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Indwelling pleural catheter-related pleural infection — SCE Respiratory MCQ

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HardPleural DiseaseIndwelling pleural catheter-related pleural infectionSCE Respiratory

A 68-year-old woman with metastatic ovarian carcinoma has had a right indwelling pleural catheter (IPC) for 10 weeks. She presents with 3 days of fever, pleuritic pain and increasingly turbid IPC output. Her temperature is 38.4°C, blood pressure is 126/72 mmHg and serum lactate is normal. Pleural fluid is purulent, with pH 7.08 and neutrophil predominance; culture subsequently grows meticillin-sensitive Staphylococcus aureus. Ultrasound shows a moderate, non-septated pleural collection. The IPC flushes easily and drains 450 mL without resistance. What is the most appropriate management?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Give pathogen-directed antibiotics and drain continuously through the IPC, retaining it unless treatment fails

Explanation lettering: E = shown as B · D = shown as C · C = shown as D · B = shown as E

This is a deep IPC-related pleural infection rather than catheter colonisation: she has fever, pleuritic pain, purulent neutrophilic fluid, low pH and a concordant pathogenic organism. Effective treatment requires antibiotics and drainage. Because the IPC is patent and accesses a non-septated collection, it should be used for continuous drainage, commonly by connection to an underwater-seal system. Routine IPC removal is unnecessary; most infections resolve with antibiotics and drainage, and removal is reserved for infection that does not resolve or inadequate drainage. A is incorrect because clamping prevents source control. B also leaves infected pleural fluid undrained. C may initially appear to provide definitive source control, but replacing a functioning IPC with another drain adds an invasive procedure without improving drainage; it becomes appropriate if the IPC is irreversibly blocked, malpositioned or infection persists despite adequate treatment. D is premature: alteplase–DNase is considered when initial drainage has ceased and a residual collection remains, particularly when loculated. Here the catheter drains freely and imaging shows no septation. E therefore integrates antimicrobial treatment, adequate drainage through the existing device and avoidance of unnecessary catheter removal.

Reference: BTS Clinical Statement on Pleural Procedures (July 2023) — https://www.brit-thoracic.org.uk/document-library/clinical-statements/pleural-procedures/bts-clinical-statement-on-pleural-procedures/ British Thoracic Society Guideline for pleural disease (11 July 2023) — https://thorax.bmj.com/content/78/Suppl_3/s1