What are the treatment and follow-up options for pleuritis?

Treatment and Follow-up for Pleuritis

The treatment of pleuritis should be directed at the underlying cause, with appropriate antibiotics for infectious etiologies, anti-inflammatory medications for pain relief, and drainage procedures for complicated cases. 1

Diagnostic Approach

• Thorough evaluation is necessary to determine the underlying cause of pleuritis, as treatment and prognosis depend on etiology 2
• Ultrasound is the preferred initial imaging modality for suspected pleural effusion and can help distinguish between exudative and transudative effusions 1
• CT scanning provides comprehensive thoracic assessment and may help differentiate between benign and malignant causes of pleural disease 1
• Diagnostic thoracentesis should be performed within 24 hours in cases of suspected pleural infection 1

Treatment Based on Etiology

Infectious Pleuritis

• Antibiotic therapy:

  • For community-acquired pleural infections: second-generation cephalosporins (e.g., cefuroxime) or aminopenicillins (e.g., amoxicillin) plus anaerobic coverage with metronidazole 1
  • For hospital-acquired infections: broader spectrum antibiotics such as piperacillin-tazobactam, ceftazidime, or meropenem 1
  • Antibiotics should be guided by culture results when available 1
  • Aminoglycosides should be avoided due to poor pleural penetration 1

• Drainage procedures:

  • Small-bore chest tubes (14F or smaller) are recommended for initial drainage of infected pleural effusions 1
  • For complicated parapneumonic effusions or empyema with persistent collections after initial drainage, combination tissue plasminogen activator (TPA) and DNase should be considered 1
  • The recommended regimen is 10 mg TPA twice daily plus 5 mg DNase twice daily for 3 days 1
  • Single-agent fibrinolytics or streptokinase are not recommended 1

• Surgical intervention:

  • Consider surgical referral if no improvement after 5-7 days of appropriate antibiotics and drainage 1
  • Video-assisted thoracoscopic surgery (VATS) is preferred over thoracotomy when surgical management is required 1

Non-infectious Inflammatory Pleuritis

• Anti-inflammatory medications:

  • NSAIDs are first-line for pain management in non-infectious pleuritis 2
  • Corticosteroids may be considered in refractory cases, particularly for autoimmune etiologies 2

• Treatment of underlying conditions:

  • For rheumatoid pleuritis: disease-modifying antirheumatic drugs 1
  • For malignant pleural disease: treatment of primary malignancy and consideration of pleurodesis for recurrent effusions 1

COVID-19 Associated Pleuritis

• Supportive care with supplemental oxygen as needed 3
• Consider COVID-19 in patients presenting with pleuritic chest pain, even in the absence of typical respiratory symptoms 3

Follow-up Recommendations

• For infectious pleuritis:

  • Regular clinical assessment of fever, inflammatory markers, and symptoms 1
  • Follow-up imaging to ensure resolution of effusions and absence of loculations 1
  • Complete antibiotic course (typically 2-6 weeks depending on severity) 4

• For nonspecific pleuritis (NSP):

  • Extended follow-up is crucial as up to 15% of patients with initial nonspecific pleuritis findings may subsequently develop pleural malignancy, most commonly mesothelioma 1
  • Median time to malignant diagnosis is approximately 12 months (range 0.8-32 months) 5
  • More vigilant follow-up for patients with asbestos exposure history 5
  • Consider repeat biopsies if clinical suspicion for malignancy remains high 1

• For post-surgical or post-transplant pleuritis:

  • Monitor for recurrent effusions, which may require thoracentesis 1
  • Late effusions (>15 days post-transplant) tend to be exudative and lymphocyte-predominant 1

Special Considerations

• In cases of nonspecific pleuritis where malignancy is suspected but initial biopsies are negative, long-term radiological monitoring is recommended 1
• For refractory cases with recurrent effusions not responding to conventional therapy, pleurodesis with agents such as minocycline may be considered 6
• Patients with persistent pleural collections and ongoing sepsis should undergo further radiological imaging to guide management 1
• Be mindful of alternative diagnoses that can mimic parapneumonic effusions with low pH and potential for loculations (e.g., rheumatoid effusion, advanced malignancy) 1

Monitoring Response to Treatment

• Assess effectiveness of drainage and resolution of fever and sepsis 5-8 days after initiating chest tube drainage and antibiotics 1
• Document treatment response in clinical notes 1
• Consider surgical consultation if drainage is ineffective or clinical improvement is not achieved within 7 days 1