Local management of pleural infection: a narrative review

The management of pleural infection remains highly challenging. Rational selection of appropriate local treatment strategies is crucial for successful management. Local treatment decisions are primarily guided by clinical features, pleural fluid biochemical parameters, and imaging characteristics, with pleural fluid pH below 7.2 directly indicating the need for pleural drainage. When multiloculated pleural effusion develops, simple drainage frequently fails, necessitating advanced interventions including intrapleural fibrinolytic therapy (IPFT), medical thoracoscopy (MT), or surgical intervention. Current evidence supports the combination of recombinant tissue plasminogen activator (t-PA) and deoxyribonuclease (DNase) as the most validated fibrinolytic regimen. MT combined with IPFT offers a promising minimally invasive approach for selected patients. Video-assisted thoracoscopic surgery (VATS) remains an important treatment option, though recent evidence from the MIST-3 feasibility trial suggests that early IPFT may achieve better quality of life outcomes. Traditional open decortication remains a backup treatment option for patients with complex pleural infection. This review aims to summarize recent advances in local treatment of pleural infection and provide clinical reference for physicians in local treatment decision-making for pleural infection.