Pleural infection - Treatment of a

Publication: 17/04/2019  
Next review: 07/01/2025  
Standard Operating Procedure
ID: 5963 
Supported by: Respiratory Dept
Approved By: Drugs and Therapeutics Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  


This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Treatment of a Pleural Infection

Any patient with a pleural effusion and pyrexia should be suspected of having a pleural infection. A pleural aspiration should be performed urgently. Ideally an ultrasound should be used to locate fluid but if not available should not delay treatment of pleural sepsis which has a high mortality rate.

 The following findings indicate pleural infection

  • Frank pus (do not put through ABG machine)
  • Organisms identified by gram stain/culture
  • PH < 7.2 (N.B. can also be low in a malignant or rheumatoid effusions)

The presence of any of the above indicates a pleural infection, which should be drained with an intercostal chest drain – please see insertion of a chest drain for a pleural effusion.

There is no consensus on the correct size of chest drain for the drainage of an empyema but if the pus is particularly thick a larger bore drain should be used.

Please see diagnostic algorithm.


Please see Trust Guidelines for recommended empirical antibiotics
Antibiotics should then be reviewed with the pleural fluid results when available.
Discussion with a microbiologist is also advised.

MIST-2 Protocol – Intra-Pleural Alteplase / Dornase alfa
An alternative to surgery in non-resolving empyema is a combination of intrapleural thrombolytics and DNAse. This should be discussed with a Respiratory Consultant. 

The treatment Regimen is:

  • Alteplase 10mg in 30mL sodium chloride 0.9% TWICE a day for 3 days (i.e. 6 doses in total).The Alteplase 10mg vial must be diluted with the 10mL water for injection provided, before diluting to 30mL with sodium chloride 0.9%.
  • Dornase alfa 5mg in 30mL water for injection TWICE a day (i.e. 6 doses in total). Dornase alfa 2,500 units (2.5mg) in 2.5mL nebuliser solution is used. Two ampoules must be diluted to 30mL with water for injection.

Give both intrapleurally via the chest drain.

  • Alteplase is given first and then the chest drain is clamped for 1 hour and then allowed to drain freely for 1 hour. This is then repeated with Dornase alfa.

The intrapleural administration of Alteplase and Dornase alfa is currently an unlicensed use of these two medicines. Patients must be given information about the unlicensed use of these medicines along with information about alternatives such as thoracic surgery.  


Record: 5963
Clinical condition:

Pleural Infection, Pleural diseases

Target patient group: Those with pleural conditions
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Management of a pleural infection in adults: British Thoracic Society pleural disease guideline 2010.

Approved By

Drugs and Therapeutics Group

Document history

LHP version 1.0

Related information

Not supplied

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