Management of pleural infections

Expert Rev Respir Med. 2018 Jun;12(6):521-535. doi: 10.1080/17476348.2018.1475234. Epub 2018 May 20.


The management of infected pleural effusion is complex. Therapeutic resolution requires determining the following: appropriate antibiotic regimen, the need for pleural drainage, the optimal drainage tube size, and the need for intrapleural therapy or surgery. Areas covered: An updating of the latest advances in the management of parapneumonic pleural effusion based on the best evidence available is provided. Expert commentary: The correct management of parapneumonic pleural effusion is based on selecting an antibiotic regimen according to the origin of the pleural infection (community-acquired or nosocomial). If pleural drainage is indicated, a small-bore chest tube is appropriate. Although the administration of fibrinolytics is not required in all cases, when necessary, recombinant t-PA in combination with deoxyribonuclease is the preferred therapy. If surgery is indicated, video-assisted thoracoscopic surgery is as effective - if not superior - as open decortication. All these therapies should be complemented with appropriate nutritional support. Further clinical trials are needed to confirm whether new therapeutic strategies such as a pleural cavity saline wash are more effective in the management of this disease.

Keywords: Empyema; fibrinolytics; parapneumonic pleural effusion; pleural drainage; pleural fluid; pleural fluid culture; pleural infection.

Publication types

  • Review

MeSH terms

  • Algorithms
  • Anti-Bacterial Agents / therapeutic use
  • Bacterial Typing Techniques
  • Biomarkers / metabolism
  • Chest Tubes
  • Diagnostic Imaging
  • Drainage
  • Empyema, Pleural / diagnosis
  • Empyema, Pleural / therapy
  • Humans
  • Nutritional Support
  • Pleural Effusion / diagnosis*
  • Pleural Effusion / therapy*
  • Pneumonia / diagnosis
  • Pneumonia / drug therapy
  • Severity of Illness Index
  • Thoracentesis
  • Thrombosis / prevention & control


  • Anti-Bacterial Agents
  • Biomarkers