Pleural infection: Early surgery or medical therapy

Mohamed Faisal Abdul Hamid
Faculty of Medicine, Universiti Kebangsaan Malaysia, Hospital Canselor Tuanku Muhriz, Cheras, Kuala Lumpur, Malaysia

Pleural infection, including complicated parapneumonic effusion and empyema, presents a management dilemma with significant clinical and economic implications. Treatment typically involves antibiotics and drainage, but the optimal strategy whether early surgical intervention or medical therapy remains under debate.

Medical therapy often includes image-guided drainage with or without intrapleural fibrinolytics, aiming to avoid invasive procedures. Early surgical approaches, such as video-assisted thoracoscopic surgery (VATS), seek to evacuate infected material and break down loculations, potentially reducing treatment duration. However, both approaches have advantages and limitations depending on timing, resource availability, and patient factors.

Findings from the MIST-3 feasibility trial underscore the variability in outcomes between early intrapleural enzyme therapy and early surgical intervention, emphasizing the need for individualized treatment strategies. Clinical decisions should be guided by factors such as disease stage, imaging characteristics, patient comorbidities, and early response to treatment. Although both approaches are feasible, neither demonstrated clear superiority in reducing hospital stay or reintervention rates. Further large-scale studies are warranted to determine the most effective, safe, and cost-efficient treatment pathway, with an emphasis on standardized management and long-term outcomes. Findings from the MIST-4 trial are anticipated to further inform clinical decision-making.