Managing pleural infections: a nationwide survey of respiratory physicians in Singapore

Abstract

Background: Pleural infection remains a major cause of morbidity and mortality, with a significant healthcare burden. Despite growing research and guideline recommendations, real-world management continues to vary widely.

Methods: An anonymous cross-sectional survey evaluating current practice was conducted among respiratory physicians across all public hospitals in Singapore. The survey examined key aspects of management, including pleural fluid diagnostics, chest drain management, surgical referral and intrapleural fibrinolytic therapy (IPFT).

Results: 95 respondents (58% response rate) completed the survey. Only 36.8% routinely inoculate pleural fluid into both plain specimen bottles and blood culture bottles, and up to 22% used plain tubes for pH analysis. Opinions on pH-guided chest drain insertion were divided: 50.6% would always consider pH, while 43.1% did not find it useful. IPFT was regarded as first line treatment following failure of standard care (antibiotics and chest drainage) by 63.2%, while 30.5% would only administer IPFT when surgery was deemed unsuitable. Most respondents (81.0%) had used a reduced dose of tissue plasminogen activator, with 12.6% doing so for all patients. The most common reduced dose was 5 mg (73.7%), largely driven by perceived reduction in bleeding risk (64.2%). Once-daily IPFT dosing was reported by 35.8%, primarily due to logistical constraints and safety concerns related to after-hours administration. Management practices, including pleural fluid sampling for microbiology and pH, indication and timing of surgery or IPFT, and IPFT dose adjustment, varied substantially between hospitals and between individual physicians within the same hospital, with no clear association with respondent seniority. Overall key challenges cited included variation in practice (48.4%), limited after-office hours expertise (44.2%) and limited surgical support (37.9%).

Conclusions: Significant variation exists in pleural infection management across Singapore. Strengthening multidisciplinary collaboration, establishing dedicated pleural services and high-quality trials are needed to optimise care pathways.Cite Now.

Keywords: Pleural Disease.