How is pericardial effusion caused by infection treated?

Treatment of Pericardial Effusion Caused by Infection

The treatment of pericardial effusion caused by infection requires targeted antimicrobial therapy against the specific pathogen, along with appropriate drainage procedures when hemodynamically significant. 1, 2

Diagnostic Approach

Before initiating treatment, identifying the causative organism is crucial:

• Pericardial fluid analysis is essential for establishing the diagnosis of viral, bacterial, tuberculous, or fungal pericarditis 1
• PCR or in-situ hybridization of pericardial fluid/tissue is the gold standard for viral pericarditis (level of evidence B, class IIa indication) 1
• Bacterial cultures (minimum three samples for aerobes and anaerobes) plus blood cultures are mandatory for suspected bacterial infection 1
• Specific tests for tuberculosis include acid-fast bacilli staining, mycobacterium culture, adenosine deaminase (ADA), interferon-gamma, and PCR 1

Treatment Algorithm by Pathogen

1. Viral Pericarditis (Most Common)

• First-line therapy: NSAIDs + colchicine 2

  • Ibuprofen (600-800mg three times daily) or aspirin (750-1000mg every 8 hours) for 1-2 weeks 2
  • Colchicine 0.5mg twice daily (0.5mg once daily if <70kg) for at least 6 months 2

• Specific antiviral therapy for confirmed viral infections: 1

  • CMV pericarditis: Hyperimmunoglobulin 4 ml/kg on days 0,4, and 8; then 2 ml/kg on days 12 and 16
  • Coxsackie B pericarditis: Interferon alpha or beta 2.5 million IU/m² subcutaneously 3 times weekly
  • Adenovirus/parvovirus B19: Intravenous immunoglobulin 10g on days 1 and 3

2. Bacterial Pericarditis

• Urgent pericardial drainage is mandatory 3
• Empiric antibacterial therapy until culture results: 3
  • Vancomycin 1g twice daily
  • Ceftriaxone 1-2g twice daily
  • Ciprofloxacin 400 mg/day
• Irrigation with fibrinolytics (urokinase or streptokinase) may be needed for purulent exudates 3
• Open surgical drainage is preferable in purulent pericarditis 3

3. Tuberculous Pericarditis

• Antituberculous regimen: 3
  • Isoniazid 300 mg/day
  • Rifampin 600 mg/day
  • Pyrazinamide 15-30 mg/kg/day
  • Ethambutol 15-25 mg/kg/day
• Adjunctive corticosteroids: Prednisone 1-2 mg/kg/day for 5-7 days, tapered over 6-8 weeks 3
• Pericardiectomy for recurrent effusions or persistent elevated central venous pressure after 4-6 weeks of therapy 3

4. Fungal Pericarditis

• Antifungal therapy tailored to the specific fungal pathogen 1
• For hydatid cysts: Percutaneous aspiration with ethanol sclerosis after pre-treatment with Albendazole (800 mg/day for 4 weeks) 1

Drainage Procedures

Indications for Pericardiocentesis:

• Absolute indications: 2

  • Cardiac tamponade (life-saving, Class I indication)
  • Suspected bacterial or neoplastic etiology

• Relative indications: 2

  • Effusions >20 mm in echocardiography
  • Smaller effusions for diagnostic purposes

Prevention of Recurrences:

• Extended catheter drainage for recurrent effusions 2
• Pericardial window creation for recurrent symptomatic effusions 2, 4
• Pericardiectomy as last resort after failed medical therapy 2

Monitoring and Follow-up

• Echocardiographic monitoring: 2

  • Small effusions (<10mm): no specific monitoring required
  • Moderate effusions (10-20mm): every 6 months
  • Large effusions (>20mm): every 3-6 months (30-35% risk of progression to tamponade)

• Laboratory monitoring: C-reactive protein to guide treatment duration and assess response 2

Special Considerations

• Mortality in untreated purulent pericarditis approaches 100%, while treated cases still have 40% mortality 3
• Untreated tuberculous pericarditis has 85% mortality 3
• HIV-infected patients have higher incidence of pericardial effusions (up to 40%) with increased risk of bacterial and fungal co-infections 1
• Cardiac tamponade requires emergency drainage regardless of etiology 5, 6

The treatment approach must be tailored to the specific infectious agent while monitoring for hemodynamic compromise that may necessitate urgent intervention.