What is the best way to treat pleurisy?

Treatment of Pleurisy

The optimal treatment of pleurisy depends critically on distinguishing between infectious (pleural infection/empyema) and non-infectious causes, with infectious pleurisy requiring immediate hospitalization, IV antibiotics, and drainage, while uncomplicated viral pleurisy is typically self-limited and managed with NSAIDs for symptom control. 1, 2, 3

Initial Assessment and Risk Stratification

First, exclude life-threatening causes before diagnosing simple pleurisy:

• Rule out pulmonary embolism (present in 5-20% of patients with pleuritic pain in emergency settings), pericarditis, pneumonia, myocardial infarction, and pneumothorax through history, physical examination, chest radiography, and ECG 3
• Use ultrasound to confirm pleural fluid presence, as it is more sensitive than plain radiography 1
• Obtain pleural fluid for analysis before starting antibiotics if infection is suspected, including Gram stain, bacterial culture, pH, glucose, LDH, and differential cell count 1, 2

Treatment of Infectious Pleurisy (Pleural Infection/Empyema)

Immediate Management

All patients with suspected or confirmed pleural infection require hospital admission and immediate IV antibiotics before culture results are available 1, 2, 4

Antibiotic Selection:

• Community-acquired pleural infection: Cefuroxime 1.5g IV three times daily PLUS metronidazole 400mg orally three times daily (or 500mg IV three times daily) 2, 4
• Hospital-acquired pleural infection: Piperacillin-tazobactam 4.5g IV four times daily 2, 4
• Alternative regimens: Benzyl penicillin 1.2g IV four times daily PLUS ciprofloxacin 400mg IV twice daily, or meropenem 1g IV three times daily PLUS metronidazole 2, 4
• MRSA suspected: Add vancomycin (15mg/kg IV every 8-12 hours, targeting trough 15-20mg/mL) or linezolid (600mg IV every 12 hours) 4
• Avoid aminoglycosides as they penetrate poorly into pleural space and are inactivated by acidic pleural fluid 1, 2, 4
• Adjust antibiotics based on culture results when available 1, 2, 4
• Continue oral antibiotics at discharge for 1-4 weeks, longer if residual disease present 2

Drainage Procedures

Drainage indications include frank pus, positive Gram stain, pH <7.2, or effusions >40% of hemithorax 1

Drainage technique:

• Use small-bore chest tubes (14F or smaller) for initial drainage 5, 2
• Use ultrasound guidance for all drain placements to optimize positioning and reduce complications 1, 2
• Do not use early VATS or thoracotomy as initial treatment over chest tube drainage 5, 2
• Involve a respiratory physician or thoracic surgeon in care of all patients requiring chest tube drainage 1, 2

Management of Persistent Collections

If chest tube drainage ceases but residual pleural collection remains, consider combination TPA plus DNase therapy 5, 2

Regimen:

• 10mg TPA twice daily PLUS 5mg DNase twice daily for 3 days (based on RCT data) 5, 2
• Alternative: 5mg TPA twice daily PLUS 5mg DNase twice daily for 3 days (based on retrospective data, may be used if necessary) 5
• Reduce TPA dose in patients with higher bleeding risk (e.g., those on therapeutic anticoagulation) 5, 2
• Obtain patient consent due to bleeding risk 5, 1, 2
• Do not use single agent TPA or DNase alone 5
• Do not use streptokinase 5
• Saline irrigation (250mL three times daily) can be considered when TPA/DNase or surgery is not suitable 5, 2

Surgical Intervention

Consider surgical referral if no improvement after 5-7 days of appropriate antibiotics and drainage 1, 2, 4

Surgical approach:

• VATS should be considered over thoracotomy when surgery is required, as it results in less postoperative pain, shorter hospital stays (2.3 days shorter), and fewer complications 5, 2
• Ensure the surgical technique can facilitate optimal clearance of infected material and achieve lung re-expansion 5
• Extent of surgery should be tailored according to patient fitness and empyema stage 5

Treatment of Non-Infectious (Viral) Pleurisy

Most viral pleuritic effusions are self-resolving and do not require drainage 1

Symptomatic management:

• NSAIDs for pain control 3
• Treatment targeted at underlying cause when identified 3

Critical Pitfalls to Avoid

• Delayed chest tube drainage increases morbidity, hospital stay, and possibly mortality 2
• Delayed antibiotic initiation in pleural infection increases morbidity and mortality 4
• Inadequate anaerobic coverage may lead to treatment failure 4
• Alternative diagnoses (rheumatoid effusion, malignancy/mesothelioma) can mimic parapneumonic effusion with low pH and loculations 2
• Up to 15% of nonspecific pleuritis cases subsequently develop pleural malignancy, requiring extended follow-up 2

Monitoring Treatment Response

• Assess fever, inflammatory markers, and symptoms regularly during treatment 2
• Document treatment response at 5-8 days after initiating drainage and antibiotics 2
• Perform follow-up imaging to ensure resolution and absence of loculations 2