Is it normal to grow bacteria from pleural fluid

Once the nature of the effusion is determined additional management decisions need to be made. Often drainage of the pleural effusion with thoracentesis will be adequate. However, there are occasions when more invasive and definitive therapy is required. In patients with parapneumonic effusions, the recommended initial invasive procedure should be a therapeutic thoracentesis rather than a diagnostic thoracentesis. The reason for this is that if all the fluid is removed and it never returns then the definitive therapy has been performed.

If the fluid recurs a second time and the biochemical parameters are still indicative of a complicated parapneumonic effusion or empyema, a chest tube should be inserted. An alternate option is to place a pigtail catheter small bore chest tube for a few days.

Fibrous loculations represent a complication in pleural effusions with significant inflammation such as bacterial parapneumonic effusions. When loculations are present a single chest tube is inadequate for drainage. In these circumstances multiple chest tubes are often used. If interventional radiology is available it is often possible to place smaller bore tubes into the specific areas of loculation and avoid multiple large bore tubes Instillation of fibrinolytics is one possible alternative to drain the effusion when fibrous loculations are present.

Fibrinolytics such as urokinase, streptokinase, and DNase are used to dissolve the bands of fibrous tissue and improve drainage. The benefits are controversial.

While this treatment option has been available since , no well-performed randomized clinical trial has shown any benefit. The most recent and best-done trial MIST1 failed to show any difference in mortality and the need for surgical intervention at 3 months A video assisted thoracoscopic surgery VATS with lysis of adhesions is also a viable option for loculated effusions.

If it is clear that there are multiple loculations then it is wise to avoid delay and proceed directly to this procedure. Evaluation of the CT finding for diagnosis of pleural effusions. Eur Radiology ; Alptekin F. An epidemic of pleurisy with effusion in Bitlis, Turkey: study of cases.

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Multiplex PCR, with results generally available within hours, is able to detect multiple pre-specified pathogens in a single nucleic acid experiment. This has been applied in a study to detect the more common pathogens associated with pneumonia and pleural infection This approach risks missing organisms not included in the panel and thus should only be considered in addition to standard bacterial culture.

For these reasons, PCR of pleural fluid remains experimental rather than routine practice. The high false negative culture rate, and the need to await culture results make the use of surrogate markers for pleural infection necessary Lymphocyte-rich fluid should raise concern of alternative diagnoses, including tuberculous pleuritis or non-infective causes.

Measures of metabolic activities e. These metabolic markers progress as fluid transit from simple to complicated parapneumonic phases. An alkaline pleural fluid pH can occur with infection from urease-producing organisms, e. Accuracy of pleural fluid pH in this context is important, and is dependent on sample collection method, with most reliable results available when collected in a heparinised blood gas syringe. However residual air in collection tube will artificially raise the pH and carried over lignocaine which is acidic can reduce pH 57 , Pleural fluid pH remains relatively stable at room temperature for up to around 4 hours, beyond which the values may not be trustworthy 57 , Alternatively, a low pleural fluid glucose and high pleural fluid LDH level are useful in supporting the diagnosis of pleural infection.

Variations in fluid appearances and biochemistry among different locules have been shown in a small series Other biomarkers, including pleural fluid procalcitonin and CRP have been investigated for their role in identifying pleural infections. None have been proven to be effective tests and are not recommended for routine use in this context. Novel pleural fluid diagnostic markers such as presepsin and soluble triggering receptor expressed in myeloid cells-1 sTREM-1 have shown to be elevated in pleural infection.

Presepsin is a protein which is released from the surface of various immune cells in response to pathogens and is reported to be increased specifically in the blood of patients with sepsis. The triggering receptor expressed in myeloid cells-1 TREM-1 is shed by the membrane of activated phagocytes and is involved in the inflammatory response. For the diagnosis of bacterial pleural effusion, however studies are lacking regarding whether it can differentiate between parapneumonic effusion and empyema More recently, pleural fluid soluble urokinase-type plasminogen activator receptor suPAR has been shown to be associated with loculated pleural effusions and may better predict the need for chest tube drainage, intrapleural fibrinolytic therapy or thoracic surgery compared with conventional pleural fluid biomarkers This promising data however requires further prospective validation which should encompass usual serum and pleural fluid biomarkers to establish the full clinical utility of suPAR for a detailed discussion, please see recent editorial by Idell and Lee For macroscopically turbid effusions, differentiation of an empyema from a lipid effusion chylothorax or pseudochylothorax is important.

