What is the treatment for pleurisy?

Treatment for Pleurisy

The treatment for pleurisy should include NSAIDs as first-line therapy for pain management, appropriate antibiotics based on the underlying cause, and drainage of pleural effusions when indicated by pH < 7.2 or presence of loculations. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Confirm pleural effusion with chest radiography
• Use ultrasound to guide thoracentesis and detect loculations
• Obtain pleural fluid for analysis (biochemistry, microbiology, cell count)
• Perform blood cultures in all patients with suspected pleural infection

Treatment Algorithm

1. Pain Management

• NSAIDs are first-line treatment for pleuritic chest pain
  • Ibuprofen or naproxen until pain resolves 1
  • Ensure adequate analgesia to allow deep breathing and coughing

2. Antibiotic Therapy

• Start antibiotics immediately upon identification of pleural infection 2, 1
• Choice of antibiotics depends on origin of infection:

For community-acquired pleural infection:

• Intravenous options:

  • Cefuroxime 1.5g TDS + metronidazole 400mg TDS orally/500mg TDS IV
  • Benzyl penicillin 1.2g QDS IV + ciprofloxacin 400mg BD IV
  • Meropenem 1g TDS IV + metronidazole 2, 1

• Oral options:

  • Amoxicillin 1g TDS + clavulanic acid 125mg TDS
  • Amoxicillin 1g TDS + metronidazole 400mg TDS
  • Clindamycin 300mg QDS 2

For hospital-acquired pleural infection:

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

Important: Avoid aminoglycosides as they have poor penetration into the pleural space and may be inactive in acidic pleural fluid 2

3. Drainage of Pleural Effusions

• Indications for chest tube drainage:

  • pH < 7.2 in pleural fluid
  • Positive cultures
  • Loculated collections
  • Large effusions causing symptoms 2, 1

• Use small-bore tubes (14F or smaller) under ultrasound guidance 1

4. Intrapleural Fibrinolytics

• For complicated parapneumonic effusions with loculations:
  • Combination therapy with tissue plasminogen activator (TPA) 10mg twice daily + DNase 5mg twice daily for 3 days 1
  • Avoid single-agent TPA, DNase, or streptokinase 1

5. Specialist Involvement

• A respiratory physician or thoracic surgeon should be involved in the care of all patients requiring chest tube drainage 2
• Consider surgical referral if no improvement after 5-7 days of drainage and antibiotics 2, 1

Monitoring and Reassessment

• Monitor temperature, white blood cell count, clinical symptoms, and radiographic improvement
• Reassess if no improvement after 48-72 hours
• Review antibiotic coverage and evaluate for inadequate drainage 1

Special Considerations for Tuberculous Pleurisy

• Standard anti-TB therapy and early complete drainage is the mainstay of treatment
• The role of corticosteroids remains controversial, with conflicting evidence regarding their benefit 3, 4

Common Pitfalls to Avoid

1. Delaying drainage of complicated parapneumonic effusions
2. Using aminoglycosides as sole therapy
3. Removing chest tubes prematurely
4. Failing to adjust antibiotics based on culture results
5. Misdiagnosing the underlying cause of pleurisy 1

Remember that pleurisy is often a manifestation of an underlying disease, and treatment should address both the symptoms and the primary condition 5.