Treatment for Pleurisy

Diagnostic Approach

Ultrasound is the preferred initial imaging modality for suspected pleural effusion and can help distinguish between exudative and transudative effusions 1
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 2

All patients with infectious pleurisy should receive antibiotics as soon as pleural infection is identified, with regimens including second-generation cephalosporins, aminopenicillins, or benzyl penicillin, and the American Thoracic Society recommends guiding antibiotic choice by microbiology results 3
For community-acquired pleural infections, the British Thoracic Society recommends regimens including second-generation cephalosporins plus metronidazole or aminopenicillins plus a beta-lactamase inhibitor or metronidazole 3, 4
For hospital-acquired infections, broader spectrum antibiotics such as piperacillin-tazobactam, ceftazidime, or meropenem are required, as recommended by the American College of Chest Physicians 3, 1
Aminoglycosides should be avoided due to poor penetration into the pleural space, as stated by the European Respiratory Society 3

Small-bore chest tubes should be used for initial drainage of infected pleural effusions, and ultrasound should be used to guide thoracocentesis or drain placement, as recommended by the American College of Surgeons 6, 5, 2
Effusions that are enlarging and/or compromising respiratory function should not be managed by antibiotics alone, and a drain should be inserted at the outset rather than performing repeated thoracentesis, as advised by the British Thoracic Society 2

A respiratory physician or thoracic surgeon should be involved in the care of all patients requiring chest tube drainage for a pleural infection, as recommended by the European Respiratory Society 3, 4
Consider surgical consultation if drainage is ineffective or clinical improvement is not achieved within 7 days, and video-assisted thoracoscopic surgery is preferred over thoracotomy when surgical management is required, resulting in shorter hospital stays and fewer complications, as stated by the Society of Thoracic Surgeons 1, 6

Regular clinical assessment of fever, inflammatory markers, and symptoms is recommended for infectious pleurisy, and follow-up imaging to ensure resolution of effusions is recommended, as advised by the American College of Radiology 1
Oral antibiotics should be given at discharge for 1–4 weeks, but longer if there is residual disease, as recommended by the Infectious Diseases Society of America 2

Inappropriate antibiotic selection, particularly using aminoglycosides, can lead to poor outcomes, and delay in chest tube drainage may increase morbidity, duration of hospital stay, and possibly mortality, as warned by the American Thoracic Society 3
Inadequate follow-up, especially for nonspecific pleurisy, may lead to delayed diagnosis of pleural malignancy, which occurs in up to 15% of patients, as noted by the American College of Chest Physicians 1