After centrifugation of the turbid fluid, empyema typically shows a clear supernatant with dense sediment whereas lipid effusions will remain turbid Figure 3. Empyema fluid are neutrophil predominant whereas lipid effusions are lymphocyte rich.

Chylous effusions are often exudates but transudative chyloascites or chylothorax can occur as a result of concurrent other aetiologies, such as liver cirrhosis or cardiac failure. Presence of chylomicrons, defines a chylothorax.

It is important to remember that the appearance of chylothorax may vary; and may not be turbid in a fasting or malnourished patient Pseudochylothorax on the other hand has a high cholesterol content 66 and contain cholesterol crystals.

Investigations for tuberculous pleuritis should be initiated when clinically indicated. Nucleic acid amplification tests allow rapid detection of mycobacterium TB complex in a variety of tissue, however the sensitivity of the test on pleural fluid remains relatively low Many surrogate pleural fluid biochemical tests have been tried to increase yield of tuberculous pleuritis in a minimally invasive manner.

Adenosine deaminase ADA is an enzyme of the lymphocytes and its activity is increased during tuberculous pleuritis. An elevated ADA is used in some endemic regions as a confirmatory test, in the clinically setting of a patient with lymphocytic pleural effusion and compatible history and chest imaging for TB.

ADA is cheap and relatively easy to perform with a fast turnaround time and can be reliably used even in stored samples ADA has been shown to be valid in immunocompromised hosts and paediatric populations 74 , However, it must be recognized that elevated pleural fluid ADA level also occurs commonly with other e. Diagnosis relying purely on pleural fluid ADA also does not provide information on mycobacterial resistance. Therefore, ADA is best used as a supportive rather than definitive diagnostic test.

Testing for ADA subsets also serves that purpose but is expensive and not easily available. In non-endemic regions, negative pleural fluid ADA is a very useful rule-out test for TB and other causes for a lymphocytic effusion should be sought Interferon gamma levels in pleural fluid is raised in tuberculous pleural effusions and many studies have confirmed a similar diagnostic performance 77 , However, interferon gamma essays are significantly more expensive than ADA and the latter is preferred especially in resource limited regions.

It must be emphasized that interferon gamma releasing assays however have no role in the diagnosis of tuberculous effusions Promising early data have found IL as another potential surrogate marker though larger studies are needed TB empyema has a very different presentation.

Imaging will show features of thickened pleura and multiloculated fluid that is difficult to evacuate and is purulent. Culture of TB empyema has a significantly higher yield of mycobacteria as well as other bacteria such as S. The mainstay of treatment for pleural infection is antimicrobial therapy and drainage of pleural fluid as outlined below. Detailed discussion is outside the scope of this review and can be found elsewhere 27 , Antibiotics are often used empirically given the low yield of cultures.

Clindamycin or Meropenem provide a reasonable alternative and methicillin resistant S. It should be emphasized that very limited information exists on pleural pharmacokinetics of commonly used antibiotics after their systemic delivery.

Dexamethasone hastened clinical recovery in a small randomized controlled trial RCT of paediatric parapneumonic effusions Its benefits in adult patients are being examined in a pilot RCT Chest tube drainage is usually needed for CPE and empyema.

Imaging-guided drain insertion is valuable especially in loculated effusions. Drain size larger or smaller than 15 Fr did not affect outcome in a large but non-randomized observational series Multiple tubes may be required to evacuate non-communicating locules. It is hypothesized that tPA breaks pleural loculations and DNase reduces fluid viscosity.

Philadelphia, PA: Elsevier; chap Updated by: Jatin M. Editorial team. Pleural fluid culture. How the Test is Performed. How to Prepare for the Test. DO NOT cough, breathe deeply, or move during the test to avoid injury to the lung. How the Test will Feel. During the test, tell your provider if you have sharp chest pain or shortness of breath. Why the Test is Performed. A normal result means no bacteria or fungi were seen in the test sample. What Abnormal Results Mean.

Abnormal results may indicate: Empyema collection of pus in the pleural space Lung abscess collection of pus in a lung Pneumonia Tuberculosis. Risks of thoracentesis are: Collapsed lung pneumothorax Excessive loss of blood Fluid reaccumulation Infection Pulmonary edema Respiratory distress Serious complications are uncommon.