Stepwise Surgical Management of Persistent Pleural and Parenchymal Sepsis Due to Pan-Resistant Pseudomonas Infection

Refractory thoracic infections require targeted antimicrobial combinations, repeated drainage interventions and often staged surgical procedures of varying complexity grades. In necrotizing pneumonia cases, successful treatment is complete removal of destroyed non-functional parenchyma, pleural cavity debridement, and complete pathogen eradication based on culture-based sensitivity-driven antimicrobials. The latter proves challenging in pan-resistant microbial strains where both medical and surgical treatments demonstrate limited effectiveness. We describe a case of persistent thoracic sepsis due to pan-resistant Pseudomonas receiving sequentially thoracoscopic decortication, thoracotomy for lobectomy, and open thoracostomy as the last treatment option to prevent fatal sepsis in view of non-available antibiotics. The immediate source-control effect raised the question of the ideal timing for selecting an aggressive thoracoplastic procedure despite its deforming nature over any other treatment approach.