy (isoniazid, rifampin, ethambutol)
• Consider adjunctive corticosteroids to hasten symptom relief and fluid resorption 2

Non-infectious Pleurisy

• Treatment directed at underlying cause (heart failure, malignancy, pulmonary embolism)
• Symptomatic management with analgesics

Monitoring and Follow-up

• Regular clinical assessment of symptoms
• Serial imaging to evaluate resolution of effusion
• Adjustment of therapy based on clinical response

Common Pitfalls to Avoid

1. Delaying antibiotic therapy while awaiting culture results
2. Using aminoglycosides for pleural infection
3. Failing to recognize when chest tube drainage is inadequate
4. Delaying surgical referral in non-resolving cases
5. Not addressing the underlying cause of pleurisy
6. Inadequate pain management

Remember that specialist involvement is crucial - a respiratory physician or thoracic surgeon should be involved in the care of all patients requiring chest tube drainage for pleural infection 1.