What is the treatment for pleurisy in an Emergency Room (ER) setting?

Treatment of Pleurisy in the Emergency Room Setting

In the ER, pleurisy treatment depends critically on distinguishing simple pleuritic pain from pleural infection (empyema/parapneumonic effusion), which fundamentally changes management from symptomatic pain control to urgent drainage and antibiotics.

Initial Assessment and Risk Stratification

The first priority is excluding life-threatening causes and identifying pleural infection:

• Rule out pulmonary embolism (found in 5-21% of patients with pleuritic pain), myocardial infarction, pericarditis, pneumothorax, and aortic dissection using history, physical exam, ECG, troponin, and chest radiography 1, 2
• Obtain chest radiography on all patients presenting with pleuritic chest pain to identify pleural effusions 1, 3
• Use ultrasound to confirm the presence of pleural fluid collections, as it is more sensitive than plain radiography 4

Management Algorithm Based on Findings

For Simple Pleurisy (No Effusion or Small Reactive Effusion)

• Treat with NSAIDs for pain management when viral pleurisy or other benign causes are suspected after excluding serious pathology 1, 2
• Most viral pleuritic effusions are self-resolving and do not require drainage 4

For Pleural Infection (Empyema/Parapneumonic Effusion)

All patients with suspected or confirmed pleural infection require hospital admission 4

Immediate Antibiotic Therapy

Start IV antibiotics immediately upon identification of pleural infection, before culture results are available 4, 5:

For community-acquired pleural infection:

• Cefuroxime 1.5g IV three times daily + metronidazole 400mg orally three times daily (or 500mg IV three times daily) 4, 5
• Alternative: Benzyl penicillin 1.2g IV four times daily + ciprofloxacin 400mg IV twice daily 4, 5
• Alternative: Amoxicillin-clavulanate 1g/125mg orally three times daily 4, 5
• Alternative: Clindamycin 300mg four times daily (covers both aerobes and anaerobes in single agent) 4

For hospital-acquired pleural infection:

• Piperacillin-tazobactam 4.5g IV four times daily 4, 5
• Alternative: Ceftazidime 2g IV three times daily 4, 5
• Alternative: Meropenem 1g IV three times daily ± metronidazole 4, 5

Critical antibiotic considerations:

• Beta-lactams (penicillins and cephalosporins) show excellent pleural space penetration 4, 5
• Avoid aminoglycosides as they have poor pleural penetration and are inactivated by pleural fluid acidosis 4, 5
• Adjust antibiotics based on culture results when available 4, 5

Pleural Fluid Sampling and Drainage

Obtain pleural fluid for analysis before starting antibiotics when possible 5:

• Send for Gram stain, bacterial culture (including anaerobes), differential cell count 4
• Blood cultures should also be obtained 4

Drainage indications:

• Any patient with frank pus, positive Gram stain, or pH <7.2 requires immediate chest tube drainage 4
• Effusions >40% of hemithorax are more likely to require surgery 4
• Use ultrasound guidance for thoracentesis or chest tube placement to optimize positioning and reduce complications 4, 5

Chest tube management:

• Small bore catheters (including pigtail catheters) should be used whenever possible as they are less traumatic and more comfortable than large bore tubes 4
• Insert at the optimal site suggested by ultrasound 4
• If drainage ceases with residual collection, flush with 20-50mL normal saline to ensure patency 4

Specialist Involvement

A respiratory physician or thoracic surgeon should be involved in the care of all patients requiring chest tube drainage for pleural infection 4. This is critical because:

• Delay to chest tube drainage increases morbidity, hospital stay, and potentially mortality 4
• Misdiagnosis, inappropriate antibiotics, and inappropriate chest tube placement contribute to disease progression 4

Advanced Therapies for Failed Drainage

If chest tube drainage ceases and leaves residual pleural collection:

• Consider combination TPA (10mg twice daily) + DNase (5mg twice daily) for 3 days via the chest tube 4
• Obtain patient consent as there is bleeding risk 4
• Single agent TPA or DNase should NOT be used (ineffective) 4
• Streptokinase should NOT be used 4

Common Pitfalls to Avoid

• Do not delay chest tube drainage in patients with significant pleural infection—this is associated with worse outcomes 4
• Do not use aminoglycosides for pleural infection despite their use in other infections 4, 5
• Do not assume small effusions are benign—if the patient remains febrile or unwell 48 hours after admission for pneumonia, pleural infection must be excluded 4
• Do not perform repeated thoracentesis instead of placing a chest tube when significant pleural infection is present 4

Disposition

• All patients with pleural infection require admission 4
• Patients with simple viral pleurisy and no effusion may be discharged with NSAIDs and close follow-up 1, 2
• Surgical consultation should be obtained after approximately 7 days if not settling with drainage and antibiotics 4