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Management of pleural infection in adults: British Thoracic Society pleural disease guideline 2010
  1. Helen E Davies1,2,
  2. Robert J O Davies1,
  3. Christopher W H Davies2
  4. on behalf of the BTS Pleural Disease Guideline Group
  1. 1Oxford Centre for Respiratory Medicine, Churchill Hospital Site, Oxford Radcliffe Hospital, Oxford, UK
  2. 2Department of Respiratory Medicine, Royal Berkshire Hospital, Reading, UK
  1. Correspondence to Dr Christopher Davies, Department of Respiratory Medicine, Royal Berkshire Hospital, Reading RG1 5AN, UK; chris.davies{at}

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Pleural infection is a frequent clinical problem with an approximate annual incidence of up to 80 000 cases in the UK and USA combined. The associated mortality and morbidity is high; in the UK 20% of patients with empyema die and approximately 20% require surgery to recover within 12 months of their infection.1 2 Prompt evaluation and therapeutic intervention appears to reduce morbidity and mortality as well as healthcare costs.3

This article presents the results of a peer-reviewed systematic literature review combined with expert opinion of the preferred management of pleural infection in adults for clinicians in the UK. The clinical guidelines generated from this process are presented in figure 1. The guidelines are aimed predominantly at physicians involved in adult general and respiratory medicine and specifically do not cover in detail the complex areas of tuberculous empyema, paediatric empyema or the surgical management of post-pneumonectomy space infection.

Figure 1

Flow diagram describing the management of pleural infection.

Historical perspective, pathophysiology and bacteriology of pleural infection

This section provides background information for reference, interest and to set the management guidelines in context.

Historical perspective

The Egyptian physician Imhotep initially described pleural infection around 3000 BC, although Hippocrates has been more famously credited with its recognition in 500 BC. Until the 19th century open thoracic drainage was the recommended treatment for this disorder but carried an associated mortality of up to 70%.4 5 This high mortality was probably due to respiratory failure produced by the large open pneumothorax left by drainage.5 This was particularly true of Streptococcus pyogenes infections which produce streptokinase and large alocular effusions free of adhesions.5 Closed tube drainage was first described in 1876 but was not widely adopted until the influenza epidemic of 1917–19. An Empyema Commission subsequently produced recommendations that remain the basis for treatment today. They advocated adequate pus drainage with a closed …

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