What is the treatment for pleurisy?

Treatment for Pleurisy

The treatment for pleurisy should focus on addressing the underlying cause, with antibiotics being the cornerstone of therapy for infectious pleurisy, and NSAIDs recommended for pain management in viral or non-infectious cases. 1, 2

Diagnostic Approach

• Ultrasound is the preferred initial imaging modality for suspected pleural effusion and can help distinguish between exudative and transudative effusions 1
• Chest radiography should be performed in all patients with pleuritic chest pain 2
• Diagnostic thoracentesis should be performed within 24 hours in cases of suspected pleural infection 1
• Blood cultures should be performed in all patients with parapneumonic effusion 3

Treatment Based on Etiology

Infectious Pleurisy (Bacterial)

• All patients should receive antibiotics as soon as pleural infection is identified 3
• For community-acquired pleural infections, recommended regimens include:
  • Second-generation cephalosporins (e.g., cefuroxime 1.5g TDS IV) plus metronidazole (400mg TDS orally or 500mg TDS IV) 3, 1
  • Aminopenicillins (e.g., amoxicillin) plus a beta-lactamase inhibitor or metronidazole 3
  • Benzyl penicillin plus ciprofloxacin as an alternative regimen 3
• For hospital-acquired infections, broader spectrum antibiotics are required:
  • Piperacillin-tazobactam 4.5g QDS IV 3, 1
  • Ceftazidime 2g TDS IV 3
  • Meropenem 1g TDS IV (with or without metronidazole) 3
• Where possible, antibiotic choice should be guided by microbiology results 3
• Aminoglycosides should be avoided as they have poor penetration into the pleural space 3

Drainage for Pleural Infection

• Small-bore chest tubes (14F or smaller) should be used for initial drainage of infected pleural effusions 3
• Ultrasound should be used to guide thoracocentesis or drain placement 3
• Effusions that are enlarging and/or compromising respiratory function should not be managed by antibiotics alone 3
• If a patient has significant pleural infection, a drain should be inserted at the outset rather than performing repeated thoracentesis 3

Viral or Non-infectious Pleurisy

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are appropriate for pain management in viral or nonspecific pleuritic chest pain 2, 4
• Treatment should be directed at the underlying cause when identified 2, 5
• For rheumatoid pleuritis, disease-modifying antirheumatic drugs are recommended 1

Specialist Involvement

• A respiratory physician or thoracic surgeon should be involved in the care of all patients requiring chest tube drainage for a pleural infection 3
• Consider surgical consultation if drainage is ineffective or clinical improvement is not achieved within 7 days 1
• Video-assisted thoracoscopic surgery (VATS) is preferred over thoracotomy when surgical management is required, as it results in shorter hospital stays (2.3 days shorter) and fewer complications 3, 1

Follow-up and Monitoring

• Regular clinical assessment of fever, inflammatory markers, and symptoms is recommended for infectious pleurisy 1
• Follow-up imaging to ensure resolution of effusions is recommended 1, 4
• Oral antibiotics should be given at discharge for 1–4 weeks, but longer if there is residual disease 3
• In patients with persistent symptoms, smokers, and those older than 50 years with pneumonia, document radiographic resolution with repeat chest radiography six weeks after initial treatment 4

Common Pitfalls and Caveats

• Failure to identify potentially life-threatening causes of pleuritic pain (pulmonary embolism, pericarditis, pneumonia, myocardial infarction, pneumothorax) before diagnosing simple pleurisy 2, 4
• Inappropriate antibiotic selection, particularly using aminoglycosides which have poor pleural penetration 3
• Delay in chest tube drainage which may increase morbidity, duration of hospital stay, and possibly mortality 3
• Inadequate follow-up, especially for nonspecific pleurisy, as up to 15% of patients may subsequently develop pleural malignancy 1