Pleural Space Infections

- Most cases secondary to pneumonia, lung abscess or complications of bronchiectasis.

- May also occur after thoracic surgery procedures, trauma, or esophageal rupture.

- Primary pleural effusions are as a result of hematogenous spread of oropharyngeal flora (streptococci/anaerobes) or due to M. tuberculosis.

Diagnosis

- Chest x-ray

- Thoracentesis

- Pleural fluid for Gram stain/culture, AFB stain/culture, pH, WBC, LDH, glucose and cytology.

- Sputum for C&S/AFB. If TB suspected, avoid quinolones and linezolid until cultures taken.

Management

- Pleural fluid drainage (may require repeat thoracentesis):

• If pH > 7.2/culture negative - typical parapneumonic effusion, treat as for pneumonia.
• If pH < 7.2 and/or glucose < 3.4 µmol/L and/or purulent - complicated effusion, typically requires:

1. additional empiric anaerobic coverage

2. chest tube drainage. If incomplete drainage, consider early administration of fibrinolytic agents and Thoracic Surgery consult.

3. thoracic CT- if pleural peel, recommend Thoracic Surgery consult for decortication/video-assisted thorascopic surgery (VATS).