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Pleural infection: past, present, and future directions

John P Corcoran¹, John M Wrightson², Elizabeth Belcher³

¹Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK.

The Lancet. Respiratory Medicine

|July 15, 2015

Abstract:

Pleural space infections are increasing in incidence and continue to have high associated morbidity, mortality, and need for invasive treatments such as thoracic surgery. The mechanisms of progression from a non-infected, pneumonia-related effusion to a confirmed pleural infection have been well described in the scientific literature, but the route by which pathogenic organisms access the pleural space is poorly understood. Data suggests that not all pleural infections can be related to lung parenchymal infection. Studies examining the microbiological profile of pleural infection inform antibiotic choice and can help to delineate the source and pathogenesis of infection. The development of radiological methods and use of clinical indices to predict which patients with pleural infection will have a poor outcome, as well as inform patient selection for more invasive treatments, is particularly important. Randomised clinical trial and case series data have shown that the combination of an intrapleural tissue plasminogen activator and deoxyribonuclease therapy can potentially improve outcomes, but the use of this treatment as compared with surgical options has not been precisely defined, particularly in terms of when and in which patients it should be used.

Insights

Pleural space infections are rising, with unclear origins and significant health risks. Further research is needed to understand infection pathways and optimize treatment strategies for better patient outcomes.

Area of Science:

Pulmonology
Infectious Diseases
Thoracic Surgery

Background:

Pleural space infections are increasing, leading to high morbidity and mortality.
Pathogen entry routes into the pleural space remain poorly understood, with some cases unrelated to pneumonia.
Microbiological profiling is crucial for guiding antibiotic selection and understanding infection sources.

Purpose of the Study:

To review current understanding of pleural infection pathogenesis and treatment.
To highlight the importance of radiological methods and clinical indices for outcome prediction.
To discuss the role of intrapleural tissue plasminogen activator and deoxyribonuclease therapy versus surgical options.

Main Methods:

Literature review of scientific data on pleural infections.
Analysis of studies on microbiological profiles and pathogenesis.
Examination of randomized clinical trials and case series on treatment efficacy.

Main Results:

The precise route of pathogen access to the pleural space is not fully elucidated.
Radiological and clinical tools are vital for predicting poor outcomes and guiding treatment.
Intrapleural tissue plasminogen activator and deoxyribonuclease show potential but require further comparative definition against surgery.

Conclusions:

Understanding pleural infection mechanisms is critical for improving patient care.
Predictive tools and refined treatment strategies are needed to manage these complex infections.
Further research is necessary to define optimal therapeutic pathways, including the role of novel intrapleural therapies.

Read full analysis

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