Controlled Trial of Intrapleural Streptokinase in the Treatment of Pleural Empyema and Complicated Parapneumonic Effusions (Introduction)

28 Dec

Controlled Trial of Intrapleural Streptokinase in the Treatment of Pleural Empyema and Complicated Parapneumonic Effusions (Introduction)Objective: To compare the efficacy of adjunctive intrapleural streptokinase (SK) with simple closed chest tube drainage (Drain) in the treatment of empyemas and complicated parapneumonic effusions.
Method: This was a controlled study of 52 patients (mean age, 57 years; 41 men) with pleura space sepsis. Forty patients (77%) had empyema and 12 had complicated parapneumonic effusions. Twenty-nine patients were treated with Drain only while 23 received, in addition, repeated daily SK, 250,000 U in saline solution (mean, 5.3 days).
Results: The two groups of patients had comparable degrees of peripheral blood leukocytosis, frequency of loculated effusions, pleural fluid pH, and lactate dehydrogenase levels. Infective organisms were isolated in 54% of which 32% were anaerobic and 21% were polymicrobial infections. The incidence of surgical decortication was 17% and mortality was 15%.

A significantly larger volume of pleural fluid was drained from patients in the SK treatment group (2.0 [1.5] L) than those in the Drain treatment group (1.0 [1.01] L). There were no significant differences, however, between the two treatment groups in terms of duration before defervescence, duration of hospital stay, the need for surgical intervention, or mortality rates.

Conclusion: We conclude that thrombolytic therapy increased the volume of fluid drained from pleural empyemas but did not markedly reduce morbidity and mortality.

Pleural empyema is a serious complication of pneumonia associated with substantial morbidity and mortality. Treatment of pleural empyemas is based on early diagnosis and prompt evacuation of the pleural cavity.’* Failure to empty the infected pleural cavity may result in deposition of fibrin with formation of multiple pleural loculations. This very often leads to delayed resolution, further pleural suppuration, and a prolonged hospital stay with the need for costly and risky surgical intervention.

The intrapleural administration of thrombolytic agents has been used to treat empyema for more than 40 years. It may prevent pleural fibrogenesis and facilitate drainage of pleural collections. This approach did not receive wide acceptance until the recent introduction of newer thrombolytic formulations with better safety profiles. This has resulted in renewed interest in these agents as an adjunctive treatment modality for empyema. A large number of reports have attested to the safety and efficacy of intrapleural thrombolysis in the treatment of thoracic empyema. None of these studies, however, has directly compared pleural thrombolysis with simple tube thoracotomy in the treatment of patients with pleural empyema. Since the management of empyema requires a multidisciplinary approach with key contributions from interventional radiologists and thoracic surgeons whose skills and expertise may vary between different hospitals, studies comparing different treatment regimens should recruit patients from the same institution.

We report a controlled study that compared intrapleural streptokinase (SK) with simple tube drainage (Drain) in the treatment of 52 patients with complicated parapneumonic pleural effusions and frank empyema.