Predicting the need for drainage in pleural infection: A comparison of clinical guidelines

Pleural infection requires early identification of individuals who are unlikely to respond to antibiotic therapy and may require drainage. Although several algorithms-Light's classification, the American College of Chest Physicians (ACCP) consensus statement, and the British Thoracic Society (BTS) 2003 and 2023 guidelines-are available, their predictive performance remains uncertain.

This retrospective diagnostic accuracy study analyzed individuals with pleural infection treated at two municipal hospitals between 2017 and 2023. Missing data were handled using multiple imputation. The outcome, the need for drainage, was defined as chest tube insertion, video-assisted thoracoscopic surgery, repeated thoracentesis with intrapleural fibrinolytic therapy, open decortication, or death attributable to pleural infection. The predictive performance of the four algorithms was evaluated using sensitivity and specificity.

Of the 215 individuals included, 57.7% experienced the outcome. Sensitivity/specificity were 70.9/74.7% for Light's classification, 85.5/46.5% for ACCP statement, 53.1/85.9% for BTS 2003 guideline, and 68.1/70.4% for BTS 2023 guideline. Thus, ACCP statement showed the highest sensitivity but lowest specificity, whereas BTS 2003 demonstrated the opposite pattern.

The choice of algorithms should depend on clinical context: ACCP statement may be preferred when minimizing missed cases is critical, whereas BTS 2003 guideline may be more appropriate for older adults or persons with frailty, where avoiding unnecessary invasive procedures is a priority.