Management of pleural infection has become less invasive and more protocolized. Guidelines now favor small-bore, image-guided chest tubes as the initial drainage approach for most cases — as effective as large-bore drains for this purpose. When simple drainage fails or the effusion is loculated, intrapleural enzyme therapy combining tissue plasminogen activator (tPA) with DNase (the evidence-based MIST-2 regimen) improves drainage and reduces the need for surgery, with surgical intervention (typically video-assisted thoracoscopic surgery) reserved for failure. Research is refining fibrinolytic dosing and developing prognostic scores and novel diagnostic biomarkers (such as IL-36γ) to guide management, against a backdrop of rising empyema incidence linked in part to antimicrobial resistance.
Further reading: ERS/ESTS statement on pleural infection management; MIST-2 intrapleural tPA-DNase; reviews of emerging fibrinolytic regimens and biomarkers.