Plateau on pleural infection outcomes a growing concern: ERS

New treatment and risk stratification strategies are “urgently needed” for pleural infection as well as ongoing research efforts to improve antibiotic stewardship, a European Respiratory Society (ERS) taskforce has warned.

In a statement reviewing the most up to date evidence on pleural infection, the ERS and European Society of Thoracic Surgeons said there has been an ongoing rise in incidence but with worryingly little improvement in patient outcomes.

Despite advances in intrapleural treatments and surgical techniques in the last decade, the lack of improvement in outcomes may be down to an inability to identify the patients who would most benefit at an earlier stage. 

The development of the RAPID score was a “major step forward” but this is not yet at the stage where it can be used to direct clinical care, the team said.

In the UK, there has been a year-on-year increase from 6.44 per 100,000 to 8.3 per 100,000 from 2008 and 2017, the review found, a trend likely to be related to an ageing population living longer with co-morbidities such as diabetes that increase risk, the increased prescribing of immunosuppressant agents but also improved access to diagnostics.

Yet it should be noted that 40% of adult pleural infection hospitalisations happen in those under the age of 64 years, the taskforce said.

Pleural infection by antibiotic-resistant pathogens is relatively common and, in a study, 37% of isolates in community-acquired infections and 77% of isolates in hospital-acquired infections were resistant to at least one of the antibiotics commonly prescribed for respiratory infections. 

In particular, there is an urgent need for a more comprehensive studies on the burden of pleural infection in those who are immunocompromised or others where the microbiology and immune response may differ, the taskforce concluded. 

Intrapleural therapy with the combination of tPA with DNase is considered by most members to be ‘rescue therapy’, but as treatment delays are associated with worse outcomes, most taskforce members said they would start it within 48 hours of standard care with chest tube drainage and antibiotics if there is evidence of treatment failure.

But more work is needed on the optimal dosing and schedule of this therapy for which currently there is only evidence of efficacy for 10mg tPA and DNase 5mg intrapleurally twice a day for six doses, they concluded.

There is potential for improved outcomes with surgical referral and discussion being initiated as early as possible, with the aim of surgery, if needed, within 10 days of medical presentation. 

And most taskforce members would consider surgical referral at day three after the initial chest tube if there is ongoing sepsis, radiological persistence and/or clinical deterioration, the statement published in the European Respiratory Journal said. 

Professor Eleanor Mishra, Consultant Respiratory Physician and Pleural Lead at Norfolk and Norwich University Hospital said the comprehensive review was focused on outcomes that were important to patients.

“It is particularly timely given the high mortality and increasing incidence of pleural infection. 

“Personally, reading this statement has led me to reflect on my practice and how we can optimise care for our patients with pleural infection,” he told the limbic.

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