Characteristics and Clinical Outcomes of Postoperative Pleural Space Infections Among Lung Transplant Recipients

Pleural space infections (PSI) are a common complication after lung transplantation (LT) and have historically been linked to impaired allograft function and decreased survival, though contemporary outcome data are limited.

This retrospective cohort included adult LT recipients (LTRs) who underwent pleural effusion drainage ≤ 90 days posttransplant from June 2013 to December 2023. Pulmonary function tests (PFTs; FEV1 and FVC percent predicted) and 1-year survival were compared between LTRs with and without culture-proven PSI using linear mixed-effects models. Survival was analyzed using an adjusted Cox proportional hazards model controlling for restrictive lung disease, with Kaplan-Meier curves to visualize survival trajectories. PSI diagnosis, microbiology, and management considerations were also described.

Among 1005 LTRs, 7% developed PSI (n = 72) and 30% had sterile effusions (n = 304). A pleural neutrophil percentage > 21% predicted infection with 71% sensitivity and 76% specificity. Gram-positive bacteria and Candida comprised 80% of isolates. Median antimicrobial treatment was 4 weeks, combined with pleural drainage. Surgical intervention within 30 days of nonoperative drainage was more frequent in PSI patients (22% vs. 7%, p < 0.001; two-thirds VATS procedures). PSI was associated with modest early pulmonary impairment (∼4%-7% lower PFTs), primarily reflecting stable (non-improving) values from Months 1 to Month 2. However, both groups showed similar trajectories thereafter, with >10% absolute PFT improvement from Month 1 to Month 12. One-year survival was 93% (PSI) versus 94% (non-PSI) (HR: 1.23, 95% CI: 0.44-4.43, p = 0.69).

PSI remains frequent post-LT but with contemporary management-including drainage, antimicrobials, and early surgical intervention-may no longer carry excess risk for sustained allograft dysfunction or death relative to pleural effusions without associated infection.