Management of Pleural Infections and Empyema

Pleural infections encompass a spectrum from uncomplicated parapneumonic effusions to life-threatening empyema. Initial management relies on prompt antimicrobial therapy guided by clinical severity and presumed pathogens, together with diagnostic thoracentesis to assess fluid biochemistry, cellular profile and microbiology. When fluid becomes loculated or purulent, drainage via chest tube with or without intrapleural enzymes or early surgical intervention is indicated to prevent fibro-thorax and persistent sepsis. Minimally invasive surgery, such as video-assisted thoracoscopic surgery (VATS), has largely supplanted open decortication in many centres, offering shorter hospital stays and improved lung re-expansion. Adjunctive intrapleural fibrinolysis, combining tissue plasminogen activator and DNase, has reduced the need for surgery in selected patients. Emerging diagnostic approaches, including metabolomic and microbiome profiling of pleural fluid, promise to refine patient stratification and personalise therapy. Despite advances, mortality remains significant, particularly in the elderly and those with comorbidities, so ongoing research focuses on optimising timing of intervention, minimising invasive procedures and discovering novel adjuvant agents to enhance fibrinolysis and host defence.

Research from Nature Portfolio

A foundational metabolomic study employed nuclear magnetic resonance to compare complicated and simple parapneumonic effusions in children with pneumococcal pneumonia. Key metabolites reflecting bacterial fermentation pathways were elevated in complicated cases, and reduced glucose levels correlated with the need for invasive drainage. Identification of butyric acid metabolites and other biomarkers offers a route to predict which patients will benefit from early pleural intervention and may guide tailored antibiotic and drainage strategies.

Management of Pleural Infections and Empyema publication trend

The graph below shows the total number of articles in management of pleural infections and empyema across all publications each year (not limited to Nature Index journals).

Technical terms

Pleural empyema: Collection of pus in the pleural space requiring drainage.

Parapneumonic effusion: Pleural fluid accumulation secondary to pneumonia.

Video-assisted thoracoscopic surgery (VATS): Minimally invasive lung surgery using small ports and a camera.

Intrapleural enzyme therapy (IET): Local administration of fibrinolytic agents and DNase to break down septations.

Metabolomics: Comprehensive analysis of small-molecule metabolites in biological fluids.

Next-generation sequencing: High-throughput DNA sequencing to characterise microbial communities.

Biomarker: Measurable biological molecule indicating disease presence or progression.

References

1. Early Video-assisted Thoracoscopic Surgery or Intrapleural Enzyme Therapy in Pleural Infection: A Feasibility Randomized Controlled Trial. The Third Multicenter Intrapleural Sepsis Trial—MIST-3. American Journal of Respiratory and Critical Care Medicine (2023).
2. Targeting the PAI-1 Mechanism with a Small Peptide Increases the Efficacy of Alteplase in a Rabbit Model of Chronic Empyema. Pharmaceutics (2023).
3. The bacteriology of pleural infection (TORPIDS): an exploratory metagenomics analysis through next generation sequencing. The Lancet Microbe (2022).
4. Metabolomic Profiling of Infectious Parapneumonic Effusions Reveals Biomarkers for Guiding Management of Children with Streptococcus pneumoniae Pneumonia. Scientific Reports (2016).
5. Safety and Efficacy of Intrapleural Tissue Plasminogen Activator and DNase during Extended Use in Complicated Pleural Space Infections. Canadian Respiratory Journal (2016).