Synopsis
Identify complicated parapneumonic effusion or empyema early, use pleural chemistry and imaging correctly, and combine antibiotics with prompt effective drainage and timely surgical escalation.
- Pleural infection includes complicated parapneumonic effusion and empyema; pus or organisms in pleural fluid establishes the need for drainage regardless of pH.
- Persistent fever, pleuritic pain or sepsis despite pneumonia treatment should prompt thoracic ultrasound, even when the chest radiograph shows only basal shadowing.
- Use ultrasound guidance for aspiration and drain placement. Septations and echogenic fluid support complexity but do not replace fluid analysis.
Key red flags
Pneumonia with persistent fever, pleuritic pain, systemic inflammation and a pleural collection whose low pH, low glucose, high LDH or septation predicts failure of antibiotics alone.
Investigation priorities
Confirm pleural fluid, estimate volume and complexity, and identify a safe sampling or drain site.
Management branches
Pneumonia has pleural fluid, persistent sepsis or pleuritic pain.
- Assess sepsis severity, oxygenation and organ function, start appropriate antibiotics promptly and request respiratory or pleural review.
- Use thoracic ultrasound to confirm fluid and perform image-guided aspiration when the result will change drainage.
Key medicines
Empirical antimicrobial therapyStart intravenous treatment promptly using the current local pleural-infection guideline, distinguishing community from hospital acquisition and including anaerobic cover where indicated.
Intrapleural alteplase plus dornase alfaA BTS-supported adult regimen is alteplase 10 mg plus dornase alfa 5 mg intrapleurally twice daily for three days; use the current local protocol and consider reduced alteplase in higher bleeding risk.