What is the treatment for pleurisy?

Treatment of Pleurisy

The treatment of pleurisy depends fundamentally on the underlying etiology, with infectious pleurisy requiring immediate antibiotics and drainage, while uncomplicated viral or inflammatory pleurisy can be managed with NSAIDs for pain control. 1, 2

Initial Diagnostic Evaluation

Before initiating treatment, establish whether pleural effusion is present and determine its nature:

• Ultrasound is the preferred initial imaging modality to confirm pleural fluid and guide any subsequent drainage procedures 1
• Perform diagnostic thoracentesis within 24 hours if pleural infection is suspected 1
• Obtain blood cultures in all patients with suspected parapneumonic effusion 3, 1
• Pleural fluid must be analyzed for protein/LDH (to distinguish transudate from exudate), differential cell count, Gram stain, and bacterial culture 3, 1

Treatment Based on Etiology

Infectious Pleurisy (Parapneumonic Effusion/Empyema)

Start antibiotics immediately once pleural infection is identified 1:

For community-acquired infections:

• Second-generation cephalosporin plus metronidazole, OR 1
• Aminopenicillin plus beta-lactamase inhibitor (e.g., amoxicillin-clavulanate), OR 1
• Benzyl penicillin plus metronidazole 1
• Avoid aminoglycosides due to poor pleural space penetration 1

For hospital-acquired infections:

• Broader spectrum coverage required: piperacillin-tazobactam, ceftazidime, or meropenem 1

Tailor antibiotics to microbiology results when available 3, 1

Drainage for Pleural Infection

Effusions that are enlarging or compromising respiratory function require drainage and should not be managed with antibiotics alone 3, 1:

• Use small-bore chest tubes (14F or smaller) for initial drainage 3, 1
• Ultrasound guidance is mandatory for drain placement 3, 1
• Connect to unidirectional flow drainage system (underwater seal) kept below chest level 3
• Obtain chest radiograph after drain insertion 3
• Do not perform repeated thoracentesis—insert a drain at the outset if significant infection is present 1

Critical drain management points:

• Never clamp a bubbling drain 3
• If drainage suddenly stops, check for obstruction by flushing 3
• Remove drain once clinical resolution is achieved 3

Intrapleural Fibrinolytics

For complicated parapneumonic effusions or empyema with residual collection after initial drainage:

• Combination TPA (tissue plasminogen activator) plus DNAse is recommended 3
• Dosing: 10 mg TPA twice daily + 5 mg DNAse twice daily for 3 days 3
• Alternative lower-dose regimen: 5 mg TPA twice daily + 5 mg DNAse twice daily for 3 days may be equally effective 3
• Obtain patient consent due to bleeding risk 3
• Do not use single-agent TPA or DNAse alone—they are ineffective 3
• Do not use streptokinase—it increases complications without benefit 3

If TPA/DNAse or surgery is unsuitable, saline irrigation (250 mL three times daily) can be considered 3

Surgical Intervention

Involve a respiratory physician or thoracic surgeon early for all patients requiring chest tube drainage 1:

• Consider surgery if no improvement after 7 days of drainage, antibiotics, and fibrinolytics 1, 4
• Indications: persistent sepsis with persistent collection, organized empyema in symptomatic patients 3, 4
• Video-assisted thoracoscopic surgery (VATS) is preferred over thoracotomy when surgery is needed—it results in 2.3 days shorter hospital stay, less postoperative pain, fewer complications, and slightly lower mortality 3

Non-Infectious (Viral or Inflammatory) Pleurisy

When life-threatening causes (pulmonary embolism, pneumonia, myocardial infarction, pneumothorax, pericarditis) are excluded:

• NSAIDs for pain management are the mainstay of treatment 2
• Treat the underlying cause (e.g., anti-TB therapy for tuberculous pleurisy) 2, 5
• Corticosteroids are not routinely recommended for tuberculous pleurisy—they provide no clinically relevant benefit in symptom relief or prevention of pleural thickening 5

Duration of Antibiotic Therapy

• Oral antibiotics should be continued for 1-4 weeks after discharge, longer if residual disease persists 3, 1

Follow-Up and Monitoring

• Monitor fever, inflammatory markers, and symptoms regularly during treatment 1
• Follow-up imaging to ensure resolution of effusions is essential 1
• Continue follow-up until complete recovery with near-normal chest radiograph 3, 4
• In up to 15% of cases of nonspecific pleurisy, pleural malignancy may be the underlying cause—inadequate follow-up risks delayed diagnosis 1

Critical Pitfalls to Avoid

• Do not delay chest tube drainage—conservative management with antibiotics alone results in prolonged illness, longer hospital stay, and increased morbidity 3, 1
• Do not use aminoglycosides for pleural infections 1
• Do not use streptokinase as a fibrinolytic 3
• Do not use single-agent TPA or DNAse 3
• Never clamp a bubbling chest drain 3
• Do not assume benign etiology without adequate follow-up—malignancy must be excluded 1