What is the primary treatment for a patient with pleurisy?

Treatment for Pleurisy

Immediate Assessment and Life-Threatening Exclusions

Before treating pleurisy, you must first rule out life-threatening causes including pulmonary embolism (found in 5-21% of cases), myocardial infarction, pericarditis, pneumothorax, and pneumonia. 1, 2, 3

• Obtain vital signs immediately—fever and tachycardia suggest infectious etiology or pulmonary embolism 1
• Perform chest radiography, electrocardiography, and consider troponin assays based on clinical presentation 2, 3
• Use validated clinical decision rules for pulmonary embolism and coronary artery disease to guide further testing 3

Treatment Algorithm Based on Etiology

For Simple Pleurisy (Non-Infectious, No Effusion)

NSAIDs are the primary treatment for uncomplicated viral or nonspecific pleurisy once serious causes are excluded. 2, 3

• Viral pleurisy (Coxsackievirus, RSV, influenza, parainfluenza, adenovirus, EBV) is among the most common causes and responds to symptomatic treatment 2, 3
• Pain management with NSAIDs is appropriate for virally triggered or nonspecific pleuritic chest pain 2, 3

For Pleurisy with Pleural Effusion (Parapneumonic/Infectious)

Start antibiotics immediately once pleural infection is identified, and perform diagnostic thoracentesis within 24 hours to guide management. 1, 4

Antibiotic Selection:

For community-acquired pleural infection: Use cefuroxime 1.5g IV three times daily PLUS metronidazole 400mg orally three times daily as first-line therapy 1, 5, 4

• Alternative regimens include benzyl penicillin 1.2g IV four times daily plus ciprofloxacin 400mg IV twice daily, or meropenem 1g IV three times daily plus metronidazole 5, 4
• Clindamycin alone is effective for penicillin-allergic patients 5
• Avoid aminoglycosides—they penetrate poorly into pleural space and are inactivated by acidic pleural fluid 5, 4

For hospital-acquired pleural infection: Use piperacillin-tazobactam 4.5g IV every 6 hours as the optimal first-line choice 5, 4

• If MRSA is suspected, add vancomycin (15mg/kg IV every 8-12 hours, targeting trough levels of 15-20mg/mL) or linezolid (600mg IV every 12 hours) 5

Drainage Decisions:

Insert a small-bore chest tube (14F or smaller) under ultrasound guidance for effusions >10mm with respiratory compromise, pH <7.2, or enlarging collections. 1, 4

• Small effusions (<10mm) can be treated with antibiotics alone 1
• Use ultrasound guidance for all drain placements 4
• Do not perform repeated thoracentesis when chest tube drainage is indicated 4

For Loculated or Persistent Collections:

Consider combination tissue plasminogen activator (TPA) 10mg plus DNase 5mg, both twice daily for 3 days, if chest tube drainage ceases but residual collection remains after 48-72 hours. 6, 4

• Obtain patient consent due to bleeding risk 4
• Reduce TPA dose in patients on anticoagulation 4
• This combination improves radiological outcomes, though mortality benefit is not yet established 6

Transition to Oral Antibiotics:

Switch to oral antibiotics only after clinical improvement is demonstrated, with amoxicillin-clavulanate 1g three times daily as first-line choice. 1, 5

• Continue oral antibiotics at discharge for 1-4 weeks, longer if residual disease persists 5, 4
• Total antibiotic duration should be 2-4 weeks depending on clinical response 5, 7
• For penicillin-allergic patients, use clindamycin 300mg four times daily 5

For Tuberculous Pleurisy

Use the standard 6-month anti-tuberculosis regimen (INH, RIF, PZA, EMB for 2 months, then INH and RIF for 4 months). 1

• Do not use adjunctive corticosteroids routinely 1
• Tuberculous empyema requires drainage (often surgical) plus prolonged anti-tuberculosis chemotherapy 1

For Malignant Pleurisy

Perform therapeutic thoracentesis to relieve dyspnea and determine rate of recurrence. 6

• Remove only 1-1.5 liters at one sitting to avoid re-expansion pulmonary edema unless contralateral mediastinal shift is present 6
• Consider pleurodesis for recurrent symptomatic effusions after confirming complete lung expansion 6
• Treat the primary malignancy 4

Surgical Intervention

Refer for surgical consultation if no improvement after 5-7 days of appropriate antibiotics and drainage. 5, 4

• VATS (video-assisted thoracoscopic surgery) is preferred over thoracotomy when surgery is required 4
• Do not use early VATS or thoracotomy as initial treatment over chest tube drainage 4

Critical Pitfalls to Avoid

• Never use oral antibiotics as initial monotherapy for empyema—this is inadequate and increases mortality risk 5
• Never omit anaerobic coverage in community-acquired infections, particularly with aspiration risk 5, 4
• Delayed chest tube drainage increases morbidity, hospital stay, and possibly mortality 4
• Up to 15% of nonspecific pleuritis cases subsequently develop pleural malignancy—extended follow-up with repeat imaging is crucial 4
• Alternative diagnoses (rheumatoid effusion, malignancy/mesothelioma) can mimic parapneumonic effusion with low pH and loculations 4

Monitoring Response

• Assess fever, inflammatory markers, and symptoms regularly during treatment 4
• Document treatment response at 5-8 days after initiating drainage and antibiotics 4
• Clinical resolution should be confirmed by fever resolution, improved respiratory status, decreased white blood cell count, and pleural fluid neutrophil count <250/mm³ 5