What are the treatment guidelines for pleurisy?

Treatment Guidelines for Pleurisy

The treatment of pleurisy should focus on addressing the underlying cause while providing appropriate drainage and antimicrobial therapy for infectious cases, with small-bore chest tubes (14F or smaller) recommended as first-line drainage when needed. 1

Diagnosis and Initial Assessment

• Pleurisy (inflammation of the pleura) can be infectious or non-infectious
• Key diagnostic tests:
  • Pleural fluid analysis (protein, LDH, cell count, culture)
  • Blood cultures
  • Chest imaging (X-ray, ultrasound, CT as needed)
  • Pleural biopsy when etiology remains unclear

Treatment Algorithm

1. Infectious Pleurisy (Pleural Infection/Empyema)

Antibiotic Therapy

• Start antibiotics immediately upon identification of pleural infection 1

• Base antibiotic choice on culture results when available 1

• For culture-negative cases:

  Community-acquired infection:

  • IV options: 1

    • Cefuroxime 1.5g TDS + metronidazole 400mg TDS orally/500mg TDS IV
    • Benzyl penicillin 1.2g QDS + ciprofloxacin 400mg BD IV
    • Meropenem 1g TDS + metronidazole

  • Oral options: 1

    • Amoxicillin 1g TDS + clavulanic acid 125mg TDS
    • Amoxicillin 1g TDS + metronidazole 400mg TDS
    • Clindamycin 300mg QDS

  Hospital-acquired infection: 2

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

Drainage Management

• Use small-bore chest tubes (14F or smaller) for initial drainage 1
• Ensure tube patency by flushing with saline if drainage is poor
• Connect to underwater seal drainage system kept below chest level 1
• For complicated parapneumonic effusions or empyema with loculations:
  • Consider combination tissue plasminogen activator (TPA) and DNase 1
    • Recommended regimen: 10mg TPA twice daily + 5mg DNase twice daily for 3 days
    • Alternative regimen: 5mg TPA twice daily + 5mg DNase twice daily for 3 days
  • Do not use single agent TPA, DNase, or streptokinase 1
  • Saline irrigation (250mL three times daily) can be considered when TPA/DNase or surgery is not suitable 1

Surgical Management

• Consider surgical referral if patient fails to improve after 7 days of drainage and antibiotics 1
• VATS (video-assisted thoracoscopic surgery) should be preferred over thoracotomy 1
• Indications for surgical intervention:
  • Persistent sepsis with residual pleural collection
  • Failure of chest tube drainage, antibiotics, and fibrinolytics
  • Organized empyema requiring decortication

2. Non-Infectious Pleurisy

• Treatment depends on underlying cause:
  • Tuberculous pleurisy: Standard anti-TB therapy (isoniazid, rifampin, ethambutol) for at least 9 months; consider adjunctive corticosteroids (prednisolone 0.75mg/kg/day initially, tapered over 2-3 months) to hasten symptom relief and fluid resorption 3
  • Viral pleurisy: Supportive care with NSAIDs for pain management 4
  • Malignant pleurisy: Treatment of underlying malignancy; drainage for symptomatic relief
  • Autoimmune pleurisy: Treatment of underlying condition

Special Considerations

• Avoid aminoglycosides as they have poor penetration into the pleural space and may be inactive in acidic pleural fluid 1, 2
• A respiratory physician or thoracic surgeon should be involved in the care of all patients requiring chest tube drainage 1
• Monitor for resolution with:
  • Temperature curve
  • White blood cell count
  • Clinical symptoms
  • Radiographic improvement
• Continue antibiotics for at least 14 days in infectious cases, with adjustment based on clinical response 2

Common Pitfalls to Avoid

• Delaying drainage of complicated parapneumonic effusions
• Using aminoglycosides as sole therapy
• Removing chest tubes prematurely
• Failing to adjust antibiotics based on culture results
• Misdiagnosing the underlying cause of pleurisy
• Using excessive force during chest tube insertion 1
• Clamping a bubbling chest drain 1

By following these guidelines, clinicians can effectively manage pleurisy while minimizing complications and improving patient outcomes.