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Loculated indwelling pleural catheter-associated pleural infection — SCE Respiratory MCQ

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HardInterventional PulmonologyLoculated indwelling pleural catheter-associated pleural infectionSCE Respiratory

A 68-year-old woman with metastatic pleural mesothelioma has a right indwelling pleural catheter (IPC) for symptomatic malignant pleural effusion with non-expandable lung. Three months later, she is admitted with fever, right-sided chest pain and increased breathlessness. There is no exit-site erythema or tunnel tenderness. IPC fluid is purulent, with a neutrophil predominance, pH 6.98 and glucose 0.7 mmol/L; culture subsequently yields meticillin-sensitive Staphylococcus aureus. Intravenous flucloxacillin is commenced and the IPC is connected to underwater-seal drainage. Flushing with saline is uncomplicated, confirming catheter patency, but little further fluid drains. After 36 hours she remains febrile with persistently raised inflammatory markers. Thoracic ultrasonography demonstrates a sizeable, multiloculated collection surrounding the intrapleural segment of the catheter. She is haemodynamically stable without respiratory failure. Her platelet count, fibrinogen and coagulation indices are normal, and she is not receiving antithrombotic medication. Which pleural source-control intervention is most appropriate at this stage?

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Correct answer: A — Administer intrapleural alteplase and DNase through the existing IPC

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

This is a deep IPC-associated pleural infection, established by systemic symptoms, purulent neutrophilic fluid, markedly adverse pleural biochemistry and growth of a pathogenic organism. Antibiotics alone are insufficient because effective pleural drainage is an essential component of source control. The IPC is patent, yet drainage has ceased and ultrasonography shows a substantial multiloculated residual collection with continuing inflammation. This meets the BTS definition of medical drainage failure. BTS guidance recommends combined intrapleural tissue plasminogen activator and DNase in pleural infection when drainage has ceased but residual infected fluid remains; monotherapy with either agent is not recommended. IPC-specific multicentre evidence, including UK centres, supports delivering the combination through a functioning IPC, commonly avoiding an additional drain or operation. A fails to address the fibrinous septations and viscous infected material. B is unnecessary while the IPC remains patent and accesses the collection; another image-guided drain would become appropriate if relevant locules were anatomically inaccessible or drainage remained inadequate after enzyme therapy. C is attractive because alteplase disrupts septations, but single-agent fibrinolysis is inferior to the recommended combination in established pleural infection. E is premature in a stable patient before intrapleural enzyme therapy; prompt surgical discussion is appropriate when medical treatment fails, but operative drainage is generally reserved for unsuccessful intrapleural treatment, inaccessible organised disease or clinical deterioration.

Reference: British Thoracic Society Quality Standard for Pleural Disease (21 May 2026) — https://www.brit-thoracic.org.uk/document-library/quality-standards/pleural-disease/bts-quality-standard-for-pleural-disease/ British Thoracic Society Guideline for Pleural Disease (July 2023) — https://www.brit-thoracic.org.uk/document-library/guidelines/pleural-disease/bts-guideline-for-pleural-disease/ British Thoracic Society Guideline for Pleural Disease (July 2023) — https://www.brit-thoracic.org.uk/document-library/guidelines/pleural-disease/bts-guideline-for-pleural-disease/